Navigating Pregnancy with Diabetes
By Alexandra Frost
People with diabetes can have happy, healthy pregnancies — but should proceed with caution and with consistent medical advice from their healthcare providers. Here are some things to consider when planning a pregnancy with diabetes and tips on how to be prepared for anything.
While it can be one of the most miraculous times of your life, having a baby can come with a host of unexpected hurdles if you have existing diabetes. From balancing your A1C while trying to conceive to maintaining your Time in Range and watching for additional complications, the entire journey can feel a little more like a second job than a miracle.
However, there is much to be hopeful about as you try to conceive, carry a healthy baby, and navigate postpartum months. Technology and monitoring devices have evolved, and doctors know more than ever before about how to manage a pregnancy with existing diabetes. Here’s what you need to know for each stage of pregnancy.
Trying to conceive with existing diabetes
Even without the additional challenges that diabetes can bring, many Americans struggle while trying to conceive. In fact, according to a report by the National Institutes of Health, 9% of men and 11% of women of reproductive age experience infertility issues, and after 1 year of unprotected sex, 12 to 15% of couples still haven’t been able to conceive.
Though it varies for everyone, trying to conceive can take a bit longer if you have diabetes. Dr. Cindy Duke, an OBGYN and fertility expert, recommends that those trying to get pregnant should strive to have an A1C under 6.2%. “They'll need to get better medication, improve their diet, exercise more… but they need to pull [the A1C] down,” she said. “That's the first thing, because an elevated hemoglobin A1C is associated with not just infertility, but pregnancy loss or miscarriage.” Meeting an A1C target within the recommended levels for the baby and mom’s optimum health after conception can take a period of months, as A1C represents average blood glucose levels over three months.
For those using a continuous glucose monitor (CGM), the American Diabetes Association recommends meeting a Time in Range goal of at least 70% within a tighter glucose range between 63-140mg/dL, and a Time Below Range (below 63) of less than 4%.
Additionally, the parent-to-be’s medical history is a significant factor.
“How old were they when they contracted the problem? How has their management [or] control been? That really is, in a nutshell, what it comes down to,” says Dr. Joel Batzofin, a Harvard-trained reproductive specialist who is board-certified in both Reproductive Endocrinology and Obstetrics/Gynecology. “If they’ve had excellent control over many years, or however many years they’ve had it, theoretically they shouldn’t have any of the problems associated with diabetes. And the reverse is true — the worse the control, the more problems you can anticipate.” He adds that the good news is physicians have tools to determine quite quickly how things have been going to help make a plan.
Having diabetes “under control”, as Batzofin put it, means that A1C levels are low enough to support a healthy pregnancy and that glucose levels are being managed with a diet and exercise program. To ensure this is the case, inform your endocrinologist and OBGYN 3-6 months before trying to conceive.
Pregnancy and potential complications
Kristin Giordano, a New York mom to two young children, was diagnosed with diabetes when she was 8 years old. “I’d always been concerned about just knowing that it can be difficult and that when you are pregnant it’s not the best-case scenario [for your health].” Long before trying to conceive, she started to do some research and requested a pregnancy planning appointment with her healthcare provider. Once she became pregnant, she says the journey wasn’t without challenges.
“It was hard because as much as I did my best to eat healthy beforehand, having to go super strict and super low carb with it was difficult,” she says. “Especially when you’re pregnant in the beginning … I was nauseous a lot with both pregnancies, and all you want is carbs.”
As Giordano notes, blood sugar can be harder to manage in pregnancy, as some women like her start to become more insulin resistant, leading to higher than typical blood sugar levels. March of Dimes explains that by the third trimester, some people might need up to three times as much insulin as they did before pregnancy. This is because your body and the placenta make hormones that can cause insulin resistance, which Giordano experienced.
“I had to do a lot of check-ins with my endocrinologist, and it’s just really a lot of anxiety and stress because you just know that the high blood sugar is what could hurt the baby,” she says. “You don’t want that to have been your fault.”
Dr. Emily A. Rosenberg, co-director of the Endocrinology in Pregnancy Program at the Division of Endocrinology, Diabetes and Hypertension at Brigham and Women’s Hospital, says there are multiple complications pregnant women and providers should watch out for:
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High blood sugar early in pregnancy – this can lead to miscarriage or congenital anomalies (abnormalities in the baby)
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High blood sugar later in pregnancy – high blood sugars are associated with Macrosomia (a larger than normal baby), leading to a higher risk of Cesarean section
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High blood pressure – this can contribute to pregnancy-related conditions such as pre-eclampsia (a condition primarily characterized by high blood pressure and high levels of protein in the urine)
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Higher risk for polyhydramnios, a condition where there is too much amniotic fluid (the fluid in the womb that surrounds the fetus)
Giordano had preeclampsia, and even started to lose vision in one eye. Her pregnancy was induced, but the baby wasn’t getting enough blood flow, resulting in an emergency Cesarean section. When it came time for her second delivery, her doctors knew her medical history and she was able to deliver earlier to avoid those birth complications.
Sensitivity to insulin can change postpartum as well, so continued collaboration with your doctors is recommended. “I went back to normal on the night of my C-section, and I put my pump back on its regular settings…I was getting a lot of low blood sugars.” She says that attempting to use her pump and nurse can add to that imbalance as well.
Making family planning decisions when you have diabetes
Cheryl Alkon, an author and mother with type 1 diabetes who wrote “Balancing Pregnancy with Pre-Existing Diabetes: Healthy Mom, Healthy Baby,” says that getting pregnant is just the beginning of a lifetime of figuring out “Oh, did I ruin my child?”
“Get yourself into the right frame of mind that ‘I’m going to do everything I can to provide the best I can for this kid’” she says. “You’ve got to be like, ‘Okay this is what I am doing. I am the best parent for this child. I am committed to what I’m doing and what I believe is right for my baby.”
Rosenberg added that planning and managing a pregnancy can be much easier with a support system. “Partners and family members can support the individual by attending doctor's visits, assisting with meal planning and helping the person make the right dietary choices, and supporting any form of exercise,” she says.
Giordano says that she hopes other people with diabetes don’t avoid pregnancy because of their condition. “If you stay in touch with your doctor, you do what they tell you to do, and don’t miss an appointment, even as hard as it may feel during the whole process and how stressful it is, the outcome is worth it.”
For more information about managing diabetes around pregnancy, check out these articles:
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Managing Your Glucose and Using a Continuous Glucose Monitor During Pregnancy
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How I Became Stronger than a Steel Magnolia – Personal story from diaTribe’s Julie Heverly
