Pregnancy in pre-existing diabetes

Making future plans around creating a family can be an exciting time for couples. There are many factors to consider when planning to have a baby. Adding diabetes into the mix makes this planning phase even more important, ensuring all aspects are both considered and addressed.

For woman living with diabetes, having a healthy baby can most certainly be achieved. While it is well known there are some increased risks to mother and baby in pregnancy, preparing, planning and the timing of the pregnancy can significantly reduce these risks.

So, when should pregnancy planning start, what does it involve and how can you best support these women and their partners?

When should pregnancy planning conversations start?

As a health professional, starting the conversation about pregnancy and pregnancy planning should be done as soon as possible. This may sound tricky, but this could be as early as adolescence years when young people become curious about lifestyle choices that either might have a negative impact on their health or have long term consequences. This could include drinking, smoking, drug taking and unprotected sex to name a few.

Early interactions often include educating and supporting women on various topics such as:

• Making healthier food choices,
• Being physically active on a regular basis,
• Ceasing or reducing smoking,
• Ceasing or reducing alcohol intake,
• The importance of safe sex and contraception, and
• Knowing the impact of not taking medications/insulin as prescribed.

Improvements to these lifestyle choices will not only assist in a person’s general health, but are also the foundations for managing their diabetes and preventing diabetes complications over time.

While starting the conversation as early as possible is recommended, ideally, formal pregnancy planning should start at least three to six months prior to a woman falling pregnant.

What does pregnancy planning when living with diabetes involve?

Let’s take a closer look at some of the things to consider as part of pregnancy planning when living with diabetes and why they are important.

Contraception

This could be considered the first step in pregnancy planning. Contraception can prevent/delay pregnancy, allowing for the woman to plan the timing of her pregnancy. It also ensures there is time to review both general health and diabetes management.

Vitamin supplements

It is well known that commencing high dose folate three months prior to pregnancy (and continuing it into the first three months of pregnancy), will significantly reduce the risk of neural tube defects in the baby. In addition to folate, iodine supplements will also support healthy foetal development.

Glycaemic control

It is recommended that woman have blood glucose levels within target range for three to six months prior to falling pregnant. Ideally this should then carry into, and across the duration of the pregnancy. If lifestyle choices alone are unable to achieve or maintain these desired blood glucose levels, then additional medication or insulin may be used to assist this.

Having blood glucose levels in target ranges prior to and at the time of conception, reduces the risk of a number of foetal abnormalities and early pregnancy complications occurring. Maintaining these ranges throughout the pregnancy will also reduce the risk of complications in pregnancy, during labour and after delivery for both mother and baby.

Early discussion about the normal changes in blood glucose levels and insulin requirements that may occur across the pregnancy, may help alleviate future concerns the mother has if requirements of medication or insulin change in this period of time. It might be helpful to explain how the hormones produced by the placenta such as estrogen, progesterone and human placental lactogen can increase insulin resistance.

Blood pressure

High blood pressure also increases the risk of complications to mother and baby during pregnancy. Obtaining a blood pressure as close to the recommended target as possible prior to pregnancy will reduce the risks. Medications may be required to achieve this, so it is important to ensure the woman is on medications safe for use in pregnancy.

Complication screening

It is important do a complete review or screening of diabetes complications prior to pregnancy. This will generally include the eyes, kidneys, feet and heart. As some of the complications of diabetes, such as eye and kidney problems can become worse during pregnancy. Screening, stabilising and treating any complications present prior to pregnancy may reduce this. You should also remember than ongoing eye and kidney checks should be carried out across the pregnancy.

Dental checks

Hormonal changes in pregnancy can affect the teeth and gums. For this reason, a dental review should also be offered and recommended to women as part of their pregnancy planning.

Medication review

As mentioned previously, some medications are not safe for use in pregnancy. For this reason, a full review of all medications being taken, should take place in the pregnancy planning phase, and where appropriate be ceased or changed.

Immunisation

The immunisation status of the woman should be assessed and where appropriate vaccinations recommended and provided. Given the current climate, this should also include discussion on Covid 19 vaccinations.

Smoking cessation

Smoking in pregnancy affects the growth and development of the baby. As smoking cessation can take time, offering support and advice during the pregnancy planning phase may increase the risk of it being achieved and reduce the potentially harmful effects on the baby.

Alcohol

Alcohol in pregnancy increases the risk of miscarriage and can cause harm to the baby and should ideally be avoided. Again, by offering education, support and advice to the woman may assist her to significantly reduce alcohol prior to falling pregnant and avoid it once knowingly pregnant.

What else needs to be considered?

As discussed, there are a number of things to consider and review in pregnancy planning for a woman living with diabetes. But what about men who are living with diabetes who are trying for a baby?

Just like women, a man’s health can have a direct effect on pregnancy outcomes too. One of the complications of diabetes for males is erectile dysfunction and reduced sexual drive. Both of which will impact the potential for conception.

In addition to these complications, diabetes that is not well managed can impact the quality of the sperm and the DNA integrity, potentially making conception more difficult to achieve. So, while we often focus on women when we think pregnancy planning, it is just as important to focus on men living with diabetes as well.

In summary

With careful planning and support, women and men living with diabetes can have a healthy pregnancy and baby. Supporting these clients to have good general health and well managed diabetes in preparation to conception can have a huge impact on both the experience and pregnancy outcomes.