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 cant 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 Ive helped
I dont think there is one who would say it wasnt worth
it. Yanas 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 didnt want to remember as often. Then
theres the carb counting
it is even tougher
when they ask you to keep records. Who the hell wants to keep records?
Cant 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
believe I had retinopathy at age 30. Dr. Schwartz, my eye doctor,
told me that if I didnt take care of my eyes before pregnancy
I could lose my eyesight. I couldnt 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. Roberts 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 dont 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 doctors
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
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 didnt want to be inducedI 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 dont
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 Ive 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 youll 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:
- 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.
- 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.
- 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.
- 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.
- 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.
- 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 bodys health is responsible for the health of two people.
Keep both of you well.
- 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
You will need to be seen by your healthcare team weekly during
your pregnancyI 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 youve 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.
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