Pre-existing diabetes and pregnancy (WM)
I have Diabetes and am planning a pregnancy – what should I do?
If you have diabetes and are planning to become pregnant, you should have your diabetes reviewed by your diabetic nurse or doctor (GP or hospital doctor) before discontinuing contraception. Good blood sugar control is very important right from the time of conception as it reduces the risks to the health of the baby and yourself. You can arrange an appointment in the hospital yourself, via text (PPCDM REQUEST to 07768466565) or email caw-tr.wm-anc@nhs.net
There are a number of things which may make your pregnancy safer:
- If your diabetes is controlled with diet, you may need to start tablets and / or insulin before or at some stage during pregnancy.
- If your diabetes is treated with tablets, you may need to be changed to insulin injections injections to optimise your diabetes control. Aim for 3.5 – 5.5 mmol/L. It is important to take folic acid supplements in the dose of 5mg daily.
- If your diabetes is treated with insulin, you may need to change your dose or the number of injections to improve overall control.
- Make sure your blood sugar is as near normal as possible for at least 3 months before becoming pregnant. Aim for 3.5 – 5.9 mmol/L before meals and no higher than 7.5 mmol/L 2 hours after a meal.
- Your long term diabetes control, as assessed by a test known as HbA1c, should ideally be less than 48mmol/lol (6.1%). Any improvement to get closer to this value will reduce the risk of miscarriage and malformations in the baby. Pregnancy is not advised if HbA1c is greater than 86mmol/mol (10%).
- It is important to take folic acid 5mg daily for at least 3 months before and for the first 3 months of pregnancy as lack of folic acid could put your baby at risk of developing spina bifida.
- If you are on medication to lower your blood pressure or cholesterol, these may need to be changed or stopped as some of these are potentially harmful to the baby during its early development.
- You should be screened for complications of diabetes such as damage to your kidneys or eyes as these could worsen with pregnancy.
- If you smoke, please stop – ask if you need help.
- If you are overweight we recommend that you lose weight before becoming pregnant and you can be supported in this by consulting a dietician.
I am pregnant – what should I do?
As soon as you know you are pregnant, you should make a self-referral for antenatal care through the hospital website, and contact the Antenatal Clinic on 020 8321 5007 so that an early appointment can be made for you to attend the Combined Obstetric Endocrine Clinic. You should attend this clinic throughout pregnancy for monitoring by a specialist team including obstetrician, endocrine doctors, diabetes specialist nurses, specialist midwifes and dieticians.
What happens during pregnancy?
You should be prepared for frequent visits to the clinic for monitoring, particularly during the first 3 and the last 3 months of pregnancy. This can be quite a challenge, but it is very important to measure your blood sugar frequently to keep it as near normal as possible throughout your pregnancy. High blood sugar before and in early pregnancy increases the risk of miscarriage and developmental abnormalities in the baby. These risks are minimised if blood sugar is kept under control.
First visit: On your first visit, you will receive dietary advice from the dietician and see the diabetes specialist nurse who will explain the frequency of monitoring and target levels recommended during pregnancy. You will be asked to test your blood sugar at least 4 times per day, extra tests being needed occasionally, or to use a sensor.
Your insulin dose may require frequent adjustment especially during early pregnancy when difficulty with control is not uncommon, compounded by the nausea and vomiting sometimes seen at this stage. Try not to get frustrated by this – you will get there!
The aim is to achieve blood sugar as near normal as possible while avoiding low blood sugar (hypoglycaemia). Occasionally we may recommend trying an Insulin pump to optimise blood sugar control.
The first ultrasound scan is carried out at around 11 – 14 weeks to confirm your dates. You will also be offered a combined test of ultrasound measurement plus blood test to screen your baby for chromosomal abnormalities such as Down’s syndrome.
You will meet the diabetic team who will explain more about the impact of diabetes on pregnancy and vice versa. You will have blood tests performed to check your HbA1c level, your thyroid function and kidney function. In some cases extra blood tests may be needed. You will also have your blood pressure checked and urine tested for presence of protein and / or infection.
Subsequent visits: Intensive monitoring of blood sugar for tight control will continue throughout pregnancy.
How does diabetes in pregnancy affect me?
Most women with diabetes will have normal pregnancies and deliver healthy babies but there are certain risks to the mother during pregnancy:
- Ketoacidosis: Women with type 1 diabetes can develop this complication during pregnancy if their blood sugar is very high or if they are unwell (e.g. if being sick or having diarrhoea). This is a serious condition requiring immediate hospitalisation and treatment and can be dangerous to the life of both mother and baby.
- Hypoglycaemia: In early pregnancy, you may experience more hypos. You may also find that the warning symptoms of hypoglycaemia are different from normal or sometimes absent. You will receive advice about this from the diabetes specialist nurse and will be provided with hypostop and / or glucagon pen and instructed in its use.
- Diabetic Retinopathy and Nephropathy: If your diabetes has affected your eyes (diabetic retinopathy) or your kidneys (diabetic nephropathy), these can worsen during pregnancy. The back of your eyes will be checked for retinopathy at your first visit and then twice more in pregnancy. Blood and urine tests will be carried out to screen for the effect of diabetes on your kidneys.
- Pre-eclampsia: Women with diabetes are more likely to develop pre-eclampsia which can cause high blood pressure and protein in the urine. Most women will be started on aspirin 75mg daily and calcium 1g daily as well as continue with folic acid 5mg daily to reduce their risk of developing pre-eclampsia. Blood pressure checks and urine tests will be performed at each visit. You are advised to see your doctor or midwife urgently if you develop any of the following warning symptoms of pre-eclampsia: persistent or severe headache, flashes of lights or blurred vision, abdominal pain, nausea / vomiting or sudden facial or limb swelling.
How does diabetes in pregnancy affect my baby?
Babies of mothers with diabetes have increased risks of several complications which can be minimised by keeping the blood sugars as close to normal as possible.
- Miscarriage
- Developmental malformations: You will be offered a detailed scan at around 20 weeks to examine the baby for abnormalities especially of the spinal cord and heart that are associated with poorly controlled diabetes.
- Growth of the baby: Babies of diabetic mothers (especially if blood sugars are high) can gain weight, deposit more fat around their body and become quite large. This can make vaginal birth difficult and increase the likelihood of needing caesarean section. Sometimes the growth of the baby may be hindered and babies may be small. This usually happens in women with complications of diabetes such as high blood pressure and nephropathy or pre-eclampsia. Your baby’s growth will be monitored by ultrasound scans at approximately 28, 32 and 36 weeks.
- Increased fluid around the baby (polyhydramnios): This can make premature delivery more likely.
- Stillbirth: Babies of diabetic mothers are at slightly increased risk of dying inside the womb during late pregnancy for reasons which are not completely known. In view of this, you will be offered delivery around 38 weeks i.e. about 2 weeks before your due date.
- Increased likelihood of early induction of labour and caesarean section.
- Neonatal problems: Babies of diabetic mothers can have problems controlling their blood sugar (hypoglycaemia) immediately after birth. They are also more likely to have breathing problems and jaundice.
What happens during labour?
During labour you will stop your usual insulin injections and be started on a drip containing glucose and insulin. The amount will be adjusted according to your blood sugar which will be measured hourly.
You and your baby will be closely monitored throughout labour to detect any complications which might arise and deal with them promptly.
What happens after the baby is born?
You will usually go back to taking the dose of insulin you were on before pregnancy. If your diabetes was controlled by tablets, you can resume them after the baby is born. Insulin and most tablets are safe with breast feeding which is recommended to start soon after birth.
Breast feeding your baby will have long term health benefits both for you and the baby and you will be given every assistance to establish breast feeding if that is your choice. As the baby takes carbohydrates away from you via breast milk, you will need to increase your intake of starchy food and may also require less insulin while breastfeeding.
You will be discharged back to your usual diabetes care arrangements – practice nurse / GP / hospital doctor, who will continue to look after your diabetes.
It is very important to plan contraception during the pregnancy, and if possible to leave hospital after birth with your choice already decided – we can usually provide a contraceptive implant, hormonal or non-hormonal coil or progesterone only pill for you. If not please speak to your GP about this. Most of the contraceptive methods are safe to use in diabetes. Before discontinuing contraception for a future pregnancy, it is important to have your diabetes reviewed again.
References:
- NICE guidance 2015 with 2020 update: Click here
- National Diabetes in Pregnancy Audit: Click here
- Diabetes UK: Click here
Further information
Your midwife or obstetrician will be happy to discuss the contents of this leaflet and answer any questions you might have at any time.
Useful telephone numbers
- Combined Obstetric Endocrine Clinic: 020 8321 5007
- Diabetes Specialist Nurse: 020 8321 6189
- Maternity helpline: 020 8321 5839
- SCBU: 020 8321 5944 / 5945
- Consultant Midwife: 020 8321 5990
- NHS Smoking Helpline: 0800 169 0 169
Click here for more patient information.
West Middlesex University Hospital
Twickenham Road
Isleworth, Middlesex
TW7 6AF
Main switchboard 020 8560 2121