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In the 35th week of her pregnancy, Sarah Neitzel, who lives with type 1 diabetes (T1D) in Colorado, suddenly sensed a frightening and dramatic change.

Her insulin needs plunged as she fought off one instance of low blood sugar after another — a concerning development given that her insulin needs had previously skyrocketed through the pregnancy. The baby’s movements suddenly slowed to being almost undetectable to her.

Frightened at those changes, she called her OB-GYN and asked for an immediate ultrasound. They put her off, she said, telling her, “You don’t need one. Everything is good.”

Shaken by that comment, she did what her “mom gut” told her to and lied, telling her OB-GYN that the specialist treating her remotely said it was an emergency and she should be brought in for an ultrasound right away. As they performed the ultrasound, the team told her they are only concerned when a baby does not move for 30 minutes. Her baby was still for 29 of those minutes.

“Something was wrong,” she said. “I just knew it.”

She pushed hard enough to get a specialist to see her and, a day later, she was induced immediately.

She — and the baby — were suffering from something called placental insufficiency, a condition more common in women with T1D.

She was one of the lucky ones, she said: Her baby daughter survived. But only, because her gut told her to keep pushing, she told DiabetesMine.

Other mothers whom she’s met through online support since that birth less than a year ago were not as lucky.

Sarah Neitzel’s healthy baby

Placenta insufficiency can be a risk to both the mother and the child, according to medical experts. It can take several forms, and everyone with diabetes who wants to have a baby should be aware of the symptoms to keep an eye out for through a pregnancy.

The good news? Experts say that with understanding and awareness of the symptoms and risks as well as a good diabetes pregnancy plan, a person with T1D and their baby should be able to overcome it just fine.

“I don’t want people to read this and be scared,” said Dr. Nasim Sobhani, medical director of the UCSF Endocrine, Diabetes and Pregnancy Program. “People with diabetes can and do have babies successfully.”

Placental insufficiency (also known as uteroplacental vascular insufficiency) is a complication of pregnancy in which the placenta is unable to deliver an adequate supply of nutrients and oxygen to the fetus (via the mother’s blood flow) to fully support the developing baby.

This can cause the baby to not get what it needs to thrive. It can impact the mother as well, by leading to premature labor, preeclampsia (elevated blood pressure and end-organ dysfunction), or placental abruption (placenta pulls away from the uterine wall).

Placental insufficiency is a risk for all pregnant people, but experts believe when the mother has any type of diabetes, there’s a higher risk.

“If we step back and think about how the baby and the mother communicate in the body, it’s through the placenta,” Dr. Ping H. Wang, chair of the City of Hope Department of Diabetes, Endocrinology & Metabolism told DiabetesMine.

“If a mother has diabetes, chances are the blood sugar can be high at times, and that can have outcomes we’d rather not see,” he said.

Remember that the placenta is an organ that grows during pregnancy. It attaches to the wall of the uterus, and the baby’s umbilical cord arises from it. This organ’s job is to provide oxygen and nutrients to the growing baby and remove waste products from the baby’s blood.

Since diabetes is known to impact organs, the placenta can be at risk, and that poses health risks to the baby as well as the mother.

Placental insufficiency can lead to congenital malformation, prematurity and even an increased risk of infant death during childbirth, Wang said.

Early on, and even sometimes up until a time of great concern, a woman may not notice any symptoms, making it an almost silent condition for much of the time.

“It’s very difficult for a patient to know (this might be happening),” Wang said.

Neitzel, from her experience, can back that up.

“I’d go (to the doctor for checkups and tests) and they’d say ‘how’s the baby moving? Ten times an hour?’ and I’d say ‘only once or twice a day’ and then they’d just say, ‘That’s the norm!’” she said.

The mother may notice swelling of the hands and feet, something that can happen in a healthy pregnancy, but something that should be assessed since it can also be a symptom of preeclampsia.

The symptoms of preeclampsia are excess weight gain, leg and hand swelling (edema), headaches, and high blood pressure.

To detect whether anything is “off” with the placenta, UCSF’s Dr. Sobhani said it’s a good idea for mothers-to-be with diabetes to pay attention to fetal movement and any changes in insulin needs.

“Insulin needs can suddenly decrease with placental insufficiency because with hormones not passing through the placenta to the baby as they should, the baby’s (and therefore the mother’s) insulin resistance drops. Should you witness a noticeable decrease in either or both, it’s a good idea to check in with your medical team,” Sobhani said.

As Healthline reports, medical tests that can confirm placental insufficiency include:

  • pregnancy ultrasound to measure the size of the placenta
  • ultrasound to monitor the size of the fetus
  • alpha-fetoprotein levels in the mother’s blood (a protein made in the baby’s liver)
  • fetal nonstress test to measure the baby’s heart rate and contractions (the mother wears two belts on their abdomen and sometimes a gentle buzzer to wake the baby)

And what if it is detected? Sobhani says doctors may recommend more frequent prenatal visits, consultation with a high-risk maternal fetal specialist, or bed rest to conserve fuel and energy for the baby.

The mother-to-be may be required to keep a daily record of when the baby moves or kicks, to monitor health and development.

If there is concern about premature birth (32 weeks or earlier), doctors may also recommend steroid injections. Steroids dissolve through the placenta and strengthen the baby’s lungs.

“One thing I have noticed in the type 1 and pregnancy community online is [doctors’] lack of understanding or willingness to listen to a type 1’s fear of placental failure. It is a topic that comes up often in T1D pregnancy group forums,” one young mother and diabetes advocate explained to DiabetesMine.

“Recently, within the span of 2 months, there were two moms who experienced placental failure who had very different end results. Mom #1 had a still birth due to placental failure after her OB-GYN and MFM [maternal fetal medicine specialist] both dismissed her concerns. Mom #2, because of the first mom’s experience, refused to be dismissed, and had a healthy girl born early due to placental failure.”

The takeaway is that it’s vital to advocate for yourself. If you suspect something is not right with your pregnancy, don’t take no for an answer when requesting the proper tests and treatment. If your doctor remains dismissive, it might be time to switch. Here’s a U.S. News & World report tool to help you locate a perinatologist (high-risk obstetrician) in your area.

“The biggest thing you can do is to optimize your disease [care] before getting pregnant,” said Sobhani.

“That’s right, the best step to avoiding placenta insufficiency actually starts before you get pregnant, by working on getting in a tight blood glucose range before conceiving,” the doctors say.

Sobhani suggests preconception consultations in which you meet with an OB-GYN as well as an endocrinologist who has experience and expertise in pregnancy and diabetes.

But, Wang points out, “Not everything in life can be planned. Surprises are the nature of humans.”

So, what if a pregnancy comes as a surprise?

“Go in as soon as you can to speak with a high-risk provider,” Sobhani advised.

The good news? For people like Neitzel who live too far from a major medical center where they could find a high-risk expert, the pandemic has offered help in the form of more accessible telehealth programs.

“COVID-19 did bring the quick adoption of telehealth,” said Wang, who added that telehealth should never completely replace in-person visits, but in cases where access is a challenge, this could help.”

Wang also believes that a good OB-GYN will know how to deal with this, and should be willing to interact with your endocrinology team if needed.

The technology like continuous glucose monitors and insulin pumps can help women hone in on tighter control with fewer challenges, he added, although it’s still hard work.

“This is a significant issue,” Wang said. “But if you plan ahead and work closely with (your medical team), you can get your blood sugar under control for your pregnancy.”

That of course is the goal, and people considering pregnancy with diabetes or at the start of one should feel confident that, armed with information, symptoms to watch for, and a solid team guiding them through pregnancy, they will have a healthy baby.

“Good outcomes can be achieved,” Wang said. “We are always excited to partner with patients to make this happen.”

[See also: 9 Things to Know About Pregnancy with Type 1 Diabetes]