Planning a Pregnancy
Women with pre-existing type 1 or type 2 diabetes can have healthy and happy pregnancies with proper preconception planning and intensive prenatal care.
The American Diabetes Association (ADA) recommends that women with diabetes who are planning a pregnancy strive for the following control goals:
- A1c of 7% or less
- Preprandial (i.e., before meal) plasma blood glucose levels of 80-110 mg/dl (4.4-6.1 mmol/l)
- Two-hour postprandial (i.e., after meal) plasma blood glucose levels of less than 155 mg/dl (8.6 mmol/l)
Hormones produced by the placenta during pregnancy increase insulin resistance. As pregnancy progresses and the placenta increases in size, so do a womans insulin requirements. Women with type 2 diabetes who control their disease with diet and exercise may be able to continue doing so, or they may have to begin insulin treatment. Those who take oral medications will probably be switched to insulin during their preconception planning. Currently, insulin is the only approved therapy for both type 1 and type 2 diabetes during pregnancy, although some promising clinical trials have been performed on oral medications for type 2 diabetes.
In addition to insulin, pregnant women should test their blood glucose levels frequently to ensure their blood glucose levels are on target. They must also remain diligent about appropriate physical activity and proper nutrition (both for control and for fetal development); a registered dietitian with experience in both diabetes and prenatal care can help develop a meal plan that meets these criteria.
There are some risks associated with pregnancy in diabetes:
- Worsening of diabetic complications. Diabetes-related complications like hypertension (high blood pressure), retinopathy (a form of diabetic eye disease), nephropathy (kidney disease), and neuropathy (nerve damage) can worsen during pregnancy.
- Fetal macrosomia. When a pregnant woman has higher than normal blood glucose levels, the fetus will store excess glucose as body fat. As a result, the baby may grow larger than normal for gestational date, a condition called macrosomia. Women with diabetes are up to four times more likely to have a cesarean section (or surgical) delivery because of this.
- Hypoglycemia at birth. A fetus of a woman with diabetes often produces excess insulin in response to high blood glucose levels. At birth, when the maternal glucose source is gone, the newborns own blood glucose levels may drop as a result. Hypoglycemia at birth is easily diagnosed with a heel stick blood test and treated with oral or IV glucose.
- Birth defects and newborn mortality. The risk of infant mortality is slightly higher for the newborns of women with pre-existing diabetes (as compared to those without), as is the risk for birth defects. However, among all women with diabetes, preconception care cuts the risk of birth defects by at least half.
Again, good preconception and prenatal care, an informed and proactive healthcare team, and tight control of blood glucose levels can help most women with diabetes avoid complications and deliver healthy babies.
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As a type 2 who is not on exogenous insulin, my highs and lows fit within a range that many would find envious. Metformin usually keeps me below 200, even when I pig out on large volumes of foods I should never have in the house, and bounceback lows rarely dip below 80. I can usually fast for the better part of a day in the 90s and 80s; I don't think I spent any part of last Yom Kippur below 85. My deepest fingerstick lows are usually in the high 70s, when I'm in so cold a...