Lois Jovanovic, M.D., answers questions about pregnancy and diabetes

BD answers questions about insulin injections during pregnancy

LOIS JOVANOVIC, MD answers questions about pregnancy and diabetes This page is sponsored by BD Diabetes Educators recommend BD syringes to their patients more than any other brand because of the fine, thin BD needles

1. For women with type 1 and type 2 diabetes, how do insulin needs change during menstruation?

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Insulin and Menstruation with Diabetes:

Pre-menstrual hormones tend to make a woman's blood glucose higher at breakfast than it normally would be. Pre-menstrual hormones also make a woman's typical blood glucose fluctuations during the day even greater than usual.

The only way to manage changing insulin requirements right before your period is to measure your blood glucose often. Your doctor can help you to figure out what insulin dose adjustments you should make each month before your period.

Usually, a woman's insulin requirement goes up 10 to 15% during the last 3 to 5 days of the menstrual cycle due to the hormone progesterone. This is the hormone that prepares the uterus to be full of extra tissue and blood to receive the egg, if it is fertilized. Rising levels of progesterone counteract that action of insulin. During these days, bedtime insulin doses may need to be increased, and possibly morning insulin doses as well.

2. For women with type 1 or type 2 diabetes, how do insulin requirements change during pregnancy?

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Insulin and Pregnancy:

Pregnancy, type I diabetes, and insulin

If you have type 1 diabetes, your insulin requirements go up and down throughout the pregnancy. Every pregnancy involving diabetes is unique, so you and your doctor will work closely together to adjust your insulin regimen in a way that meets your specific needs.

When the egg first implants in your uterus, it secretes a hormone that tells the ovary to make more progesterone. This is the hormone that prepares the uterus to be full of extra tissue and blood to receive the egg, if it is fertilized. Progesterone counters the action of insulin. So when your progesterone levels rise, you may need to take more insulin.

With type 1 diabetes, by the time your pregnancy test turns positive, your progesterone levels are two to three times higher than the levels in a non-pregnant woman. Your insulin requirement is generally 20% higher 5 to 6 weeks after your last menstrual period. Your insulin requirement continues to rise slowly until 9 to 11 weeks, when the ovaries stop making progesterone and the placenta takes over progesterone production. This switch may be associated with a temporary drop in progesterone levels.

If you are thin and very insulin sensitive, when this drop in progesterone happens, your insulin requirement may drop suddenly. At this time, you have a higher risk of nighttime low blood sugar (hypoglycemia). If this happens while you sleep, you may not feel your blood glucose levels drop.

Your doctor will probably tell you to carefully increase your insulin doses to maintain normal blood glucose levels throughout the early part of the pregnancy. Every night, you will need to test your blood glucose at around 3:00 am. When the 3:00 am test readings fall to less than 70 mg/dl, your doctor may reduce your bedtime insulin dose substantially. This insulin dose reduction may last for approximately 8 to 10 days. Then your insulin requirements will begin to rise again. From that point on, there is a smooth rise in insulin requirement during each trimester of your pregnancy.

When you reach term and contractions begin, your insulin requirement will drop again. The contracting uterus is exercising and using up glucose for energy. Therefore, at 37 weeks' gestation, you will need to wake up in the middle of the night again to measure your blood glucose. If the 3:00 am readings are less than 70 mg/dl, your bedtime insulin dose will need to be reduced. After the baby is born, your insulin requirements may drop again.

All of these insulin dose adjustments are essential to your developing baby's health. This means that you will need to check your blood glucose often and let your doctor know the results, so that your insulin doses can be quickly and safely adjusted.

If you have type 1 diabetes and you are overweight when you become pregnant, your insulin sensitivity and insulin dose requirements may be different from those of a thinner pregnant woman. Your doctor will set up an insulin plan that is right for your specific needs.

Your doctor will tell you how often to check your blood glucose. Typically, you will check 8 to 10 times a day: before each meal, one hour after each meal, at bedtime and at 3:00 am. Keep good records of your blood glucose readings... these will help the doctor to fine-tune your insulin doses throughout the pregnancy. The health of your baby depends on these frequent dose adjustments.

Pregnancy, type II diabetes, and insulin

If you have type 2 diabetes, your insulin plan during pregnancy will depend on your insulin resistance, your weight and the carbohydrate content of your meals.

Just like the type 1 woman, your insulin requirements will rise a little bit during each trimester of your pregnancy. Unlike the type 1 woman, because of your type 2 insulin resistance, your insulin requirements may not drop during early pregnancy.

Your doctor may advise you to limit the carbohydrates in your diet. The doctor will also continually adjust your insulin doses before and during the pregnancy. If you eat more than 30% to 40% of your total calories as carbohydrate, you may need much larger doses of insulin than if you limit the carbohydrate content of your meals. This is because of the carbohydrate intolerance associated with type 2 diabetes.

3. For women with type 1 or type 2 diabetes, how do insulin needs change after pregnancy?

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Insulin After Pregnancy:

No matter what type of diabetes you have, once the placenta is removed, progesterone - the main source of anti-insulin hormone - is gone. Your pituitary gland will go through some changes that also help to lower progesterone levels, and your body will release any leftover insulin that had built up.

After delivery, hormone changes cause your insulin requirements to drop significantly. In fact, for 24 to 48 hours after delivery, even a woman with type 1 diabetes may need little or no insulin.

While your body is going through many post-delivery adjustments, your insulin doses will also be fine-tuned. Eventually, your insulin doses will return to pre-pregnancy levels, unless you decide to breast-feed.

Breast-feeding typically reduces your need for long-acting insulin, because some of your blood glucose is siphoned into the breast to produce milk that contains milk sugar (lactose). However, the lactation hormones you produce at this time counteract the action of insulin. So, you may need more short-acting mealtime insulin to cover your carbohydrates than you would need if you were not breast-feeding.

4. I have gestational diabetes. How will my insulin requirements change during and after pregnancy?

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Gestational diabetes and insulin:

Gestational diabetes develops near the end of the second trimester of pregnancy, when the pancreas can't make enough insulin to meet the extra demands of pregnancy.

In most cases, a low-carbohydrate meal plan and exercise are enough to treat the gestational diabetes. However, if diet alone cannot keep blood glucose levels within a range of 90 mg/dL to 120 mg/dL, then insulin must be taken.

If you need to take insulin, the doctor may suggest that you use a long-acting insulin to cover your low-level insulin needs throughout the day, and a separate, fast-acting insulin to cover the carbohydrates you eat at mealtimes.

With gestational diabetes, once the pregnancy ends the diabetes goes away in 90% of cases. Insulin doses may be stopped when a woman with gestational diabetes goes into labor. However, gestational diabetes is a window into the future. If you have had gestational diabetes and you are overweight, now is the time to take action.

If you do not become lean and fit after pregnancy, your risk of developing type 2 diabetes is around 10% per year, cumulative. This means that in 5 years, your risk of type 2 diabetes will be up to 50%. If you reach the 5-year mark without having diabetes, then your lifetime risk caps at 60%. If, however, you are able to become lean and fit after the baby is born, then your lifetime risk is only 25%.

5. For women with type 1 and type 2 diabetes, how do insulin needs change during menopause?

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Insulin and Menopause:

The biological changes that take place in the seven to eight years prior to menopause are called peri-menopause. During these years you transition from normal menstrual periods to no periods at all.

During peri-menopause, the levels of estrogen and progesterone hormones can fluctuate, resulting in wide swings in blood glucose levels. With lower estrogen levels you may have increased insulin resistance and higher blood sugar. However, an early sign of dropping progesterone in the peri-menopausal period is a reduced insulin requirement. If you have type 1 or type 2 diabetes and are approaching menopause, you will need to check your blood glucose several times a day, including a 3:00 am reading. This will help your doctor to make the necessary adjustments to your insulin doses.

6. For women with type 1 and type 2 diabetes, how do insulin needs change during stress or illness?

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Insulin and Stress or Illness:

Stress comes in three forms: emotional, physical, and hormonal.

Physical stress can be caused by trauma or illnesses that cause inflammation or infection. Hormonal stress occurs during childhood growth and development, puberty, the menstrual cycle, pregnancy and menopause. The body reacts the same way to all three types of stress: it produces stress hormones.

During times of stress, your insulin requirements rise in direct proportion to the amount of stress you experience:

• Mild stress usually raises insulin requirements about 10-15 %
• Moderate stress raises insulin requirements about 20 to 30%.
• Severe stress can increase your insulin requirements by as much as 100% over your usual dose.

During a stressful time, the only way to tell if your insulin doses are appropriate is to monitor your blood glucose often. Your doctor will tell you what adjustments to make to your insulin regimen.

7. Why do doctors prefer insulin over oral medications during pregnancy?

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Pregnancy and Diabetes - Oral Medications or Insulin:

First generation oral agents cross the placenta and may affect the baby. They can cause the fetus to secrete too much insulin and suffer severe hypoglycemia (low blood glucose). Oral agents are also not strong enough to meet the rising insulin requirements of pregnancy.

Insulin does not cross the placenta. Because the outcome of pregnancy is directly related to blood glucose control, insulin is the preferred diabetes regimen for pregnancy.

8. Is it a good idea to ask your doctor to start on insulin if you have type 2 diabetes, don't take insulin and are trying to conceive? Why would this help?

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Trying to Conceive with Type 2 Diabetes:

If you plan to become pregnant and your fasting plasma blood glucose is greater than 90 mg/dL or your post-meal blood glucose is greater than 120 mg/dL one hour after eating, then your doctor may recommend that you take insulin. The best pregnancy outcomes are associated with blood glucose levels below these limits.

Researchers do not know the exact blood glucose level that increases the risk of spontaneous abortion and birth defects. They do know that if the A1c test level is above normal, then the risk of pregnancy-related complications goes up.

If you have type 2 diabetes and are managed with diet or diet plus oral agents, monitor your blood glucose often. If the readings are higher than 90 mg/dL before meals, and higher than 120 mg/dL one hour after meals, then your doctor may discontinue the oral agents and start you on insulin before conception occurs.

Preconception counseling is best given by the team of healthcare professionals who will care for you during the pregnancy, too. This team may include a nurse educator, dietician, endocrinologist, and obstetrician. Most major university medical centers have a diabetes and pregnancy team.

9. Can birth control pills affect glucose levels?

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Diabetes and Birth Control Pills:

Current low-dose birth control pills will not affect your blood glucose levels, so they should not affect your insulin doses. Some women with type 1 diabetes actually take birth control pills to counteract menstrual hormone swings, so that they do not have to change their insulin doses.

10. How can I avoid bruising when I inject?

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Insulin Injections and Bruises:

Bruising is a common occurrence. Some places in the body have more tiny blood vessels than other places, so if a particular injection site tends to bruise, then avoid that spot for future injections. To minimize bruising, put pressure on the injection site after the syringe is removed, and also remain still for a few minutes after the insulin injection. If you are using an insulin pen, a 5mm pen needle might reduce bruising.

11. Does the baby get extra insulin from the mother?

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Fetus and Insulin:

Insulin does not cross the placenta, so your insulin will not appear in the baby's blood. Only your blood glucose can cross the placenta. High blood glucose can harm your developing baby, and that's why your doctor may want you to take insulin during your pregnancy.

12. Is the baby already making his own insulin? Does the mother get insulin from the baby?

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Fetus and Insulin:

Fetal insulin does not cross the placenta. Even though the baby makes insulin by the 10th gestational week, the fetal insulin does not transfer into the mother's blood.

13. After the baby comes, it is very hard to take care of ourselves. Injections, testing, and record keeping become harder to do. What tips do you have for busy mothers?

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Diabetes Control for Diabetic Mothers:

A newborn does take up most of your waking attention! However, you need to devote as much time as possible to good blood glucose control.

If you are breast-feeding, it is mandatory to keep your blood glucose levels as near normal as possible. If you have high blood glucose levels it will sweeten your milk, which may cause problems for your baby.

14. Can stomach injections increase stretch marks?

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Insulin Injections and Stretch Marks:

No. Stomach injections cannot increase stretch marks.

15. What areas of the stomach are okay to inject into, especially late in pregnancy?

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Insulin Injections During Pregnancy:

You can inject in any place where you can 'pinch an inch'. The skin is tight over the area where the uterus is located, and it is impossible for an inch to be pinched in that location late in pregnancy.

Dr. Lois Jovanovic is Director of Research and Chief Scientific Officer of Sansum Diabetes Research Institute. Sansum has been on the forefront of the effort to guarantee women with diabetes the same opportunity for a healthy outcome of pregnancy as a non-diabetic woman.

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This is not a health care site. The editor is not a health care professional, is not qualified, and does not give medical or mental health advice.

Everyone is different in regards to what kind of regimen is needed (diet, exercise, medication, dosages, tests, etc).

Please consult with qualified professionals in order to find the right regimen and treatment for you. Do not make changes without consulting your health care team. .

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