Concerned about starting a family with diabetes? Diabetes and pregnancy can be a difficult pairing -- although contrary to old school thinking, it is more than possible to have a healthy pregnancy and healthy baby if you’re living with type 1 or type 2 diabetes.
To get some of the best and most down-to-earth advice possible, we talked recently with two wonderful experts, one from the physician side and one from the patient POV:
Dr. Kristin Castorino of the William Sansum Diabetes Center in Santa Barbara, who among other things follows in the footsteps of famous D-pregnancy expert Dr. Lois Jovanovič, serving as the attending physician at the Santa Barbara County Public Health department teaching medical residents how to care for women with diabetes and pregnancy.
Brooke Gibson, a type 1 for 32 years who has had four healthy pregnancies (!) and is founder of T1D Sugar Mommas, a San Francisco Bay Area support group for expectant and new mothers with type 1 diabetes.
Both were kind enough to share their best gems of insight with our community in the following double-interview.
As always, we encourage anyone with first-hand knowledge of these topics to chime in, in the comments section below.
(Also, stay tuned for an overview of Gestational Diabetes, that we’ll publish soon with some great tips on dealing with that condition specifically.)
DM) Ladies, in your opinion, what are the biggest overall misconceptions about diabetes and pregnancy?
Dr. Castorino) I think the greatest misconception about diabetes and pregnancy is that there are only two states – pregnant and not pregnant. In reality, pregnancy is much more complicated. A woman’s body physiology is changing rapidly – and may require almost weekly modifications to her diabetes regimen, such as changes in insulin requirement or changes in the way your body responds to carbohydrates. The first trimester is a period where women are most sensitive to insulin and may also be struggling with morning sickness and both of these can lead to more frequent hypos. On the other end – the third trimester is known for significant insulin resistance. Most women’s insulin requirements double their pre-pregnant amount by the final weeks of pregnancy. Not to be forgotten is the postpartum period. Soon after delivery, most T1 women’s insulin requirements drop by 70-80% especially if they are breastfeeding.
Brooke Gibson) From a general overall perspective, the biggest misconception seems to be that diabetic women cannot have healthy babies, and this is the furthest thing from the truth.
What do women tend to worry about most that's unfounded?
Dr. Castorino) It’s true that most women with pre-existing diabetes worry that they cannot have a healthy baby. Their Internet searches, and possibly old medical opinions have skewed the latest data which shows that women with T1 that is well-controlled have healthy babies in most cases. I hope all women with T1D (especially young ones) know that T1 should not impede plans for pregnancy. Also, many women with T1 are very concerned they will pass T1 on to their child. Though there is a risk – see ADA facts – in most cases the risk is not significant (1 in 100). But for men with T1 the risk is higher (1 in 17). With all the advances in diabetes technology, most diabetes experts agree that this should not be a deterrent to people with T1 who are considering starting a family.
Brooke Gibson) I think one of the biggest things… is that if they have a single high blood sugar, they are doing lots of damage to their baby. While long-term high blood sugars can have a developmental effect, an individual single blood sugar that is corrected quickly should not impose any problems. This was something that I was consistently told by my perinatologist. Especially in my first pregnancy when I would freak out about having a high blood sugar, she would remind me that I was not keeping it there for an extended period of time and I was doing the best I could do to correct it quickly.
What SHOULD women with diabetes be most concerned about during pregnancy?
Dr. Castorino) During pregnancy, your goal should be to be in the best control of T1 or T2 of your life. During pregnancy, the goal is near normal blood sugar most of the time. Scientists at the University of Colorado (Teri Hernandez & Lynn Barbor) showed that women without diabetes have blood sugar range of ~ 60 – 110mg/dL during pregnancy. From all the research that has been done for women with diabetes during pregnancy, the best way to create a normal glucose environment for babies is to avoid things that cause big glucose fluctuations. By far, the No. 1 cause of unpredictable blood sugars is food – especially food that you know makes your blood sugar high. One trick is to be “boring” by frequently eating meals that are reproducible and easy to accurately bolus for. For variety, try new colorful vegetables.
- In general, if you are a man with T1D, the odds of your child developing diabetes are 1 in 17.
- If you are a woman with T1D and your child was born before you were 25, your child's risk is 1 in 25.
- If your child was born after you turned 25, your child's risk is 1 in 100.
- Your child's risk is doubled if you developed diabetes before age 11.
- If both you and your partner have T1D, the risk is between 1 in 10, and 1 in 4.
Brooke Gibson) As mentioned, high blood sugars are something you want to try and avoid as much as possible, and... the further you progress into the pregnancy the more insulin resistance you will most likely experience. By the time you're in your third trimester, your basal rates can be changing every 1 to 2 days. This is not true for everyone, but for most T1D women. And it's important to remember that every pregnancy is different. My insulin needs were different in each one of my four pregnancies.
What is your top tip for women with T1D who are already or trying to get pregnant?
Dr. Castorino) My top tip is that becoming pregnant is a marathon, not a sprint. Women spend many years trying to avoid pregnancy, then all of a sudden, the stars align and they are ready to start a family. It’s normal to require a year or two to become pregnant. This is a good time to make sure you have all the tools you need for the best T1D control of your life. If you are considering getting a new CGM or pump, get it. If you’ve been wanting to change up your exercise routine – make those changes and learn how they affect your glucose control.
My second tip is that miscarriage is common for ALL WOMEN (10-17% of pregnancies end in miscarriage), but not all women prepare for pregnancy and are closely watching for the earliest signs of pregnancy. In fact, about half of all pregnancies in the United States are planned, and the rest are a surprise. Many women miscarry and don’t even realize it. So when you are working hard at getting ready for pregnancy, it’s also important to find a balance and enjoy life “BC” – before children.
Brooke Gibson) One of the most important steps besides having good blood sugar control is to make sure you have a good supportive medical team. You need an endocrinologist and OB/GYN who aren't going to make you feel bad for any reason and who will help and support you. They must be knowledgeable and able to guide you and not make you feel like you're just screwing it up along the way. It's very important to be open to suggestions and changes as you monitor your blood sugars and food intake. Additionally, finding a local group like our T1D Sugar Mommas is a great support system! It's wonderful to be able to talk to women who are in family planning stages, currently pregnant or have already had children.
Likewise, what is your top pregnancy tip for women with T2 diabetes?
Dr. Castorino) Women with T2 can learn from their T1 sisters, since much of “what works” for T1 can be used for T2. For example, consider using a continuous glucose monitor to help better manage glucose values, especially related to meals. Just like T1, women with T2 should strive for near-normal blood sugars while avoiding low blood sugars.
Tight glucose control during pregnancy usually aims for 60-105 mg/dL before meals, and less than 140 mg/dL after eating.
Target A1C during pregnancy is less than 6 percent.
All pregnant women get an ultrasound around week 18 to monitor the baby's development; with diabetes, expect to get ultrasound scans much more often.
Brooke Gibson) I'm not an expert in this area, but I think it would have to be the same advice as a T1: Make sure you have a good supportive medical team and any other additional support that you can. It will be important to watch your diet closely as an unlike with T1 you cannot give insulin to control your blood sugars to cover anything you eat.
What should these women be looking for in a healthcare professional who can guide them through a healthy pregnancy?
Dr. Castorino) Most women with T1 or T2 in pregnancy need more than one person on their healthcare team:
- Perinatologist (High Risk Obstetrician) – Having diabetes during pregnancy is considered a high risk pregnancy in most areas.
- Obstetrician (OB/GYN) – This is the person who will deliver your baby. It is nice when they are comfortable with diabetes but it is often not the case. Ask your OB how she or he manages women with diabetes. This will help you to build your team.
- Diabetes and Pregnancy Expert – Look for another healthcare professional who knows this field well, such as a dietitian, diabetes educator, perinatologist, or endocrinologist – the title is less important than the experience.
- ____________ (fill in the blank) Anyone else who could be instrumental in supporting a healthy pregnancy, like a counselor or psychiatrist, or dietitian.
Build your dream team so that you have the support you need.
Brooke Gibson) It's definitely a bonus if your doctor has experience with T1D and pregnancy. But sometimes your healthcare professionals will just prefer to focus in their specific expertise. Making sure you are in good communication with all of your doctors is what is most important. You can have your endocrinologist help you to control your blood sugars and your OB who can guide you throughout your pregnancy. Make sure your endocrinologist or OB professional knows to ask for the additional tests that a T1D might want or need, such as an echocardiogram for a fetus at around 18 to 20 weeks and the stress testing towards the end of pregnancy.
Bonus question for T1D Momma Brooke: As someone who went through multiple diabetic pregnancies yourself, what would you most like to share on the topic?
Brooke Gibson) Being a pregnant T1D is definitely an additional full-time job along with everything else going on in your life. It's important to stay on top of your blood sugars and be in good contact with your medical team.
One of the biggest things I’ve learned is to not be too hard on yourself. Find a support system that helps you throughout this experience. A lot of the fears you may have may be exactly the same as someone who doesn't have diabetes. Every woman hopes to have a healthy, happy baby.
Know that it is possible to have healthy babies. And also look at it as an advantage to take a few extra peaks at the growing baby inside your belly. I definitely enjoyed every one of my extra ultrasounds!
Thank you to our resident doctor and patient experts!
**NOTE ALSO**: T1D ExChange is currently conducting a survey of women with pre-existing T1D who have given birth in the last 10 years, to enhance medical knowledge on diabetic pregnancies. If you qualify, please take the survey here.
Some Resources on Diabetes and Pregnancy
JDRF Toolkit for Pregnancy and Type 1 Diabetes -- a comprehensive guide for future and current expectant parents with type 1 diabetes available electronically and in print.
Diabetic Mommy -- an online blog and community site run by a mom with type 2 diabetes.
“Balancing Pregnancy with Pre-existing Diabetes” -- guidebook by advocate and T1D mom Cheryl Alkon.
“Diabetes and Pregnancy: A Guide to a Healthy Pregnancy” -- comprehensive guide for women with T1, T2, or gestational diabetes by David A. Sacks.
Seven Things That Are Awesome About Being Pregnant with Type 1 Diabetes -- a fun take on the condition by prolific blogger and advocate Kim Vlasnik on her site Texting My Pancreas.