So you\u2019ve got type 1 diabetes and you\u2019re thinking about having a baby. We\u2019re not going to lie: pregnancy with type 1 diabetes isn\u2019t a walk in the park. But we\u2019re also here to tell you that you can have a healthy pregnancy and a healthy baby. Here\u2019s the first of a four-part series on what to expect when you\u2019re expecting with type 1 diabetes, starting with pre-conception: what to do and be aware of before you even try to get pregnant.<\/p>\n
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1. Women with type 1 diabetes can \u2013 and do \u2013 have healthy pregnancies and healthy babies. <\/strong><\/p>\n This basic fact can get lost once you\u2019re actually pregnant, when it seems like every lab tech, ultrasound technician and doctor you go to wants to remind you that, because of your diabetes, you are automatically classified as \u201chigh-risk.\u201d They\u2019ll say things like, \u201cwomen with diabetes are at higher risk of miscarriage\u201d \u2013 or \u201cbabies of women with diabetes have higher rates of birth defects\u201d or \u201cwomen with diabetes are more likely to have c-sections.\u201d[1]<\/a> This is statistically true if you just look at women with type 1 diabetes versus women without type 1 diabetes. But you might want to push back — because what those statistics fail to mention is…<\/p>\n In other words, if you are able to maintain near-normal blood glucose levels for most of your pregnancy, then your baby will be at near-normal risk of the above problems \u2013 most studies that do <\/em>take average blood glucose levels into account show a direct relationship between glucose control and the risk of problems.[2]<\/a> Unfortunately, many studies on pregnancy and type 1 lump all the pregnant type 1s together, regardless of their HbA1cs (or only measure them at baseline, rather than throughout the pregnancy). And many doctors focus so much on what can go wrong in a diabetic pregnancy that they forget to emphasize what you can do to make things go right. This can make pregnancy with diabetes more emotionally stressful than it needs to be (more on which in a bit). But first, speaking of blood glucose control . . .<\/p>\n In order to have the best chances of a healthy pregnancy and healthy baby, you want to have your blood sugar levels as close to normal as possible before <\/em>you get pregnant. This is because your embryo goes through important developmental steps before you even know it\u2019s there \u2013 for example, the neural tube, which becomes its spinal cord, goes through crucial stages of development before you\u2019re even likely to have noticed that you\u2019ve missed your period. To minimize the risk of birth defects, it\u2019s important to be start at a good spot. Talk with your doctor about what your target A1c should be, and practice birth control until you achieve it. Also, start taking a daily supplement of 600 mcg of folic acid (either on its own or in a multivitamin) two to three months before you start trying \u2013 folic acid greatly reduces the risk of neural tube defects. Folic acid is important for all women who are thinking of getting pregnant, but especially so for women with pre-existing diabetes, since we\u2019re at an increased risk (again, because of hyperglycemia) of neural tube defects.<\/p>\n You might think that diabetes already <\/em>requires a lot of time with doctors \u2013 but believe me: you ain\u2019t seen nothing yet. As mentioned, having type 1 diabetes automatically classifies you as a high-risk pregnancy. This means that in addition to your regular ob\/gyn and endocrinologist, you will also be sent to a perinatologist\/maternal fetal medicine specialist, which is a type of doctor specifically trained in high-risk pregnancies. The good part about being classified as high-risk is that you\u2019re going to be seeing a lot more of your baby (via ultrasound) \u2013 and a lot earlier — than your low-risk friends. The bad part is that you are going to get really, really tired of waiting rooms.<\/p>\n Before you get pregnant \u2013 or early in your pregnancy \u2013 it\u2019s a good idea to get your kidney function evaluated and to schedule a visit with your eye doctor to check for signs of retinopathy. Pregnancy can make pre-existing retinopathy worse, so if you have signs of it, it\u2019s important to seek care throughout your pregnancy.[3]<\/a> You also should get your TSH (thyroid stimulating hormone) levels tested at the beginning of your pregnancy and after you give birth. This is because people with type 1 are at greater risk of thyroid issues to begin with, and pregnancy can affect your thyroid function.<\/p>\n In addition to your normal ob visits (and visits to your endo, who will likely want to see you at least once a month), anticipate some, if not all (if not more!), of the following appointments with the perinatologist\/maternal fetal medicine specialist:<\/p>\n – possible pre-conception consultation<\/p>\n – initial visit\/consultation once you\u2019re already pregnant<\/p>\n – genetic screening appointment Note: having type 1 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\u2019s blood \u2013 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\u2019s risk of chromosomal abnormalities like Down syndrome.[4]<\/a><\/p>\n – early anatomy scan (around 16 weeks) to check to see if your baby\u2019s development is progressing properly<\/p>\n – regular anatomy scan (around 20 weeks) to see if development is progressing properly<\/p>\n – fetal echocardiogram (usually performed after 18 weeks)\u2013 an ultrasound (usually with a specially trained cardiologist\/ultrasound sonographer) to examine the fetus\u2019s heart for possible defects.[5]<\/a><\/p>\n – growth scans \u2013 ultrasounds to check the baby\u2019s growth. Type 1 diabetes can affect your baby in both directions. It\u2019s associated with vascular complications that can hinder babies\u2019 growth; on the flip side, higher-than-normal blood glucose levels can cause the baby to grow bigger than it typically would.[6]<\/a> The exact number of growth scans (and their timing) will be determined by your ob or perinatologist, but they usually begin toward the middle or end of your second trimester.<\/p>\n – fetal non-stress tests. [7]<\/a> These are tests, usually performed toward the end of your pregnancy, to make sure that the baby is still doing okay and doesn\u2019t need to be delivered early. Your doctor will hook you up to a fetal heart rate monitor, have you lie down or recline, and then monitor the baby\u2019s heart rate as the baby moves. (The \u201cnon-stress\u201d part refers to the fact that they don\u2019t do anything to provoke or stress the baby \u2013 they\u2019re just observing what\u2019s already occurring and making sure everything\u2019s all right.) These tests, which often take at least 40 minutes (or longer if your baby happens to be asleep!), will begin toward the end of your pregnancy. You\u2019ll probably start with once-a-week tests and then move on to twice-a-week for the last month of your pregnancy.<\/p>\n In addition to the normal pregnancy lab work, expect to be having a hemoglobin A1c drawn every month instead of the normal three. Other diabetes-related blood draws can include tests for thyroid-stimulating hormone and free thyroxine levels, blood urea nitrogen, serum creatinine, and spot urine-to-creatinine ratios.[8]<\/a><\/p>\n As noted, there\u2019s a strong correlation between the rate of birth defects and the mother\u2019s blood sugar levels (in short, the closer to normal yours are, the lower the risk of birth defects in your baby).[9]<\/a> A continuous glucose monitoring system (CGMS) can be extremely useful in achieving this goal \u2013 and luckily, more and more insurance companies are recognizing their importance. But whether or not you have access to a CGMS, plan on 4-7 finger sticks per day at the very least \u2013 probably many more.[10]<\/a> Usual testing times include when you wake, before and one to two hours after meals, before bed, and the middle of night.<\/p>\n You may have spent many years happily using long-acting basal insulins like Lantus and Lente, enjoying their long-lasting and relatively steady actions on your blood sugar. If so, you may be surprised when your doctor suddenly recommends \u2013 or insists \u2013 that you switch to NPH while you\u2019re pregnant.[11]<\/a> NPH, should you have been born too late to experience it, is an earlier form of long-lasting insulin \u2013 and, much like hair-sprayed bangs and MC Hammer pants, it had its heyday in the 90s and has never made a comeback. NPH requires twice-a-day injections and has serious swings in its activity, which gives you much less flexibility in your meals and exercise schedule \u2013 and puts you at risk of hypoglycemia when it\u2019s at its peak activity. And yet once you get pregnant, you may find yourself being counseled to go back on NPH.<\/p>\n The reason for this seemingly illogical recommendation \u2013 after all, pregnancy is when you\u2019re supposed to have even tighter control than normal! \u2013 is that Lantus and Lente have not been studied in pregnant women to the same extent that NPH has. If you don\u2019t want to go on NPH, you can try fighting back with your doctor (and acknowledging that you are aware that you are acting against their professional advice). Or, if you know you\u2019re going to try to get pregnant . . .<\/p>\n Insulin pumps eliminate the need for any <\/em>kind of basal insulin, since they\u2019re able to deliver a continuous slow drip of fast-acting insulin to cover your between-meal needs. They also can give you a lot more scheduling flexibility and precision in your dosing. Most insurance companies recognize the importance of insulin pumps for type 1 diabetics, but if yours has given you a hard time in the past, it\u2019s worth trying again: they may have a different policy during pregnancy. And if you still run into trouble, try contacting the sales team of the pump manufacturer directly. They\u2019re trained in dealing with insurance companies and can help you get coverage.<\/p>\n But wait, you say. Diabetes already is <\/em>a second job. Fair enough, but unfortunately, in pregnancy, it\u2019s going to get even more intense. Your doctor is likely going to want you to send in weekly logs of your insulin doses and blood sugar levels so that he or she can help you try to continue hitting your blood sugar targets as your pregnancy progresses. Consider asking him\/her for a sample spreadsheet for you to use as a template, or (if you\u2019re into Excel) taking the time to set one up for yourself that you can use week after week. Also be sure to ask your doctor what variables he or she wants you to be tracking \u2013 in addition to insulin doses and blood glucose values, other options include food\/carb intake, exercise, sickness, sleep and stress. Do not be surprised if at some point during your pregnancy, you feel like throwing your logbook out the window. To combat this desire . . .<\/p>\n The blood sugar targets for pregnancy are tight. Like, seriously, nearly ridiculously tight: 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%.[12]<\/a> In other words, during pregnancy \u2013 a time when hormones are going to make your blood sugars even more difficult than normal \u2013 your goal is to not have diabetes. You can decide whether that idea makes you want to laugh or cry \u2013 but regardless, here\u2019s the dirty (and somewhat reassuring) truth: no one can achieve these targets all the time<\/em>. And, what\u2019s more, while it\u2019s important to do your best, there is no evidence that occasionally straying out of bounds does your baby any harm. So when this happens, take a deep breath, take a correction bolus, and try to feel some compassion for yourself: as is always true with diabetes, there are factors affecting your blood glucose that are out of your control.<\/p>\n \n [1]<\/a> http:\/\/www.diabetes.niddk.nih.gov\/dm\/pubs\/pregnancy\/<\/p>\n [2]<\/a> http:\/\/www.diabetes.niddk.nih.gov\/dm\/pubs\/pregnancy\/<\/a> (\u201chow Diabetes can affect you and your baby\u201d)<\/p>\n [3]<\/a> http:\/\/diabetes.niddk.nih.gov\/dm\/pubs\/america\/pdf\/chapter36.pdf<\/p>\n [4]<\/a> http:\/\/www.ucsfhealth.org\/education\/cell-free_fetal_dna_testing\/<\/p>\n [5]<\/a> http:\/\/www.heart.org\/HEARTORG\/Conditions\/CongenitalHeartDefects\/SymptomsDiagnosisofCongenitalHeartDefects\/Fetal-Echocardiogram-Test_UCM_315654_Article.jsp<\/p>\n [6]<\/a> http:\/\/emedicine.medscape.com\/article\/127547-overview#aw2aab6b7<\/p>\n [7]<\/a> http:\/\/www.acog.org\/~\/media\/For%20Patients\/faq098.pdf<\/p>\n [8]<\/a> http:\/\/emedicine.medscape.com\/article\/127547-overview#aw2aab6c11<\/p>\n [9]<\/a> http:\/\/emedicine.medscape.com\/article\/127547-overview#aw2aab6b7<\/p>\n [10]<\/a> http:\/\/emedicine.medscape.com\/article\/127547-overview#aw2aab6c11<\/p>\n [11]<\/a> http:\/\/perinatology.com\/Reference\/CDAPP%20SS%20Guidelines%202002.pdf<\/a> (see p. 3) nph (category B): http:\/\/reference.medscape.com\/drug\/humulin-n-novolin-n-insulin-nph-999006#6<\/a> (lantus and lente are category c)<\/p>\n2. Most of those risks are directly tied to your blood sugar levels<\/strong><\/h2>\n
3. You want to get your A1c as close to normal as possible (without too many low blood sugars) before you conceive<\/strong><\/h2>\n
4. Be prepared to be seeing a lot of doctors.<\/strong><\/h2>\n
5. Prepare for extra lab work<\/strong><\/h2>\n
6. Get ready for more finger sticks. (And maybe start fighting for a continuous glucose monitoring system.)<\/strong><\/h2>\n
7. Watch out for the return of NPH<\/strong><\/h2>\n
8. Investigate your options for an insulin pump (<\/strong>at least for the duration of your pregnancy.)<\/h2>\n
9. Be prepared for diabetes to become a second job\u00a0<\/strong><\/h2>\n
10. Accept the fact that your blood sugar won\u2019t always be perfect<\/strong><\/h2>\n
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