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Pregnancy
Toolkit
www.jdrf.org.ukCopyright © 2014 JDRF Juvenile Diabetes Research Foundation Ltd (JDRF) is a registered charity in England and Wales (No. 295716) and in Scotland (No. SCo40123). A company limited by guarantee (England No. 201638). Registered office: 19 Angel Gate, City Road, London, EC1v 2PT Tel.: 020 7713 2030 Email: info@jdrf.org.uk Web: jdrf.org.uk Disclaimer This book is not intended to replace and does not replace legal or medical advice and the information in this book is provided for general educational purposes only. Although the authors and JDRF believe the information contained in this book is accurate as at the date of publication, no representation or warranty, expressed or implied, is given to this effect. Information in this book may prove to be inaccurate, whether at the time of publication or at any time in the future and neither the authors or JDRF accept any duty to correct any information in light of subsequent events, research or changes of opinion. In no circumstances should any person use or rely on this book or any information contained therein in substitution for advice from qualified medical professionals and no one should make any changes to the management of the health of any person or animal with type 1 diabetes without first consulting a physician or qualified medical professional.
JDRF Pregnancy Toolkit
Contents
Introduction and goal of this guide..............................................................................................................................................5
Planning for a pregnancy with type 1 diabetes
Pre-pregnancy goals for the mum-to-be........................................................................................................................................ 6
An unplanned pregnancy – important considerations....................................................................................................... 9
Conception misconceptions................................................................................................................................................................. 10
As you move towards pregnancy
Your multidisciplinary team...................................................................................................................................................................11
Conception – things to think about................................................................................................................................................ 12
Involving your partner................................................................................................................................................................................ 12
Employment and pregnancy................................................................................................................................................................. 13
First trimester (weeks 1 – 12)
Blood glucose control – hypoglycaemia and hyperglycaemia................................................................................... 14
Antenatal visits............................................................................................................................................................................................... 15
Specific appointments/screening in the first trimester................................................................................................... 16
Should I call my diabetes team?........................................................................................................................................................ 17
Second trimester (weeks 13 – 27)
Insulin requirements and blood glucose control.................................................................................................................. 18
Antenatal visits............................................................................................................................................................................................... 18
Second trimester misconceptions................................................................................................................................................... 19
Specific appointments/screening in the second trimester.......................................................................................... 19
Your partner and the second trimester........................................................................................................................................ 20
Important facts.............................................................................................................................................................................................. 20
Third trimester (weeks 28 – 40)
Insulin requirements and blood glucose control................................................................................................................. 22
Antenatal visits – preparing for the birth................................................................................................................................... 22
Specific appointments/screening in the third trimester................................................................................................ 23
Your birth plan................................................................................................................................................................................................ 23
3JDRF Pregnancy Toolkit
Labour and birth
Timing of your delivery..............................................................................................................................................................................25
Premature labour-before 37 weeks.................................................................................................................................................25
Spontaneous labour...................................................................................................................................................................................25
Induced labour................................................................................................................................................................................................25
Blood glucose control during labour............................................................................................................................................. 26
Caesarean section....................................................................................................................................................................................... 26
After your baby is delivered................................................................................................................................................................. 26
Your blood glucose levels after birth.............................................................................................................................................27
Post birth and back at home
Things you need to think about post birth................................................................................................................................ 28
Managing type 1 diabetes for one again.................................................................................................................................... 28
Contraception................................................................................................................................................................................................. 29
Looking after yourself............................................................................................................................................................................... 29
Six week check up....................................................................................................................................................................................... 30
Research studies in pregnancy and type 1 diabetes............................................................................................. 31
Acknowledgements..................................................................................................................................................................................... 32
4JDRF Pregnancy Toolkit
Introduction and goal of
this guide
If you are consulting this guide you have ready for pregnancy, giving yourself enough time
probably made the decision or are starting to to make important changes.
think about the possibility that you and your
Throughout this toolkit, we’ll talk about
partner would like to try for a baby. many of the factors that you have to consider
Most women with type 1 diabetes are aware that when getting ready for a baby. In the next
they should plan for pregnancy but many women few chapters, we will discuss pregnancy with
don’t know why it’s so important. type 1 diabetes, with special emphasis on
preconception planning, the actual pregnancy
If you’re pregnant or planning a pregnancy,
and delivery. We’ll also explain the type 1
and have type 1 diabetes, you need to plan
diabetes management goals for pregnancy and
months in advance to have the best chance
how to obtain the best possible support from
of having a healthy pregnancy and a healthy
healthcare providers at every stage.
baby. It’s important to have your blood glucose
controlled as well as possible before conceiving This is all about what to expect when you’re
to minimise the risk to mother and baby. By expecting…with a type 1 diabetes twist.
planning ahead you can make sure you are
5JDRF Pregnancy Toolkit
Planning for a pregnancy
with type 1 diabetes
Why plan? 5. Take folic acid
Don’t believe the stories you’ve heard about 6. Have eyes and kidneys checked.
“can’t” and “won’t.” With careful planning and 7. Have you been vaccinated against rubella?
plenty of support, you and your partner CAN have
8. Manage your dental health
a healthy, happy pregnancy and baby.
9. Look at your lifestyle
The definition of ‘right time’ varies from family
to family, but when type 1 diabetes is part of the You can also watch a short video clip outlining
family-planning scenario, you have a few extra the steps you need to take for planning a
things to consider. Aside from the financial and pregnancy by visiting the following website:
emotional readiness that all couples strive for, www.womenwithdiabetes.net/
the health of the woman with type 1 diabetes WomenwithDiabetes/Thingsyouneedtoknow/
carrying the child is even more important. An WhyPlanRisks/
unplanned pregnancy with type 1 diabetes can
1. See your diabetes care team and GP
directly impact the health of the child and the
mother, and it’s important to have your type 1 as When you’re ready to plan a pregnancy, contact
controlled as possible before conception. Until your diabetes care team and let them know your
you feel you have reached this point it is really plans. Schedule an appointment with your GP as
important that you should continue to use your well as it is important that they are aware of your
normal method of contraception. plans too.
To find out more about why planning your It is important that your GP or the team looking
pregnancy is important, visit the following after your diabetes refer you to their specialist
website produced by Dr Valerie Holmes at pre-pregnancy planning team. Once you are
pregnant, you will spend a lot of time consulting
Queen’s University Hospital, Belfast to view
with your diabetes healthcare team and tweaking
video clips of women with diabetes talking about
your management plan, and it’s important to
planning for pregnancy:
have a team you both trust and feel comfortable
www.womenwithdiabetes.net/
bearing all to – emotionally and physically!
WomenwithDiabetes/Thingsyouneedtoknow/
As part of the team looking after you there will
be a diabetologist who specialises in assisting
Pre-pregnancy goals for the women who have diabetes in pregnancy and
mum-to-be an obstetrician who specialises in looking after
There are many things to consider as you plan for women with type 1 diabetes.
your pregnancy. Here is a pre-pregnancy checklist A diabetes specialist nurse (DSN) and/or a
of things you need to do as you prepare for diabetes specialist midwife (DSM) will also help
pregnancy. you through every step from planning to delivery.
1. See your diabetes healthcare team and GP The team should also have a dietitian, as a
– let them know your plans healthy pregnancy with type 1 diabetes is a
delicate balance of food, insulin and the needs of
2. Control your blood glucose/HbA1c
your growing child.
3. Check your medication
You will feel much more confident and
4. Check your insulin prepared during your pregnancy if you have a
6Planning for a pregnancy with type 1 diabetes
multidisciplinary team that you trust to help you pre-pregnancy healthcare team. You won’t be
manage your pregnancy. alone in your journey to control your blood
glucose, and your pre-pregnancy healthcare
2. Control your blood glucose/HbA1c team will work with you to help you achieve your
It’s never too early to be working towards your targets.
goal of good blood glucose control/HbA1c. It’s The insulin needs of women with type 1 diabetes
best for the health of both you and your baby will constantly change throughout pregnancy.
that you are in tight and streamlined control Prior to pregnancy, some women with type
of your type 1 diabetes before conceiving. It is 1 diabetes may move to an insulin pump to
recommended that women aim to achieve and improve the precision of dosing and the ability to
maintain their HbA1c goal for a few months adjust basal rates. Some women may have the
before becoming pregnant. use of a continuous glucose monitor (CGM) to
The HbA1c is a benchmark of your overall type better monitor glucose trends. Other women find
1 diabetes control that doctors and hospitals that using a pump and CGM during their planning
use. The National Institute for Health and Care and pregnancy can help them to maintain steady
Excellence (NICE) recommends that women who HbA1c results. However, any changes you make
are planning a pregnancy with type 1 diabetes to your type 1 diabetes management routine are
should be offered a monthly measurement of part of your unique circumstances, and these
HbA1c and aim for the following goals: decisions must be weighed carefully with your
diabetes team to ensure you understand the
benefits, drawbacks, and commitments required.
HbA1c
If it is safely achievable, women with type 1
3. Check your medication
diabetes who are planning to become pregnant Know your medications. Some medications and
should aim to maintain their HbA1c below 43 supplements are not considered safe during
mmol/mol (6.1%). Women should be reassured pregnancy, particularly during the first three
that any reduction in HbA1c towards the target months, so you will want to have an extensive
of 43 mmol/mol is likely to reduce the risk of talk with your healthcare team about each
congenital malformations. Women whose HbA1c medication and supplement prior to conception.
is above 86 mmol/mol (10%) should be strongly
Statins, angiotensin-converting enzyme inhibitors
advised to avoid pregnancy.
and angiotensin receptor blockers are common
Blood glucose medications for women with type 1 diabetes
that are not recommended for use in pregnancy,
You should agree your own pre-pregnancy meaning that they have a risk of causing damage
targets with your healthcare team. During your to the foetus.
pregnancy, preprandial (before meals) blood
glucose levels of 3.5 to 5.9mmol/L; and one hour 4.Check your insulin
postprandial (after meals) plasma blood glucose
levels below 7.8mmol/L should be the target Some types of insulin are not suitable for use
levels you are working with.* during pregnancy so discuss this with your
diabetes care team. In addition the insulin regime
*It is important to agree individual targets that you are using may not be the best for the frequent
are right for you with your diabetes care team. adjustments and changes which occur with
Source: NICE Diabetes in Pregnancy Guidelines pregnancy.
www.nice.org.uk/cg063
5. Take folic acid
Taking folic acid is important for all women
While these are the current targets recommended planning a pregnancy, to reduce the risk of
by NICE, it is important to remember that a condition called spina bifida, a fault in the
everyone is different. Therefore, it is important development of the spine and spinal cord which
that you agree your individual targets with your leaves a gap in the spine. However, as this
7JDRF Pregnancy Toolkit
condition is more common in women with type
1 diabetes than in the general public, you’re “Before we started trying for a baby I remember asking
advised to take 5mg of folic acid when planning my consultant if my HbA1c was low enough for us
to proceed. We had been working hard to lower my
a pregnancy, and up to at least 12 weeks HbA1c. It felt strange asking permission to try and get
during pregnancy. This dose is higher than that pregnant, but it was great when he smiled and said:
recommended for women without type 1 diabetes “Absolutely, these levels should be fine.”
and you’ll need to ask your GP for a prescription. Holly
6. Have your eyes and kidneys checked
It is vital that your diabetes team check your eyes is within the normal weight range. Calculate your
and kidney function as part of your pre-pregnancy BMI using this online calculator:
checks. Pregnancy puts extra pressure on the www.nhs.uk/Tools/Pages/
small blood vessels of the eyes and the kidneys, Healthyweightcalculator.aspx
so it’s important to minimise the impact on these Ideally, your BMI should be within the normal
organs as much as possible. range before you conceive to increase your
chances of a healthy pregnancy.
7. Have you been vaccinated against
rubella? Eat a healthy diet:
It is important that you’ve been vaccinated Include whole grains, fruits, vegetables and low-
against rubella (German measles) to ensure that fat dairy products in your diet, while reducing
your unborn baby is protected should you be your intake of junk food and high-fat foods. It is
exposed to it. Rubella can cause miscarriage, still important to get your weight in the proper range
births and birth defects in unborn babies. to increase the chances of conception. Eating a
balanced diet can also stabilise blood glucose
8. Manage your dental health levels, which in turn improves your chances
of conception. Ask your DSN, DSM, dietitian
Gingivitis (inflammation of the gums) during or type 1 diabetes specialist for individual
pregnancy is very common affecting 70-100% recommendations about calorie and carbohydrate
of women. Hormonal changes during pregnancy intake during the conception phase.
can exaggerate how gum tissue reacts to plaque,
causing dark and red, swollen and tender gums Exercise regularly
that are more likely to bleed. Patients with Exercise is important for all women who want
diabetes are more likely to develop periodontitis, to or already are pregnant. A good exercise
a more serious form of gum disease. The best programme gets your body in the best shape
way to prevent oral complications is to: possible for the demands of carrying a baby.
• Have a routine dental check-up and Regular exercise can also regulate your blood
professional clean to control any existing glucose levels, further enhancing your chances
problems before your pregnancy for conception, a healthy pregnancy and a
healthy baby (it can also help lower stress,
• Maintain good oral hygiene by brushing
your teeth after each meal and using floss which is a plus!). You must take extra care to
or interdental brushes. Using a toothpaste monitor your blood glucose to avoid the negative
containing triclosan can also help reduce consequences of low blood glucose levels.
gingivitis during pregnancy. Reduce your caffeine intake:
9. Look at your lifestyle It has been suggested that a high intake of
caffeine during pregnancy may increase the
Get your weight in the healthy target range: risk of miscarriage. Be prepared to reduce
Carrying too much weight can make conception your intake of caffeine during conception and
difficult and increase the risk of pregnancy pregnancy if you drink more than one or two
complications, such as preeclampsia. cups of caffeinated coffee (or the equivalent in
other beverages) per day.
To find out if you are carrying extra weight you
will need to check if your body mass index (BMI)
8Planning for a pregnancy with type 1 diabetes
Eliminate alcohol consumption and smoking: Finally you should ensure you have someone
Both alcohol and smoking can have detrimental from your healthcare team you can contact as
effects on an unborn child, so it is highly soon as you think you may be pregnant.
recommended that both be discontinued prior
to attempting to conceive. Help with stopping An unplanned pregnancy:
smoking should be available either through your
GP or hospital team. Visit the following websites
Important considerations
for more information: While an unexpected or unplanned pregnancy
www.nhs.uk/conditions/pregnancy-and-baby/ isn’t the ‘best case scenario’ for a woman with
pages/alcohol-medicines-drugs-pregnant. type 1 diabetes, it does not mean that there will
aspx#close be a negative outcome for you or the baby. Many
www.nhs.uk/conditions/pregnancy-and-baby/ people have heard that high blood glucose levels
pages/smoking-pregnant.aspx#close at conception and/or during the baby’s early
Now that you’re attending the pre-pregnancy formation is associated with an increased risk of
planning service and are fully aware of all the pre- congenital anomalies or birth defects. However,
pregnancy goals, you and your partner are ready with the current technology available, many
to try for a baby. There is a lot to think about, more women today have blood glucose within
especially when you’re also managing your type a healthy range at the baby’s conception and
1 diabetes. But this doesn’t mean that your during the first few weeks of their unexpected
pregnancy isn’t going to be healthy and amazing pregnancy.
– you just need a little extra TLC to get you across
the finish line. It is best not to get bogged down trying to
determine exactly what your blood glucose
At the pre-pregnancy planning appointments, you
levels were or whether they were high enough
should receive a health check including blood
tests, treatment for any conditions that may to increase your risk of complications. Even if
interfere with your pregnancy and you should you feel certain that your blood glucose was
also get your immunisations updated. You should not within the recommended range, the most
also receive additional assessments for diabetic important step to take at this point is to get on
retinopathy (eyes), nephropathy (kidneys), track with your pregnancy by getting your levels
neuropathy (nervous system), and cardiovascular under control as soon as possible. Begin by
disease (heart) prior to conception. It’s important checking your blood glucose more frequently.
to have a baseline for these concerns before Enlist the help of professionals by scheduling an
getting pregnant. appointment with your diabetes healthcare team
Make note of your thyroid function level prior to as soon as possible. Next, ensure that you know
conception and compare your results during and what to expect during a pregnancy and follow
after your pregnancy. This is because you have an your healthcare team’s recommendations.
increased risk of developing thyroid disease.
A child can be a very motivating factor for many
It is also important that you, your partner women to get their blood glucose levels under
and other family members know how to treat
very tight control. Much can also be said about
hypoglycaemia. Hypoglycaemia is common in
the value of a mother’s outlook and its impact
pregnancy and may happen more often, and be
more severe, than before you were pregnant. on the unborn child. To set your unborn child up
for a positive introduction to the world, use the
IMPORTANT NOTE: If you do not already have a next few months to prepare mentally, physically,
glucagon kit, now is the time to get a prescription
emotionally, and financially for his or her arrival.
from your doctor and familiarise yourself and your
family members with how and when to use it.
9JDRF Pregnancy Toolkit Conception misconceptions MYTH: Every woman with type 1 diabetes who becomes pregnant is put on bed rest. FACT: Women are put on bed rest for a number of reasons during pregnancy, but type 1 diabetes is not one of them. Common reasons for bed rest during pregnancy include threatened miscarriage, high blood pressure or preterm labour. There are also varying degrees of bed rest: from resting at home to resting in hospital either partially or completely. However, there is no evidence to suggest that complete bed rest is beneficial. It is best to keep exercising during pregnancy, unless one of the problems mentioned above develop. MYTH: Having a blood glucose level in the 10–18mmol/L range during the first few weeks of pregnancy (before the pregnancy is confirmed) will cause the baby to have birth defects. FACT: It is true that the first six weeks of pregnancy are critical because your baby’s organs are forming during this time. Fortunately, birth defects are quite rare for women with type 1 diabetes. However, they occur more frequently than in the general population and high blood glucose is associated with increased risk. One high reading should not cause concern, however consistent high readings over time should be minimised. Good control before a pregnancy and during the first trimester will reduce this risk significantly. If you are concerned about the high blood glucose levels experienced during the first few weeks of your pregnancy, you should discuss these concerns with your diabetes team who will tell you about the ultrasound screening of your baby for such problems which is routinely available. 10
As you move towards pregnancy
As you move
towards pregnancy
After pre-conception appointments, your Diabetologist:
head will probably be swimming with all of
This doctor is your type 1 expert and during the
the information you receive. You may feel
preparation and duration of your pregnancy, they
overwhelmed and even a little distressed. Take
will be invaluable in keeping your type 1 as well-
your time to digest the information. Talk about
managed as possible. Inform your diabetologist
your concerns with your partner, and lean on one
that you’re preparing for a pregnancy and once
another as you move toward these goals. Take
you’re pregnant, stay in close contact. Your
the time you need to prepare both emotionally
diabetologist will be the one to help you tweak
and physically.
your regime as your insulin needs change.
Once you have decided to start trying to get
pregnant, you may feel heightened levels Obstetrician:
of excitement and anxiety. It is important to
Your obstetrician is crucial because they will be
acknowledge that type 1 diabetes does require
making the decisions with you about when and
some additional monitoring during pregnancy
how your child will be delivered. Pregnancy brings
compared to your peers who do not have type 1
about a lot of changes, both emotional and
and this might not feel fair all the time. Be sure
physical, so make sure you have an obstetrician
to remind yourself that the end goal remains the
same for everyone: a healthy baby and a healthy that you can be honest with and you trust.
mother.
Diabetes Specialist Nurse (DSN) or
Now that you understand the importance of Diabetes Specialist Midwife (DSM):
pre-pregnancy planning, you may feel you’re
You may have a DSN or a DSM on your team, or
ready to go ahead and try for a baby. Let’s go
both! Your DSN or DSM will work with you and
over the people who will be involved in your care
your diabetologist to help you manage your type
throughout your pregnancy.
1 diabetes. Like any other midwife, your DSM
Your multidisciplinary team will help you to manage all aspects of type 1 and
pregnancy, including preparation for birth and
General Practitioner (GP): breastfeeding, and will stay in close contact with
you throughout your pregnancy.
Your GP is best for “big picture” health moments.
Although your pregnancy and your type 1 will be Dietician:
best handled by your specialists, your GP is there A specialist dietician will be available both
for the before, during, and after, so keep them in
before pregnancy and during pregnancy to advise
the loop on your decisions to start a family.
on a healthy diet during pregnancy and for
management of your type 1 diabetes.
“The DSN who looked after me for both pregnancies Visit the following website to see a clip describing
was amazing. She was practical, reassuring and the multidisciplinary team who will look after you
realistic about the demands of the day to day
management of full time work, pregnancy and type 1
before and during your pregnancy:
diabetes.” www.womenwithdiabetes.net/
Emily
WomenwithDiabetes/Thingsyoumightnotknow/
SupportTeam/
11JDRF Pregnancy Toolkit
Conception: conceiving. The increasing number of doctor
visits and the abundance of discussions related
things to think about to your blood glucose level can be isolating for
your partner so they may want to come with you
Know your cycle: to these appointments.
Pinpointing when you ovulate each month is
the single most helpful task in improving your Ask for and/or offer help:
chances for conception. There are many ways to Consider ways to involve your partner and
do this, like watching the calendar, taking your suggest specific ways they can help you. Rather
body temperature or purchasing an ovulation than a generic request to “be more patient” with
predictor kit. Books and websites offer a wide you during your pregnancy, request that they take
variety of options to help you better track your over a task such as food shopping, vacuuming, or
menstrual cycle and sexual activity. But don’t preparing dinner one night each week. During the
let conception become an intimidating science time that you would normally spend completing
experiment. Relax and enjoy this special time and these tasks, relax in a quiet place and spend time
the process involved. recording your blood glucose levels, reviewing
your numbers for patterns and making necessary
Be patient: adjustments.
Pregnancy can happen today, in six months or Plan ahead:
in 12 months. There is no magic number. Even
if you follow all of the instructions you’re given, It’s important to make your type 1 diabetes
pregnancy may not occur immediately. Relax, management a priority before conception
take a deep breath, and try not to focus on it too rather than trying to force the extra tasks into
much. As the saying goes, “As soon as you stop your already busy schedule. Because low
focusing on it, it will happen.” However, it can be blood glucose levels are more common during
an extremely frustrating time, especially when pregnancy due to the ever-changing insulin
making extra effort with your diabetes control. requirements, it is very important to prepare your
partner for dealing with them. As well as making
Most teams will be happy to provide simple
sure they know where the food, juice and glucose
fertility checks in this situation at an earlier stage
tablets are to treat unexpected lows, make sure
than normal so you should discuss it with them.
they know how to use a glucagon kit and when to
use it.
Involving your partner
It takes two:
Talk:
Pregnancy is a team effort, so your partner should
It is natural for your partner to be concerned prepare for conception by getting a check-up,
about the challenges type 1 diabetes can eating a healthy diet, exercising regularly, quitting
bring to a pregnancy, in terms of your health smoking, and limiting alcohol intake.
and your baby’s health. Be open and discuss
their concerns, as well as your own. Review Mind your moods:
your current daily requirements for managing Mood swings and emotional changes are going to
type 1 diabetes and the ways you expect your become pretty common during your pregnancy.
management routine to change after you become That’s probably no surprise. But did you know
pregnant. that your blood glucose level can affect your
moods and emotions too? If both of you have wild
Understand your roles: mood swings and emotional outbursts, things
Make sure your partner understands their role in could get unpleasant. Be patient and considerate
your pregnancy. Teamwork and communication with each other.
are important for any pregnancy, but especially
important for a couple managing type 1 diabetes Heavy-lifting:
and pregnancy. Don’t let the focus of type 1 As your pregnancy moves along, there may be
diabetes take over the happiness and fun of restrictions on what or how much you can lift, as
12As you move towards pregnancy
well as limits on your activity. Get your partner to Research your employer’s benefit plan regarding
use their muscles and make sure your needs, and pregnancy. Employers’ benefits vary widely
the needs of the home, are taken care of. about the amount of time you are allowed to
take off work with and without pay after giving
Paternity leave: birth. Sometimes, type 1 diabetes can create
Employers must now offer paternity leave, and complications during pregnancy that require time
there are others who offer maternity/paternity off work or bed rest. Talk to your HR department
leave for same-sex couples. Find out from your and ask about your entitlement (for example, your
paid time off after the birth might be affected by
respective employers what options are available
your doctor prescribing bed rest/time off work
to you and your family. Be sure to explore all
prior to the birth). Familiarise yourself with the
leave options and consider how you will use the
Equality Act 2010 (England, Scotland and Wales)
paternity leave most effectively after the birth
and the Disabilities Discrimination Act if you are
of your child. Some families take their leave
in Northern Ireland and be prepared to advocate
together, while others stagger their days. Discuss
for what you need to make sure you have a
these options with your partner and do what
healthy pregnancy. This can mean anything from
works best for your family.
having a scheduled snack time at work to taking
time off work.
Existing children:
To find out more about your rights at work, visit
If you already have young children you may need
the following websites:
to consider the availability of additional support,
as the very careful control of your blood glucose www.gov.uk/working-when-pregnant-your-rights
may be associated with increased risks of a hypo. www.gov.uk/equality-act-2010-guidance
Employment and pregnancy www.nidirect.gov.uk/the-disability-
discrimination-act-dda
With the careful control of your blood glucose (Northern Ireland only)
levels that is required during pregnancy, and
www.nhs.uk/conditions/pregnancy-and-baby/
if you work very variable hours or do a lot of
pages/your-health-at-work-pregnant.aspx#close
travelling, you may need to consider whether you
will need to renegotiate your hours to have more
of a ‘standard’ working day.
13JDRF Pregnancy Toolkit
The first trimester
(weeks 1-12)
Now that you have found out you’re pregnant, it’s Make sure you have plenty of hypoglycaemia
one of the most exciting and demanding times in treatments available. Your healthcare team
your life, and there’s plenty to do! can give you a gel containing glucose that you
can swallow if your glucose levels are low.
While your tummy may not be bulging, your
You should also make sure you have glucagon
body is already changing in many other ways.
to inject in an emergency to raise your blood
You may notice that your skin is a little less glucose, and that your partner or family
prone to breakouts, that your hair seems thicker members know how to use it.
and shinier than before, and that your hair and
fingernails are growing at a rapid rate. You will You may also want to consider how to manage
also see changes with your type 1 diabetes too. the increased risk of hypos at work. This is a
delicate matter as you may not be ready to
Blood glucose control tell your employer that you are pregnant, but
it’s important that colleagues are aware of the
Hypoglycaemia symptoms and treatment for hypoglycemia.
(low blood glucose) It’s extremely important during this time that
In this first trimester, as the cells which are your partner becomes familiar with signs of a low
developing into your baby are growing and blood glucose level. Some of these symptoms
multiplying every day, your body may revert back may be new or unusual, so it’s important that
to its pre-diabetes days and actually start making they stay alert and be ready to act. Learn together
some of your own insulin again. What causes by testing frequently and paying attention to
this is a bit of a biological mystery, but it’s very subtle signs.
common. JDRF researchers are studying this Some women find a continuous glucose monitor
phenomenon, which may help find new ways to (CGM) to be really useful during these first few
regenerate beta cells as part of a cure for type 1 weeks of pregnancy, especially with the rising
diabetes. incidence of low blood glucose levels. This is
expensive technology and is often not available
Regardless of the cause, this can cause a
within the Health Service. However, if you feel
frightening tendency towards low blood glucose
that a CGM is right for you and your needs, talk
levels, which are not uncommon in the first
with your doctor about getting access to this
trimester. Make sure you are testing your blood technology.
glucose before every meal and one hour after
every meal. Ideally your blood glucose should be Hyperglycaemia
between 3.5 and 5.9mmol/L before meals and (high blood glucose)
below 7.8mmol/L one hour after meals. Always
test before going to bed and before driving. It is extremely important to pay close attention to
high blood glucose readings during pregnancy.
Diabetic ketoacidosis, which develops from a
“Up until about week 23, my insulin requirements period of sustained high blood glucose, can be
were less than before I was pregnant. I love that this fatal to your baby. If your blood glucose readings
is because my pancreas was able to produce its own
insulin, for the first time in 17 years! I went low a lot, but
are above 10mmol/L remember to check for
to me that was fine, I knew that this wouldn’t harm the ketones. Your healthcare team will provide you with
baby.” ketone testing strips to test your blood or urine.
Holly Diabetic ketoacidosis can occur without you
feeling seriously ill, making it a dangerous
14The first trimester (weeks 1-12)
condition. If you are unwell (for example, if you you’re guaranteed a few extra visits. Women
are being sick or have diarrhoea) or if your blood with type 1 diabetes are often given a long list
glucose is over 10mmol/L and on rechecking after of appointments during the course of their
an hour still remains greater than 10mmol/L, you pregnancy, and each is important in its own way.
should test your blood or urine for ketones. Any However, to make it as easy as possible you
more than a small amount of ketones in your should be seen by your team at a joint diabetes
urine or a blood ketone level above 0.6mmol/L antenatal clinic, where all the healthcare
means you need to get checked out urgently by professionals you need to see are in the same
your diabetes healthcare team. place.
Blood glucose challenges Antenatal checkups
One of the biggest emotional hurdles in Just like any other pregnant woman, you’ll have
managing a pregnancy with type 1 diabetes regular appointments to see your midwife.
is handling blood glucose issues. During A routine pregnancy usually includes two or
pregnancy, a woman is responsible for creating three ultrasounds, but with type 1 diabetes and
a safe environment for the baby to thrive in, and pregnancy, you may have up to one ultrasound
type 1 diabetes can make guilt and worry rise to a per month and sometimes even more frequently
whole new level. Pregnancy with type 1 diabetes towards the end. Women with type 1 diabetes
is about maintaining stable and healthy blood are screened often to check the development
glucose levels as consistently as you can. For and size of the baby and to ensure that things
many women with type 1 diabetes, new blood are going along smoothly. Macrosomia, which
glucose thresholds are set, and these new describes a baby who is larger than the 90th
goals can seem very intimidating. Your diabetes percentile for weight, can result from high blood
healthcare team may recommend that you set glucose levels during pregnancy.
a fasting blood glucose goal between 3.5 and
5.9mmol/L. This may be a scary goal for some You may want to discuss with your employer the
of you because of hypoglycemia unawareness, frequency of appointments you will be required to
fear of middle-of-the-night blood glucose lows, attend during your pregnancy and agree a plan to
manage this.
and many other type 1 diabetes concerns. Even
if you’ve been managing your diabetes for a
Your diabetes healthcare team
long time, pregnancy presents a whole new
set of challenges. You are not alone in dealing Diabetologist and diabetes specialist nurse
with these challenges. You will be working in or midwife
partnership with your diabetes healthcare team
to manage these challenges. You will most likely see your diabetologist every
two weeks during pregnancy to help you to
maintain your blood glucose level. Together with
“Prior to getting pregnant I was already on a pump, but the diabetes specialist nurse (DSN) or diabetes
my husband and I decided that we wanted as much specialist midwife (DSM) they will give you
information as possible to help us control my blood blood glucose targets, help you with your blood
glucose. I say ‘us’, I see it very much as a two person glucose monitoring and alter your insulin dose as
effort to keep my blood glucose within target. We
necessary. Your insulin requirements may change
decided to privately fund a CGM, our hospital weren’t
able to help us with one. It’s certainly been expensive,
at every visit to ensure your blood glucose levels
but it’s reassuring to be able to see what my blood are the best they can be.
glucose is doing all the time and it’s helped me keep my
Your team are there to help you throughout your
lowest ever HbA1c.”
pregnancy so please let them know about any
Holly concerns you have.
Dietician
Antenatal visits Type 1 diabetes and pregnancy can also create
With every pregnancy comes plenty of some tricky food situations. Not every pregnant
appointments at the antenatal clinic, and woman craves cucumber slices and oranges
when you’re pregnant with type 1 diabetes, (sometimes it’s a very strong desire for the
15JDRF Pregnancy Toolkit
greasiest hamburger you can get your hands on). Your healthcare team will arrange an eye
What if you’re dealing with morning sickness and examination for you if you have not had one in
don’t want to eat breakfast, even though you’ve the past six months. At the eye screening clinic
taken insulin for it? How about if you’re craving a the healthcare professional may use eye drops
cheesecake every afternoon, but dealing with a to make your pupils bigger and then use a digital
stubborn high blood glucose trend? The dietician camera to take a photograph of the back of your
on your diabetes healthcare team will be able to eyes.
help. Pregnancy hormones can weaken the blood
There are certain foods that are not safe for a vessels of the eyes, so if you don’t have pre-
growing baby, including soft cheeses, sushi, liver existing diabetic eye disease, you need to be
and liver products such as pate. Your dietician closely monitored during pregnancy for changes
can help you understand what’s safe for baby, in eye health. If this occurs you may well be
safe for you, and easiest on your blood glucose offered treatment which is safe in pregnancy. Very
occasionally, you may be recommended to avoid
levels. Even if you meet with your dietician only
further stress on the eyes by having a caesarean
a few times throughout the pre-pregnancy and
delivery. So it’s important that you discuss any
pregnancy stages, it’s very useful to relearn
developments with your medical team.
things like carb counting, how certain foods may
impact your blood glucose and understand the 2. Kidney test
benefits of incorporating low glycaemic index
foods in your diet. With this knowledge, you People with type 1 diabetes are at higher risk
can help manage cravings without adversely of having kidney problems known as diabetic
impacting blood glucose control and minimising nephropathy. If your kidney function has not
the postprandial (post-meal) glucose peaks over been checked in the last 12 months then your
7.8mmol/L which is often a particular problem healthcare team will test it. They will take a urine
after breakfast. A little information can help you sample to check for protein, which would indicate
have an occasional treat! that your kidneys are not working as well as they
should be. They will also take a blood sample to
For more information on the healthcare team who check that the levels of substances filtered by the
will help support you through your pregnancy, kidneys are normal.
visit:
As with all pregnant women your urine will be
www.womenwithdiabetes.net/
checked for protein at each clinic visit. There may
WomenwithDiabetes/Thingsyoumightnotknow/ be causes other than type 1 diabetes for this.
SupportTeam/
3. Ultrasound scan
Specific appointments/screening You will be offered an ultrasound scan between
in the first trimester 8 and 14 weeks of pregnancy to estimate when
your baby is due and to check whether you are
1. Eye examination expecting more than one baby. This scan may
also be part of a screening for Down’s syndrome
Everyone with type 1 diabetes should have
should you decide to have the test (see box for
regular eye examinations at least once a year
more information).
but when pregnant, you should have these
examinations more regularly. Eye screening
detects diabetic retinopathy.
16The first trimester (weeks 1-12)
Blood test plus nuchal translucency scan for Down’s syndrome
This involves a blood test and an ultrasound scan. All women should be offered a dating scan between
weeks 8 and 14 of pregnancy. In addition, most clinics* offer pregnant women a nuchal translucency
scan and a blood test between 11 weeks, 0 days and 13 weeks, 6 days of pregnancy. If you choose to be
screened for Down’s syndrome, the dating scan and the nuchal translucency scan can be carried out at
the same time, between 11 weeks and 13 weeks, 6 days of pregnancy.
The blood test measures two proteins associated with pregnancy. At the ultrasound scan appointment,
the sonographer measures the thickness of the nuchal translucency (a pocket of fluid) at the back
of your baby’s neck. The information from the blood test is combined with your age and the nuchal
translucency measurement and used to work out your individual chance of having a baby with Down’s
syndrome.
*This screening is not routinely offered in Northern Ireland.
Should I call the diabetes team?
One question you may ask yourself is: “Should I call the diabetes team?”. Here’s a quick chart to help
you make the decision.
This is a good time to call your diabetes team, to make them aware of
My blood glucose is only a the situation. You may be able to flush the ketones by drinking lots
little elevated, but I have of water and closely monitoring both your hydration and your blood
moderate ketones. glucose levels. If your blood ketone level is above 0.6mmol/L call your
diabetes team for advice.
If you are vomiting due to morning sickness, and you are experiencing
I’m so nauseous and sick low blood glucose levels that you are unable to bring up adequately,
that I can’t keep any food call your diabetes team. They may want to adjust your insulin doses
down or my blood glucose over the phone or want you admitted for observation until your nausea
level regulated. passes. Speak to them on the phone and see how they would advise
handling this situation.
Did you pass out due to your low blood glucose level? Did you fall and/
I had a bad low and now
or jostle your tummy in an abrupt manner? If so, you should call your GP
I’m scared that something
or diabetes team as soon as possible so that you and your baby can be
is wrong with my baby.
checked out.
If you and your diabetes team are comfortable with your self-adjustment
of insulin doses and basal rates, make your dose changes in small
I am low every morning
increments so that you can keep track of what works and what needs
and high almost all
more or less. You should be able to call them and have an over-the-
afternoon. What can I do?
phone consultation. The constantly changing insulin needs of pregnancy
require this kind of teamwork, so don’t be afraid to ask for help!
To find out more about what happens in the first trimester, visit:
www.womenwithdiabetes.net/WomenwithDiabetes/Thingsyoumaywanttoknow/
17JDRF Pregnancy Toolkit
The second trimester
(weeks 13-27)
In the next three months, you are going to start food cravings. This is very normal! Eating lots
looking pregnant as everything gets bigger. of small meals is the best way to keep from
At this stage of your pregnancy, you are likely feeling hungry all of the time and to stabilise
to feel some or all of the following common blood glucose levels. Since heartburn is not
symptoms which are not related to your diabetes: uncommon during this phase, eating more
fatigue, occasional dizziness, nasal congestion, slowly may help you avoid this uncomfortable
heartburn, indigestion, flatulence, increased condition.
appetite, occasional headaches, constipation,
nausea, and vomiting. You may also see Blood glucose control
continued breast enlargement, bleeding gums, Most importantly, you should be prepared for an
mild swelling of the ankles, varicose veins in the increase in the frequency of low blood glucose
legs, and hemorrhoids. (Sounds like fun, right? levels, which may also come on more quickly
Just remember, you’re building a beautiful baby!) or be more difficult to detect until they are
very low. It is important to store snacks and/or
Insulin requirements and glucose tablets in every possible place that you
blood glucose control may be during the next three months – in your
car, handbag, desk, work bag, gym bag, and by
Insulin your bed.
Until now, you may have made very few changes Keep in contact with your antenatal diabetes care
to your insulin dosage. The second trimester team and use their help if you are not confident
will bring a number of changes regarding your making changes to your insulin doses during this
type 1 diabetes management. Not only will you rapidly changing phase and discuss any concerns
and your baby be growing, but also your insulin you have.
requirements will start to increase. Talk with your partner about what you’re
This increase in your insulin requirement is due experiencing, especially in regard to low blood
to your increasing body size and the hormones glucose levels. You won’t regret having a second
produced by the placenta, which cause insulin set of eyes helping to keep you safe from
resistance. Frequent blood glucose testing will unexpected lows.
make it easier to adjust your dose and your Continue to pay close attention to any high blood
insulin to carbohydrate ratio. glucose readings (above 10mmol/L). Test for
It is not uncommon to see your insulin ketones anytime your blood glucose is above
requirements double during your second 10mmol/L or you are feeling unwell, and contact
trimester and your insulin to carbohydrate your healthcare team if you have ketones or are
ratio decrease dramatically (meaning less unsure what you should do.
carbohydrate will be covered by one unit of
insulin). The exact point when this change
Antenatal visits
starts to happen differs from person to person. Your antenatal visits during the second trimester
Proper nutrition and physical activity are as may be both fun and anxiety inducing. You will
important as ever during this time because continue to have ultrasounds, but don’t be
gaining excess weight during pregnancy will alarmed if/when you begin having more than
require even greater increases in insulin doses. your pregnant friends without type 1 diabetes.
You may also notice an increase in your hunger Quite simply, ultrasounds are the best way for
levels and some new – and perhaps bizarre – your healthcare team to keep a close eye on
18The second trimester (weeks 13-27)
Second trimester misconceptions
MYTH:
As I have type 1 diabetes, it is too dangerous for me to carry multiple births (i.e. twins, triplets).
FACT:
Women with type 1 diabetes are no different than women who don’t have type 1 diabetes when it
comes to successfully carrying multiple births. There are numerous cases of successful multiple births
on record.
MYTH:
I am pregnant and I have type 1 diabetes, therefore I should not get the flu vaccination
FACT:
Everyone with type 1 diabetes, including pregnant women, should get a flu vaccination every year
to protect themselves and their unborn children. The best time to get a flu vaccination is between
October and mid-November, before the flu season begins.
your baby’s development. Ultrasounds can be This is a blood test that measures four proteins
fun because they provide in utero photos of your associated with pregnancy. This information is
baby. Today’s high-resolution photos provide combined with your age and used to work out
lots of detail about your baby. You may be able to your individual chance of having a baby with
see your baby’s face or see him/her sucking their Down’s syndrome. This test only measures risk
thumb. However, don’t be surprised if you notice and is not a diagnostic tool.
yourself feeling anxious prior to your ultrasound
appointments out of fear that a problem will be Diabetes does not increase your risk of having
discovered. a baby with Down’s syndrome, but if your
quadruple screen does show an increased risk,
you will probably be offered an amniocentesis. If
Specific appointments/screening you are offered this, it is common to feel uneasy,
in the second trimester scared, or even panicky. Talk to your healthcare
team about any concerns you have.
1. Eye examination
For more information visit nhs.uk:
At 16 - 20 weeks you will be offered another eye www.nhs.uk/conditions/pregnancy-and-baby/
examination if you were found to have diabetic pages/screening-amniocentesis-downs-
retinopathy at the first antenatal appointment. syndrome.aspx
It is really important that eye screening is
carried out if it is required and you discuss any * This test is not routinely offered in Northern
developments with your antenatal team. Ireland.
2. Quadruple screening test 3. Anomaly scan
If it has not been possible for you to have the You will be offered this ultrasound scan at around
combined screening test for Down’s syndrome 20 weeks. This is a detailed scan which checks
in the first trimester (perhaps because of a late for major physical abnormalities in your baby
booking appointment or owing to foetal position) and is offered to all pregnant women. Your type
you may be offered the quadruple screening test in 1 diabetes means you have a slightly higher risk
the second trimester.* The test is offered between of having a baby with heart problems and so
15 - 20 weeks. particular attention will be given to scanning the
19JDRF Pregnancy Toolkit
heart. Some units routinely offer a more detailed the testing of your blood glucose level. Now is
screening of your baby’s heart by an expert. the time to have a talk with your partner and
Others just reserve this for anyone whom they consider temporarily adjusting their role in your
have any concerns about, either as a result of the type 1 diabetes management. Foster a sense of
routine anomaly scan or because the mother has partnership in the pregnancy by discussing your
had difficulty with obtaining good control during likelihood of experiencing more frequent low
the first trimester. blood glucose levels with lower blood glucose
readings during the second trimester. Discuss
4. Foetal growth scans the signs and symptoms of low blood glucose
and review the use of your Glucagon Emergency
As previously mentioned, as a woman with type Kit. Consider giving your partner permission to
1 diabetes you may also be offered additional ask you to test or to test your blood glucose if/
ultrasound scans throughout your pregnancy as when they are unsure about the cause of your
they are the best way of monitoring your baby’s behaviour. This extra observation is important
growth and these scans may start later on in the not only for your health, but for the health of your
second trimester. unborn baby.
Type 1 diabetes and pregnancy can be
overwhelming if you focus on the enormity of your Important facts:
responsibilities as a mother and a woman with
• Women with type 1 diabetes are at an
type 1 diabetes. Keep in mind that this needless
increased risk of delivering their baby early,
worry and stress can take away from the beauty
but many women will not deliver early.
and joy of your pregnancy. You will want to look
back on this special time with your baby with fond • Appropriate nutrition is especially
memories. To foster a positive atmosphere, focus important for women with type 1 diabetes
on the gift of your pregnancy and the triumph you during pregnancy. Gaining too little or too
will feel when your healthy baby is born. much weight can increase your chances of
a preterm birth.
• Women with type 1 diabetes are at a higher
“I’ve had more scans than my non-diabetic pregnant
friends which has been fun. It’s lovely to be reassured risk of developing pre-eclampsia (high
that everything is progressing fine, but also to see our blood pressure and protein in urine during
little one again.” pregnancy). Therefore, your blood pressure
Holly and urine should be checked during every
antenatal visit. Good blood glucose control
can help reduce the risk of developing pre-
Your partner and the eclampsia.
second trimester • Women with diabetes are at an increased
risk of infections such as urinary, vaginal,
Your partner will not only see your body beginning
and kidney infections. During pregnancy,
to transform now, but they will also likely notice
this kind of infection can be harmful and
some significant emotional changes in you. Mood
increase the risk of preterm delivery.
swings are very common during this trimester. It
is important that your partner does not confuse • Pregnancy hormones can cause your
the moodiness caused by a low blood glucose gums to become swollen or inflamed or
level with the moodiness of pregnancy. Similarly, to bleed easily, leading to gum disease
weepiness, forgetfulness, and a scattered and increased chances of preterm labour.
mindset are commonly seen during the second Gum infections, such as gingivitis, are also
trimester and are easily confused with a low more common in women with diabetes.
blood glucose level. Therefore, practicing good oral hygiene and
visiting your dentist is even more important
You may be accustomed to being the primary for women with diabetes who are pregnant.
manager of your condition at all times, including
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