To support patients in Joslin’s pregnancy clinic, we are teaming up with Revlon in their Love is On challenge, which is an online fundraising challenge that is dedicated to benefiting causes focused on advancing women’s health, including diabetes. This post originally appeared on January 11, 2016.
Sometimes things don’t go as planned and without any preparation you may find yourself pregnant. Unfortunately, diabetes doesn’t give your body a break once you find out you are expecting. In fact, being pregnant while having diabetes kick-starts a whole new list of self-care issues you should be aware of in order to keep you and your baby healthy. In part two of our new series, Florence Brown, M.D., Director of the Joslin-Beth Israel Deaconess Diabetes and Pregnancy Program, will be answering questions about what to do if you have diabetes and find out you are expecting.
Speaking of Diabetes: Will my normal blood sugar patterns be disrupted?
Dr. Florence Brown: Yes, changes in insulin requirements occur throughout pregnancy. Typically, insulin requirements increase in the first nine weeks of pregnancy, decline through week 16 and then rise until week 36. Insulin requirements from 36 weeks until delivery may be stable or even decline. These changes in insulin resistance are caused by placental hormones which increase as the placenta grows, such that total daily insulin requirements may double or triple in pregnancy. If insulin doses are not adjusted frequently, blood sugars may elevate, potentially increasing pregnancy and fetal risks. This underscores the need for frequent visits for diabetes care during pregnancy to assess glucose patterns and adjust insulin based on these patterns. Diabetes education and nutrition counseling is provided to help women understand how to self-adjust their own insulin dose between visits which will also improve diabetes control.
SD: If I require insulin, is it safe for the baby? Are there medications that I should talk to my doctor about and possibly discontinue?
FB: Almost all women with preexisting diabetes will need insulin during pregnancy. Insulin has been the treatment of choice for diabetes in pregnancy since its discovery. Still, many new types of insulin have been developed and not all these have been studied in pregnancy in randomized controlled trials. Types of insulins that have been studied in pregnancy include the human insulins regular (R) and NPH (N) and newer analog insulins lispro (Humalog®), aspart (Novolog®) and detemir (Levemir®). These three analog insulins have been found to be as safe and effective as the human insulins in pregnancy. If you use a different type of insulin, speak to your health care professional about changing the type of insulin that you use to one that has been studied for use in pregnancy.
Oral medications have not been shown to be safe and effective in pregnancy for women with preexisting diabetes. If you learn that you are pregnant while taking an oral medication, contact your health care provider so that you may start insulin and transition off your oral medication. Certain oral medications such as glyburide and metformin are safe in the first trimester, so do not stop these medications until you achieved good diabetes control with insulin. We know that high blood glucose levels in the first trimester are not good for the baby.
There are other new types of injectable medications such as pramlintide (Symlin®) and the GLP-1 agonists. There are many types/brands of GLP1 agonists including exenatide (Byetta®/Bydureon®), liraglutide (Victoza®, Saxenda®), albiglutide (Tanzeum®), dulaglutide (Trulicity®). These have not been studied in pregnancy and are not known to be safe or effective. Please contact your health care provider if you are taking these medications. Ideally you should stop these when you are planning your pregnancy.
SD: Do I have to change my diet?
FB: The inherent motivation that ensues with pregnancy allows women to focus on healthy behaviors that are good for them and their fetus. Meet with your nutritionist to discuss healthy changes to your diet. Pregnancy is a time to follow the “Healthy Plate” filling ½ of your plate with non-starchy vegetables, ¼ with a lean protein (beans, chicken, fish or lean meats) and ¼ with whole grains. Nuts and seeds and fruits make great snacks. Consistent carbs divided over 3 meals and 3 snacks helps with portion control. Make your carb choices whole grains, fruits or dairy. Avoid sugary foods and drinks, white rice, pasta or bread and processed foods.
SD: What are warning signs that I should get to the doctor right away?
FB: If you have high blood sugar that persists despite treatment or nausea, vomiting or ketones in the urine contact your diabetes providers for immediate assistance. Diabetic ketoacidosis (while infrequent) is dangerous to you and your fetus and must be treated quickly.
Contact your diabetes provider if you have a severe hypoglycemic episode. Your insulin dose may be too much.
If you have bleeding or abdominal pain or contractions, sudden swelling in one leg or shortness of breath or chest pain contact your obstetrician or go to your local emergency room.
SD: Any tips for staying healthy while pregnant?
FB: All healthy lifestyle behaviors that apply to the general population are important for pregnant women as well. Eat healthy food as noted above in question 3, and get adequate sleep. Moderate low impact exercise such as walking is safe and beneficial for most pregnant woman. If you are at bedrest, exercise is probably not appropriate for you. Your obstetrician is available to answer any concerns about exercise.
SD: What can I expect during delivery? Is there a special procedure for those with diabetes?
FB: Blood glucose levels will be monitored closely during labor, delivery and postpartum. Once you are no longer eating, while in labor, your health care providers may choose to manage your diabetes with an insulin drip. This allows for tighter and more precise control of blood glucoses due to the rapid onset and discontinuation of action that is an advantage with IV insulin. Immediately after delivery, your insulin requirements will drop dramatically. Many women will require only approximately ½ of their preconception dose. Insulin doses may remain lower than preconception while breast feeding.
SD: After I take the baby home, how long will it take for my body to be “back to normal”?
FB: All women take some time to recover from pregnancy. By six weeks, postpartum bleeding has stopped and most women are able to resume physical activity/exercise to start to get back in shape. Women with diabetes are at greater risk of wound infection and may have slower healing after a cesarean delivery. Getting “back to normal” requires focus and effort. It is important to continue the “Healthy Plate,” pursue regular physical activity and to lose the weight that was gained in pregnancy.
SD: How do neonatal activities like breastfeeding and irregular sleep hours affect my diabetes?
FB: Breastfeeding may lower insulin requirements as glucose, protein and fat is used to make breast milk. However, sleep deprivation may result in increased food intake and weight gain.
SD: Tell me about the Pregnancy Program at Joslin and Beth Israel Deaconess Medical Center? What resources are available?
FB: Our team of providers includes our coordinator Breda Curran, a nutritionist and diabetes nurse educator, four endocrinologists and a maternal fetal medicine specialist (a high risk obstetrician). Additional resources include an exercise physiologist who is available to provide educational services for safe exercise in pregnancy. Joslin’s technology program supports our pregnant patients who use insulin pumps and continuous glucose monitoring systems. The Joslin’s Beetham Eye Institute sees many of our patients for their dilated eye exams during pregnancy. Behavioral health services are available for our patients who are experiencing life stressors.
SD: Is there research at Joslin focused on diabetic pregnancy complications?
FB: The Patti lab, led by Mary-Elizabeth Patti, M.D., Co-Director of the Advanced Genetics and Genomics Core and Director of the Hypoglycemia Clinic at Joslin Diabetes Center, is investigating mechanisms by which environmental or nutritional factors can help offset metabolic risk, potentially by altering DNA regulation and metabolism at a cellular level in offspring. Specifically, in the pregnant mouse, the Patti lab is looking at the nutritional exposures in pregnancy that may affect diabetes risk in the offspring.
The Loeken lab, led by Mary Loeken, Ph. D., Investigator in the Section on Islet Cell and Regenerative Biology at Joslin Diabetes Center, studies how women who have diabetes, either type 1 or type 2, are at increased risk of having a baby with a birth defect. Her lab uses a mouse model of diabetic pregnancy to elucidate the mechanisms by which maternal hyperglycemia interferes with expression of genes that control formation of organs, such as the brain, spinal cord and the heart. Her lab has also shown that if hyperglycemia is avoided early in pregnancy (when these organ systems form) the risk for birth defects is not significantly higher than in nondiabetic pregnancies.
Elvira Isganaitis, M.D., Research Associate and Staff Endocrinologist at Joslin Diabetes Center, and the Joslin/BIDMC Diabetes and Pregnancy Program are looking at types of stem cell populations from human umbilical cord (derived from fetal tissue) to see if mom’s diabetes in pregnancy affects overall types of cells, gene expression and cellular differentiation.
The Joslin/BIDMC Diabetes in Pregnancy Program is studying the effect of maternal glucose levels and other factors on fetal growth and birth weight in infants of women with type 1 diabetes. We have previously, studied the effect of glucose control on the risk of preeclampsia. Having a hemoglobin A1c that is in target in the beginning of pregnancy reduces the risk of preeclampsia at the end of pregnancy.
Be sure to check out part one of our series, where Dr. Brown discussed what to do if you have diabetes and are considering getting pregnant. If you have diabetes and are pregnant, or are thinking about becoming pregnant, visit the Pregnancy Program’s webpage for more information or to make an appointment.