Challenges of Pregnancy with Type 1 Diabetes: A Clinician’s Perspective
By Rachel Garcetti, PA-C, M.S.
Physician Assistant, Pregnancy and Women’s Health Clinic of the Barbara Davis Center (BDC)
For many women, pregnancy is one of the most exciting events in their lives. For women living with type 1 diabetes (T1D), the thought of pregnancy can trigger mixed emotions. Pregnant women with T1D describe feeling overwhelmed, excited, stressed, and even scared. At the root of these emotions, are the drastic changes that accompany pregnancies complicated by T1D. Changes like the fluctuating insulin requirements throughout pregnancy and the postpartum period, the tighter glucose targets of pregnancy, and the physical and emotional stresses of pregnancy that many women experience (i.e. fatigue, weight gain, morning sickness, etc.), can all be quite challenging.
Many women with T1D have seen movies that portray pregnant women with T1D in a negative light, or have had interactions with people, (sadly) including healthcare professionals, that have given them the impression that having a successful pregnancy with T1D is near impossible.
In the Pregnancy and Women’s Health Clinic at the BDC, our message is that with proper pregnancy planning and close diabetes follow-up throughout gestation a woman with T1D can have a healthy pregnancy and healthy baby.
Pregnant women with T1D are faced with many challenges, but some of these begin even before a pregnancy occurs. One of the most important things for women with T1D is to plan their pregnancies. We recommend a preconception visit to review blood sugar goals, discuss current medications which may need to be stopped or changed, and outline what it entails to be pregnant with T1D. We also recommend a preconception visit with a high-risk obstetrician, and any other specialists deemed necessary based on a woman’s health history. If a woman is planning to get pregnant soon, we say that it’s best to “act like you’re pregnant now” with respect to blood sugar control and A1c targets.
The most critical time for a baby’s development is the first 42 days after conception (referred to as “organogenesis”) so A1c levels need to be optimized prior to conceiving. By the time a woman finds out she is pregnant, many of the major organs have already formed and adverse effects on these organs from high blood sugar levels cannot be reversed. Thus, we recommend an A1c <6.5% prior to conception, and then a tighter target of between 5 and 6% for the duration of the pregnancy.
For women with A1c levels above target, there is an increased risk of the baby having problems with his heart, kidneys, extremities, brain and spinal cord. There is also a higher risk of miscarriage and stillbirth in women with poorly controlled diabetes at conception and throughout pregnancy. Achieving an A1C < 6% can be intimidating for many women when outside of pregnancy they are trying to maintain an A1c < 7%.
Once a pregnancy is confirmed, the first pregnancy visit at the BDC should occur within 1-2 weeks. Because of the dynamic changes of insulin sensitivity throughout pregnancy, it is best for a pregnant woman with T1D to be seen in the Pregnancy and Women’s Health Clinic every 2-4 weeks with weekly email/phone correspondence for interim insulin adjustments.
Not only do insulin needs change, but for women with T1D there can be changes in the health of the eyes and the kidneys during pregnancy. Women who have problems with their eyes and/or kidneys prior to pregnancy are more likely to experience progression due to the stress of the pregnancy. We ask pregnant women with T1D to collect 24-hour urine samples at least once each trimester to monitor protein excretion and kidney function throughout pregnancy. We also monitor blood pressure at each pregnancy visit.
Women with T1D are four times more likely to develop a condition called preeclampsia compared to women without diabetes. Preeclampsia is characterized by elevated urine protein levels, along with elevated blood pressure, starting after 20 weeks gestation. This risk is even higher if poor blood sugar control persists throughout pregnancy. Preeclampsia is concerning because the only cure is delivery, which can lead to a preterm birth.
We also recommend dilated eye exams at least once each trimester to monitor for progression of diabetic eye disease. Eye disease may worsen when glucose levels are dropped quickly in women whose A1cs are suboptimal at conception and are working hard to improve control during the formation of the baby’s organs. In this situation, closer monitoring is warranted. Fortunately, this eye condition usually improves after delivery.
Another challenge is the financial burden of managing diabetes and pregnancy and the significant time required for visits with healthcare providers. The monetary cost of co-pays/office visits, procedures, lab studies, medications, diabetes testing supplies and technologies, time off work, etc., is a major stressor for many pregnant women with T1D. However, pregnancies complicated by T1D are considered high-risk, so a team approach with close follow-up and monitoring of mom and baby is necessary to improve the chances of having the best pregnancy outcomes.
Once a pregnant woman with T1D has successfully navigated the bumpy road that is “diabetes and pregnancy,” she needs to prepare for labor and delivery and the postpartum period. We are frequently asked if insulin needs will be stable again after delivery. Unfortunately, the changing insulin needs will continue well into the postpartum period. Once the baby is delivered, the insulin requirements will decline rapidly to levels near the pre-pregnancy requirements and in many cases, even lower.
Breastfeeding, which is recommended in women with T1D, can cause further challenges with respect to insulin needs. While breastfeeding, insulin needs are reduced even further. This dynamic state of daily insulin requirements can be a struggle postpartum, but with close monitoring of glucose levels, is very manageable.
Although managing a pregnancy complicated by T1D is very challenging for both the patient and clinician, words cannot describe the feeling of seeing a mother and her perfectly healthy baby at her postpartum visit, happy and thriving. With motivation, dedication, hard work, and support from an excellent diabetes care team, it can be done safely and successfully. Many women with T1D report they had the best glucose control of their life during pregnancy because they would do whatever it takes to have a healthy baby. This level of motivation is inspiring to those of us who have witnessed it. These courageous women gladly accept the challenges of this daunting journey and would do it all over again (and many do) when they see what all the preparation and hard work was for.
The Children’s Diabetes Foundation is proud to sponsor the Helping Little Hands Program, which supports pregnant women with diabetes who lack the financial resources for diabetes technology and care, which are two crucial elements for the health and safety of mom and baby.
