PREGNANCY, YOUR BABY, AND DIABETES THIS TOPIC IS DIVIDED INTO TWO MAIN SECTIONS: Pre-pregnancy and Diabetes Pregnancy for the Woman with Diabetes PE 07002 (02/12) 1 of 1 To view or print: http://www.healthsystem.virginia.edu/docs/per To order: http://www.virginia.edu/uvaprint/ Pre-pregnancy and Diabetes •A careful balance of your meal plan, activity, and insulin needs to be achieved and maintained before and during pregnancy. •Choosing to have a baby is a big decision and an exciting time. It may also be a time when you are more concerned about your health if you have diabetes. •Today, the chances are better than ever that a woman with diabetes will have a healthy baby. Keeping blood sugar levels near the target range before and during pregnancy helps to ensure a positive outcome of your pregnancy. •What are the target blood sugar values for the non-pregnant woman with diabetes? –Fasting: 70 -130 mg/dl –Before meals: 70 -130 mg/dl –HbA1c< 7% •Having diabetes increases the risk of problems for you and your baby. During pregnancy, the sugar in your blood goes to the baby so it can grow and develop. If your blood sugars are too high, they can cause birth defects and other problems. •Because the baby’s organs are formed during the first 12 weeks of life, the risk for birth defects is greatest if blood sugars are poorly controlled during the first trimester. •You can reduce your risks of birth defects to that of someone that does not have diabetes by having a normal HbA1c and blood sugars consistently in your target range before you become pregnant. •You will need to continue to use contraceptives until your blood sugars are in the target range and your HbA1c is normal. This test gives you a three month average of your blood sugars. Page 2 of 15 Controlling Your Blood Sugar Before Pregnancy •It is a good idea to begin working before pregnancy with the health care team who will provide your prenatal care. This team includes an obstetrician, pediatrician, nurse educator, and dietician. Pregnancy can bring out some of the long term complications of diabetes. Get a check up now of your eyes, kidneys, heart, and BP. •If you take oral diabetes medications, you will stop taking them and begin taking insulin. Oral medications and Glargine insulin may be harmful to the developing fetus. ACE inhibitors (for kidney disease) should also be discontinued when you become pregnant. Your doctor will decide on the best substitute medication for you. •Your insulin needs may increase, or you may take more than one type to meet your blood sugar target goals. Two to four injections/day is common before and during pregnancy. •Meet with a dietician to develop a meal plan. •If you have a regular exercise program, continue it. You will need to test more often when you exercise. You may need an exercise snack before, during, or after exercise. •You will need to test and record your blood sugars at least 4 times a day to be sure your target ranges are working. •Once your blood sugars are lower, you may experience more low blood sugar reactions, so you need to carry at all times a quick-acting source of sugar such as glucose tablets, gel, or hard candies. •Cigarette smoking and alcohol are harmful to your unborn child. If you smoke, stop smoking. Alcohol and caffeine should be avoided during pregnancy. Page 3 of 15 Other Considerations  There is very little chance your baby will be born with diabetes. If you have type 1 diabetes, there is a 1 -2% chance that your child will develop diabetes over his or her lifetime. Men with diabetes have a 6% chance of having a child with diabetes. If you have type 2 diabetes, there is a 30% chance your child will get diabetes as an adult.  •There is no ideal age to become pregnant. Women between the ages of 20 -35 years have fewer health risks.  •A pregnancy is very demanding when you have diabetes. This can be a stressful time for you. It takes knowledge, time, effort, planning, and money for the extra health care cost. You may need to take time off from work or arrange for help caring for other children or with housework. Now is the time to talk and plan with your partner and other supporting people about the demands of pregnancy and diabetes. Page 4 of 15 Pregnancy for the Woman With Diabetes •Women with diabetes are affected by all of the normal changes that occur during a pregnancy. Some of these changes can cause problems with blood sugar control. •When you have an infection such as a cold, the need for insulin increases and the risk for DKA increases. Test your urine for Ketones if your blood sugar is greater than 200mg/dl. •The amount of sugar lost into the urine increases. Therefore glycosuria or sugar in the urine can occur with normal blood sugar levels. •Diabetes increases the risk for certain problems in the mother and baby: –preeclampsia (a combination of high blood pressure, protein in the urine, and swelling in the hands, face, and feet). –urinary tract infections –hydramnios or too much water in the sac around the baby, which may cause the uterus to stretch and may lead to early delivery. This occurs in 25% of diabetic pregnancies. Bed rest is recommended. –large babies at birth (over 9 lbs) –low blood sugar and breathing problems in the baby after birth –stillbirth –while it is frightening to hear about these possible problems, it is important to know why blood sugar control is so vital. Keeping your blood sugar target range near normal will help prevent these problems. •All women produce Ketones more easily during pregnancy. Ketones result when body fats are broken down for energy instead of sugar. So ketosis and diabetic ketoacidosis or DKA can occur more rapidly in women with diabetes when they are pregnant. Ketones cross the placenta and affect the fetus. This can be avoided if blood sugars are in good control. •The placenta, the organ that feeds the baby, produces hormones that go against the action of insulin. These hormones increase as pregnancy goes on. This leads to a change in insulin needs during pregnancy. You will need more insulin as the weeks go by. Page 5 of 15 Caring for Diabetes During Pregnancy •The target blood sugar level for pregnancy is: –60-95 mg/dl fasting before breakfast –60-105 mg/dl before other meals –less than 120 mg/dl 90 minutes to 2 hours after meals –above 60 mg/dl during the night •Your prenatal care will probably be provided by a team of health professionals. The team includes an obstetrician, endocrinologist, nurse educator, dietician, and perhaps a social worker. •You may need to visit your doctor as often as every other week during the first and second trimesters, and then every week until delivery. •Test and record your blood sugar levels. Use this information to see how the food you eat, your activity, and your insulin affect your blood sugar levels. Bring your record with you to each of your appointments. •Follow your meal plan as prescribed by your dietician. •Your insulin dosage will change often, especially during the last half of pregnancy. Page 6 of 15 Gestational Diabetes: Diabetes Discovered During Pregnancy •This type of diabetes appears for the first time during pregnancy. It occurs in 7-10% of all pregnant women. •Women at risk: –Women who are older than 35 years –A previous pregnancy with a baby weighing 9 lbs. or more at birth –family history of diabetes or previous GDM –overweight – ethnic background of African American or Hispanic •Gestational diabetes, as this is called, may occur because hormones produced by the placenta in all pregnant women may make insulin work less well. •These hormones increase as pregnancy goes on. More insulin is needed to maintain normal sugar levels. If the pancreas is unable to produce enough insulin, gestational diabetes occurs. •Gestational diabetes is usually found in the 24-28 week of pregnancy. A special screening blood test is done at that time called a glucose tolerance test. •Gestational diabetes does increase the risks of certain problems for the mother and baby. The risks are greatest in the last trimester and if the blood sugar levels are not well controlled. Some of the problems are: –large babies at birth (>9 lbs) –low blood sugar and breathing problems for the baby after birth –jaundice or yellowish skin in the baby 2-3 days after birth (temporary) –stillbirth –hydramnios (too much water around the baby) which may cause the uterus to stretch and may lead to early delivery –preeclampsia (a combination of high blood pressure, protein in the urine, and swelling of the hands, face, and feet) –urinary tract infections –gestational hypertension –vaginal yeast infections •After pregnancy, the symptoms of diabetes usually disappear. You need to have your blood sugar tested following delivery to be sure you no longer have diabetes. Page 7 of 15 Caring for Gestational Diabetes •The purpose of the treatment is to keep the blood sugar near the target range. The target blood sugar levels for pregnancy are: –fasting: less than or equal to 95 mg/dl –90 minutes to 2 hours after a meal: less than or equal to 120 mg/dl –This may vary depending on your individual needs. •The first treatment is a meal plan and exercise with blood sugar monitoring daily. •Insulin injections may later be needed for better blood sugar control. •Test and record your blood sugar levels. Use this information to see how food, activity, and insulin affect your blood sugar. Bring this record with you to each of your appointments. •You will be asked to visit your obstetrician more often than women without gestational diabetes. It is very important that you keep your appointments. You may be referred to a specialist in diabetes or highrisk pregnancies. •After pregnancy, the symptoms of diabetes usually disappear. Only 2% continue to have diabetes immediately after delivery. You must continue to seek medical care if this is so. You will have another GTT at your post-partum visit to make sure that your blood sugars are back to normal. •If you no longer have diabetes and you plan to become pregnant again, you should have a screening blood sugar test before your pregnancy and once you are pregnant. •Type 2 diabetes is likely to return later in life. If you are at your ideal body weight, you have a 25% chance of developing type 2 diabetes. If overweight, your chances increase to 60%. Page 8 of 15 More About Controlling Your Blood Sugar DIET INSULIN • Eating meals and snacks spread out throughout the day and at bedtime will help to keep your blood sugar levels in the target range. • Do not go on a weight-reduction diet. More calories are needed to meet the energy needs of the baby (300 more calories/day). • Follow your meal plan as set out for you by your dietician. • You will learn about carbohydrate counting. EXERCISE • Exercise burns calories, decreases blood sugar levels, and increases feelings of well-being. • Check with your doctor about the exercise program that is right for you. Walking and swimming are good activities. • Check your blood sugar levels more often when you exercise. If you are prone to low sugars, carry fast acting sugar with you or eat an exercise snack. • Most women take more than one injection of insulin per day, usually with two types of insulin. This helps keep the blood sugar in the target range. • You will be taught how to inject insulin and you may be taught to adjust your insulin dose based on your blood sugar readings and carbohydrate meal content. HYPERGLYCEMIA • Signs and symptoms of hyperglycemia or high blood sugar are: • • • • • • high blood sugar Ketones in your urine more urine output than usual increased thirst dry skin and mouth decreased appetite, nausea, and vomiting and blurry vision • fatigue, drowsiness, or no energy • Vaginal yeast infections • Call your doctor right away if you have these symptoms. Do not skip insulin. Page 9 of 15 Team Care •At each visit to your obstetrician, your weight, blood pressure, general health, and growth of the baby will be checked. •Your urine will be checked each time for glucose, Ketones, protein, and bacteria. •Your meal plan will be reviewed with you. Be sure to bring your blood sugar logbook and meter. You may meet with a dietitian to learn more about your meal plan or with a nurse to learn more about diabetes during pregnancy. •Between visits, write down any questions or concerns you have so that you remember to ask them during your visits to your health care team. •Contact your doctor right away if you notice:  more than trace Ketones in your urine  blood glucose values consistently above target  decreased movement of your baby (less than 4 kicks/hr after 28 weeks)  any infection or illness (fever, nausea, or vomiting)  lower abdominal (stomach) cramps  vaginal bleeding or leakage of fluid  sharp back pain or abdominal pain  burning or pain when passing urine Page 10 of 15 Team Care Continued...  dizziness, fainting, blurred vision, or spots before your eyes  rapid weight gain  swelling of your hands, face, or feet  low sugar that someone else has to help you treat, or so severe that you pass out  severe nausea or vomiting with high sugar and Ketones in your urine Special tests and procedures during pregnancy ‒ An ultrasound test to determine the size, growth, and position of the baby and placenta, this uses sound waves to measure and it is safe. ‒ A 24 hour urine test done every so often to test for protein and creatinine. These tests measure kidney health. ‒ Ophthalmology visit to check the health of your eyes. ‒ Non stress test done periodically to record your baby’s movements and changes in heart rate. How often depends on how well your diabetes is controlled. ‒ Drawing of your blood to measure A1C or 3 month average of your blood sugars. ‒ Quadruple screen is a blood test done at 16 -18 weeks of pregnancy. This gives information about whether your baby is at high risk for birth defects. Page 11 of 15 Meal Planning for Diabetes in Pregnancy To control your blood sugar, you need to watch what, how much, and when you eat. It is important to consume balanced meals and snacks, paying special attention to amounts and types of carbohydrates. Here are some general guidelines. 1. Eat consistently during the day, distributing your carbohydrate choices evenly. The best way is to eat 3 meals a day. •Try not to go longer than 4 hours without eating during the day •Healthy snacks are ok if you become hungry 2. Include a good source of protein at every meal and snack. High protein foods are: ●Low-fat meats ●Natural peanut butter ●Chicken ●Nuts ●Fish ●Low fat cottage cheese ●Low fat cheese ●Eggs 3. Eat breakfast soon after waking •Have no more than 2 carbohydrate servings •It is best to avoid fruit, fruit juice, and cold cereal with milk •Include some protein and healthy fat 4. AVOID SUGAR AND CONCENTRATED SWEETS. These include: ●Table sugar ●Regular soda ●Honey ●Chocolate ●Molasses ● Ice cream ●Candy ●Fruit canned in heavy or lite ●Jams and jellies syrup ●Cookies ●Sugar-sweetened drinks (like ●Cakes Kool-Aid, Hi-C, and sweet tea) 5. Artificial sweeteners may be used to sweeten foods and drinks •Studies have shown that moderate amounts are safe for you and your baby 6. Choose high fiber foods, such as: •100% whole wheat bread or “White Wheat” •Fresh and frozen vegetables •Beans and legumes •Fresh fruit Page 12 of 15 7. 8. White-colored foods may cause your blood sugar to rise significantly. These foods, and healthy alternatives, include: Lower your total fat intake “White Food”: Try This: •Eat lean sources of protein •Chicken •Roast beef •Turkey •Ham •Fish •2% or low-fat cheese White rice White bread Regular pasta Potatoes Brown rice Whole wheat bread Wheat pasta Sweet potato •Look for leaner cuts of red meat, such as round and loin •Look for less marbling •Remove all visible fat and skin from meats •Bake, broil, steam, boil, or grill foods (rather than frying) •Use skim or 1% low fat milk and dairy products 9. Watch sodium intake •Limit lunch meat, bacon, sausage, and hot dogs •Rinse canned beans and vegetables •Resist the urge to use the salt shaker •Limit frozen and pre-prepared meals/snacks and canned soups •Guidelines: < 100 mg for snacks and side dishes and < 400 mg for meals 10. Include small amounts of healthy fats, such as: •Olive and canola oil (rather than vegetable oil) •Nuts, peanuts, almonds, and walnuts •Avocados 11. Food safety is important! •Avoid undercooked meat •Avoid shark, swordfish, king mackerel, and tilefish •Limit all other fish to 12 oz. or less per week •Eat no more than 6 oz. (1 can) of light tuna per week (avoid albacore) •Cook eggs until done •Only consume pasteurized milk and dairy products •Watch out for cross-contamination (i.e. handling raw meat and eggs) 12. Regular exercise can help control blood sugar levels. Try these things: •Walking •Swimming •Housework •Playing with kids Page 13 of 15 Breakfast: Snack: Lunch: Snack: Dinner: Snack: 2 Carbohydrate servings 1 Carbohydrate serving 3 Carbohydrates servings 1 Carbohydrate serving 3 Carbohydrates servings 1 Carbohydrate serving Carbohydrate Food Choices 1 serving = 15 g carbohydrate Starch  Supplies energy and fiber  An example of a serving is 1 slice of bread Fruit  Supplies vitamins, minerals, and fiber  An example of a serving is 1 small fresh apple Milk  Supplies calcium, phosphorous, protein, and vitamins  An example of a serving is 1 cup of milk (8 oz.) Page 14 of 15 Sample Menus for Diabetes in Pregnancy Breakfast Breakfast Sandwich Oatmeal 1 poached or scrambled egg 1 whole grain English muffin (2) 1 slice cheese 1 slice Canadian bacon 1 cup cooked oatmeal (2) 1 tsp Splenda ® 1 tsp cinnamon ¼ cup of nuts Lunch Ham Sandwich and Yogurt Soup and ½ Sandwich 2/3 cup light yogurt (6 oz. container) (1) 2 slices low sodium ham 2 slices whole wheat bread (2) Lettuce and tomato Mustard and/or mayonnaise 1 cup low sodium vegetable soup (1) 1 slice whole wheat bread (1) 1 slice reduced-fat American cheese 2 oz. deli turkey 1 slice tomato 1 small apple (1) Dinner Chicken Fajitas Healthier Hamburger 3 oz. chicken breast 1 6-inch flour tortillas (1) 2/3 cup rice (2) 1 oz. 2% shredded cheese Shredded lettuce 2 Tbl reduced-fat sour cream 3 oz. hamburger patty 1 hamburger bun (2) Green salad with non-starchy veggies 1 corn on the cob (1) 1/3 cup salsa Snacks 3 cups air-popped popcorn (1) ½ banana and 1 Tbl of natural peanut butter (1) 2/3 cup (6 oz.) light yogurt 2 Tbl nuts (1) 6 crackers with 2 oz. tuna (1) ½ cup peaches with ½ cup non-fat cottage cheese (1) 3 graham crackers with natural peanut butter (1) 1 small apple (1) and 1 oz. of low-fat cheese 1 cup carrot sticks with 2 tbsp low-fat ranch dressing ½ medium baked potato with ¼ cup shredded 2% cheese (1) Page 15 of 15