Congratulations – you’re pregnant! (Or, alternatively: uh oh – you’re pregnant!) Either way, this is where your adventures in pregnant blood sugar management will truly begin. You have a challenging road ahead of you, but the good news is that there’s a lot you can do to increase your chances of a healthy pregnancy and a healthy baby. (For preconception tips see here).
1. (Keep up the) work on your A1c:
Hopefully by this point your HbA1c is at the target level that you and your doctor agreed upon before conception. This is important because very high blood sugar over time is associated with an increased risk of birth defects and miscarriage. (Though, on the more optimistic flip side, the closer your blood sugar is to normal, the lower the chance of problems.) If your A1c was extremely high in the months before conception, you need to have a frank conversation with your doctor about what impact these levels may have had on your developing embryo, and what this might determine about whether to continue the pregnancy (or what your risk is of losing it). If it’s a go, you need to immediately start working on bringing your blood sugar under control.
2. Test, test, test.
In order to come anywhere close to the super-human blood glucose targets of pregnancy (60-99 mg/dl fasting, a peak of 100-129 mg/dl after meals, an average daily blood glucose of 110 mg/dl, and an A1c of less than 6.0% ), you need to be testing your blood glucose a lot. As in, probably more than a dozen times a day. As noted in our pre-conception tips, a Continuous Glucose Monitoring System (CGMS) can be enormously helpful in tracking your pregnancy blood sugars, since it gives you a nearly real-time graph of where your blood glucose has been and where it’s heading — and having advance warning of an impending low is also an important safety feature when you’re aiming for tight targets. If your insurance company has given you trouble in the past about covering a CGMS, it is a good time to approach them again. (Call the CGMS manufacturer and ask for their help.)
3. Log, log, log.
Insulin requirements increase dramatically during pregnancy, and the only way to stay on top of what those requirements are is to keep a log of what you’re eating, how much insulin you’re taking, and what your blood sugar is (you can throw in other factors, too, like exercise and sickness, but those are the basics). Ideally, your endocrinologist or certified diabetes educator will be able to review these records weekly and help you tweak your doses as your pregnancy progresses.
4. Note the limits of genetic testing (and possible benefits of being high risk)
Having type 1 – which automatically will define you as “high risk” – does have one upside: it may qualify you for insurance coverage for a new type of genetic testing called cell-free DNA, a far less invasive option to amniocentesis or CVS that tests for many chromosomal abnormalities via a simple blood draw. Turns out that there is fetal DNA circulating in the mother’s blood – which is weird and cool. In cell-free DNA, they extract some of this DNA from your blood and analyze it to determine your fetus’s risk of chromosomal abnormalities like Down syndrome. No genetic test can test for your baby’s chances of developing Type 1 diabetes, however – these tests can only look for conditions, like Down Syndrome (aka trisomy 21), that are caused by chromosomal abnormalities.
5. Have a plan for morning sickness
Morning sickness sucks for everyone, but for women with pre-existing diabetes, it can be dangerous: if you eat food and take insulin – and then throw up the food you took the insulin to cover – you’re at risk of a serious low blood sugar. (And unfortunately, “morning sickness” can occur at any time during the day, contrary to its name.) Making things even trickier, many women with morning sickness find that easy-to-digest carbs like saltines and pretzels are the easiest thing to keep down – foods that are hardly a diabetic’s best friend. It’s a good idea to talk with your endocrinologist or diabetes health care provider (i.e. someone who’s familiar with you and your diabetes) about what to do to manage your morning sickness and diabetes at the same time.
Some things you might also want to consider:
– If your morning sickness is severe, your doctor or caregiver may be able to prescribe anti-nausea medication to help you keep food down.
– As noted, morning sickness can put you at risk of serious lows. Be sure to carry a source of fast-acting carbs at all times (glucose tablets, juice box, etc). -It’s also a good idea to start carrying around glucagon in your purse and/or to stash a kit in your desk. (But remember: if your blood glucose is so low that you need glucagon, chances are you won’t be able to give it to yourself. Be sure to tell a colleague or friend where you store it, and teach them when and how to use it.)
– Consider an insulin pump. As noted in the pre-conception tips, an insulin pump can be a great management choice for pregnancy. Not only does it lessen the chance that you’ll be put back on NPH for long-acting insulin, but it gives you the ability to adjust insulin doses on the fly. This means that if you are having difficulty keeping food down, you can give yourself a lower temporary basal rate and lessen your chances of becoming hypoglycemic.
6. Be aware that if you choose to read What To Expect When You’re Expecting, you may want to kill someone.
This so-called “pregnancy bible” (which, it’s worth noting, was not written by doctors) is often referred to as What to Expect When You’re Expecting An Eating Disorder — and that’s by women who don’t have diabetes! The answer to a reader’s question about weight gain early in pregnancy, for example, includes a snide parenthetical about how she might be spending too much time with Ben and Jerry. This would be irritating in and of itself. But when you have a disease that already prevents you from having any sort of meaningful relationship with Ben or Jerry, let alone when you’re pregnant, and you’re feeling gross and bloated despite not having consumed any ice cream at all, don’t be surprised if you want to hurl the book across the room.
7. Beware of Internet Message Boards
The internet and pregnancy have a complicated relationship. On the one hand, the diabetes online community (DOC) can be a great source of support during pregnancy (for example, the “Oh, Baby!” forum on TuDiabetes.org). But the internet also can be a great source of confusion, incorrect “information,” and fear. If the advice on message boards is making you panicked (and, in many cases, it should!), seek out books that are non-alarmist, practical, and science-based. My personal favorites are Expecting Better, by Emily Oster and The Panic Free Pregnancy. As for books about diabetes and pregnancy in particular, check out Cheryl Alkon’s Balancing Pregnancy With Pre-Existing Type 1 Diabetes.
8. Find a team of caregivers that supports your approach to diabetes management
Talk to enough women who have gone through pregnancy with Type 1 diabetes, and it becomes clear that obstetricians and hospitals have wildly differing attitudes when it comes to taking care of pregnant women who have pre-existing diabetes. Some caregivers and hospitals will automatically want to induce you or perform a c-section at 38 weeks, while others will be fine letting you go to your due date (or beyond). Some hospitals have policies in which they insist on taking over your glucose management during labor (via insulin and glucose drips); others will let you continue to manage your glucose on your own. It’s a good idea to find out early in your pregnancy what your caregiver’s approach is (and what the policy is at the hospital where you intend to give birth), so that you can make any necessary changes in your care team or delivery location before you get too far along.
9. Keep (or start) exercising!
Pregnancy is not a time to suddenly decide you want to run a marathon or start a career as a power lifter, but physical activity is extremely beneficial during pregnancy, both for your blood sugars and your baby. If you weren’t particularly active before pregnancy, even a daily 30-minute walk can help improve your insulin sensitivity. And if you were a serious athlete before pregnancy, it’s likely fine (and good for you!) to keep up your regular workout routine for as long as you feel okay doing it. Here are the latest guidelines from the American College of Obstetricians and Gynecologists.
10. Don’t be surprised if you feel resentful, scared, unexcited, overwhelmed, or all of the above
Some women enter pregnancy 100% sure of their decision to become mothers and enjoy the entire experience, back aches and all. But others – one might say most women, even those without diabetes – have emotions that are more conflicted, at least occasionally. If this describes you, keep in mind that feeling apprehensive about having a baby is normal for all women, even if they don’t have diabetes, and even if they were convinced before pregnancy that having a baby was their #1 goal in the entire world. So if you’re feeling less than psyched, or more than a little nervous about it, don’t beat yourself up: there is nothing wrong with you. Pregnancy is a time of conflicted emotions to begin with, and if you throw in an extremely challenging, relentless and demanding disease, these feelings may be amplified. You may find yourself resenting pregnant friends who talk about the hot fudge sundae they just inhaled, or being tempted to punch people who suggest that pregnancy is a time to savor (and then feel guilty that you’re not savoring it). You may feel guilty about a high blood sugar, or wonder if you’re going to be able to handle the demands of diabetes with the demands of motherhood. You may find yourself feeling down or anxious or even depressed. If so, do not panic – but do get help. Look for communities of other diabetic pregnant women online (for example, the Oh, Baby! forum mentioned above), seek out support groups at your local diabetes center and, if you feel truly down, contact a psychologist or psychiatrist. Research is increasingly suggesting that having a mother who’s depressed can have long-term bad health effects on a child’s health and development. Pregnancy is not the time to be a martyr or to suffer in silence.
11. Remember: pregnancy with diabetes is hard, but you will get through it.
As is always true with diabetes, you can only do your best. While it’s important to work hard at achieving excellent control, remember that an occasional blood sugar that is higher that you like is not going to do long-term damage to your child. And if you feel yourself getting frustrated and burnt out, try to keep in mind some of the long-term benefits of all the hard work you’re putting into your pregnancy: for many women, the intensified demands of managing a diabetic pregnancy can actually lead to improvements in their own health. You’re likely to find yourself testing more often, exercising more frequently, eating more healthily, and seeing more doctors than you’d ever thought possible. Sure, it’s hard and often annoying work, but the ultimate result is positive — for everyone involved.