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For a healthy pregnancy, the planning starts now
B y T r a c e y N e i t h e r c o tt
38 Diabetes Forecast | august 2010
Amy de la Cruz, 34
Fort Worth, Texas
Photographed
by Marge Ely
For Amy de la Cruz, exercise is key to good diabetes control during pregnancy. “I stayed active the whole time,” she
says. “I went on a walk two days before [delivery].” She also maintained strict blood glucose control. “I kept my A1C
below 6 throughout the entire pregnancy,” she says. “I was very, very obsessive about carb counting. It was very
intense.” Her hard work paid off in July 2009 when de la Cruz, a nurse, gave birth to her son, Nicholas. Her only regret:
worrying too much during the pregnancy. “Overall, on average, you are doing a good job of maintaining your blood
sugar,” she says. “Don’t stress out about the occasional spikes you’ll have. I spent so much energy worrying for nothing.”
Kerri Sparling, 31
Boston, Mass.
Photographed
by Paula Swift
Though Kerri Sparling didn’t start trying to have a baby until 2009, it was pregnancy she was pondering in
2003 when she went on an insulin pump to gain better control over her type 1 diabetes. Once pregnant,
Sparling, a diabetes blogger (sixuntilme.com), took her diabetes management up another notch. “I thought, ‘If
this is really my goal, every step counts,’ ” she recalls. “I started to become a very actively involved patient.”
Still, pregnancy came with worries. “I didn’t imagine it was going to be so emotionally difficult,” she says.
“Every meal felt like a guiltfest.” But, she adds, all the work was worth it. After a month of bed rest (due to
preeclampsia), Sparling gave birth to a healthy baby girl in April 2010.
regnancy is a time of wonder and amazement—and lots of bodily changes that seem to
defy explanation. (Think of the bizarre cravings and food aversions. The weird skin
and hair changes. Oh, and your feet will probably get bigger, too.) Many pregnant
women experience caroming hormonal mood swings, but for women with preexisting diabetes, those nine months are also packed with crazy blood glucose ups and
downs. “I spent the entire first trimester with my face buried in the fridge,” says
Kerri Sparling, 31, who has type 1 diabetes and whose daughter was born in April.
“I was low all the time. It wasn’t until probably the second trimester that the insulin
resistance kicked in. Everything I ate, the insulin didn’t cover it.”
It’s true that diabetes makes pregnancy more complicated. But it’s just as true
that, with good care and planning, women with both type 1 and type 2 can have safe
pregnancies—and healthy babies.
1
Stage
Before You Begin
It may seem counterintuitive, but you’ll actually
want to see your doctor before you start trying
to get pregnant. This is called a “preconception
visit,” and it’s where you’ll get a lot of information
about what pregnancy may bring (remember to
take notes!). It’s also a chance for your doctor to
assess your general health and adjust your regimen accordingly. Depending on how you manage
your diabetes, you may need to see both an endocrinologist and an ob-gyn at this point. Preexisting diabetes automatically makes your pregnancy
“high risk,” even if it goes along without a hitch.
An obstetrician who specializes in such pregnancies will be more accustomed to treating women
with diabetes. And remember, you’ll probably be
coming into the office a lot once you get pregnant
(as much as once or even twice a week in the third
trimester), so if you’re choosing new docs you may
want to consider how convenient they are to where
you live or work.
In addition to a higher chance of miscarriage,
there are two major types of risks that a mother’s
diabetes poses to a developing baby. The first
occurs in the earlier part of the pregnancy, when
organs are beginning to grow and serious birth
defects can occur. The second concern comes
later in the pregnancy, when babies of diabetic
mothers run a risk of growing too big (this is
known as macrosomia), which can create problems for delivery and harm the newborn.
First Things First
Before you get down to baby-making business, there are a few lifestyle changes you may need to make.
Here are some ideas for how you can reach your pre-pregnancy goals.
•
Stop Smoking
Pick up a hobby
that keeps
your hands
busy when cravings
hit.
•
Get Your A1C Under
7%
Test often—
and review
the results
with your
doctor.
•
Prevent
Birth
Defects
Take 400 to 800
micrograms
of folic acid daily.
•
Eat NutrientRich Foods
Book an appointment with a registered dietitian
to learn about
healthy eating.
•
Ditch
Alcohol
Instead of wine,
for example, try a nonalcoholic
spritzer made
from seltzer
water and a splash of juice.
•
Skip possibly Unsafe Foods
Swear off raw meat,
lunch meat, raw fish
and smoked seafood,
soft cheeses like brie
and gorgonzola, fish
with high mercury
levels (like tuna), and
unpasteurized milk.
•
Exercise
More
Take a
30-minute
walk at
lunchtime.
august 2010 | Diabetes Forecast 41
All of these problems are best prevented,
quit because they pose a risk to the baby. Statins,
ACE inhibitors, and many other drugs—including some over-the-counter meds, like ibuprofen—aren’t considered safe for use in pregnancy.
When in doubt, ask your doctor or nurse if a particular medication or supplement is OK.
Before you become pregnant, you will need
certain tests. Some of these apply to any woman
contemplating pregnancy. For example, your
doctor will want to make sure that you’ve had
immunizations. And you and the baby’s father
may choose to undergo genetic testing, to see if
you carry predispositions to any conditions. For
women with diabetes, there are some additional
screenings. Besides an A1C test, you should have
your cholesterol, thyroid function, and blood
pressure checked. Hypothyroidism, or abnormally low thyroid function, is quite common,
especially in people with type 1 diabetes, and
may affect the developing baby’s nervous system. It should be treated before you conceive; if
you take thyroid hormone replacement, you will
probably need a higher dose during pregnancy.
Also, talk with your doctor about safe blood
pressure–lowering medications since many are
off limits to expectant mothers.
Women with diabetes should also get a
comprehensive eye exam before conceiving.
Pregnancy can stimulate the development of the
eye disease retinopathy, a common complication
of diabetes. If the disease becomes too advanced,
it can prevent a vaginal delivery, because pushing
during labor can further damage the eyes. Women
with diabetes will also have their kidney function
tested before pregnancy. Since pregnancy can harm
their kidneys, women with advanced
kidney disease may be advised to
avoid pregnancy. Women with both
diabetes and heart disease may also
be poor candidates for pregnancy.
About 4 percent of all pregnant women without preexisting diabetes will develop
Finally, while diabetes itself
gestational diabetes sometime around the 28-week mark. While the cause
doesn’t affect fertility, polycystic
is not yet understood, gestational diabetes occurs when the mother’s body
ovary syndrome, which is associated
becomes resistant to insulin, causing glucose levels to build up in the blood. As with type 1 and type 2 diabetes, high blood glucose levels can cause problems with type 2 diabetes, can (box, p. 46).
If you’re having trouble getting pregfor both mother and baby. Women with gestational diabetes usually get a nant, your doctor can recommend
special meal plan and are encouraged to exercise; they also have to test their
fertility treatments, which are as safe
blood glucose and may need to inject insulin. Gestational diabetes usually goes
for women with diabetes as they are
away after pregnancy, but brings an increased risk for the condition in other
pregnancies—and for type 2 in the future.
for women without.
first and foremost, by keeping your blood glucose in
check. This is why your A1C (average blood glucose
over the past two to three months) should be below
7 percent before you conceive. Some doctors advise
going lower, say 6.5 or 6. During the pre-conception
visit, you and your doctor will determine a safe A1C
goal and devise a way to get there before pregnancy.
If you have type 2 diabetes that is treated with diet
and exercise, oral medications, or a combination,
you may need to go on insulin for the duration of
the pregnancy, or even before (box, p. 51).
Your doctor may also discuss whether you need
to lose weight. If so, “that’s probably the best thing
besides getting blood sugar under control,” says
Deborah L. Conway, MD, assistant professor in the
Department of Obstetrics and Gynecology at the
University of Texas Health Sciences Center in San
Antonio. “[For obese women,] any amount of weight
loss prior to pregnancy is going to reduce the impact
that just the obesity alone has on pregnancy.” Obesity
increases pregnancy complications like high blood
pressure and can also up a woman’s chances of having a cesarean section. Your doctor will advise you on
how much to lose before trying to get pregnant.
About three months before you start attempting to conceive, you will also need to begin taking
400 to 800 micrograms of folic acid daily, which
prevents birth defects like spina bifida. You can
find folic acid supplements in the vitamin aisle, or
you can get a prescription from your doctor. Some
prenatal vitamins don’t have enough folic acid, so
check before you use one as your only source of
the essential nutrient. Your doctor will also advise
you about which current medications you need to
What Is Gestational Diabetes?
42 Diabetes Forecast | august 2010
Tanima Banerjee, 32
Ann Arbor, Mich.
Photographed
by amy Kimball
Tanima Banerjee already had a full plate when she found out she was pregnant: She was a graduate student getting her master’s
in statistics. Her A1C was below 7 percent, but her doctor explained that she still needed to make some changes to ensure a
healthy pregnancy. First up: a switch from metformin (Banerjee has type 2 diabetes) to insulin. She also saw a dietitian who
helped her count carbs and add protein to her meals. “Sometimes it was harder,” says Banerjee. “I was in school at that time so
I had to carry an amount of food because I had to eat snacks.” Banerjee’s focus on meal planning helped her gain a healthy
amount of weight. She delivered a baby girl, Sreeja, in September 2009.
2
Stage
The Nine-Month Stretch
Pregnancy changes the body in many ways. For one
thing, you’ll see your blood glucose can behave like
never before. (Management gets extra tricky if you
have morning sickness and can only eat a few foods.)
In the first trimester, you might not notice much
difference, though some women with diabetes actually experience hypoglycemia (low blood glucose)
during this time. Around week 20, a woman’s insulin resistance increases, raising her blood glucose.
Insulin resistance builds as pregnancy continues; by
the end of the third trimester, insulin needs may be
double what they were before pregnancy.
Because your blood glucose levels will be in a
state of flux, and because you’ll want to maintain
tight glucose control, your doctor may advise you
to test more often. Your results directly affect your
baby, so it’s important to not only read the numbers
but use them to make any necessary changes to
your diet or your insulin regimen.
Monitoring your weight is also important,
whether you have diabetes or not. According to
Institute of Medicine recommendations, underweight women should gain 28 to 40 pounds over
the course of a pregnancy; normal-weight women
august 2010 | Diabetes Forecast 43
Now that she’s pregnant for the second time, Heidi Wickstrom is drawing on knowledge she garnered three years
ago, when she gave birth to her daughter, Campbell. “It’s really important to have the A1Cs in a good range,” she
says. Wickstrom also learned what it means to have a large baby (the delivery was tough going); this time around,
she may have a cesarean section. “If I had gone back, I would have had a C-section,” she says. “She was 9 pounds,
and with my frame it was difficult.” But the greatest lesson she has learned is that, with diabetes, it’s possible to
have a healthy baby: “I might be a little more relaxed this time.”
Heidi Wickstrom, 38
Ladera Ranch,
Calif.
Photographed
by Brian Davis
44 Diabetes Forecast | august 2010
should gain 25 to 35; overweight women should gain
15 to 25; and obese women should gain 11 to 20.
Gaining the weight is easy for most women. Making sure you don’t top those recommended numbers
might be tougher. Contrary to what you may have
heard, a pregnant woman doesn’t need to eat for
two. In fact, you need only about 300 extra calories per day (depending on your activity levels and
weight) to nourish a growing baby. But you’ll want
them to be the “best” calories possible—fruits and
vegetables, whole grains, lean proteins—since they
are building the new little being inside of you. A registered dietitian can help you create a meal plan.
You can help keep your weight (and blood glucose) down by exercising. Most pregnant women
can safely work out with a doctor’s go-ahead. Skip
high-impact exercises like kickboxing or contact
sports. And avoid activities that require you to lie
on your back during the second and third trimesters; that can reduce blood flow to the fetus. Bike
riding, swimming, and walking “are fine to continue
through pregnancy,” says Jennifer Wyckoff, MD, a
clinical assistant professor of internal medicine at
the University of Michigan Health System. Prenatal yoga classes can be a great place to strengthen
muscles in the company of other pregnant women.
Whatever you choose, take plenty of breaks, stay
hydrated, and stop if you feel pain or discomfort.
During pregnancy, you’ll review your
blood glucose log on a regular basis with your doctor
or nurse and get an A1C test every few weeks. You’ll
also have general check-ups monitoring blood pressure and weight gain on a schedule set by your doc.
All pregnant women get an ultrasound around week
18 to monitor the baby’s development; women with
diabetes usually get additional ultrasound scans at
other times in the pregnancy. Sometime between
weeks 20 and 22, your obstetrician will order a
more detailed scan called a fetal echocardiogram,
to make sure the fetal heart is growing correctly. If
you have retinopathy, you’ll also get follow-up eye
exams every trimester. You may need to check fasting urine ketones in the morning if you’re sick or if
your blood glucose is persistently high.
And yes, all those tests and scans and appointments may leave you feeling overmonitored—even
annoyed—at times. But remember that it’s all to
ensure a safe delivery and a healthy baby.
3
Stage
Labor and Delivery
Most women look to this moment with equal parts
fear, dread, and excitement. While many women
with diabetes have a vaginal birth without complications, the chances of having a cesarean section or having labor induced before your due date
are increased. That’s partly because women with
diabetes are more likely than others to have large
babies, in which case vaginal delivery can damage the baby’s collarbone or shoulders. It’s also
because diabetes and obesity increase a woman’s risk for high blood pressure and a condition
called preeclampsia (box, below). These conditions often require early delivery to prevent harm
to the mother and baby. The upside is somewhat
more control of the circumstances around labor
and delivery; the downside is that induction often
leads to more intense, painful contractions that
come faster, plus an increased chance of having a
cesarean section.
Whether you are expecting to have a vaginal
birth or a cesarean section, you should talk to your
obstetrician about your diabetes management plans
during labor and delivery to make sure the doctor
and nurses who will be delivering your baby are
familiar with diabetes. Women who have a cesarean section usually receive intravenous infusions
of insulin and glucose, and have their blood glucose
monitored by hospital staff. If you take multiple
daily injections, chances are you’ll have the IVs
during vaginal delivery, too. Women who use an
insulin pump and have a vaginal birth are often
About Preeclampsia
About 18 to 30 percent of pregnant women with diabetes develop preeclampsia, a condition marked by high blood pressure and proteins in the
urine that shows up after the 20-week mark. (The risk is higher with preexisting high blood pressure or kidney disease.) Other symptoms include
blurred vision, sudden weight gain, and swelling. Untreated, preeclampsia
can harm the baby and put the mother at risk for stroke and seizures.
The only way to get rid of it is to deliver the baby, but if you’re too early
in your pregnancy, your doctor might put you on bed rest and prescribe
medication to lower your blood pressure and help the developing baby’s
lungs mature. Doctors may induce labor in a woman diagnosed with
preeclampsia once the fetus has gotten big enough.
august 2010 | Diabetes Forecast 45
able to keep the pump on during labor and delivery,
but talk with your doctor to determine if this is an
option for you.
Testing during labor is important because, says
Wyckoff, “you can’t really predict what’s going to
happen to the blood glucose during the delivery.
You just have to act and react.” Depending on your
hospital’s and doctor’s preferences, you may be
able to monitor your own blood glucose if you give
birth vaginally.
Post-delivery, your blood glucose levels will
drop, and so will your insulin needs. Women can
typically cut their insulin dose by a third or a half
following delivery, to near pre-pregnancy levels—
or even lower for a day or two. Talk to your doctor
before you go into labor to make a plan for how
you will adjust your dosing and avoid hypoglycemia. Don’t rely on the hospital docs and nurses
to manage your insulin and eating regimen after
childbirth.
4
Stage
A New Life
A newly born baby of a mother with diabetes will
undergo extra scrutiny. For one thing, the newborn
is at an increased risk of hypoglycemia after being in
the glucose-heightened environment of the mother’s
womb. At birth, the baby may still produce extra
insulin to cover the mother’s added glucose. Any
low blood glucose usually goes away within a couple
of days, but if left untreated it can lead to seizures.
Jaundice, a common condition in newborns, is also
more frequent when the mom has diabetes, but it’s
not serious and, with treatment, is resolved within a
few days. (Be prepared, though: If your baby is still
being treated for jaundice after a couple of days, you
may have to go home while he or she is still at the
hospital, which can be upsetting.)
While blood glucose numbers stabilize and
PCOS and Infertility
by Katie Bunker
F
or women with type 2 diabetes
who have trouble getting pregnant, an underlying condition
that was present before diabetes
could be the culprit. Polycystic ovary
syndrome (PCOS) is the leading cause of
ovulation-related infertility. It’s characterized by irregular menstruation (missed,
infrequent, or heavy periods) and accompanied by one or more other symptoms
that include acne; abnormal hair growth
on the face, back, and other areas (hirsutism); and cysts growing on the
outside of the ovaries. Some women also
have skin tags or dark patches of skin on
the neck or thighs (acanthosis nigricans),
which usually signal not just PCOS but
also insulin resistance. PCOS indicates a higher risk for type 2 diabetes, abnormal cholesterol levels, cardiovascular
disease, and endometrial and ovarian
cancers. It also can lead to infertility and puts pregnant women at a higher risk for gestational diabetes, miscarriage,
pre-term birth, and preeclampsia (box, p. 45).
About 5 to 10 percent of women ages
46 Diabetes Forecast | august 2010
18 to 44 are affected by PCOS, according
to a study published in Clinical Obstetrics
and Gynecology in 2007. (The statistic
is hazy partly because many women
go undiagnosed for years, and partly
because the criteria for diagnosis have
changed over time.) Usually, PCOS and
insulin resistance come first and may
later advance to type 2 diabetes. “The
majority of women with PCOS don’t have diabetes [when they’re diagnosed],”
says Shahab Minassian, MD, chief of
reproductive endocrinology and infertility at Reading (Pa.) Hospital and Medical
Center and former codirector of Drexel
University’s Center for PCOS.
Once diagnosed, women with PCOS
who do not suffer from other fertility
issues have a good chance for a successful pregnancy: Minassian estimates the
success rate among his younger infertile
patients to be 60 to 70 percent. For
women in their late 30s, that rate might
drop to about 50 percent, he says. Losing
weight often mitigates the condition.
Doctors may prescribe the diabetes drug
metformin as a frontline treatment for
women with PCOS who are trying to conceive. Studies have shown that boosting insulin sensitivity with metformin
helps to regulate periods, correct problems with infertility, and reduce abnormal
hair growth; in pregnant women with
PCOS, there is some early evidence that
metformin use may decrease miscarriage
rates. Women trying to get pregnant may need additional fertility medication;
clomiphene (Clomid) is the most commonly prescribed option. (In women with
PCOS who are not trying to get pregnant,
oral contraceptives are prescribed to help regulate menstruation.)
In general, women with diabetes
and PCOS who maintain good blood
glucose control, watch their weight, and
get appropriate treatment should have
reason to feel optimistic about success
in pregnancy. “Generally, they have a
good prognosis, but sometimes it’s a long
road,” says Richard Legro, MD, of the
Department of Obstetrics and Gynecology
at the Penn State University College of Medicine. “I think there’s still a lot to be discovered about PCOS.”
return to pre-pregnancy levels quickly after delivery, mothers should pay especially close attention
to their glucose readings if they’re breast-feeding.
“We strongly encourage women with diabetes
to breast-feed,” says Wyckoff, although she cautions that “women with diabetes who are breastfeeding do have a tendency for hypoglycemia.” If
you tend to go low, have a snack before, during, or
after breast-feeding. If you’re nursing your baby,
you should eat the same number of calories postpregnancy as you did while expecting since breastfeeding requires added calories and nutrients.
Breast-feeding your child can reduce his or her
risk of type 1 diabetes. “The baby gets immune antibodies from the breast-feeding,” says Lois Jovanovic,
MD, MACE, head of the Sansum Diabetes Research
Institute in Santa Barbara, Calif. “On the flip side,
drinking cow’s milk before the six-month mark may
raise a baby’s chances of developing type 1 diabetes
later on.” Since most infant formulas are made from
cow’s milk, Jovanovic recommends that women
who are unable to breast-feed pick soy formula, even
though it is more expensive.
Some research suggests that bottle-fed babies
have a higher risk of childhood obesity—and therefore type 2 diabetes—than breast-fed babies. But
Jovanovic says the link is in how much the babies
eat, not what they eat. Mothers tend to feed a baby
the entire bottle while breast-fed babies stop eating when they’re no longer hungry; the result is
more calories for bottle-fed babies. If you’re bottlefeeding, look for cues that your baby is full, then put
aside the bottle even if it isn’t empty.
Women with diabetes who have poorly controlled
blood glucose may have a harder time producing
milk right away, according to Pat Shelly, IBCLC,
RN-C, MA, director of the Breastfeeding Center in
Washington, D.C., who works with many type 1 and
type 2 women and sees a link. “I tell them, ‘Oh, no
wonder your milk isn’t coming in. You’re diabetic.
Keep nursing,’ ” she says. “It’s going to take an extra
day or two.” That might mean supplementing with
formula in the meantime, which can be frustrating
if you are trying to exclusively breast-feed. A lactation specialist can help you through this transition
period. To prevent a delay in lactation, keep your
blood glucose tightly controlled during pregnancy
and while you’re breast-feeding. And speak with a
lactation consultant if you have PCOS; women with
that condition have an even greater chance of breastfeeding problems.
It’s natural to feel overwhelmed by the thought
of caring for your new baby, especially if you’re a
first-time mom. But keep in mind that you still need
to take care of yourself, too. Don’t lose sight of your
own diabetes management while you’re tending to
your baby’s every last coo. And remember: It’s OK to
ask for help. Enlist family and friends to watch the
baby or make dinner or straighten up the house.
While women with diabetes aren’t at an increased
risk for postpartum depression, the extra work of
managing your diabetes when you have a newborn
(who sleeps only a few hours at a time) can be made
near impossible if you’re also facing the “baby blues.”
Postpartum depression can bring sadness, anxiety,
mood swings, insomnia, and loss of appetite. More
serious signs include thoughts of hurting your baby
or yourself. If you suspect you have postpartum
depression, talk to your doctor right away. Reaching
out to your partner or other family members, too, can
help alleviate feelings of being overwhelmed.
he nine months of pregnancy can be a
challenge to any woman, but the stakes
are higher for women with diabetes. And
so is the motivation. “Once a woman is
pregnant, she’ll go to the moon and back
because she really wants this baby,” says
Jovanovic. In fact, many women with
diabetes find that they have the best
glucose control of their life during pregnancy. “I didn’t want to screw this up,”
says Sparling. “This was so, so important
to me that I was willing to do whatever to make sure she came out right.”
After months of constant blood glucose
checks, intense carb counting, and
endless doctor appointments, Sparling
says the preparation and tight control
paid off. “It’s so worth it.” ▲
For more women’s stories about pregnancy, go to forecast.diabetes.org/babystories.
august 2010 | Diabetes Forecast 47