A Doable Challenge
Women with Type 1 or Type 2 diabetes who are considering pregnancy have reason to feel optimistic. That’s because women with diabetes can and do experience healthy, uneventful pregnancies and give birth to perfectly healthy babies. That said, however, a pregnancy with preexisting diabetes is always considered high-risk, and its outcome is largely dependent on a woman’s efforts to keep her blood glucose levels as close to the normal range as possible for the entire duration of her pregnancy.
The American Diabetes Association recommends blood glucose goals for pregnant women that are lower than those suggested for the general population: 60–99 mg/dl before meals and 100–129 mg/dl one hour after eating. Anyone with diabetes knows that staying in that range every day for nine months requires tremendous commitment, even when not pregnant. Achieving those goals while pregnancy hormones are wreaking havoc with your insulin needs and while your whole body is growing and changing is another thing altogether. Add morning sickness, exhaustion, swollen ankles, and normal pregnancy anticipation into the mix, and you have a full bag of stress triggers.
So how does a pregnant woman with diabetes manage to keep herself and her baby healthy while also balancing her usual family, work, and other life responsibilities? This article offers strategies based on experiences from my own two pregnancies as well as those from other women with diabetes who have made the effort to do all that was in their power to bring healthy children into the world. (Note: This article focuses on women with existing Type 1 or 2 diabetes before pregnancy rather than women who develop gestational diabetes during pregnancy).
When I first mentioned wanting to have a baby to my endocrinologist, he urged me to get my glycosylated hemoglobin (HbA1c) level to 6% or lower (it was 6.6% at the time). The HbA1c test gives an indication of average blood glucose levels over 2–3 months; a normal HbA1c level in person who doesn’t have diabetes is 4% to 6%. He also gave me a referral to meet with a perinatologist, or high-risk obstetrician. That meeting was a moment of truth for me: The doctor spelled out in plain terms the birth defects, including spinal and other major organ damage, that could happen to my baby if I did not maintain his recommended blood glucose control while pregnant.
I remember leaving his office feeling scared but also determined. He had encouraged me by telling me that he had lots of patients with diabetes who had worked hard and given birth to babies with no birth defects at all. Though I ultimately chose a different high-risk obstetrical practice, I am still thankful that in my meeting with that doctor, he didn’t try to sugarcoat the facts (no pun intended).
Besides getting my HbA1c lower, I knew that my other assignment was to spend time figuring out, with all of my heart and soul, if I truly wanted a baby and could do what was needed to make sure that baby would come into the world with just as good a chance as any of not having permanent birth defects. While I worked on both of those things, my husband and I continued to use birth control.
Like the other doctors I spoke with, endocrinologist Lois Jovanovic, former CEO and Chief Scientific Officer of the Sansum Diabetes Research Institute and author of Medical Management of Pregnancy Complicated by Diabetes, strongly urges women with diabetes to make a conscious choice to become pregnant and to get their blood glucose levels in the recommended range before trying to conceive. “Love your baby first,” she says. “That means you’ll do anything, even checking your blood sugar every hour, 24 hours a day, to make sure your baby is healthy. A woman with diabetes needs to be really unselfish and make sure that this is the right point in her life for a pregnancy.”
Establishing “tight” blood glucose control before conception is important, because keeping blood glucose levels in the recommended range during the first trimester is critical to preventing birth defects — and a woman doesn’t always know exactly when she becomes pregnant. Uncontrolled high blood glucose can even cause a woman to miscarry early in her pregnancy.
In addition to blood glucose control, a woman needs to make sure that she is in optimal health in every way and needs to be assessed for any possible complications that could be made worse during pregnancy, including retinopathy (eye disease), kidney disease, high blood pressure, and cardiovascular disease. Women with Type 1 diabetes should additionally be screened for thyroid disease.
“Six months before I tried to get pregnant, I made my appointment to see that my eyes were all right,” says Karen Eason, a mom with Type 1 diabetes who has two healthy daughters. “All of those appointments — eyes, kidneys — to make sure that I was all right were just part of what I knew I needed to do before we began trying.”
Knowing your health status in every way — mentally, physically, and emotionally — before trying to conceive is the first step toward achieving a healthy pregnancy. (Check out “Preconception Planning Checklist” for a list of steps to take before becoming pregnant.)
Finding a health-care team
When Bjay Wooley, editor of DiabeticMommy.com and mom of a healthy 12-year-old son, got pregnant, she was a student at a major university and went to see the campus doctor there. He gave her the impression that pregnancy wouldn’t be a big deal, despite Wooley’s Type 2 diabetes. Fortunately, at the same time, she went to see a certified diabetes educator (CDE) who referred her to an experienced perinatologist who had seen many women in her position. Wooley was admitted to the hospital to help get her blood glucose under control, and with the help of her CDE and obstetrical team (and her own dedication), she was able to continue through with a healthy pregnancy.
Ideally, the time to assemble the medical professionals you need during pregnancy is before conception. Begin by talking with the doctor who provides your diabetes care and getting a referral to an obstetrical practice affiliated with a hospital equipped with a neonatal intensive care unit (NICU), in case the baby should have any complications after delivery. It is not uncommon for babies of mothers with diabetes to have some hypoglycemia after delivery. This is a short-term, reversible problem, but it may need to be treated in the NICU depending on its severity.
Set up an appointment to meet with a doctor from the practice to talk about how he works with women with diabetes. Look for a doctor that you “click” with — remember, you will be seeing him frequently throughout your pregnancy. Talk with both your diabetes care provider and the obstetrician about who will help you to manage your blood glucose levels during the pregnancy. Some obstetricians prefer to keep track with you, while others are happy to have you work with your endocrinologist or CDE, as long as you are keeping them posted.
Jennifer Ferry, who has Type 1 diabetes and is the mom of two healthy daughters, worked with a high-risk practice during her first pregnancy that had her make daily calls with her blood glucose reports. During her second pregnancy, however, she preferred working with a CDE who followed her blood glucose levels with a weekly fax and follow-up phone call. “That felt more than sufficient to me, and my blood sugars were right in the recommended range,” Ferry says.
It is critical that all of your doctors and other health-care professionals be willing to communicate with each other as a team. Often that step is made easiest when they all work together at the same hospital, but that does not always have to be the case.
In addition to your other care providers, you may also want to find a nutritionist who can help you make adjustments for eating during pregnancy and possibly a personal trainer who can help you adjust your exercise routine for pregnancy. Many women who experience high levels of stress during pregnancy also seek out a psychotherapist or support group for help.
And don’t forget about your baby’s medical needs: When selecting a pediatrician, you want to find one who understands the issues connected to babies of women with diabetes. For example, sometimes the babies of mothers with diabetes can be bigger than other babies, due to increased glucose levels in the womb. A baby’s size will eventually even out though, as he grows to meet his natural genetic endowment in the months after birth. An experienced pediatrician will recognize this phenomenon.
For women not living in or near a metropolitan or university area, the choices in physicians may be more limited. According to Dr. Jovanovic, it is critical to find an obstetrician-gynecologist who delivers at least five babies of mothers with Type 1 or Type 2 diabetes (not gestational diabetes) every year. If that means traveling within a radius of a hundred miles, she encourages people to do so.
Support and adjustments
Many women who become mothers discover that the “superwoman” ideal is truly a myth: No one can be all things to all people or do all things perfectly all of the time. For women with diabetes who are pregnant, the extra time, energy, and pressure of blood glucose management and scheduling medical appointments may feel overwhelming at times.
It is important to think about what life adjustments can be made so that you can give your pregnancy the focus it needs. For Jennifer Ferry, that meant leaving her job during her first pregnancy so that “being pregnant could be my job,” she says. If you are fortunate enough to be in a financial position to do so, you may consider that option. Sometimes women with diabetes can qualify for short-term disability if work proves to be too stress-inducing or will not allow time for frequent blood glucose monitoring and making insulin adjustments. Ideally, your employer will work with you to create the flexible time you need for medical appointments or allow you to go to a part-time schedule for some of the pregnancy as needed.
Some women feel all right about maintaining their usual work schedule but feel overwhelmed by the demands of housework, yard work, or care of older children on the home front. Hard as it may feel, it is important to ask for help from partners, relatives, and friends during your pregnancy so that you can take care of yourself. An hour or two of child care here and there can make all of the difference in terms of giving you the time you need to rest, cook healthy food, or exercise. While it may feel selfish asking for this time, you’re doing so to take the best care of your unborn child.
“During my pregnancy, I asked for more help from others,” Bjay Wooley recalls. “I’m the kind of person who hates to ask for help. I’m kind of a trouper. But because I made my pregnancy a priority, I started to ask for help.”
Some women also discover that their friends without diabetes have difficulty understanding what they’re going through during pregnancy. One woman I spoke with talked about how frustrating it felt when a couple of her girlfriends who were pregnant at the same time frequently made plans to get together at a restaurant to pig out. “I explained to them that I really needed to stay on my meal plan to keep my blood sugars in check,” she said, “but they would try to encourage me to go for that extra slice of pizza or huge dessert. Maybe they felt guilty eating that way if I wasn’t, but it got so that I didn’t want to go out with them anymore.”
Other women describe how friends don’t understand why they are going to so many doctor appointments — especially during the third trimester when women with diabetes are monitored several times a week with a fetal nonstress test to make sure the baby’s activity level is normal. It’s frustrating when your friends can’t relate to your experience (in spite of your explanations), but what’s ultimately most important is that you respect that a pregnancy with diabetes really is different and that you attend to your needs.
If you’re not getting the support you need from your established social circle, you may want to seek out or even create a local support group for women with diabetes who are pregnant or go online to www.DiabeticMommy.com to become part of that cyber-support network.
Trimester by trimester
For women with diabetes, each trimester truly contains its own challenges. Because the first trimester is the time of much of the fetus’s major organ development, it is critical to maintain blood glucose in the recommended range during this time. However, women may not find out right away that they are pregnant, and even when they do, their blood glucose levels can fluctuate wildly because of the introduction of pregnancy hormones into their systems. This is the time when women need frequent contact with a physician or CDE who can help them to make insulin adjustments as needed. During my second pregnancy, my endocrinologist had me wear a continuous glucose monitoring system in my first trimester for three days so that we could see what was going on with my glucose levels 24 hours a day and then make adjustments to my insulin doses from there.
Morning sickness can also disrupt some women’s blood glucose control during the first trimester. How do you know how much rapid-acting insulin to take when you’re not sure how much of your meal you’ll be able to eat or keep down? I discovered that insulin pump therapy allowed me to easily take part of my premeal bolus before I ate, then take more during the meal as needed. On days I felt nauseated, being able to do this made all of the difference in my blood glucose control.
The second trimester is when most women see their insulin needs increasing each week, as pregnancy hormones cause them to become more and more insulin resistant. Some women describe this time as “chasing their blood sugars” — needing to add more insulin just when they thought they’d found the dosage they needed. Insulin pump therapy, which mimics the human pancreas by secreting small amounts of insulin into the bloodstream in an ongoing manner, makes it easier for a woman to make adjustments in her basal rates at this stage in pregnancy. In fact, many women with Type 1 diabetes go on the pump before conception with the specific purpose in mind of making pregnancy management simpler and better.
This pattern of increasing insulin needs usually continues into the third trimester, which is often a challenging time because it’s when the woman is at her largest. She may feel more tired and less able to exercise. For me, swimming helped to keep me in shape during the last few months when walking more than a few blocks felt like running a marathon.
Planning for delivery
It is during the third trimester that women need to sit down with their obstetrician and talk through a birth plan. For women with diabetes, a baby’s due date is somewhat flexible. Because we are at a higher risk for stillborn babies, many physicians routinely schedule babies to be delivered at week 38 or 39, which can be done by induction or Caesarean section (C-section), depending on factors including the size of the baby (estimated by an ultrasound report).
Talk with your doctor about what he recommends, and let him know your hopes for the birth, so that you can be on the same page as much as possible. Remember, women with diabetes statistically deliver by C-section more than other women. For some, this is a disappointing prospect. While many women with diabetes do have vaginal births, it’s worth making peace with the idea of a C-section, in case that becomes a necessary option.
Talk with your doctor about how your insulin will be managed during delivery. For example, many hospitals require a pump, including infusion site, to be removed during any surgery, including a C-section. If that is the case, ask how soon you will be able to reconnect to your pump. During labor and vaginal delivery, many women need little or no insulin because of the strenuousness of contractions. Who will be monitoring your blood glucose levels? Will your endocrinologist be consulted? Will the obstetrics team make adjustments? Knowing how all of these things will be determined ahead of time will help to make you feel more in control in the moment.
Also, make sure to talk with your doctor about the hospital’s policies on handling babies of women with diabetes. Some hospitals routinely take babies to the nursery for up to six hours after birth to monitor blood glucose levels; at least knowing this information can help you to prepare emotionally for this experience.
If you feel sad or angry that your baby may not be with you in the moments after birth, you are not alone. Many mothers with diabetes have been there and experienced that same frustration. “It felt like it took more time for my second daughter and me to bond,” says Karen Eason, whose daughter was placed in the nursery for blood glucose observation. “I knew that her blood sugar was going to be fine, but they were very strict at looking at the numbers.”
Delivery and beyond
Delivering a baby, vaginally or through a C-section, is truly awesome and completely exhausting all at once. Again, talking through what will happen with your insulin or medicine adjustments and blood glucose management ahead of time is important. Knowing that you may be feeling exhausted or overwhelmed, you may want to appoint an “advocate” for you — a partner, parent, or close friend who can help you reinsert your infusion site, check your blood glucose levels as needed, etc.
Having an advocate can be important because, unfortunately, not everyone you encounter among hospital staff will have the knowledge they need to help you. Many nurses know little about insulin pump therapy, and some have less education than they should about diabetes in general. Hypoglycemia can happen in the hours and even first few days after delivery as your body begins to adjust to being in a nonpregnant state. I remember checking my blood glucose to find it was 45 mg/dl the first night after my C-section and buzzing the nurse to bring me juice. Five minutes went by, then 10. I buzzed again…and when she finally came by she was annoyed that I had buzzed a second time. The next day I had my husband bring me glucose tablets so that I wouldn’t be dependent on the nursing staff again!
All of this adjustment in your body is taking place at the same time as you start to realize that you have given birth to your very own boy or girl. Whether they need to spend time in the NICU or nursery or get to be right there in your arms, the moment of realizing that you have just met your own child is like no other. “The first time I had a baby, before I was diagnosed with diabetes, I took getting pregnant and having a baby for granted,” recalls Karen Eason. “But when my second daughter was born, it truly felt like a miracle. You realize what a miracle bringing a child into the world truly is.”
And so your diabetes should not stop you from experiencing that possibility. Educate yourself as much as possible, make a commitment to yourself, and put your baby first as much as you can while you are pregnant.