Type 1 diabetes and pregnancy Information for patients 1 2 Contents How will diabetes affect my pregnancy? 4 How will diabetes affect my baby? 5 My antenatal care 6 Hypoglycaemia 9 Planning for your birth 12 After your baby is born 15 Nutrition and related issues 17 Diet and lifestyle Controlling your blood glucose levels with diet Fluid intake Fat in foods Calcium Iron Folic acid and diabetes Diabetic products Symptoms in pregnancy How much weight should I expect to put on? Physical activity Suitable snacks Additional information Breastfeeding and diabetes 31 What happens once my baby is born? 34 For the future 37 References and useful links 39 3 This booklet aims to tell you what care to expect during and after your pregnancy when you have diabetes. It will not answer every question you may have, so please write any concerns down and ask your midwife or doctor. We run a joint antenatal and diabetes clinic at Barnet Hospital and the Royal Free Hospital. We have a dedicated multidisciplinary team who will review you on a regular basis to provide advice and support throughout your pregnancy. The team consists of a consultant endocrinologist, obstetrician, diabetes specialist midwife, diabetes specialist nurse and a diabetes specialist dietitian. How will diabetes affect my pregnancy? With good pre-conception care and good diabetes control there is every chance of a successful pregnancy. As soon as your pregnancy is confirmed, you should attend the joint diabetes antenatal clinic. Here you will receive support and advice to enable you to obtain and maintain good control of your diabetes as early in your pregnancy as possible. The aim is to achieve the following blood glucose levels: Pre-meal: 3.5-5.3 mmol/l One hour after meals: less than 7.8 mmol/l 4 By achieving and maintaining good blood glucose levels throughout your pregnancy you will reduce the chance of developing complications during your pregnancy and increase the ability of your baby to grow and develop normally. How will diabetes affect my baby? Your baby will not be born with diabetes. However, if uncontrolled, high levels of glucose in your blood cross the placenta and get into the baby’s blood; this will stimulate your baby to make more insulin in order to bring its glucose levels down. As insulin stimulates growth as well as controlling blood glucose levels, the baby may grow larger than normal, which in turn can make delivery more difficult and stressful. High blood glucose levels may also affect how efficiently the placenta works and so can sometimes lead to smaller babies. Establishing good blood glucose control before conception and continuing this throughout pregnancy will reduce the risk of miscarriage, congenital malformation, stillbirth and neonatal death. 5 My antenatal care Appointments You will be offered an appointment in the joint diabetes antenatal clinic approximately every fortnight. At each clinic visit, you will have your blood pressure checked and your urine tested as part of the assessment of both your health and that of your developing baby. The type of clinician you see will depend on the stage you are at with your pregnancy and your blood glucose control. You will have contact with the diabetes and obstetric doctors, diabetes nurse, diabetes midwife and diabetes dietitian as appropriate. Blood and urine tests A blood test to estimate your HbA1c will be taken in early pregnancy, as well as the routine blood tests. This measures your average diabetic control over a two to three month period and assists the diabetes team to plan your care. Your kidney function will also be assessed if this has not been done in the last 12 months by a blood and a urine test. Antenatal screening If you are interested in finding out about specific antenatal screening tests available, discuss this with your doctor or midwife. 6 Retinal (eye) screening Retinal screening will be offered at least twice in your pregnancy to monitor the health of your eyes. Blood glucose testing You will need to monitor your blood glucose levels regularly. Your diabetes specialist midwife or nurse will discuss this with you and may change your blood glucose monitor if needed. The aim will be to keep your blood glucose levels within the following targets: Fasting or before meals Between 3.5-5.3 mmol/l One hour after meals Less than 7.8 mmol/l Diet Your diabetes specialist dietitian will give you advice to help you to maintain a healthy diet and to control your blood glucose levels. Please see pages 17-29 for information on nutrition and related issues. Medication Insulin is safe in pregnancy and you will remain on it. Due to increasing insulin resistance caused by hormones from the growing placenta, your doses of insulin will continue to increase until baby arrives. The aim of keeping your blood glucose within target levels is to optimise the outcomes for both you and your baby. 7 Ultrasound scans An early ultrasound scan will be offered to confirm and date your pregnancy. At around 20 weeks gestation you will be offered an anomaly scan – this is a scan to look at the physical development of the baby. You will also be offered a foetal cardiac scan, which is a detailed scan of the baby’s heart. This will be done at University College Hospital, based in London, where the specialist scan is available. From about 28 weeks gestation you will be advised to have an ultrasound scan to measure the growth of your baby and the amount of fluid around the baby every four weeks. 8 Hypoglycaemia In early pregnancy there is an increased risk of becoming hypoglycaemic. Hypoglycaemia means ‘low blood glucose levels’ – less than 3.5 mmol/l. This is too low to provide enough energy for your body’s activities. Signs of hypoglycaemia Everyone experiences different symptoms but common ones include: sweating dizziness headache tingly hands, feet, lips and tongue trembling hunger feeling tearful, stroppy, anxious, irritable palpitations impaired/blurred vision feeling weak/tired. 9 Treatment for hypoglycaemia Mild/moderate Severe hypoglycaemia hypoglycaemia If you are able to, take 15-20g Your friends/family may need of quick acting carbohydrate, to help you and need to know eg: how to. 4-6 Dextrose tablets 2 tubes Dextrogel If conscious: 4-6 lumps of sugar Give a sugary drink or 170-220ml Lucozade honey – this may need to Energy (new formula of be poured into your mouth 8.9g per 100ml). if you don’t recognise your symptoms and are Please check the bottle as reluctant to be treated. a new lower sugar Lucozade was released in If unconscious: April 2017. Call an ambulance. Give an injection of 4-5 teaspoons of sugar Glucagon which will raise 200ml orange juice your blood glucose. Glucagon only lasts for a Followed by: short time so when a good snack eg two conscious you must have digestive biscuits/crackers a sweet drink to stop the or a piece of fruit OR hypo returning. eat your next meal early. Continue with small amounts of sweet drinks Recheck your blood glucose until well enough to eat. after 10-15 minutes – it should Check blood glucose level. be above 4 mmol/l 10 Hypoglycaemia unawareness You may lose some of your ‘hypo’ awareness meaning you may not recognise if you are becoming hypoglycaemic, so: Increase the number of times you check your blood glucose every day or check at different times. Always check your blood glucose before driving or using machinery. If levels are under 5.5 mmol/l, eat and test again. If glucose levels are higher than that but falling, eat and test again before driving. Discuss your hypoglycaemic episodes with your health care team so you can look for patterns to use as warning cues. Ensure those around you are aware of how to treat you if you cannot treat yourself. Wear an ID bracelet that identifies you as a person with diabetes. Discuss the use of glucagon and any other concerns with the diabetes team. Ensure you carry hypo treatments with you at all times, eg Glucogel, glucose tablets or a small bottle of orange juice. 11 Planning for birth Towards the end of your pregnancy you will need to plan when and how your will give birth to your baby with your doctors. Your medical history, and the size and position of the baby, will all need to be considered. Ideally the aim is for you to have a normal vaginal delivery. This is recommended from 38 completed weeks of pregnancy (occasionally earlier) and often induction of labour is advised. Vaginal delivery If the plan is for a vaginal delivery, you will be advised to phone the delivery suite when you think you are in labour. It will be necessary to control your blood glucose levels carefully throughout your labour, and this is usually achieved by an intravenous glucose and inuslin infusion. The insulin dose will be adjusted according to the results of hourly blood glucose monitoring. The aim will be to keep your blood glucose levels between 4-7 mmol/l. During your labour it is recommended that the baby’s heart rate is monitored continuously, so that any potential complications can be detected quickly. High or low blood glucose levels can affect the baby’s heart rate. If your labour is to be induced, the procedure will be explained and you will be given a date and time to go in to hospital. You will continue your usual insulin and 12 blood glucose monitoring regime until you are in established labour.