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Pregnancy in women who already have diabetes treated with insulin

Before pregnancy?
Most women with diabetes have healthy pregnancies and babies. There are some increased risks to mother and baby but these can be thought about and usually dealt with in advance. It really important to know that good diabetes control before and throughout pregnancy will improve your health and that of your baby.

Before pregnancy?
Use effective contraception and plan pregnancy. Deal with general health issues such as you diet, fitness, weight and especially alcohol and smoking. Try to achieve good diabetes control before pregnancy; babies are at a greater risk for birth defects and miscarriage otherwise. Find out if there are any risks to your health because of blood pressure, eye or kidney problems which can worsen in pregnancy. Certain medications should be adjusted or stopped before you fall pregnant – especially certain blood pressure treatments. You should be seen by the Specialist diabetes team before you become pregnant so that everything can be checked; the diabetes control assessed and plans for the future pregnancy agreed. It is advisable to take 5mg of Folic Acid up to three months prior to conception and for the first 12 weeks of pregnancy.

What diabetes control should I aim for before becoming pregnant?
Aim to get your blood glucose is as good as possible for at least three months before you try to become pregnant. This means a blood sugar of 4-7 mmol/l before meals and an HbA1c (longterm test) of 7% or less.

When pregnant?
Report straight away to you medical team so that early specialist diabetes antenatal care can be planned. You or your midwife can contact the Diabetes Specialist Midwife 01902 695146 to arrange a review.

Does pregnancy affect my insulin dose?
For good blood glucose control you may need extra insulin injections and your overall insulin dose will usually increase by about 50%.

What about hypos?
In pregnancy it is not uncommon to experience mild hypos more frequently and you may find that warning symptoms are different from usual. Women with diabetes are at higher risk of having hypos during the first 16 weeks of pregnancy. If you have any problems dealing with hypoglycaemia, or any severe attacks of hypoglycaemia be sure to report this to the diabetes specialist team straight away. If you are taking insulin it is advisable to have a Glucagon injection at home in the event of a hypo.

Can I follow a regular exercise plan?
Exercise plays an important role in keeping your blood glucose under control before and during pregnancy. Gentle exercise like walking and swimming are recommended
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What about clinics?
You will be asked to attend the hospital frequently for assessment by both the diabetes and the obstetric teams. Initially you will be seen every 2-4 weeks but later in pregnancy you will be seen every week. At around 19 weeks you will have a detailed ultrasound scan to check your baby's size and development. From around 26 weeks the baby will begin to put on weight; it is important to keep your glucose control as near normal as possible at this time to avoid the baby growing too large or being too small.

Can I have a normal delivery?
The aim is to try for a normal labour and delivery where possible. Sometimes if the baby has become overweight or your blood pressure goes up, the obstetrician may wish to induce labour early. Ask your obstetrician or midwife about how this will be done in your case. During labour your insulin and calories will be given in a 'drip' containing glucose and insulin. The amount of insulin will be adjusted every hour depending on your blood tests. The drip will continue until after the baby is born.

What to expect after delivery?
After delivery of your placenta, your insulin needs will drop dramatically. You may be kept on an intravenous insulin/glucose drip for a few hours after delivery and your insulin dose will bead jus ted as needed. Your blood glucose will be checked regularly after delivery, until your levels stabilise. When you resume your normal diet, you should return to your pre-pregnancy insulin dose.

Breastfeeding is the healthiest way for a woman to feed her baby. There are clearly established important health benefits now known to exist for both the mother and her child. Having insulin treated diabetes should not stop you from breastfeeding. However you would need to make dramatic adjustments to your insulin doses to reduce the risk of having hypos when breastfeeding. This is due to the increase in amount of energy that is used to make breast milk. See leaflet on Breast Feeding and Diabetes for more information. Please ask the Diabetes Specialist Midwife about expressing colostrum before your delivery.

What does this all mean for the baby before and after birth?
Having high blood sugar can affect the baby's growth in the womb. This can cause the baby to grow larger, which can sometimes make delivery difficult but it can also slow down the baby's growth and both can affect development.

Shortly after birth, the baby may continue to make extra insulin even though high levels of blood sugar are no longer present This may cause the baby to have low blood sugar (hypoglycaemia).About half of all babies born to mothers with diabetes may be hypoglycaemic at birth. Your baby's blood glucose will be regularly measured soon after birth, every hour for the first 3 hours,and then every 6 hours for the first 24 hours after birth. If it is low it will be treated straight away.

Usually the hypo is easily treated by feeding the baby straightaway, including breast feeding. If the hypo is more severe, your baby might need a glucose drip into a vein. The hypo generally does not harm the baby. It is more likely that the newborn baby will develop jaundice. This usually fades over a few days, without the need for medical treatment. Some babies may need photo light treatment for jaundice in the first few days after birth.

Sometimes newborns, particularly if born early, can have breathing problems because their lungs have not fully matured. Again, this usually clears up with time. Extra oxygen may be needed at this time but only for few days.

There a very slightly higher risk of still birth, but if the glucose levels are reasonably controlled throughout pregnancy, this risk is much lessened and is rare.

Will my baby be taken away to a special baby unit at birth?

Babies born to mothers who are treated with insulin do not go to the special care baby straightaway after birth, they stay with their mothers and are observed there. Only babies with breathing problems or low blood sugars that need a drip need go to the special baby unit.

Will my baby develop diabetes?
It is unlikely that your baby will develop diabetes. The inheritance of diabetes is very complicated even close relatives have only a slightly higher than normal chance of developing diabetes. Your baby should behave and develop like any other baby. For people history of diabetes staring in older life, keeping you children fit and healthy with a good diet and plenty of exercise is the best way to prevent diabetes in much later life.

What to expect postnatally?
Producing milk requires substantial amounts of energy. Your body will need less insulin to control your blood glucose level after your baby is born. Continue checking your blood glucose levels and you may need to adjust or decrease your insulin requirements until you are taking the correct dose. You are at an increased risk of hypoglycaemia following the birth, and especially when breastfeeding, so you should always have some food nearby to eat before and during breastfeeding or expressing. It is very important to be aware of this so that you maintain a safe environment for yourself and your baby.

  • Recognise the stress of a crying baby and the effect this has on blood sugars.

  • Be aware of increased exercise, day and night. Try to eat before or while breastfeeding or expressing breast milk.

  • Have easily available quick acting carbohydrate, ideally as a complex carbohydrate (see examples below).

  • Be aware of the increased risk of hypoglycaemia after you have had your baby particularly when driving, so always have a snack available in the car.

  • Examples of snacks to eat before or while breastfeeding

  • Glass of milk + cereal bar

  • Glass of milk + banana

  • Yoghurt or fromagefrais

  • Rice pudding (low sugar) + piece of fruit

  • Sandwich – 2 slices of bread with either ham, salad, tuna,cheese

  • 4 crackers + cheese spread

  • Chappatti and small portion of curry

What care should I take following the pregnancy?
You have just delivered a beautiful baby and you should feel proud of the effort you have made. With baby's arrival, your focus turns to caring for your little one. But keep in mind that to take good care of your baby you need to take good care of yourself. Stick to your habits that helped you keep your blood glucose levels on target during pregnancy. Even so, for many, it is a period of odd blood glucose swings. Please continue to monitor your blood glucose levels and adjust insulin doses as you remain at risk of hypos as long as you continue to breastfeed. Remember to get advice on contraception and planning for future pregnancies from your doctor, specialist midwife, or diabetes antenatal team.

Seeking advice and what care to expect
Seek advice early from you medical team and involve them in contraception and pregnancy planning. Women with diabetes planning pregnancy should be under the specialist diabetes team as soon as they know they want to plan a pregnancy or as soon as they know they are pregnant – ask to be referred if you are not. You should have a full preconception check for your blood sugar control and diabetes complications and full advice and support throughout. During pregnancy you will be in a special antenatal clinic run jointly by the maternity and diabetes services. You should know exactly who your specialist diabetes and antenatal team are. Your diabetes, blood pressure, eyes and kidneys will be closely reviewed and discussed with you– as well as keeping a good on baby's progress. You should have a delivery plan made well in advance and you should be confident of how your diabetes will be managed during labour. You should know how you will be followed up after delivery. You can ask to see all of the standard care plans that held by the specialist teams that tell you what will happen at various stages of pregnancy. You should always know what the plan of action is – ask if you don't. An Infant Feeding Specialist is also available for help and advice on breast feeding. The Diabetes Specialist Midwife is available for advice on care before, during, and after delivery. You can also refer yourself to the preconception clinic by contacting our Diabetes Specialist Midwife directly on 01902 695146.