Introduction

You have type 1 or type 2 diabetes and you are pregnant or hoping to get pregnant soon. You can learn what to do to have a healthy baby. You can also learn how to take care of yourself and your diabetes before, during, and after your pregnancy.

Pregnancy and new motherhood are times of great excitement, worry, and change for any woman. If you have diabetes and are pregnant, your pregnancy is automatically considered a high-risk pregnancy. Women carrying twins-or more-or who are beyond a certain age are also considered to have high-risk pregnancies. High risk doesn't mean you'll have problems. Instead, high risk means you need to pay special attention to your health and you may need to see specialized doctors. Millions of high-risk pregnancies produce perfectly healthy babies without the mom's health being affected. Special care and attention are the keys.

Taking Care of Your Baby and Yourself

Keeping your blood glucose as close to normal as possible before you get pregnant and during your pregnancy is the most important thing you can do to stay healthy and have a healthy baby. Your health care team can help you learn how to use meal planning, physical activity, and medications to reach your blood glucose goals. Together, you'll create a plan for taking care of yourself and your diabetes.

Pregnancy causes a number of changes in your body, so you might need to make changes in the ways you manage your diabetes. Even if you've had diabetes for years, you may need changes in your meal plan, physical activity routine, and medications. In addition, your needs might change as you get closer to your delivery date.

"I took good care of my diabetes before and throughout my pregnancy. And now I have a healthy little girl!"

How Diabetes Can Affect You and Your Baby

High blood glucose levels before and during pregnancy can

• worsen your long-term diabetes complications, such as vision problems, heart disease, and kidney disease
• increase the chance of problems for your baby, such as being born too early, weighing too much or too little, and having low blood glucose or other health problems at birth
• increase the risk of your baby having birth defects
• increase the risk of losing your baby through miscarriage or stillbirth

However, research has shown that when women with diabetes keep blood glucose levels under control before and during pregnancy, the risk of birth defects is about the same as in babies born to women who don't have diabetes.

If your blood glucose level is too high, then your baby also gets too much glucose.

Glucose in a pregnant woman's blood passes through to the baby. If your blood glucose level is too high during pregnancy, so is your baby's glucose level before birth.

Your Diabetes, Before and During Your Pregnancy

As you know, in diabetes, blood glucose levels are above normal. Whether you have type 1 or type 2 diabetes, you can manage your blood glucose levels and lower the risk of health problems.

A baby's brain, heart, kidneys, and lungs form during the first 8 weeks of pregnancy. High blood glucose levels are especially harmful during this early part of pregnancy. Yet many women don't realize they're pregnant until 5 or 6 weeks after conception. Ideally, you will work with your health care provider to get your blood glucose under control before you get pregnant.

If you're already pregnant, see your health care provider as soon as possible to make a plan for taking care of yourself and your baby. Even if you learn you're pregnant later in your pregnancy, you can still do a lot for your baby's health and your own.

The checklist below can help you make a plan for a safe and healthy pregnancy. More information on each topic then follows. Your health care team can help you with tasks that are difficult for you. Tackle one thing at a time to keep from being overwhelmed.

Planning Ahead

Before you get pregnant, talk with your health care team about your wish to have a baby. Your team can work with you to make sure your blood glucose levels are on target. If you have questions or worries, bring them up. If you're already pregnant, see your doctor right away.

My Health Care Team

Regular visits with health care providers who are experts in diabetes and pregnancy will ensure you get the very best care. Your team may include

• a medical doctor who specializes in diabetes care, such as an endocrinologist or a diabetologist. You will continue to need monitoring and advice on glucose control throughout your pregnancy and after.

• an obstetrician-gynecologist, or "OB/GYN," who has managed pregnancies of women with diabetes. Ask for a referral if your current gynecologist does not also deliver babies, as not all gynecologists do. When calling around to find an OB/GYN, ask about experience with women with diabetes. Maternal-fetal medicine specialists, also called perinatologists, have special training to take care of women with high-risk pregnancies. You will see your OB/GYN regularly throughout your pregnancy.

  
  "I'm working with my health care team to take good care of myself and my diabetes. We're doing all we can to make sure I have a healthy baby and a safe pregnancy. It's not always easy, but I'm so motivated!"

• a nurse educator or nurse practitioner, who provides prenatal care and advice on managing diabetes.

• a registered dietitian to help with meal planning. A good diet-for glucose control and nutrition-has never been more important than now. The phrase "You're eating for two" is not about quantity as much as food choices.

• specialists who diagnose and treat diabetes-related complications, such as ophthalmologists and optometrists for vision problems, nephrologists for kidney disease, and cardiologists for heart disease. If you are already experiencing complications from diabetes, you'll need those conditions monitored throughout your pregnancy as well.

• a social worker or psychologist to help you cope with stress, worry, and the extra demands of pregnancy. You may already have this kind of support, or you may suddenly need it. If anxiety mounts, do not hesitate to mention your uneasiness to your OB/GYN. Ask for a referral if you need more help working through issues.

• a pediatrician-a doctor who cares for children. You might want to ask friends, family, or your health care team for recommendations. Many pediatricians visit their newest patients at the hospital soon after their arrival.

• a neonatologist-a doctor who cares for newborn babies. The hospital will assign a neonatologist if urgent care for your baby is needed at the hospital.

You are the most important member of the team. Your health care providers can give you expert advice. But you'll be responsible for the day-to-day actions needed to keep your diabetes under control.

My Blood Glucose Levels

Daily Blood Glucose Levels

You'll check your blood glucose levels using a blood glucose meter several times a day. Most health care providers recommend testing at least four times a day. Ask your health care provider when you should check your blood glucose levels and check off the answers using the chart below.

"I check my blood glucose at least four times a day. The results show whether I need to change my meal plan or insulin to keep my blood glucose on target."

I should check my blood glucose levels

• fasting-when I wake up, before I eat or drink anything
• before each meal
• 1 hour after the start of a meal
• 2 hours after the start of a meal
• before bedtime
• in the middle of the night-for example, at 2 or 3 a.m.

The daily goals recommended by the American Diabetes Association for most pregnant women are shown below. Write down the goals you and your health care team have chosen.

When	Plasma Blood Glucose (mg/dL)	My Goals
Before meals and when you wake up	80 to 110
2 hours after the start of a meal	Below 155

Source: American Diabetes Association. Preconception care of women with diabetes. Diabetes Care. 2004;27(Supplement 1):S76-78.

See the chart below for goals recommended by the American College of Obstetricians and Gynecologists.

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When	Plasma Blood Glucose (mg/dL)	My Goals
Fasting	105 or less
Before meals	110 or less
1 hour after the start of a meal	155 or less
2 hours after the start of a meal	135 or less
During the night	Not less than 65

Source: American College of Obstetricians and Gynecologists (ACOG) Committee on Practice Bulletins. ACOG Practice Bulletin Number 60: Pregestational diabetes mellitus. Obstetrics and Gynecology. 2005;105(3):675-685.

The A1C Test

Another way to see whether you're meeting your goals is to have an A1C blood test.

Results of the A1C test show your average blood glucose levels during the past 2 to 3 months. Write the goal you and your health care team have chosen below.

Goal for My A1C Test

Source of Recommendation	Target Number	My Goal
American Diabetes Association	4 to 6 percent-normal* or Less than 1 percent above the upper limits of normal*
American College of Obstetricians and Gynecologists	No higher than 6 percent

^*Normal values vary according to laboratory; check with your doctor.

Low Blood Glucose

When you're pregnant, you're at increased risk of having low blood glucose, also called hypoglycemia. When blood glucose levels are too low, your body can't get the energy it needs. Usually hypoglycemia is mild and can easily be treated by eating or drinking something with carbohydrate. But left untreated, hypoglycemia can make you pass out.

Although hypoglycemia can happen suddenly, it can usually be treated quickly, bringing your blood glucose level back to normal. Low blood glucose can be caused by

• meals or snacks that are too small, delayed, or skipped
• doses of insulin that are too high
• increased activity or exercise

Low blood glucose also can be caused by drinking too much alcohol. However, women who are trying to get pregnant or who are already pregnant should avoid all alcoholic beverages.

"I keep a box of crackers on my bedside table. If I have low blood glucose during the night, I eat some crackers right away to bring my blood glucose back up to normal."

Using Glucagon for Severe Low Blood Glucose

If you have severe low blood glucose and pass out, you'll need help to bring your blood glucose level back to normal. Your health care team can teach your family members and friends how to give you an injection of glucagon, a hormone that raises blood glucose levels right away.

High Blood Glucose

High blood glucose, also called hyperglycemia, can happen when you don't have enough insulin or when your body isn't able to use insulin correctly. High blood glucose can result from

• a mismatch between food and medication
• eating more food than usual
• being less active than usual
• illness
• stress

In addition, if your blood glucose level is already high, physical activity can make it go even higher. Symptoms of high blood glucose include

• frequent urination
• thirst
• weight loss

Talk with your health care provider about what to do when your blood glucose is too high-whether it happens once in a while or at the same time every day for several days in a row. Your provider might suggest a change in your insulin, meal plan, or physical activity routine.

My Ketone Levels

When your blood glucose is too high or if you're not eating enough, your body might make chemicals called ketones. Ketones are produced when your body doesn't have enough insulin and glucose can't be used for energy. Then the body uses fat instead of glucose for energy. Burning fat instead of glucose can be harmful to your health and your baby's health. Harmful ketones can pass from you to your baby. Your health care provider can teach you how and when to test your urine or blood for ketones.

If ketones build up in your body, you can develop a condition called ketosis. Ketosis can quickly turn into diabetic ketoacidosis, which can be very dangerous. Symptoms of ketoacidosis are

• stomach pain
• frequent urination or frequent thirst, for a day or more
• fatigue
• nausea and vomiting
• muscle stiffness or aching
• feeling dazed or in shock
• rapid deep breathing
• breath that smells fruity

Checking Your Urine or Blood Ketone Levels

Your health care provider might recommend you test your urine or blood daily for ketones and also when your blood glucose is high, such as higher than 200 mg/dL.

You can prevent serious health problems by checking for ketones as recommended. Ask your health care team about when to check for ketones and what to do if you have them. Then check off the instructions below and fill in the blanks.

I should test my urine or blood for ketones

• every day before breakfast
• when I'm sick
• when my blood glucose is _____________ or higher
• other times: _________________________________

If you use an insulin infusion pump, your health care provider might also recommend that you test for ketones when your blood glucose level is unexpectedly high.

Your health care provider might teach you how to make changes in the amount of insulin you take or when you take it. Or your provider may prefer that you call for advice when you have ketones.

My Checkups

Pregnancy can make some diabetes-related health problems worse. Your health care provider can talk with you about how pregnancy might affect any problems you had since before pregnancy. If you plan your pregnancy enough in advance, you may want to work with your health care provider to arrange for treatments, such as laser treatment for eye problems, before you get pregnant. Your diabetes-related health conditions can also affect your pregnancy.

"I check my urine every morning for ketones. That's one of the things I do to keep my baby and myself safe and healthy."

Have a complete checkup before you get pregnant or at the start of your pregnancy. Your doctor should check for

• high blood pressure, also called hypertension
• eye disease, also called diabetic retinopathy
• heart and blood vessel disease, also called cardiovascular disease
• nerve damage, also called diabetic neuropathy
• kidney disease, also called diabetic nephropathy
• thyroid disease

You'll also get regular checkups throughout your pregnancy to check your blood pressure and average blood glucose levels and to monitor the protein in your urine.

Smoking

Smoking can increase your chance of having a stillborn or premature baby. Smoking is also especially harmful for people with diabetes. If you smoke, talk with your health care provider about how to quit.

My Meal Plan

If you don't already see a dietitian, now would be an excellent time to start. Your dietitian can help you learn what to eat, how much to eat, and when to eat. Together, you'll create a meal plan tailored to your needs, usual schedule, food preferences, medical conditions, medications, and physical fitness routine.

Many women need changes in their diet, such as extra calories and protein, during pregnancy. You might need to see your dietitian every few months during pregnancy as your needs change. Eating a well-balanced diet helps ensure that you and your baby are healthy.

How Much to Eat

"My dietitian helped me include my favorite foods in my meal plan."

Talk with your dietitian about how many servings to have at each meal and snack. Your dietitian can also provide advice about portion sizes. Your meal plan will be based on how many calories you need for pregnancy and your goals for weight gain during the pregnancy. For most women whose weight is in the normal range before pregnancy, gaining 25 to 35 pounds is recommended. If you're underweight or overweight at the start of your pregnancy, your weight goal may differ. For overweight women, the recommended weight gain is no more than 15 pounds.

"Eating small meals and snacks throughout the day helps keep my blood glucose under control."

Vitamin and Mineral Supplements

Your health care team will tell you whether you need to take a vitamin and mineral supplement before and during pregnancy. Many pregnant women need supplements because their diets don't supply enough of the following important vitamins and minerals:

• iron-to help make extra blood for pregnancy and for the baby's supply of iron
• folic acid-to prevent birth defects in the brain and spinal cord
• calcium-to build strong bones

Alcoholic Beverages

You should avoid alcoholic beverages while you're trying to get pregnant and throughout pregnancy. When you drink, the alcohol also goes to your baby. Alcohol can lead to serious, lifelong problems for your baby.

Artificial Sweeteners

Artificial sweeteners can be used in moderate amounts. If you choose to use sweeteners, talk with your dietitian about how much to have.

My Physical Activity Routine

Daily physical activity can help you reach your target blood glucose levels. It can also help you reach your blood pressure and cholesterol target levels, relieve stress, improve muscle tone, strengthen your heart and bones, and keep your joints flexible. Talk with your health care team about moderate physical activity, such as walking or swimming. Consider whether you have any health problems and which exercises would be best for you. Your health care team may advise you to avoid exercises that increase your risk of falling, such as downhill skiing.

A sensible goal for most women is to aim for 30 minutes or more of activity, most days of the week. If you've been active before pregnancy, you may be able to continue with a more moderate version of your usual exercise routine. But if you haven't been active, start with an activity such as walking. Vigorous physical activity, such as walking briskly, can lead to low blood glucose. Pregnant women sometimes do not have the typical signs of low blood glucose.

"I wasn't very active before I got pregnant. But my doctor said that walking every day would be safe and good for me and my baby."

My Medications

Medications for Diabetes

During pregnancy, the safest diabetes medication is insulin. Your health care team will work with you to make a personalized plan for your insulin routine. If you've been taking diabetes pills to control your blood glucose levels, you'll need to stop taking them. Researchers have not yet determined whether diabetes pills are safe for use throughout pregnancy. Instead, your health care team will show you how to take insulin.

If you're already taking insulin, you might need a change in the kind, the amount, and how or when you take it. The amount of insulin you take is likely to increase as you go through pregnancy because your body becomes less able to respond to the action of insulin, a condition called insulin resistance. Your insulin needs may double or even triple as you get closer to your delivery date. Insulin can be taken in several ways. Your health care team can help you decide which way is best for you.

Other Medications

Some medications are not safe during pregnancy and should be discontinued before you get pregnant. Tell your health care provider about all the medications you currently take, such as those for high cholesterol and high blood pressure. Your provider can tell you which medications to stop taking.

Changes in My Daily Routine

Sick Days

When you're ill, your blood glucose levels can rise rapidly. Diabetic ketoacidosis, a dangerous condition for you and your baby, can occur. Talk with your health care team about what you should do if you get sick. Be sure you know

• what to do if you're nauseated or vomiting
• how often you should check your blood glucose
• how often you should check your urine or blood for ketones
• when you should call your health care provider

Being Away from Home

When you're away from home-for several hours or for a longer trip-you'll want to be prepared for problems. Make sure you always have the following with you:

"When I'm not feeling well, I check my blood glucose more often than usual. I know that being sick can make my blood glucose level go too high."

• a snack or a meal
• food or drinks to treat low blood glucose
• your diabetes medicines and supplies
• your blood glucose meter and supplies
• your glucagon kit
• your health care team's phone numbers for emergencies

Checking Your Baby's Health During Pregnancy

You are likely to have tests all through your pregnancy to check your baby's health. Your health care team can tell you which of the following tests you'll have and when you might have them. Your health care provider might also suggest other tests. If certain diseases or conditions run in your family, you might meet with a genetic counselor. The counselor may recommend tests based on your family history and can explain the risk of certain conditions for your baby.

Maternal Blood Screening Test

The maternal blood screening test is also called the multiple marker screen test, the triple screen, or quad screen. It measures several substances in your blood. Results can tell you whether your baby is at risk for spinal cord and brain problems, Down syndrome, and other birth defects. If the results show an increased risk for problems, additional tests such as ultrasound or amniocentesis can provide more information.

Ultrasound

Ultrasound uses sound waves to provide a picture of areas inside the body. The picture produced by ultrasound is called a sonogram. Ultrasound can show the baby's size, position, structures, and sex. It can also help estimate age, evaluate growth, and show some types of birth defects.

Fetal Echocardiogram

The fetal echocardiogram uses ultrasound to check for problems in the structures of the baby's heart.

Amniocentesis

Amniocentesis uses a thin needle inserted through the abdomen into the uterus to obtain a small amount of the fluid that surrounds the baby. Cells from the fluid are grown in a lab and then analyzed. Amniocentesis can help tell whether your baby has health problems and if your baby's lungs have finished developing. Developed lungs are needed for the baby to breathe without help after delivery.

Chorionic Villus Sampling (CVS)

CVS involves a thin needle inserted into the placenta to obtain cells. Cells then are analyzed to look for health problems. Ultrasound is used to guide the needle into the placenta, either through the vagina and cervix or through the abdomen and uterus. The placenta is composed of tissue and blood vessels that develop to attach the baby to the mother's uterus so the developing baby can get nutrition from mom.

Kick Counts (Fetal Movement Counting)

Counting kicks is an easy way to keep track of your baby's activity. You'll count how many times the baby moves during a certain period of time.

Nonstress Test

A fetal monitor checks whether your baby's heart rate increases as it should when the baby is active.

Biophysical Profile

Ultrasound checks your baby's muscle tone, breathing, and movement to obtain a biophysical profile. Ultrasound also estimates the amount of amniotic fluid surrounding the baby.

Contraction Stress Test

This test measures the baby's heart rate during contractions using a fetal monitor. The results can help your doctor decide whether the baby needs to be delivered early.

About Labor and Delivery

Timing of Delivery

Your health care team will consider your health, your baby's health, and the state of your pregnancy in deciding how and when delivery should occur. Some doctors prefer to deliver babies of women with diabetes 1 or 2 weeks before their due dates to lower the risk of problems. Your doctor may recommend inducing labor before your due date or delivering the baby surgically using a cesarean section, also called a c-section. However, most women with diabetes have the option of delivering vaginally. You'll want to talk with your health care team about your options well ahead of time.

The factors your health care team will consider in deciding what type of delivery is best for you and your baby may include

"I talked with my doctor way before I was due about my options for delivering my baby."

• your baby's size and position
• your baby's lung maturity
• your baby's movements
• your baby's heart rate
• the amount of amniotic fluid
• your blood glucose and blood pressure levels
• your general health

Blood Glucose Control During Labor and Delivery

Keeping your blood glucose levels under control helps ensure your baby won't have low blood glucose after birth. Because you'll be physically active when you're in labor, you may not need much insulin. Hospital staff will check your blood glucose levels frequently. Some women take both insulin and glucose, as well as fluids, through an intravenous (IV) line during labor. Infusing insulin and glucose directly into your bloodstream through a vein provides good control of blood glucose levels. If you are using an insulin pump, you might continue to use it throughout labor.

If you are having a c-section, your blood glucose levels may increase because of the stress of surgery. Your health care team will closely monitor your blood glucose levels and will likely use an IV for insulin and glucose to keep your levels under control.

After Your Baby Arrives

About Breastfeeding

Breastfeeding is highly recommended for the babies of women with diabetes. Breastfeeding provides the best nutrition and helps your baby stay healthy.

"Even though I have diabetes, I can still breastfeed my baby. My milk gives my baby exactly what he needs."

Your Meal Plan

If you're breastfeeding, you might need more calories each day than you needed during your pregnancy. Your dietitian can provide personalized recommendations and answer any questions you have about what, when, and how much to eat.

Your Medications

After you've given birth, you might need less insulin than usual for several days. Breastfeeding can also lower the amount of insulin you need. Diabetes pills are not recommended during breastfeeding.

Low Blood Glucose

You'll be at increased risk for low blood glucose, especially if you're breastfeeding. You might need to have a snack before or after you breastfeed your baby. Your health care team may suggest that you check your blood glucose more often than usual.

For More Information

How can I find diabetes educators and dietitians?

Diabetes Educators

To find diabetes teachers-nurses, dietitians, and other health professionals-call the American Association of Diabetes Educators toll-free at 1-800-TEAMUP4 (832-6874). Or go to www.diabeteseducator.org and see the "Find a Diabetes Educator" section.

Dietitians

To find a dietitian, call the American Dietetic Association's National Center for Nutrition and Dietetics at 1-800-877-1600. Or go to www.eatright.org and see the "Find a Nutrition Professional" section.

Where can I get more information about diabetes?

National Diabetes Information Clearinghouse
1 Information Way
Bethesda, MD 20892-3560
Phone: 1-800-860-8747
Fax: 703-738-4929
Email: ndic@info.niddk.nih.gov
Internet: www.diabetes.niddk.nih.gov

National Diabetes Education Program
1 Diabetes Way
Bethesda, MD 20892-3560
Phone: 1-800-438-5383
Fax: 703-738-4929
Email: ndep@mail.nih.gov
Internet: www.ndep.nih.gov

American Diabetes Association
National Service Center
1701 North Beauregard Street
Alexandria, VA 22311-1742
Phone: 1-800-DIABETES (342-2383)
Fax: 703-549-6995
Email: AskADA@diabetes.org
Internet: www.diabetes.org

Juvenile Diabetes Research Foundation International
120 Wall Street
New York, NY 10005-4001
Phone: 1-800-533-CURE (2873)
Fax: 212-785-9595
Email: info@jdrf.org
Internet: www.jdrf.org

Where can I get more information about pregnancy?

Eunice Kennedy Shriver National Institute of Child Health & Human Development Information Resource Center
P.O. Box 3006
Rockville, MD 20847
Phone: 1-800-370-2943
Fax: 301-984-1473
Email: NICHDInformationResourceCenter@mail.nih.gov
Internet: www.nichd.nih.gov

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National Diabetes Information Clearinghouse

1 Information Way
Bethesda, MD 20892–3560
Phone: 1–800–860–8747
TTY: 1–866–569–1162
Fax: 703–738–4929
Email: ndic@info.niddk.nih.gov
Internet: www.diabetes.niddk.nih.gov

The National Diabetes Information Clearinghouse (NDIC) is a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). The NIDDK is part of the National Institutes of Health of the U.S. Department of Health and Human Services. Established in 1978, the Clearinghouse provides information about diabetes to people with diabetes and to their families, health care professionals, and the public. The NDIC answers inquiries, develops and distributes publications, and works closely with professional and patient organizations and Government agencies to coordinate resources about diabetes.

Publications produced by the Clearinghouse are carefully reviewed by both NIDDK scientists and outside experts. This booklet was reviewed by Boyd E. Metzger, M.D., Tom D. Spies Professor of Metabolism and Nutrition, Division of Endocrinology, Metabolism & Molecular Medicine, Northwestern University Feinberg School of Medicine, and Julie M. Slocum Daley, R.N., M.S., C.D.E., Women & Infants' Hospital of Rhode Island.

This publication is not copyrighted. The Clearinghouse encourages users of this publication to duplicate and distribute as many copies as desired.

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NIH Publication No. 08-5491
February 2008