Diabetes in pregnancy

Women with pre-existing diabetes

Women with pre-existing diabetes (Type I, Type 2 or another form of pre-existing diabetes) get the best chance of a healthy pregnancy, birth and postnatal period if their diabetes is well controlled before birth. There are some precautions you can take to ensure that you and your baby remain as safe as possible.

If you have pre-existing diabetes you should talk to your diabetes team to stabilise your diabetes before you try and conceive. Ideally we like your HbA1c (a test that looks at average sugar control over a period of a few months) to be lower than 48mmol/l. By having good control of your sugars you can significantly reduce your chance of complications of pregnancy, such as miscarriage, stillbirth, congenital malformation, birth trauma (to mother and baby), fetal macrosomia (excessively large baby), increased early intervention, perinatal mortality, worsening retinopathy (eyesight problems) or nephropathy (kidney problems), obstetric complications and the risk of inheritance of diabetes. If your diabetes control has been problematic, you may be advised to try and control your diabetes better before you consider coming off contraception. This will generally be the case if your HbA1c is greater than 86mmol/l.

Women with pre-existing diabetes will also be advised to take a higher dose (5mg) of folic acid starting from 3 months before you stop contraception. This dose needs to be prescribed by a doctor (your GP or diabetes consultant). This reduces your chance of having a baby with spina bifida. It may also be necessary to have a medication review with your doctor in order to reduce the chance of pregnancy complications. You will be advised to take low dose aspirin (150mg) from 12 weeks gestation until birth as this can reduce the chance of you developing blood pressure problems later in the pregnancy.

Gestational Diabetes

Diabetes that develops in pregnancy is called gestational diabetes. This is usually a temporary form of diabetes that occurs during pregnancy, up to 90 % of women will recover after the delivery of the baby. Diabetes in pregnancy is a result of insulin resistance (inability of the insulin hormone to work effectively) and the inability to increase production of insulin when the demand increases in pregnancy. Most women who develop diabetes in pregnancy have a normal healthy pregnancy.

Who has a higher chance of developing diabetes in pregnancy?

Any woman could develop gestational diabetes, however you are at an increased risk if:

• you are overweight or obese (body mass index (BMI) above 30)
• you have polycystic ovary syndrome (PCOS)
• you previously had a baby who weighed 4.5kg (10lb) or more at birth
• you had gestational diabetes in a previous pregnancy
• you have had an unexplained stillbirth or neonatal death in a previous pregnancy
• you have a family history of diabetes
• you are of south Asian, Black, African-Caribbean or Middle Eastern origin (even if you were born in the UK)
• you are taking certain medication such as anti-psychotics
• during your pregnancy you have
• A bigger than expected baby (Large for gestational age)
• Excess of amniotic fluid (polyhydramnios)
• Sugar in your urine (glycosuria)
• Screening for gestational diabetes

If you have a higher chance of developing diabetes in your pregnancy you will be screened using a glucose tolerance test (GTT) when you are between 24-28 weeks pregnant. A GTT involves fasting overnight (not eating or drinking anything apart from water):

• In the morning, you will have a fasting blood test. You are then given a glucose (sugar) drink.

• 2 hours later the blood test is repeated to see how you body reacts to the glucose drink.

If you have had previous gestational diabetes or if you have glucose in your urine you will be offered an early GTT.

In some cases, finger prick testing can be used to diagnose gestational diabetes, for example; if you have had bariatric or metabolic surgery, if you are unable to drink the sugary drink for the GTT or if you are 36 weeks or over.

If you are diagnosed with gestational diabetes

If you do have diabetes in pregnancy you will be looked after by a specialist diabetes team. This will include a diabetes consultant, obstetric consultant, diabetes midwife, diabetes nurse and dietician. You will also be advised to have some extra scans during pregnancy to check the growth of your baby. Although some women who develop gestational diabetes can control their blood sugars by making changes to their diet, it is quite common to need to take other medication. This might include tablets and/or injections; both are known to be safe to take during pregnancy. You

will also be advised to measure and record your own blood sugars using a finger prick test.

There will be several appointments at the hospital and you will be given the telephone contact details of someone from the team, who you can contact if you have any concerns or need further advice.

Slightly earlier delivery of your baby may be advised, depending on how your pregnancy has progressed. The timing of your baby’s birth will of course be discussed with you so that you feel fully informed of the reasons for recommendations and feel aware of the range options available to you.

After your baby is born

After birth, your baby is more likely to have low blood glucose (neonatal hypo-glycaemia). Because of this, it is recommended to stay in hospital for a minimum of 12 hours after the baby is born for some extra observations. Babies of mothers with diabetes should stay with their mothers unless there is a clinical complication.

Breastfeeding your baby can help reduce the chance of your child developing diabetes and/or obesity in later life. Woman who develop gestational diabetes are at increased chance of developing Type 2 diabetes later in life. If you do develop gestational diabetes you can reduce your chance of this happening by breastfeeding and keeping to a healthy weight throughout your life. We therefore encourage harvesting of colostrum at 36-37 weeks gestation.

Your emotional wellbeing

It is really important that you look after your own mental wellbeing when pregnant. Sometime this may feel challenging amongst additional appointments, scans and checks. See here for more information about looking after you and the support available.

Preventing the development of Type 2 Diabetes if you have had GDM

If you have had GDM in a previous pregnancy you can refer yourself for the Healthier You NHS Diabetes Prevention Programme:

The Healthier You NHS Diabetes Prevention Programme, also known as the Healthier You programme, identifies people at risk of developing type 2 diabetes and refers them onto a nine-month, evidence-based lifestyle change programme.

The Healthier You programme is available both as a face-to-face group service and as a digital service. When referred into the programme, people are free to choose between the two.

The face-to-face group service receive personalised support to manage their weight, eat more healthily and be more physically active – which together have been proven to reduce a person’s risk of developing type 2 diabetes.

Research shows the Healthier You NHS Diabetes Prevention Programme has reduced new diagnoses of type 2 diabetes in England, saving thousands of people from the potentially serious consequences of the condition. It cuts the risk of developing type 2 diabetes by more than a third for people completing the programme

The digital service offers similar support but through the use of digital tools such as wearable technologies that monitor levels of exercise, apps where users can access health coaches, online peer support groups and the ability to set and monitor goals electronically.

How to join the programme? A history of GDM is the main entry criteria only now to the Diabetes Prevention Program. You can also register whilst pregnant.

If self-registering whilst pregnant, contact will be within 1-month post-partum.

To book a place or ask any questions, call 0333 577 3010. When phoning, the team will ask for:

• History of gestational diabetes/NHS number/General Medical Practice Code.

Group sessions are held at local, accessible community venues at varying times, including daytimes, evenings, and weekends. Alternatively, you can take part remotely (via a computer/laptop/mobile) via the group or 1:1 digital platform.

Further sources of information