Pregnancy and Type 1 Diabetes

When you are pregnant, your ideal scenario is to not gain too much weight, pass each milestone without worry, and have a safe, fast delivery that results in a healthy baby. When you have Type 1 diabetes, however, the ideal pregnancy may seem unattainable. Lisa Pink, a new mother, was able to manage her pregnancy along with her diabetes to have a healthy baby girl. She summed up her experience: “It’s a lot of work. However, it’s also worth it when you hold your healthy, perfect baby!”

Before conception

Lisa learned she had Type 1 diabetes when she was 25 years old. She didn’t think about pregnancy and starting a family until she reached her mid-30s. Lisa didn’t know any mothers with Type 1 diabetes, but two of her friends knew of women who had managed their diabetes throughout successful pregnancies. Encouraged, Lisa went to her doctor a year before she and her husband began trying to become pregnant, which is highly recommended. A woman with Type 1 diabetes should attain healthy blood glucose levels before conception. This is important for the baby’s health during pregnancy but also before conception. The National Institutes of Health recommends that a woman with Type 1 diabetes have blood glucose levels in the target range of 80 to 110 mg/dl before eating and 100 to 155 mg/dl one to two hours after eating for three to six months before becoming pregnant. During pregnancy, the recommended target blood glucose range is 60 to 99 mg/dl before eating and 100 to 129 mg/dl one to two hours after eating.

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Safe sugar

Meeting these target ranges will help decrease the chance of too much sugar being passed to your baby. Too much sugar may cause a fetus to grow too quickly or possibly harm the early development of organs. Having a large baby was one of Lisa’s concerns, so she started using a continuous glucose monitor (CGM) to make sure her numbers were in her target range. “This helped me track trends and changes and to be better prepared for insulin needs,” Lisa said. “For the most part, everything went well. I was able to continue to exercise once the first trimester nausea subsided, and I didn’t gain too much weight, only about 20 to 25 pounds, which is good. One of the concerns was that the baby would get too big, but she was sizing well throughout and weighed 7 pounds, 2 ounces, at birth.”

Complications and concerns

It is important to ask your doctor about setting goals in an appropriate range. Eating healthy and getting enough exercise can also help you manage blood glucose levels and lessen your need for insulin. And finding an obstetrician who is sensitive to the monitoring and needs of a woman with Type 1 diabetes is essential. Lisa felt she needed extra assurance that everything was going well and that her concerns about the effect of high blood sugar on the fetus were considered. “So I got extra tests,” she said. “I had a harmony DNA test done at about 16 weeks to test for the chance of chromosomal abnormalities, tests for neural tube defects and spina bifida, and a fetal EKG to check for heart abnormalities. Obviously, each test added stress at the possibility of something being wrong with the baby, but everything turned out fine. Additionally, my condition required fetal monitoring once a week after 30 weeks and that increased to twice a week after 36 weeks. It was at one of these fetal monitoring sessions where they noticed the baby’s movement was not optimal and my high blood pressure put me into the hospital to deliver early.”

Early delivery is one of the main concerns for woman with Type 1 diabetes. Being pregnant and having Type 1 diabetes means that you have to be more vigilant. All pregnancies can have complications, but Type 1 makes you more vulnerable to specific issues like preeclampsia, which is gestational hypertension or high blood pressure. In general, women with Type 1 are susceptible to this because they often have high blood pressure before they get pregnant. Many pregnant women with Type 1 diabetes also worry about developing insulin resistance. During pregnancy, the placenta provides the fetus with nutrients and water. The placenta also makes a variety of hormones to help you stay pregnant. In early pregnancy, hormones can cause increased insulin secretion and decreased glucose production by the liver, which can lead to hypoglycemia, or low blood glucose. In later pregnancy, hormones like estrogen, cortisol, and human placental lactogen can have a blocking effect on insulin, a condition called insulin resistance. As the placenta gets bigger, more of these hormones are made, and insulin resistance becomes greater.

Women with Type 1 diabetes have a lot to consider when trying to conceive as well as during pregnancy and delivery. Unexpected things can happen during delivery, and having a birth plan in place may help. Lisa learned some important steps during her delivery when the unexpected happened to her. It started when her doctor’s office was acquired by another hospital, so her endocrinologist was not able to see her in the hospital. She had to deliver at the hospital affiliated with her obstetrician. Fortunately, the hospital’s endocrinologist was able to help make sure her blood sugar was in control during and after labor. When Lisa’s numbers climbed during labor, she realized she did not have a specific plan for blood sugar control while she was in the hospital or a plan for her pump settings. So this was all done on the fly with a doctor she had never met. Fortunately, the new doctor communicated with her regular doctor during this time to keep him updated and help get Lisa’s settings right after delivery. “As a 35-year-old Type 1 diabetic, my birth plan really was whatever needed to be done to keep me and the baby healthy, so I was willing to do whatever was necessary for that,” Lisa said. “Any plans I may have had went out the door when my blood pressure was high and I had to go into labor 12 days before my due date. Preeclampsia is a risk for diabetic mothers, and so I had to be aware of that throughout the pregnancy. My blood pressure was creeping up toward the end, but didn’t really become an issue until that 38th week. I was feeling well for most of the pregnancy, but really started to feel sluggish the last two months, with my ankles swelling, and that’s when my blood pressure was increasing.”

Breastfeeding

After her early but successful labor and delivery, Lisa faced a new challenge: would she be able to breastfeed her beautiful daughter? “Absolutely! I was told that it would not be an issue. They test a baby’s blood sugar as part of the standard post-delivery tests, and I don’t think having diabetes necessarily increases her chances by that much, and there’s no deficiency or issues with my breastmilk despite my diabetes. I had difficulty getting her to latch on, but we definitely tried and I was able to breastfeed some of the time, but mostly pumped milk for her, especially when I went back to work. Regardless of my condition, breastfeeding is hard, and your baby needs to eat, so please don’t be afraid to ask for and feed your baby formula if you need to, despite how much breastfeeding pressure there is. Your baby’s health is the most important thing. Our baby was not getting enough food and so was jaundiced and had high bilirubin levels because she was not eating and therefore not expelling waste. Although we were in the hospital four days postpartum, due to my high blood pressure treatment…we had to go back to the hospital two days later for her to get light therapy treatment for her jaundice. This was not necessarily related to my diabetes, but still is a concern I was not really aware of.”

A team effort

When asked if she had any advice for other women with Type 1 diabetes who are considering having children, Lisa stated, “The main thing, as with all diabetes care, is that you have to have your team — endocrinologist, nutritionist, diabetes educator, if necessary, and obstetrician. They all have to be working together and communicating to make sure you are taking care of yourself and that your numbers are on track. This is in addition to all the other pregnancy milestones that other women need to worry about, because you have to be in the best condition possible before you get pregnant. It’s a lot of work, and my husband was also a big part of that team to make sure I was on track and keeping all my appointments and taking my vitamins, etc. It definitely takes a lot of people.”