Treating Diabetes in Pregnancy

One of the happiest things I do is to help women with diabetes through their pregnancies. Whenever I meet a new young woman patient with diabetes I discuss pregnancy. Often women with diabetes feel that they can’t go through a pregnancy and for many that is simply wrong. It definitely takes more work to go through pregnancy when you have diabetes, but of the many mothers I’ve helped I don’t think there is one who would say it wasn’t worth it. Yana’s story shows the struggle and joy of being pregnant with type 1 diabetes.

©2004 Mark Harmel / www.harmelphoto.com

"I am the luckiest mom and luckiest woman with diabetes in the world."

Yana's Birth Story

For my diabetic self, pregnancy was the best thing that ever happened to me. I guess I always knew I wanted to have children, but there are many fears that come to mind when you are a woman who has had type 1 diabetes for 25 years and has a lot of diabetic baggage. I wondered: will I be able to control my sugars? Will my baby suffer the consequences of my diabetes? Will I wind up with a C-section? All valid fears. For me I was saved by planning…

After marrying Robert in 1999 we began to think about becoming parents. The first step was getting my diabetes under control. I chose an insulin pump, but I had a hard time learning how to live with it. It felt like a constant reminder that I was a woman with diabetes; something I didn’t want to remember as often. Then there’s the carb counting…forget it…it is even tougher when they ask you to keep records. Who the hell wants to keep records? Can’t I just live in denial? Then I had to refocus my energy on the goal...a healthy baby.

First I got used to the pump. Then I got my A1C to an all time low of 7%! But at my pre-pregnancy eye exam I was shocked to find out that I had diabetic damage in both eyes…I couldn’t believe I had retinopathy at age 30. Dr. Schwartz, my eye doctor, told me that if I didn’t take care of my eyes before pregnancy I could lose my eyesight. I couldn’t even begin to imagine what that could be like. After many surgeries and amazing care I was in the clear.

During that time I switched my diabetes care to Dr. Harmel and her team. Working with them I got my A1C to 5.5%--in the normal range. So with my sugars under control and my eyes in the clear I was given the green light to start trying to get pregnant. After several nerve wracking months during which I thought I might be infertile, I discovered I was pregnant. Robert’s and my dream of creating a family together was becoming true. But now I had to be even more careful. I increased my testing frequency, thought twice about whatever I put into my mouth and was always worried about pump failure.

When I was three months pregnant my fears were actualized and I had a pump set failure. I was at work and did not have my extra pump changing kit with me. I was so upset at myself. I was worried that my actions and this failure would hurt my baby. My husband came over with a kit and helped me change the pump infusion set. I was so upset that I could not see anything through my tears. To think that my diabetes was hurting this little being that had not yet seen the light of day was overwhelming. The hard part is that you don’t know anything for sure until you give birth and that was a long way away.

On the whole my pregnancy was amazing. I was coming to the doctor’s office every week and working with my diabetes team, who treated me with warmth, respect and great care. My insulin requirements were steadily increasing throughout the pregnancy and I increasingly had to rely on my husband Robert to help me deal with my insulin pump.

Time flew by and before I knew it I was a month away from delivery. I now had to go in weekly to my OB for a fetal monitoring test. After two weeks I was told my baby seemed a little bigger than normal and that if I wanted to have a vaginal delivery I would have to be induced. I didn’t want to be induced—I was very upset. I felt like the whole experience of feeling the first contractions, packing the bags and heading to the hospital in the middle of the night was taken away from me. But I had to get over myself and think of the baby. So I had the amino, waited for my parents to fly in from New York and went to the hospital at 4:30 AM to have a baby!

My diabetes team had prepared me for what to do during and after delivery, and what to expect about insulin requirements while breast feeding. During labor they called the hospital frequently. My mother and husband were at my side during the whole process. I was started on a pitocin drip at 6AM, got an epidural at 12:30 PM and by 4:30 PM I was ready to push. I worked very hard for two hours. At one point I saw the doctor looking at the nurse saying “I don’t know how long we can do this”. At this point something bigger than me took over and within ten minutes I pushed my baby out.

Benjamin Adam Nackman was born on Thursday, November 7, 2002. 8 lbs 3 oz and 20” long. They put him on my chest and I held him in my arms. I was in shock. That was my baby. Healthy and normal. He had all ten fingers and all ten toes and he made the most beautiful crying sounds I’ve heard.

He was checked by the nurses and pediatricians to make sure that his sugars were in the normal range. He had to spend an extra day in the hospital, but Benjamin was a trooper and two days later we were sent home. He is such a gift and a blessing for Robert, myself and our family. I am in the luckiest mom and the luckiest woman with diabetes in the world. I am now planning for round two.

Preparing for Pregnancy

The first rule is to plan your pregnancy. Your blood sugar level at the time you conceive is important to the healthy development of the baby, so you’ll want at least 3 months if not more to get ready. I have a basic check list I go through with my patients before they try to get pregnant. This is:

1. Have your eyes checked by your ophthalmologist. Unfortunately pregnancy can make diabetic eye disease worse. In a very few of my patients their eye disease was so bad that they were advised not to become pregnant (or else they would go blind). Most women do fine, but need to be checked every three months during their pregnancy to be sure no problems develop.
2. Have your kidney function tested with blood and urine tests. Even patients with mild kidney damage can have healthy pregnancies. Kidney function may get slightly worse during pregnancy, but returns to the level it was before pregnancy once the baby is born. However, if you have more severe kidney damage your kidney function could become permanently worse during pregnancy. This is something you should talk over with your kidney specialist. I have never had a patient have new problems with kidney function during or after pregnancy, but you need to check.
3. Stop or change all drugs that shouldn't be used in pregnancy. This list is long, but you may not know that Lantus or Levamir insulin shouldn't be used in pregnancy. If you are taking one of these you will need to switch to NPH or an insulin pump and stabilize your blood sugar levels prior to pregnancy. If you are taking oral medications for diabetes you will need to switch to insulin. Other drugs people with diabetes often take are statins (for cholesterol) and ACE-inhibitors or ARBs, for high blood pressure. These drugs must be stopped and switched to something safe for pregnancy before you get pregnant. Thyroid hormone is safe and required during pregnancy if you are taking it, but you should have your levels tested before and during pregnancy to be sure they stay normal.
4. Make sure your heart is normal. Not to alarm you, but heart disease is the one thing that can cause a mother to die during pregnancy. Most women of childbearing age don't have any problems with their heart, but be sure you ask.
5. Treat your blood pressure aggressively. High blood pressure during pregnancy can cause serious problems and requires different medications than it does when you are not pregnant, so be sure to check with your health care team.
6. Be SURE that your A1C level is less than 7% before you become pregnant. The risk of deformities in your baby goes way up if your blood sugar levels are too high. This is not to say that 100% of babies will have problems if your sugar levels are elevated, but who wants to risk it? During pregnancy is the one time when your body’s health is responsible for the health of two people. Keep both of you well.
7. Take folic acid supplements (1 gram or more) for several months before you try to get pregnant to help prevent spinal defects in your baby (this is true whether or not you have diabetes).

The Pregnancy Timeline

Once you are pregnant you need to be followed by a healthcare team familiar with treating diabetes in pregnancy. Sometimes this will be your obstetrician but I prefer to treat my patients myself. Early in pregnancy your insulin requirements will fall; later in pregnancy they will go up and up because insulin resistance increases. Immediately after you deliver your insulin requirements plummet and then gradually go back up again to your pre-pregnancy needs. Finally, breast feeding will change your insulin and calorie requirements, as will the lack of sleep…

You will need to be seen by your healthcare team weekly during your pregnancy—I often substitute faxed blood sugar records alternating with weekly visits, but it really depends on the patient.

Remember, you may be familiar with your body and your diabetes, but you’ve never experienced the changes brought on by pregnancy before. Those of us who have treated patients with diabetes who are pregnant can provide you with the benefit of our experience. A healthy baby--and mother--is everyone's goal.

Excerpted from CONQUERING DIABETES © Copyright 2005 by Anne Peters, MD. Reprinted with permission by the author and by Hudson Street Press, a member of Penguin Group (USA) Inc. All rights reserved.

For more information, visit ConqueringDiabetes.com

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