Planning a pregnancy with Diabetes   (April 26, 2008)

I recently answered a question here at MyDiabetesCentral.com about the use of insulin in pregnancy and had referred the reader to a webpage about planning a pregnancy at my other website. Looking it over, I realized that some of the information was incomplete, as new insulins and new medications for hypertension have become available since I had last updated that webpage. So, for those of you who might be interested, here's what the update says:

If a young woman with diabetes (or previous gestational diabetes) is planning a pregnancy soon, there's a list of things to do. Here's some advice to review with your physician and diabetes team:

1. Tighten up your targets. Blood sugar values should be as close to normal as possible prior to conception to minimize risk to the developing fetus. The fasting blood glucose should be between 60 and 90 mg/dl (3.3-5 mmol/L). Before meals aim for 90-100 mg/dl (5-5.6 mmol/L). At one hour after a meal, blood glucose should be less than 130 mg/dl (7.2 mmol/L). At two hours following a meal it should be less than 120 mg/dl (6.7 mmol/L). Aim for blood sugars below 140 mg/dl (7.8 mmol/L) all the time, preferably averaging about 85 mg/dl (4.7 mmol/L). And begin adjusting insulin doses, based on frequent blood sugar levels, to meet your new targets.

2. Do more blood sugars. Eight to twelve blood sugar tests a day will probably be needed to get the very tight control of blood sugar that is desired. Definitely start checking after meals. (There are different times to check after eating, either 60, 90, or 120 minutes. Discuss your doctor which might be best in your circumstances.)

3. Check your blood sugar before driving. If it's low, eat and wait before putting the car in gear -- don't risk a car crash from hypoglycemia! And keep some quick-acting carb, and some "real" food (such as peanut butter and crackers) in your automobile.

4. Start telephoning your doctor's office weekly with blood sugar reports (or faxing them) to help decide if changes in insulin dose are needed.

5. Plan on lots of shots. Three or four insulin injections per day, and sometimes more, will actually make it easier to get the very tight blood sugar control needed.

6. Maybe start an insulin pump, especially if you have elevated blood sugar levels despite your best efforts.

7. If you are presently taking Humalog or Novolog insulin: These insulins have been used in pregnancy for several years now without apparent ill effect. If you have good control using this type of insulin, then continue with it.

8. If you are presently taking Apidra or Lantus or Levemir insulins: These insulin products are new on the market, and there are no clinical studies available about their safety in pregnancy. You should discuss with your physician about what to do.

9. Start folic acid supplementation. Babies of mothers with diabetes are at increased risk of spina bifida. Folic acid (folate) has been shown to reduce this risk. The most recent recommended amount is 4 to 5 mg/day which is much more than in prenatal vitamins. Therefore the extra amount will have to be prescribed by a physician. Folic acid should be started at least one month prior to conception and continued for at least the first 6 weeks of pregnancy

10. Stop ACE inhibitors or ARBs. If you are taking a medication in either of these two classes of medications because of renal disease (protein in your urine) or hypertension (high blood pressure), then this drug needs to be stopped prior to conception. However, the protein in your urine may return during the pregnancy. If you do have kidney disease then you should consult with your endocrinologist and a high-risk pregnancy specialist. There are additional increased risks to a pregnancy. The decision for a pregnancy in this circumstance should be made very carefully.

11. Talk to a dietitian if it's been a while. There are lots of new ideas, such as carb counting, that you might not know about.
 
12. Get your eyes examined. If the blood sugar levels are aggressively lowered to obtain tight control, there's a chance of developing worsening retinopathy. Therefore, the eyes should be checked by a qualified opthalmologist, preferably before conception, or during the first trimester of pregnancy, and perhaps again during the third trimester of the pregnancy.
 
13. Get a 24-hour urine sample to assess how your kidneys are doing. The two lab tests that should be checked are called "creatinine clearance" and "24-hour urine protein".
 
14. Start checking urine ketones every morning. It'll be recommended during pregnancy, and you might as well start now.

15. Carry quick-acting carbohydrate to treat possible hypoglycemia.

16. Be sure your spouse and anyone else nearby knows how to give you a glucagon shot if you're knocked out by low blood sugar. Keep a Glucagon Emergency Kit handy (and be sure your family and friends know where it is!).

17. Stop smoking. There are several ways of doing this. Consult with your physician about how to approach it.

18. Always wear identification that you have diabetes. With the very tight control that is recommended, you might have a severe insulin reaction that would need help from someone else.

19. Plan to stay very active both before and during pregnancy, until your obstetrician tells you to slow down. Diabetes is not a reason to slow down; actually the reverse seems true: the more you exercise, the easier it should be to keep your blood sugar levels down.
     
20. Be sure that you are comfortable with the obstetrician who will be caring for you. If you don't yet have an "OB," get one, and be sure you discuss each other's expectations about diabetes care during pregnancy, before you become pregnant.

That's quite a list, but with good planning and lots of work, the chances for a successful pregnancy for the woman with diabetes is excellent.