You can have a healthy baby and a safe pregnancy if you have type 2 diabetes, but it is important to plan ahead.
Before pregnancy
Planning a healthy pregnancy
It is important for your blood glucose levels to be in the normal range before you get pregnant. Your baby’s organs will during the first nine weeks of pregnancy, which is often before a person even knows they are pregnant.
Planning your pregnancy and keeping your blood glucose in the normal range reduces the risk of birth defects in your baby. Potential problems for the baby may involve the heart, spinal cord or kidneys.
We strongly recommend seeing your physician before planning a pregnancy. Your physician will do a blood test called an A1C that measures your average blood glucose over the last three months. Once your A1C is less than seven per cent, it is safe to get pregnant.
You should use a reliable method of birth control until your blood glucose is in the normal range. Birth control methods may include condoms used with spermicide foam or the birth control pill. Your health-care team can help you decide which birth control method is best for you.
Blood glucose targets
These are the different blood glucose targets before and during pregnancy. Test your blood glucose before breakfast and two hours after breakfast, lunch and dinner.
Type 1 or type 2 diabetes
blood glucose levels | A1C % goal | Before meal goal (mmol/L) | 2 hours after meal goal (mmol/L) | 1 hour after meal (mmol/L) |
| Not planning pregnancy | < 7.0 | 4– 7 | 5 – 10 | 10 |
| Before pregnancy (normal range) | < 7.0 | 4– 6 | 5 – 8 | 8 |
| During pregnancy | < 6.0 | 3.8 – 5.2 | 5.0 – 6.6 | Less than 7.8 |
Folic Acid
It is important to start taking folic acid when you are planning a pregnancy to prevent neural tube (spinal cord or brain) defects.
Anyone planning pregnancy should take 1 mg folic acid at least three months before getting pregnant and continue until the end of the first trimester.
Ensure your prenatal vitamins have 1 mg folic acid or add extra folic acid if your prenatal vitamin only has 0.6 mg of folic acid. You can purchase folic acid at the pharmacy without a prescription in 0.4 mg or 1 mg tablets.
Continue to take prenatal vitamins until you stop breast/chestfeeding. Check with your obstetrician for further recommendations.
Check for diabetes complications before getting pregnant
It is important to be aware of any diabetes complications you may have before you become pregnant. Some complications can get worse during pregnancy, which may leave you with a permanent medical problem.
Eye exams
See an eye specialist (optometrist or ophthalmologist) before you become pregnant to look for any signs of eye changes called retinopathy. Laser treatment for retinopathy can protect the eye from getting worse during pregnancy. Laser treatment is safe in pregnancy, but untreated eye disease can worsen during pregnancy and cause permanent damage.
Urine Test for Protein
Checking for protein in urine can find early kidney changes. You should have blood and urine tests to make sure your kidneys are healthy.
Blood pressure monitoring
High blood pressure can develop or worsen during pregnancy. Your physician will monitor your blood pressure before and during your pregnancy.
Checking your medication
Some medication, such as blood pressure pills, may not be safe to take during pregnancy. Review your medication with your physician before trying to get pregnant. Your physician may prescribe a different medication that is safe to take in pregnancy instead.
Some natural and homeopathic supplements may also not be safe during pregnancy. Please tell your physician about everything that you are taking.
Diabetes medication
If you are on diabetes pills like metformin, we often recommend switching to insulin before and during your pregnancy.
Insulin is safe in pregnancy because it does not cross the placenta to the baby. It is also safe to inject insulin into your stomach while you are pregnant. The insulin and the needle will not harm your baby.
However, metformin is also safe to take in pregnancy. Talk to your health-care provider about what medication will best meet your needs. Babies start to make their own insulin at nine weeks.
During pregnancy
Please note that the normal range for blood glucose is 20 per cent lower during pregnancy than it is when you are not pregnant.
| A1C % goal | Before meal goal (mmol/L) | 2 hours after meal goal (mmol/L) | 1 hour after meal (mmol/L) |
| < 6.0 | 3.8 – 5.2 | 5.0 – 6.6 | Less than 7.8 |
Supplements
We recommend you take the following supplements:
- 2 x 81 mg of acetylsalicylic acid (ASA) for a total of 162 mg starting at 12 weeks to reduce the risk of preeclampsia
- 2,000 IU of vitamin D
Please discuss any supplements you plan to take with your physician.
Adjusting insulin doses
The amount of insulin needed to keep blood glucose in the normal range will change throughout your pregnancy.
Testing blood glucose before breakfast and two hours after breakfast, lunch and dinner (sometimes before dinner) will allow you to see if your insulin dose needs to be changed. Meet with your diabetes team to learn how to change your insulin doses throughout your pregnancy.
Insulin doses will need to increase, especially during the second half of the pregnancy, as you become more insulin resistant. This starts anytime from 20 weeks and continues until 36 weeks.
Blood glucose can go low more often near the end of the pregnancy as the placenta is changing. If blood sugars continue to go low, more fetal monitoring (fetal stress tests) will help make sure the baby is well.
Adjust treatment to reduce lows (Hypoglycemia)
Prevent low blood glucose levels by matching your insulin dose to your food and activity.
During pregnancy, you should check your blood glucose more often to catch low blood glucose levels that you may not be able to easily feel. As blood glucose levels get closer to normal, the usual signs of low blood glucose may change. You may no longer feel the early warning signs of shakiness or sweatiness and might only have other mild signs of low blood glucose, such as sleepiness or confusion.
Set an alarm on your continuous glucose monitor to warn you when a low blood glucose is approaching.
Treat low blood glucose with15 grams of fast acting carbohydrate such as ¾ cup of juice or pop. Retest blood glucose in 15 minutes. If blood glucose is still less than four, have another 15 grams of carbohydrate. Once your blood glucose is over four, have a snack if your next meal is more than an hour away.
If you are using a hybrid closed loop pump, treat lows with seven to 10 grams of carbohydrate to prevent blood glucose from rising too much after treating a low blood glucose.
Use glucagon for a severe low blood glucose, if you are unconscious and unable to eat. Glucagon is safe to give in pregnancy. An easy-to-use glucagon nasal spray is a good option. It is important that your family members or friends learn how to use it. Please ask your physician for a prescription.
Keeping food and activity consistent
It is important to prevent high and low blood glucose levels. You can do this by matching insulin to food and activity levels.
Work with your dietitian and nurse to help you understand how to make changes to your food and insulin.
Testing blood glucose right before breakfast and then two hours after breakfast, lunch and dinner will allow you to catch any lows before they become serious.
Treat low blood glucose with 15 g of fast acting carbohydrate such as ¾ cup of juice or pop. Retest blood glucose in 15 minutes. If blood glucose is still less than 4, have another 15 g of carbohydrate. Once your blood glucose is over four, have a snack if your next meal is more than an hour away.
Diabetes in pregnancy clinics
At Mount Sinai Hospital, we have specialized clinics that provide comprehensive care to patients with diabetes in pregnancy. You can see an endocrinologist to manage your diabetes at our Diabetes and Endocrinology in Pregnancy Clinic and a maternal-fetal medicine (MFM) specialist for pregnancy care at the Medical Disorders of Pregnancy Clinic.
Ask your physician about a referral to one or both of those clinics to ensure you receive comprehensive care for diabetes in pregnancy, including:
- Blood tests and an ultrasound of the baby at 11 to 13 weeks gestation
- Blood tests at 16 weeks
- An ultrasound at 18 to 20 weeks, if needed
- A placental ultrasound scan at 22 weeks
- Ultrasounds every four weeks after 24 weeks of pregnancy to monitor your baby’s health and growth
- Weekly pregnancy appointments after 34 weeks
Possible pregnancy complications
Diabetes can increase your risk of the following pregnancy complications:
- Worsening high blood pressure or preeclampsia/eclampsia
- Hydramnios (excess amniotic fluid)
- Advanced diabetes complications
Your health-care providers will monitor your blood pressure, amniotic fluid levels and general health throughout pregnancy.
It is important to tell your health-care provider if you have severe headaches or visual changes.
Possible complications for your baby
High blood glucose during early pregnancy can increase the risk of birth defects that can affect the heart, spinal cord or kidneys.
High blood glucose during any stage of pregnancy can increase the risk of the following complications for your baby:
- High birth weight, over nine pounds
- Preterm delivery
- The following treatable conditions that usually go away in a few hours or days:
- Breathing problems
- Low blood glucose
- Jaundice
- Too many red blood cells
- Low calcium levels
- Heart problems
