Living with

WHILE PREGNANT

Approved by Glycemic Oversight Committee 12/12/17

Table of Contents

What Is ...... 2 Symptoms Of Low Sugar...... 13

What Can Happen To My Baby...... 2 Therapy In ...... 14

Blood Sugar Ranges For How Your Insulin Works...... 14 Gestational Diabetes...... 3 Drawing And Injecting One Insulin...... 15 Diabetes Out Of Balance, Mixing, Drawing And Injecting Insulin..... 16 Low And High Blood Sugar...... 3 Preparing And Injecting Insulin Requirement During Pregnancy...... 4 With A Reusable Pen...... 17 In Site Selection And Rotation...... 18 Gestational Diabetes...... 4 Proper Use And Disposal...... 18 Dietary Guidelines For Gestational Diabetes...... 5 Sick Day Management...... 19

Carbohydrate Counting ...... 6 Sick Day Food List...... 19

Examples Of Carbohydrates ...... 19 For Carb Counting...... 7 Ideas To Make You Feel Better...... 19 Foods Low In Carbohydrates...... 8 Coping With Heartburn...... 20 Non Carbohydrate Foods...... 8 What Is Preterm Labor...... 20 Nutrition Labels...... 9 Extra Test(s)...... 21 Gestational Diabetes Meal Plan What To Expect After Delivery...... 21 Recommendations...... 10-11 Reducing Your Risk After Eating Out Wisely...... 12 Gestational Diabetes ...... 22 Exercise And Pregnancy...... 13 Healthy Start For My Baby...... 23 Stress Management...... 13 Breast Feeding Guidelines...... 23 Medications Used In Pregnancy...... 13 References...... 24 What Is Gestational What Can Happen Diabetes? To My Baby? It is a type of diabetes only in pregnancy Most babies are n Usually goes away after the birth of the baby. born healthy, but if n Usually detected at 24-28 weeks or the third trimester mothers’ blood sugar (all women are screened.) remains high, the n Normal hormone changes of pregnancy make some following problems pregnant women have higher blood sugar levels. could occur: n Difficult delivery What are the risk factors? n Possible C-section n Family n A high n Overweight before pregnancy n Baby gains too much fat n Older than 25 years n Baby may need to stay in hospital due to breathing n Previous baby weighing over 9 pounds problems, low blood sugar or jaundice n Previous still birth or n Severe high blood sugars, birth defects or still birth n Gestational diabetes in another pregnancy Keeping the blood sugars close to normal helps protect n Member of an ethnic group with a high incidence of the baby from problems. We can help you. diabetes such as Native American, Hispanic, African American and Asian How can I protect my baby? n Causes: The hormones from the work against Eat 5-6 small healthy meals and snacks every day the action of insulin. It is called “insulin resistance.” n Exercise daily As baby grows, more hormones are produced, causing n Test your blood sugar 4 times each day more insulin resistance. n Take your if needed

PAGE 2 Living with Diabetes while Pregnant Blood Sugar Ranges Diabetes Out Of Balance For Gestational Diabetes – Pregnancy

Fasting 1 Hour 2 Hours After Meal After Meal 60-95 < 140 <120 Hypoglycemia Hyperglycemia Low Blood Sugar High Blood Sugar Your provider will ask you to check your blood sugars 4 times each day. EARLY Blood Sugar 50-60 Several Blood 1. Right after you wake up in the morning (after an g Hunger Sugars >180 8-10 hour fast.) g Headache g Very thirsty 2. One hour after you start eating or drinking your first g Dizzy g Dry skin food in the morning. g Sweaty g Increased urination 3. One hour after your first bite of lunch. g Shaky g Very tired g 4. One hour after your first bite of dinner or supper. Grouchy g Increased 5. You could set a timer or alarm to go off after the heart rate start of your meal, about 1 or 2 hours, to remind you to check your blood sugar. LATE g Slurred speech Blood Sugar >240 NOTE: People who are not pregnant are allowed to SYMPTOMS g Confusion g Nausea have higher blood sugars than you are…because they g Seizures g Vomiting are NOT pregnant. g Passed out Use Glucagon or call 911 BG <60 g Call doctor or Rule of 15/15 provider g 15 grams fast acting g Test blood sugar sugar such as 4 oz g Drink water juice, 5-6 lifesavers, g Take medication – 4 tablets, do not omit 8 oz skim milk g Wait 15 minutes g Repeat blood sugar test g If >60 eat meal TREATMENT or protein with carbohydrate snack

g Too much g Not enough medication medication g Missed meal or g Too much food snack g Illness or infection g Unusual or g Not enough exercise unplanned exercise CAUSES

Tucson Medical Center PAGE 3 Insulin Requirement During Pregnancy

Insulin Resistance In Gestational Diabetes

During pregnancy, your body makes more hormones and goes through other changes, such as weight gain. These changes cause your body’s cells to use insulin less effectively, a condition called insulin resistance. Insulin resistance increases your body’s need for insulin a hormone produced by your pancreas. If your pancreas cannot make enough insulin, you will have gestational diabetes. All pregnant women have some insulin resistance during late pregnancy. However, some women have insulin resistance even before they get pregnant, usually because they are overweight. These women start pregnancy with an increased need for insulin and are more likely to have gestational diabetes.

PAGE 4 Living with Diabetes while Pregnant Dietary Guidelines For Gestational Diabetes

Eat 3 regular meals and 3 snacks every day. The ideal timing is to eat your meals and snacks that contain carbohydrates 2-3 hours apart. This allows your blood sugar levels to normalize between each meal. Drink at least six to eight 8-ounce glasses of water or sugar free, caffeine-free beverages every day. Eat a variety of non-starchy vegetables such as broccoli, cauliflower, cucumbers, carrots, etc. each day with your meals and snacks. Choose a variety of whole grain products, such 100% whole wheat bread, brown rice or whole wheat pasta. Eat a variety of lean meats with each meal and snack such as lean beef, lean pork, skinless chicken and turkey. You may also eat meat substitutes such as low fat cheese, low fat cottage cheese, eggs and peanut butter. Limit fish and shellfish to no more than 12 ounces per week. Products with low mercury concentration are safe to eat including: shrimp, canned light tuna, salmon, pollock and catfish. Avoid fish with high concentrations of mercury such as shark, swordfish, king mackerel and tile fish. Avoid drinking fruit juices or regular soda (unless your blood sugar is already too low.) Squeeze a fresh lemon into your water for variety. Use a water infuser pitcher with lemon, mint, cucumber or slices of strawberries. Avoid eating table sugar or concentrated sweets, such desserts, jelly, jams, honey, candy or syrup.

Tucson Medical Center PAGE 5 Carbohydrate Counting Carbohydrate (carb) counting is simply counting the grams of carb from the foods you 1 carbohydrate choice = 15 grams eat each day. It is becoming a way of life for many people, and it works especially well for those with diabetes. By measuring the number of grams of carb in your meal plan, you can better control your blood glucose levels and weight. The main carbohydrate containing foods are starches, fruits, milk/yogurt and sugar/sweets. Almost all foods contain carbohydrates. The amount of carbohydrates in each product must appear in the 8 ounces milk = small apple = product label. Therefore, one must learn how to read 12 grams 15 grams food product labels. For those foods that do not have labels, such as fresh fruit, learning the appropriate portions sizes of the food is necessary. The amount of carbs you eat at a meal is more important than the specific foods. The key is to eat only the amount of carbohydrates you need each day at the right times. Of course, you want to eat healthy carbohydrates foods such as whole grains, beans, non-starchy vegetables, fresh fruits and low fat milk. Important Points to Remember

Managing portion sizes is the most difficult part 1 teaspoon 1 tablespoon 1 ounce of carb counting, especially when eating out. It is Use this for oil and butter Peanut butter of cheese important to follow the recommended portion sizes as indicated on your meal plan. The rest can be taken home to enjoy later. Even the healthiest foods can increase your above the goal if you overeat. You may need to adjust the amount of carbohydrate you eat when you exercise. You should discuss this with your dietitian.

If your blood sugar levels go too high or too low, you 3 ounce 1/2 cup 1 cup need to review what you ate, the portion size, the type To measure Equivalent to size of computer For cooked of food, and the time of day in relation to your meal your meats mouse. Use for rice or pasta vegetables plan. This label was produced by the Modest Nutrition team Not everyone reacts to foods in the same way, so and should be used for educational purpose only. portions and choices need to be monitored to see what foods work best for you.

PAGE 6 Living with Diabetes while Pregnant Examples Of Carbohydrates For Carb Counting

Starches, breads, grains and starchy vegetables Each serving has about 15 grams of carbohydrates g 1 slice of bread (whole wheat, rye) g 1 small 6-inch tortilla g ½ English muffin, hot dog or g 1/3 cup of cooked rice or pasta hamburger bun g ½ cup of corn, hominy, peas g ½ pita g ½ cup of mashed potato g ½ cup of cooked cereal g 6 saltine crackers (oatmeal, cream of wheat) g 3 cups of popcorn g 1 5-inch pancake g 3 graham crackers squares g ½ cup beans, lentils or split peas g ¾ oz pretzels

Milk and yogurt – Each serving has about 15 grams of carbohydrates g 1 cup of skim, 1%, 2% or whole milk g ½ cup of evaporated milk g 1/3 cup non fat dry milk powder g 1 cup plain or sugar free yogurt g 1 cup soy/almond/rice milk (unflavored <15 grams)

Fruits – Each serving has about 15 grams of carbohydrates g 1 small apple, orange, kiwi, g ½ mango pear or peach g 3 medium prunes g ½ cup apple sauce (unsweetened) g 2 figs g ½ banana g 2 tbsp raisins g ¾ cup of blackberries, blueberries g 1 cup whole strawberries g 1 cup melon cubes g 2 small tangerines g 12 cherries g 15 grapes g ½ cup canned fruits (unsweetened or light syrup) Sugar and sweets – Each serving has about 15 grams of carbohydrates g 1 tbsp sugar g 2 small fat free cookies g 1 tbsp honey g ½ cup of ice cream g 1 tbsp all fruit jelly or jam g ½ cup of sugar free pudding g 2 tbsp light maple syrup g 5 vanilla wafers g 2 inches brownie (unfrosted)

Tucson Medical Center PAGE 7 Foods Low In Carbohydrates

Non-starchy vegetables: 1 cup of raw or ½ cup cooked vegetables = 5 grams of carbs g Artichoke g Cauliflower g Okra g Vegetable juice g Asparagus g Celery g Onions g Water chestnuts g Beans g Cucumbers g Pea pods g Water Cress (green, wax, Italian) g Eggplant g Peppers g Zucchini g Bean sprouts g Green onions g Salad greens g Beets g Greens g Sauerkraut g Broccoli (kale, collard, mustard) g Spinach g Brussels sprouts g Radishes g Tomato g Cabbage g Leeks g Tomato juice g Carrots g Mushrooms g Turnips

Non Carbohydrate Foods

Proteins/Meat or meat substitutes: Include protein with every meal. g Lean beef g Lamb g Salmon g Chicken g Pork g Fish (halibut, cod, g Turkey g Shrimp rainbow trout, herring)

AVOID: g Raw or uncooked meats, fish, poultry or eggs. g Raw or unpasteurized milk or dairy products such as soft serve yogurt, brie, gorgonzola. g Deli meats unless they are heated until steaming hot. g High mercury levels fish such as shark, swordfish, king, mackerel and tile fish.

Fats: Choose low fat and heart healthy types. Free Foods

Choose: Limit/avoid: g Mustard g Diet Jello g g g Olive oil or canola oil g Butter Catsup Sugar free gum g g g Nuts and seeds g Regular cream Broth** Sugar free iced tea g g g Avocado cheese Lemon Sugar free Kool-Aid g g g Olives g Gravy Lime Water g g g Oil based salad dressings g Mayonnaise Soy sauce** Diet soda g g g Margarine g Bacon Relish Crystal Light g g g Low fat sour cream g Coconut Pickles** Sugar substitute (avoid g Sweet’NLow and Equal) g Low fat cream cheese Salsa g Vinegar **High sodium

PAGE 8 Living with Diabetes while Pregnant Nutrition Labels

1. Read the serving size and number of servings per container – Example: Serving size = 2/3 cup Serving per container = 8

2. Read the grams of “Total Carbohydrates” – Example: Total carbohydrate = 37 grams DO NOT COUNT sugars separately. They are included in the grams of total carbohydrates. If you eat 1/3 cup, the total amount of carbohydrates is 18 grams. That is because if you eat 1/3 cup, you are actually eating half-servings of the product. Therefore, you will be eating: 37 grams divided by 2 = 18 grams or a little more than 1 carb choice

3. Dietary fiber: If the amount of dietary fiber is >5 grams you can subtract half of that amount from the total carbohydrates. – Example: If dietary fiber is 8 grams, you can subtract 4 grams from the total carbohydrates.

Tucson Medical Center PAGE 9 Gestational Diabetes Meal Plan Recommendations

For the Rest of Pregnancy n No sugar/honey/pancake syrup/regular jelly n No regular soda or Gatorade n No juice or milkshakes n Drink water instead n No Kool-Aid or regular Jello

Breakfast n Limit carbohydrates (carb) to 30 grams (2 servings) n Include 2-3 ounces lean protein (meat/cheese/eggs/peanut butter/cottage cheese) Sample Day 1 – Breakfast Sample Day 2 – Breakfast n 1 whole wheat english muffin n Cheese quesadilla: n 1 scrambled egg – 1 6-inch corn tortilla n 1 ounce cheese – 1 ounce of low fat cheese n 1 tbsp butter or margarine n 1 cup of low fat milk

AM Snack n Limit carbohydrates to 15 grams (1 serving) n Include 1-2 ounces protein Day 1 – AM Snack Day 2 – AM Snack n 1 cup yogurt less than 20 gm n 6 crackers n ¼ cup of nuts n 1ounce low fat cheese

Lunch n Limit carbohydrates to 45-60 grams (3-4 servings) n Include 3 ounces of lean protein n Include 3 cups raw or 1½ cups cooked non-starchy vegetables

Sample Day 1 – Lunch Sample Day 2 – Lunch n Tuna sandwich: n Chicken burrito: – 2 slices of whole wheat bread, 2 ounce tuna salad, – 1 medium flour tortilla,1-2 ounce cooked chicken, lettuce and tomato 1-2 tbsp guacamole, lettuce and tomato – 1 tsp mayonnaise n 1 small orange n 1 small pear n 1 cup of carrot sticks Afternoon Snack n Limit carbohydrates to 15 grams (1 serving) n Include 1-2 ounces protein

Day 1 – PM Snack Day 2 – PM Snack n 12-15 small grapes n 1 cup melon cubes n 1 ounce low fat cheese n ½ cup low fat cottage cheese

PAGE 10 Living with Diabetes while Pregnant Gestational Diabetes Meal Plan Recommendations

Dinner n Limit carbohydrates to 45-60 grams (3-4 servings) n Include 3-4 ounces lean protein n Include 3 cups raw or 1½ cups cooked non-starchy vegetables

Day 1 – Dinner Day 2 – Dinner n 1 medium baked potato n 2 6-inch corn tortillas n 1 cup low fat milk n 1 cup low fat milk n 2-3 ounce grilled chicken breast n 2 ounce ground beef n 1 cup of steamed broccoli n 1 ounce grated low fat cheese n 1 tbsp low fat sour cream n Chopped lettuce, tomato, onion and salsa n 1 tsp butter or margarine n 1 tbsp low fat sour cream

Bedtime Snack n Limit carbohydrates to 30 grams (2 servings) n Include 1-2 ounces lean protein Day 1 – Bedtime Day 2 – Bedtime n 3 graham crackers n 3 cups light popcorn n 1 tbsp natural peanut butter n ¼ cup of nuts

Gestational Diabetes Meal Plan Recommendations For

For Breastfeeding n Increase breakfast carbohydrates to 45 grams n Increase lunch and dinner carbohydrates to 60 grams n Increase all snacks to 30 grams of carbohydrates with 1-2 ounces protein

When Done Breastfeeding n Omit snacks n Limit carbohydrates to 45-60 grams per meal (3-4 servings) n Lean protein 3-4 ounces per meal n Include a lot of non-starchy vegetables n No juices/regular soda/Gatorade

Tucson Medical Center PAGE 11 3. Sushi rolls with cooked seafood or vegetables like Eating Out Wisely avocado or cucumber are safe. 4. Lettuce wraps and fresh spring rolls wrapped in rice Eating out can be a challenge when trying to maintain a paper are other good options. good blood sugar control. The cooking methods and the portions sizes tend to be different than the ones you use 5. Ask for low sodium soy sauce and dishes with at home. Below you will find some suggestions to help minimal sauces to avoid extra salt. you make healthy food selection enjoy your meal and still 6. Avoid the “hidden sugar” sauces such as teriyaki, maintain a good blood sugar control when eating out. sweet and sour, oyster, plum and barbecue. Fast Food Restaurants 7. Avoid fried foods such as egg rolls, fried prawns or fried won tons. 1. Select plain small hamburgers. You may add mustard and/or light mayonnaise but avoid any sweet sauces Italian Food Restaurants or spreads (such as ketchup, thousand island or 1. Select fresh tomato sauce dishes. Avoid fettuccine barbecue.) and other pasta with Alfredo sauce. 2. Choose English muffin or whole wheat bread when 2. If you eat pizza, select a thin crust and add a variety available. Avoid biscuits and croissants for breakfast. of vegetables. Avoid the extra cheese and meats. 3. Choose grilled chicken or other lean meat options. 3. Select oil and vinegar salad dressing and avoid Avoid breaded and deep fried foods and if you must creamy dressings. eat these foods, remove the bread or batter coating. 4. Avoid eating bread with your meals. However, if you 4. Avoid sandwiches with cold deli meats as they may must eat it, then eat one piece and select a main contain Listeria (harmful bacteria.) entrée without any starch. Mexican Food Restaurants Other Hints When Eating Out 1. Select carne asada (charbroiled beef) or chicken and 1. Know your meal plan. If you don’t remember it then vegetable fajitas. You may add 1or 2 corn tortillas for use the Plate Method to select the proper portion starch. Try to include a salad and salsa (especially Pico and distribution of the food. de Gallo) to avoid eating other side dishes such as 2. Ask for dressing and sauces on the side. rice. 3. Make a habit of ordering a salad or grilled 2. Select cooked black or pinto beans instead of refried. vegetables as your first course. 3. Order a salad or broth-based soup as an appetizer 4. If you must have something sweet after your meal, right away. Try to avoid chips while waiting for the request fresh fruit as a dessert. meal. A few chips will use up your carbohydrate allowance quickly. 5. Don’t hesitate to ask questions about how a food is prepared. 4. Avocado, sour cream and olives are fine to include. These foods do not increase blood sugar levels but they add some fat calories - watch the portion sizes! 5. Be aware of the types of cheese used on some Mexican dishes. Avoid soft cheeses such as queso fresco (which may be made of unpasteurized milk.) Asian Food Restaurants 1. Select brown rice and steamed or sautéed protein and vegetable dishes. 2. Select miso soup, edamame and soba noodle dishes. If you select rice or noodles be careful with the portion sizes.

PAGE 12 Living with Diabetes while Pregnant Exercise & Pregnancy Medications Used Be good to yourself and your baby. In Pregnancy

Regular exercise is one of the best things you can do Glyburide: a pill that helps the pancreas produces during your pregnancy. more insulin and control after meal blood sugars. It It is not harmful and may help control your blood sugar should be taken 30 minutes before the meal. and weight gain. Side effects: Low blood sugar, rash, headache Exercise should be something you can do easily. Start slowly and talk with your provider before starting. When taking glyburide you should do the following: Walking, swimming, stationary bicycling, dancing, low n Monitor your blood sugars impact aerobics, yoga, Pilates and arm exercises are all good. n Eat your meals and snacks on time n Carry 15 gram carbohydrate snack when taking a It is best to exercise 5 days a week, no longer than 30 walk or exercising minutes at one time. You must stop if you are dizzy or in pain. Be aware of your signs and symptoms of low Exercise 20-30 minutes after each meal will help lower blood sugar. If you think your blood sugar is blood sugar. low take the following actions: Drink plenty of water before, during and after exercise. n Check your blood sugar if possible. n If the blood sugar is 50-60, drink 8 ounce milk, 4 ounce fruit juice, or chew 4 glucose tablets. Stress Management n Recheck the blood sugar in 15 minutes. n If blood sugar is not above 60, then repeat step 2 Illness and emotional stress can make your blood sugars go and 3. up even when you are following your diet. n Follow up with a carbohydrate and protein snack Relaxing your body can reverse this effect. such as crackers and peanut butter or a meal if close Exercise: Remains one of the best ways to relieve stress. to meal time. Ask your health care provider about what exercises you Metformin: A pill that decreases the amount of sugar can do safely. your liver “overproduces” when you have diabetes. If you feel overwhelmed or have family stress, use Side effects: nausea, diarrhea, metallic taste in mouth breathing, meditation, or any other relaxation techniques that you have learned. Symptoms Of Low Blood Sugar Breathe Deep: Sit comfortably and put your hand on your belly. When you breathe, let your belly rise instead n Sweating n Nervousness of your shoulders. n Weakness n Shakiness Relax your muscles: Tighten up and then relax your n Nausea n muscles one at a time. Start with your feet and work up. Hunger n Dizziness n Anxiety Imagine a quiet restful place: Picture it in your mind. Rest a hand on your belly and picture your baby n Confusion n Headache in a safe comfortable place to rest and grow. n Blurred vision n Fast heartbeat

Tucson Medical Center PAGE 13 Insulin Therapy How Your Insulin Works In Pregnancy Basal: Steady and long-acting insulin that works between meals and throughout the night. For Gestational Diabetes: When diet, exercise, and oral medications fail to bring the blood sugar Bolus: Rapid burst of insulin that works to match food down, insulin should be used during pregnancy. Most or lower high blood glucose. women do not have to continue taking insulin after the Basal-bolus therapy: Also called “flexible therapy” pregnancy. because it allows for greater flexibility throughout the For : Insulin therapy is mandatory. day. Meals do not have to be eaten at the same time every day and insulin can be taken prior to meals, For : Depending on the stage of the whenever those meals are scheduled. disease, insulin therapy may be a temporary treatment. Insulin is a hormone that lowers the blood sugar when it is too high. It helps achieve blood sugar target levels which will make a person with diabetes feel better and have more energy. Using insulin can help prevent problems with mother and baby. Bolus: Short-acting insulin Insulin can come in a vial or a pen. The needle is very Examples: Humulin R, Novolin R Onset: ½ to 1 hour n Peak of Action: 2-3 hours small and not considered painful. A R.N. or Diabetes Duration: 3-6 hours Educator will train you on how to draw the insulin up and give it once or several times a day. She will show Starts to work quickly but has a short duration of action. you how to rotate the sites and dispose of the syringe or Injection is usually before meals. pen needle.

Bolus-Rapid Acting insulin: Examples: Humalog, Novolog and Apidra Onset: within 15 minutes n Peak of Action: 1-2 hours Duration: 3-4 hours Starts to work very quickly, but lasts only a few hours. Injection is usually taken before a meal.

Basal-Intermediate-acting insulin: Examples: Humulin N, Novolin N Onset: 2-4 hours n Peak of Action: 4-10 hours Duration: 10-16 hours Works more slowly than regular insulin, but last longer. Injection is usually taken 2 times per day (morning and night.)

PAGE 14 Living with Diabetes while Pregnant Drawing And Injecting Insulin

1. Wash your hands with soap and water. 2. Test your blood glucose and record results in the log book. 3. If you are using a cloudy insulin, roll the bottle (do not shake) between your hands to mix. 4. Wipe the top of the bottle with alcohol and set it down. 5. Use a new disposable, one-time use syringe with each administration. 6. Draw the plunger out (pulling air into the syringe) to the mark that measures the dose of the insulin you will be taking. 7. Insert the needle into the top of the bottle. 6. Push the plunger into the bottle and inject the air from the syringe into bottle. 9. Leave needle in the bottle and turn the bottle upside down. 10. Draw up your dose (units) of insulin by slowly pulling back on plunger. 11. Remove any air bubbles. Air bubbles in the syringe will not harm you if they are injected, but they can reduce the amount of insulin in the syringe. To remove air bubbles, tap the syringe so the air bubbles rise to the top and push up on the plunger to remove the air bubbles. Recheck the dose and add more insulin to the syringe if necessary. 12. Remove the needle from the insulin bottle. Carefully replace the cap on the needle. 13. You are now ready to give the insulin. 14. Choose an injection site for your insulin shot. 15. Do not inject near joints, the groin area, belly button, the middle of the abdomen, or on scars. 16. Clean the injection site (about 2 inches of your skin) gently with alcohol. 17. Give the injection at a 90 degree angle (straight in.) 18. Push the plunger down to inject the insulin. 19. Hold the needle in place for 5 seconds (count to five) before removing. 20. Pull the needle straight out. 21. Safely dispose of the needle into your sharps container.

Tucson Medical Center PAGE 15 Mixing, Drawing And Injecting Insulin

1. Wash your hands. 2. Pick up the CLOUDY bottle and turn it upside down. 3. Roll the bottle gently between your hands to mix the insulin. 4. Set the bottle back on the table. 5. Wipe the top of both (clear and cloudy) bottles with alcohol. 6. Remove the caps from the top and bottom of the syringe. 7. Pull the plunger down to the correct unit mark for your CLOUDY insulin dose as ordered. 8. Insert the needle into the CLOUDY bottle. 9. Push the plunger down to inject air into the CLOUDY bottle. 10. Withdraw the empty syringe from the bottle. Set the bottle aside. 11. Pull the plunger down to the correct unit mark for the CLEAR insulin dose as ordered. 12. Insert the needle into the CLEAR bottle. 13. Push the plunger down to inject air into the CLEAR bottle. 14. Leave the needle in the bottle. 15. Turn the bottle upside down with the needle in it. 16. Hold the bottle at eye level. 17. Pull the plunger down to the correct unit mark for the CLEAR insulin dose. 18. Look for air bubbles in the syringe. 19. If you see air bubbles in the syringe, push the insulin back into the bottle, and repeat steps 17 and 18. 20. Pull the bottle away from the needle, and set aside the CLEAR bottle. 21. Pick up the CLOUDY bottle of insulin. 22. Turn the CLOUDY bottle upside down and push the needle into the bottle. Be very careful not to move the plunger. 23. Pull the plunger down and withdraw the correct number of units for the CLOUDY insulin. 24 The plunger should now be on the unit mark showing the total units of both the CLEAR and CLOUDY types of insulin. For example, 6 units of CLEAR insulin are already in the syringe. Add 14 units of CLOUDY insulin for a total of 20 units in the syringe. 25. Pull the bottle away from the needle. Set both bottles on the table. 26. Look for air bubbles in the syringe. 27. If you see air bubbles, discard the dose and begin again. 28. Set the syringe down. Do not let the needle touch anything. 29. Pinch or spread the skin at the chosen injection site. 30. Wipe the area with alcohol. Let the alcohol dry. 31. Pick up the syringe. Hold it like a dart. 32. Insert the needle straight into the skin at a 90-degree angle. Make sure the needle is all the way through the skin. 33. Push the plunger down to inject the insulin. 34. Hold the needle in place for 5 seconds (count to five) before removing. 35. Pull the needle straight out. 36. Safely dispose of the needle into your sharps container.

PAGE 16 Living with Diabetes while Pregnant Preparing And Injecting With A Reusable Pen

1. Wash your hands with soap and water. 2. Test your blood glucose and record results in the log book. 3. If you are using cloudy insulin, turn the pen upside down and right side up several times or roll the pen between your hands, to mix it. Do not shake vigorously. 4. Take the cap off the pen. 5. Clean the rubber stopper of the cartridge with alcohol swab. 6. Remove the paper tab from disposable, one-time-use needle. Always use a fresh, sterile needle. 7. Screw needle onto the pen. 8. Remove outer plastic needle cap and inner needle cover. 9. Prime the needle by dialing 2 units or per manufacturer’s instructions. Hold pen upright and push plunger on end of the pen to push insulin through the needle. You should see a few drops of insulin at the tip of the needle. If you do not, repeat this step until you do. 10. Dial in dose of insulin you need. 11. Clean area of skin where you will give the injection. 12. Push the needle straight in, using a palm grip, keeping the thumb up. 13. Push plunger on end of the pen with thumb to inject the insulin. 14. Count to 5 or 10 slowly before taking the needle out of the skin. Do not rub skin. 15. Replace the outer plastic needle cover, unscrew and remove the capped needle. 16. Discard used needle in your sharps container. 17. Place the outer pen cap on the pen for storage. The pen should not be stored with a needle attached. (Insulin may leak out, or air may leak in, if stored with the needle on.) 18. Do NOT refrigerate insulin pens once in use.

Tucson Medical Center PAGE 17 Site Selection Proper Use And Rotation And Disposal Injection Sites To maintain healthy injection sites, only use 1. Move the site of each injection. Inject at least 1½ syringes or pen needles one time. inches away from the last injection site. By rotating 1. Needle reuse contributes to the build-up of scar your injection sites, you will make your injections tissue, which may interfere with insulin absorption. easier, safer, and more comfortable. If the same Insulin may not work as expected if injected into injection site is used over and over again, you may that area. develop hardened areas under the skin that keep the 2. Please remember that syringes and pen needles are insulin from being absorbed properly. sterile products that are designed for single use only. 2. The abdomen except for area around the belly They are no longer safe after one use. button. 3. The top and outer thighs, avoid injecting too close Dispose of the Syringe and Needle to the bony area above the knee. 1. Use a hard plastic empty (old laundry detergent 4. The back of upper arms where there is fatty tissue. container) or commercial “sharps” container. When the container is full, replace the lid and tape securely 5. The abdomen absorbs insulin the fastest, followed and write “Do Not Recycle.” by the arms, thighs and buttocks. 2. Drop the entire syringe and needle into your 6. As the pregnancy progresses and the fatty layer container for used “sharps” equipment. between the skin and the baby becomes thinner, When the container is full, put the lid or cover on it stop injecting in the abdomen and use the other and throw it away with the trash. sites. Do NOT put this container in the recycling bin. Some communities have specific disposal laws. Check with your local health department for specific disposal instructions in your community.

PAGE 18 Living with Diabetes while Pregnant Sick Day Management Morning Sickness Management Actions: How to Prevent Nausea 1. Test blood sugars every 2-4 hours Do not use coffee and alcohol since they can upset your 2. Drink more sugar free fluids to prevent dehydration and harm the baby. 3. Eat or drink carbohydrate food replacements or Keep away from stale odors, strong cooking odors, nutritional supplemental drinks smoke, cleaning fluids, paints, perfumes, or other 4. Call the provider if: BG >240, vomiting, scents. diarrhea several times, fever >100 degrees, Do not eat foods that cause gas like garlic, onion, bell Urinary Tract Infection pepper, cabbage and beans. Nutrition Considerations: Stay away from high fat foods that make you feel worse, 1. Eat small amounts of carbohydrates (15 gm) every such as: fried foods, fatty meats, gravies and sauces, oil, 1-2 hours. See sick day food list below butter, cream or lard. 2. If vomiting, diarrhea or fever add caffeine free liquids 3. Contact health care provider if unable to keep food or liquids down Ideas To Help You Feel Better Sick Day Food List Get up slowly in the morning. Get plenty of fresh air by opening windows, using fans, Sometimes you may be too sick to follow your regular or taking a walk outdoors. meal plan. Eat 1-2 servings of the carbohydrate containing foods listed below every 1-2 hours as Drink water or no-calorie liquids at least ½ hour before tolerated. or after meals. Use extra portions from the free foods list: broth, If water makes you sick, try sipping on a sugar free tart caffeine free beverages, diet soda and other sugar free drink such as sugar free lemonade. drinks. Eat chilled food items from your meal plan instead of Each serving has about 15 grams of hot foods, such as fruit, cottage cheese, crackers, sugar carbohydrates free yogurt or nuts. n 1 slice of toast Eat all meals and snacks on your meal plan. n 6 saltine crackers Contact your health care provider if you cannot follow n ½ cup regular gelatin the recommended meal plan. n ½ cup of soup n ½ cup of regular ice cream n ¾ cup light yogurt n ½ cup of applesauce (no added sugar) n ½ cup of juice n ½ cup of regular clear soda n ** 1 can of Glucerna®, Boost® or Ensure® ** Carbohydrate content may vary. Please read nutrition label

Tucson Medical Center PAGE 19 Coping With Heartburn What Is Preterm Labor How to feel relief In Pregnancy? 1. Follow your meal plan The usual length of pregnancy is 40 weeks. Preterm 2. Eat three meals and snacks at the right time labor is contractions of the uterus that happen before 3. Drink milk the 37th week of your pregnancy. These changes are 4. Drink fluids allowed between meals normal after 37 weeks and result in the birth of your baby. The earlier that your baby is born, the higher the 5. Eat slowly risk that your baby will have problems. 6. Do not eat before going to bed If preterm labor is noticed early and treated, it may be Stay away from foods that can cause possible to stop your contractions and prevent your heartburn baby’s . 1. Greasy, fried or deep fried foods Warning signs of preterm labor: 2. Spicy foods like chili or salsa 1. Menstrual-like cramps 3. Sausage 2. Pressure or heaviness felt in your abdomen, pelvis or 4. Garlic thighs 5. Tomato sauces 3. Abdominal cramping: above or below the belly 6. Pizza button 7. Coffee (decaffeinated and caffeinated) 4. Change in vaginal discharge: thick ,sticky, yellow mucous or water, and pink or bloody discharge; Using antacids for heartburn these are not normal 1. Check with health care provider about which 5. Uterine contractions, tightening or balling up of the antacid to take, how much is safe and which are low uterus. A feeling like the baby is pushing out in salt. 6. Leaking fluid that you cannot control 2. Over-the-counter products may be helpful. 7. Feeling like something is not right, flu like symptoms or feeling lousy Examples that may help include: 1. Tums What to do to help prevent preterm labor? 2. Mylanta 1. Drink plenty of fluids 3. Riopan 2. Take rest periods to put your feet up. 4. Gelusil 3. Share household duties with family members Do not take Alka-Seltzer, baking soda, soda mints or Rolaids as they contain salt and aspirin What to do if you get the above warning signs: Exercise 1. Lie on your left side 1. Take a walk. It may help 2. Drink 2-3 glasses of water 2. Sit quietly and breath deeply 3. Call your health care provider Resting 1. Sit upright after meals 2. Wait 2 hours after eating to lie down 3. Sleep with head elevated

PAGE 20 Living with Diabetes while Pregnant Will I Need Extra Tests What To Expect During Pregnancy After Delivery? To Check My Baby’s Most times, gestational diabetes goes away after the birth of the baby. Health? On your 6-8 weeks postpartum appointment, your provider will check your risk for diabetes with a lab If you have gestational diabetes, your test (75g 2 hour .) doctor may recommend that you have some extra tests to check your baby’s Because you had diabetes during pregnancy, you health such as: are at risk of Type 2 diabetes in the future. Follow up with your primary care provider to be tested for n Ultrasound exam, which use sound waves to it yearly. make images that show your baby’s growth and whether your baby is larger than normal. n Non-stress test, which uses a monitor placed on your abdomen to check whether your baby’s heart rate increases as it should when your baby is active. n A kick count, which counts the baby’s movements (kick, swish or roll). You should feel at least 10 movements in 1-2 hours.

Tucson Medical Center PAGE 21 Reducing Your Risk After Gestational Diabetes Eat a healthy diet Eat foods low in fat and watch portion sizes. Eat foods high in fiber such whole grains, beans and a variety of fruits and vegetables. Avoid sweets, high sugar beverages and fast food restaurants. Keep a healthy weight If you are overweight, lose weight. Aim to get to your goal weight within one year. Losing weight can help you reduce the risk of getting gestational diabetes with your next pregnancy. Women who remain overweight after pregnancy are more likely to develop Type 2 diabetes in the next 5 years. Stay physically active Try to exercise at least 3-5 times per week for 30-60 minutes. Remember any activity counts. Take the kids to the park, use the stairs instead of the elevator, park away from the entrance of stores or buildings, etc. Breastfeed your baby Studies show breastfeeding your baby can reduce the risk of diabetes for you and your baby. Try to breastfeed for about 6-12 months. Breastfeeding can also help you to lose weight. If you are breastfeeding, you may continue to follow your gestational diabetes meal plan and add another carbohydrate choice for breakfast. Continue the 3 snacks, but once you stop breastfeeding, you may reduce them. Drink plenty of water and other sugar free beverages. Plan for future Give your body a “break” from the effects of diabetes during pregnancy for at least 2 years. If you get pregnant again, remember to tell your OBGyn doctor you had gestational diabetes with your last pregnancy and possibly get tested for gestational diabetes earlier in the pregnancy.

PAGE 22 Living with Diabetes while Pregnant How Can I Give My Baby A Healthy Start?

You can give your baby a healthy start by breastfeeding. provides the best nutrition for your baby and protection against certain illnesses. To help prepare for breastfeeding: Talk with your health care team about your plans to breast feed. Ask your provider to recommend a certified to help you with breastfeeding. Take a breastfeeding class. Pregnant women who learn about how to breastfeed are more likely to be successful than those who do not. Talk with friends who have breastfed or consider joining a breastfeeding support group. Breast Feeding Guidelines

Breastfeed as soon as possible after birth. The sucking instinct is very strong within the first hour of life. You will need to add about 300-500 calories daily to your meal plan of 3 meals and 3 snacks a day. Include 3 or more servings of milk products daily as well as plenty of fluids such as water and other sugar free, caffeine free beverages. Continue taking the prenatal vitamin during breastfeeding to ensure that you are getting all the vitamins and minerals you and your baby need. If you took insulin before your pregnancy, you will probably need to take less while you are breastfeeding to prevent low blood sugar. To prevent low blood sugar check with your provider or diabetes educator for insulin adjustment recommendations.

Tucson Medical Center PAGE 23 References

1. CommuniCare Health Centers www.communicarehc.org 2. Sweet Success California Program (CDAPP) 3. www.womenshealth.gov/breastfeeding 4. American Diabetes Association www.diabetes.org 5. BD Getting started Gestational Diabetes www.bd.com 6. National Diabetes Information Clearing House (NIH) www.diabetes.niddk.nih.gov 7. www.nutritioncaremanual.org 8. Medical Management of Pregnancy complicated by Diabetes, 5th Edition. Edited by Donald R. Coustan. MD. American Diabetes Association. 2013. 9. Joslin’s Diabetes Deskbook; A guide for Primary Care Providers, 3rd Edition, Richard S. Beaser MD & Staff of Joslin Diabetes Center, Joslin Diabetes Center 2014.

PAGE 24 Living with Diabetes while Pregnant