Pregnancy and Diabetes

If you believe the movies, pregnancy and diabetes don't mix. Just look what happened to Julia Roberts in the tearjerker Steel Magnolias. Because she had diabetes, her doctor urged her to not get pregnant. She ignored his warnings and died of kidney failure. Time for the audience to start sobbing.

Of course, movies aren't the best source of medical information. If Steel Magnolias had been true to life, Julia's doctor wouldn't have been making dramatic pleas. Instead, he would have talked to her about blood sugar levels and insulin pumps or shots. (That kind of dialogue just doesn't cut it in Hollywood.) In reality, by carefully planning how to keep their diabetes under control, most diabetic women can have safe pregnancies and healthy babies, says Dr. Martin Abrahamson, chief of adult diabetes at the Joslin Diabetes Center in Boston, Massachusetts.

Of course, the planning you do depends on which type of diabetes you have. A woman with type 1 diabetes, whose body doesn't make any insulin, will be taking insulin as a matter of course. A woman who has type 2 diabetes and is using pills or controlling her disease through diet and exercise generally has to switch to insulin -- at least for the duration of the pregnancy. And gestational diabetes -- that is, diabetes that develops during pregnancy -- is managed differently.

Plan ahead

If you're a woman with diabetes and want to have a child, keep in mind that a successful pregnancy starts before conception. Your first step should be to control your blood sugar, ideally three to six months before you conceive. Extra sugar in your blood could raise the risk of birth defects by as much as tenfold. And if you wait until you're pregnant, it could be too late. Most birth defects occur within the first eight weeks of pregnancy -- before many women even know they're carrying a child.

Birth defects aren't the only danger. High blood sugar raises the risk of miscarriage, premature delivery, and preeclampsia, a dangerous rise in the mother's blood pressure. You'll also be at great risk of retinopathy, a diabetes-related eye condition, if you don't get your blood sugar under control while pregnant. Extra sugar can also make a baby grow unusually large, a condition known as macrosomia. The baby may become so big that a vaginal delivery is impossible, and a cesarean section is necessary.

Making adjustments

Ideally, Abrahamson says, pregnant women should bring their blood sugar levels lower than the range a diabetic would normally be asked to aim for. That means shooting for a hemoglobin A1C blood test that shows a level of 7 percent or less. Your fasting blood sugar level (tested eight hours after your last meal) should be between 70 and 100 milligrams of glucose per 100 milliliters of blood. Two hours after a meal, your levels should be lower than 120 or 130 milligrams. In the second and third trimesters, aim for a fasting blood sugar level between 65 and 95, and try to keep it to 120 milligrams or lower two hours after eating.

To reach this goal, you'll have to test your sugar levels several times each day with a glucometer, a small, portable device that can measure the amount of sugar in a drop of blood. And pay careful attention to your diet.

Since pregnancy causes extra stress on your body, you may need very different amounts of insulin at different times during the pregnancy. At some point, your body may break down fat for energy, leaving behind a toxic byproduct -- ketones -- which can lead to a dangerous condition called ketoacidosis. For this reason, testing your urine daily for ketones is a good idea. The American Diabetes Association also recommends that you keep a log of all your blood sugar test results and enlist a registered dietitian to help you develop a meal plan for your pregnancy.

You'll also have to adjust your medications. Many women need extra insulin during pregnancy. And if you have type 2 diabetes, you will probably have to switch from your oral medications to insulin. (If a woman with type 2 is unable to get her blood glucose into the target range with diet and exercise within a fairly short period of time, such as a few weeks, she will have to take medication. This is almost always insulin.) Some oral medications have also been linked to birth defects -- another reason that women switch to insulin during pregnancy. If you are having trouble keeping your blood sugar under control with insulin injections, ask your doctor about getting an externally worn insulin pump.

Once you're pregnant, don't delay in finding an obstetrician. Ideally, you want a doctor who has experience with diabetes and high-risk pregnancies.

Labor, delivery, and beyond

As you get close to delivery, your obstetrician will be watching your condition closely. Labor is hard work, and your insulin needs will change dramatically during the process. Your obstetrician will probably put you on an intravenous drip of glucose and insulin and monitor your blood sugars during the birthing process.

Your insulin requirements will change drastically again immediately after delivery. You may not need any insulin at all for 24 to 72 hours after delivery. After that period, your body will slowly begin to readjust. Some women have wild swings in their blood sugar levels in the days after they deliver; others stay relatively level.

If you decide to breastfeed your baby, your blood sugar can plunge unexpectedly. You can protect yourself by having a snack containing both protein and carbohydrate before or during breastfeeding. Remember that nursing mothers need a few extra calories, and plan your meals accordingly.

When pregnancy isn't safe

Although these days almost any diabetic woman can have a successful pregnancy, there are a few instances in which women should probably not consider conceiving. Abrahamson says that if a woman has severely weakened kidneys (with less than 50 percent of normal function), extensive retina damage, or hypertension, she may not be able to complete a pregnancy without harm to herself or her baby.

References

Diabetes and Pregnancy. American Diabetes Association.

Interview with Dr. Martin Abrahamson, chief of adult diabetes at the Joslin Diabetes Center in Boston, Massachusetts.

Standards of Medical Care in Diabetes -- 2014. http://care.diabetesjournals.org/content/37/Supplement_1/S14.full

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