Pregnancy is still one of the most challenging times for women with diabetes. A new book that we announced last week aims to address each of these challenges.
Staying Healthy with Diabetes—Planning & Managing Your Pregnancy was authored by Suzanne Ghiloni, R.N., B.S.N., C.D.E. and edited by Florence Brown, M.D., with much help from other Joslin staff. Here, Ghiloni answers seven questions about pregnancy and diabetes.
Why did you decide to write a book on this topic?
It was long overdue. We receive many inquiries from women with diabetes and their family members who are interested in learning about how to prepare for a pregnancy with diabetes. We also find that there are women who have an unplanned pregnancy and would like know how to optimize their diabetes self-management skills and reduce the risk of complications to themselves and to their baby.
You hope that women will read the book well in advance, before they are pregnant?
Absolutely. Our program goal is to have women with pre-existing diabetes be prepared for the experience. Pregnancy with diabetes is a vigorous nine-plus months. An unplanned pregnancy is often traumatic and for women with diabetes it has more serious implications. High blood glucose is not healthy for the developing baby. Medical appointments need to be much more frequent, usually every two weeks, and this certainly impacts a woman’s life. Planning and awareness can make a pregnancy less stressful.
In the book, we not only explain goals and targets but the reasons for achieving them. When you understand why you’re doing something, you’re much more likely to do it.
Besides the appointment schedule, what do women usually find most surprising?
Most women who haven’t had any pre-pregnancy counseling are shocked to learn that they are expected to have normal—or very close to normal—blood glucose levels. That can be frightening to women as they are worried that they cannot achieve this.
On the positive side, we want women to be aware that there are very high success rates for pregnancy with pre-existing diabetes, and that their healthcare team will work closely with them to make it a success.
At the Joslin-Beth Israel Deaconess Medical Center Diabetes in Pregnancy Program,we help women learn the diabetes self-management skills necessary to control blood glucoses at normal levels. We ask women to come for preconception care ideally six months before they plan to become pregnant so we can work with them more intensively to enhance their control. (We’re aiming for an A1C level of under 7% and as close to 6% as possible without low blood glucoses before pregnancy.) These visits give us opportunities to assess how women manage with diabetes and to enhance their self-care skills as necessary. And they can meet the team and begin to feel comfortable with us.
The book has lots of details about diet—what do you emphasize?
The goal is healthy eating for two. The meal plan remains as important as it is in diabetes in the non-pregnant state. We work to make sure that the woman gets adequate nutrition and nutrients to support a healthy pregnancy. We cover topics such as calcium, iron, carbohydrates, glycemic index, caffeine and mercury. Collaboratively, we work very hard to match the insulin and the carbohydrate intake, because we are looking for such tight control. A target of one-hour-after-meal blood sugars of 130 requires fine-tuning of carbohydrate counting.
What do you say in the book about exercise?
We hope that women already are getting exercise, since starting a new exercise program in pregnancy is not ideal. However, if a woman has not been exercising, we will encourage moderate exercise, such as walking, as long as the treating obstetrician agrees. We know that it helps with blood glucose stabilization, weight maintenance, cardiovascular health and feeling good in general. It also helps make labor and delivery somewhat easier.
Joslin’s clinical guidelines for pregnancy, which we updated this fall, now recommend that women aim to enter pregnancy with a normal body-mass index, or at least lose some of their excess weight if needed. Exercise can help in achieving a healthier weight before pregnancy.
Are you seeing an increase in gestational diabetes?
Yes, gestational diabetes has been increasing, just as obesity and type 2 diabetes having been increasing. In addition, the new guidelines have lowered the targets for that diagnosis.
Most women who develop gestational diabetes are feeling wonderful and all of a sudden they get a phone call: You have gestational diabetes! This is often traumatic to hear. Sometimes the obstetrician doesn’t have enough time to explain, or the office staff delivers the news. So the women tend to be quite worried until they come in for an appointment here.
How do you help with the emotional aspects of pregnancy with diabetes?
We want women to have a positive attitude and to know that we’re in it together with them. We’re the personification of the JoslinCare team concept—the woman is always at the center but she’s got help. It’s a time when it’s really important to have other support people.
At Joslin we provide coaching support, because we see women go through the ups and down. Almost every woman says to me, “Every time I see a high blood sugar on my meter I become upset.” And we know that with type 1 diabetes, and even with type 2, they’ll see some high numbers. Our work is to provide reassurance and especially to provide education on how to prevent and remedy the highs and lows.
We see the women so often that we get to know them very well, which is nice. And we typically rotate visits between the physician and the educators because each of us brings our own area of expertise to each appointment.
The most wonderful aspect of our work is knowing that we have played a part in this new life. One of the nicest compliments I’ve received in my work as an educator was from a former pregnancy patient who told me that she thinks of me, and how I helped her, on her son’s birthday every year.