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Pregnancy with Type 1 or Type 2 Diabetes

This next section is for women who wish to become pregnant, or are already pregnant, and are living with type 1 or type 2 diabetes.

You can have a healthy baby if you have type 1 or type 2 diabetes. The key is to obtain optimal blood glucose levels before and during pregnancy. This will require more work on your part but every new mother we've talked to says it's worth it!

Planning with your doctor before you become pregnant is vital. Speak to your doctor about your plans at least 3 months before trying to conceive. A team approach is used at our Centre, where you can see a nurse and dietitian at each preconception visit. With the support of a team, the right formula for your healthy pregnancy will be developed.

Most women do not know that they are pregnant until approximately 5-6 weeks into the pregnancy. During this time the fetus' organs and spinal cord are developing and ideal blood glucose control is important to reduce the baby's risk for birth defects. Rates of spontaneous abortion and stillbirth are similar to women without diabetes but rise in women whose diabetes is poorly controlled. For these reasons, it is best to start working on the following goals about 3 months before conception:

  • Achieve an A1C below 7 percent, and, if possible, below 6 percent.
    This blood test determines your average blood glucose for the past 2-3 months. A1C levels above this are associated with increased risks of miscarriages and fetal abnormalities.
  • Obtain an "ideal" blood glucose level
    On a day-to-day basis, obtaining "ideal" blood glucose levels is your goal. Your doctor or diabetes educator will work closely with you to help you attain this goal. For most women, this means focusing more than ever on their diabetes management to achieve a successful balance between insulin, food and activity. You will need to start testing your blood glucose at least 4 times a day.
  • Have your eyes and kidneys checked
    Your eyes and kidneys need to be assessed prior to, as well as during, pregnancy. Pregnancy can affect eye and kidney complications. Women with significant protein in the urine before pregnancy are at risk for high blood pressure during pregnancy.
  • Have a medical exam
    You need medical examinations by an endocrinologist (a diabetes specialist) prior to and during your pregnancy.
  • Take a folic acid supplement
    Take a folic acid supplement of 0.4-1mg daily prior to pregnancy to reduce the risk of a neural tube defect in the baby. This should be increased to 4mg daily if a neural tube defect occurred in a previous pregnancy, or if there is a family history of neural tube defects. A neural tube defect is an abnormality affecting the spinal column or the brain. Taking folic acid throughout your pregnancy may have other beneficial effects.
    It is important to discuss this with your doctor beforehand.
  • Take a prenatal multivitamin daily
    If you are taking a multivitamin, limit your intake to one per day to avoid excess intake of vitamin A (less than 10,000 IU of vitamin A daily).
    Again, your doctor will advise you on what is best for you.
  • Switch to insulin if appropriate
    If you have type 2 diabetes and take pills to control your diabetes, your doctor will suggest switching to insulin before you become pregnant.

Managing diabetes during pregnancy and after

Along with the joys of pregnancy, come some challenges that can affect the woman with diabetes at various times throughout her pregnancy. The following is some helpful information as it relates to each trimester (approximately each three-month time period) of your pregnancy. You can also learn more about the stages of pregnancy in our Pregnancy Health Centre.

Managing diabetes in the first trimester | Managing diabetes in the second trimester |
Managing diabetes in the third trimester | The birth and afterwards | Breastfeeding

Managing Diabetes in the First Trimester

Much of what you will experience in the first trimester is common to all pregnant women whether they have diabetes or not.

During this stage the fetus is developing rapidly and all of the major organ systems are formed. Visit our Pregnancy Health Centre to learn about the changes that are happening at this time

Discomforts associated with pregnancy in the first trimester include morning sickness and heartburn

There are also some issues unique to women living with diabetes. Use the links below to explore these issues.

Nutrition in the First Trimester
The nutritional needs of the pregnant woman with diabetes are similar to the pregnant woman who does not have diabetes. With diabetes, how these nutritional needs are met should be discussed with a dietitian. Taking into account weight, weight gain, appetite and blood glucose results, a dietitian can develop individualized meal guidelines with you. The goal of these meal planning guidelines is to help you maintain healthy blood glucose levels while providing adequate nutrition to both you and your baby. Pregnant women are encouraged to eat smaller and more frequent meals. This usually means 3 meals and 3 snacks for the woman with diabetes. The amount of food varies from woman to woman depending on her rate of weight gain.

A focus on the carbohydrate content of each meal and snack is important because of the effect it has on blood glucose. Timing of meals and snacks that contain carbohydrate is important to reduce the risk of hypoglycemia, which is a common problem in the first trimester.

If you have a sweet tooth and like to use sugar substitutes, be aware that these should be used in moderation as they may satisfy your hunger but cause you to eat less-nutritious foods. For example, diet soft drinks have no nutritional value and are no substitute for a glass of milk. However, evidence suggests that aspartame (Nutrasweet), sucralose (Splenda) and acesulfame potassium (Sunnett) are safe to use during pregnancy. A registered dietitian can provide you with specific and personalized suggestions for healthy eating during your pregnancy.

Weight Issues and Morning Sickness
A weight gain of 2-8lbs (1-3kg) is normal during this trimester. The rate of weight gain is just as important as the total weight gain.

The baby's weight is related to the size of the mother as well as to the amount of weight gained during pregnancy.

Weight loss in the first trimester is often related to morning sickness, therefore treatment of the morning sickness through eating habits and/or medication is important. Diabetes does not influence whether you will develop morning sickness or not, but morning sickness can affect your blood glucose. Test your blood glucose more often. A temporary reduction of your short-acting insulin may be necessary.

Dieting during pregnancy can be harmful for women with diabetes. Eating an inadequate number of calories will cause your body to break down fat for fuel and produce ketones. Ketones are produced when fats are broken down and can be harmful to the fetus in large amounts. Even if a woman is significantly overweight, weight loss efforts during pregnancy are not recommended.

Hypoglycemia in the First Trimester
Hypoglycemia is most common in the first trimester because your body is more sensitive to insulin due to hormonal changes. "Tight" blood glucose control can lead to more frequent hypoglycemia, especially during the night.

Symptoms of hypoglycemia can change and become more subtle. Be aware that your blood glucose may be low if you feel tired, have blurred vision, develop a numb tongue, have nightmares or wake up in the night for no reason.

Treat low blood glucose promptly, trying not to over- or under-treat. The recommendation is 1/2 cup of fruit juice (15gm of CHO) or 2-4 glucose tablets for a mild reaction (between 3.3-3.9mmol/L). Increase these amounts to 1 cup of fruit juice or 4-6 glucose tablets to treat moderate hypoglycemia (less than 3.3mmol/L). Wait 10-15 minutes, test and repeat treatment if necessary. Repeat until blood glucose is 4 mmol or greater. Follow with a carbohydrate-containing snack, if you are not eating a meal within an hour. A dietitian can help you decide what is best for you so that you do not over-treat by eating continuously until you feel better.

It is recommended that you have a Glucagon Emergency Kit on hand in case you experience a major blood glucose reaction when you are not able to treat yourself. Glucagon is a hormone produced by the body. An injection of glucagon can be used to raise a person's blood glucose quickly. Your doctor or diabetes educator can teach a family member or friend how to give you glucagon and can explain follow-up procedures.

Some women find they need to decrease their insulin to prevent frequent low blood glucose (more than 2 lows/week). Family members should review the signs and symptoms of low blood glucose and its treatment.

Exercise Recommendations in the First Trimester
Exercise and activity levels may need adjustment to accommodate your pregnancy. Starting a vigorous exercise routine after you become pregnant is not recommended. If you were active before pregnancy, speak with your diabetes specialist and obstetrician about how much and when to exercise. Walking is preferred to running or high impact exercise as it does not interfere with oxygen flow to the baby nor does it have the same impact on blood pressure. Pregnant women with high blood glucose or diabetes complications, such as high blood pressure or blood vessel damage, should speak with their doctor before exercising.

Insulin Adjustment and Monitoring your Health

Insulin Adjustment
Placental hormones influence the amount of insulin needed in pregnancy. In the first trimester, you may be more sensitive to insulin and need less of it. A diabetes nurse educator can help you learn to self-adjust insulin in order to balance the amount of carbohydrate you eat, physical activity and the possible effects of stress on your blood glucose. During pregnancy, most women prefer the flexibility that four injections per day allow. If you are not already taking four daily injections, we recommend that you speak to your doctor about this option.

Monitoring your Blood Glucose and Urine Ketones
Frequent blood testing before and sometimes two hours after meals is recommended to help you and your diabetes care team make the appropriate adjustments to your insulin. In each trimester, check your meter result against a laboratory result to ensure your meter is reading accurately. There are many meters available that offer fast and accurate results. If your meter is 2-3 years old, it may be time to update it.

If your blood glucose is above 12mmol/L, test for ketones in your urine. Ketones are acids produced from fat breakdown, and in moderate to large amounts are unhealthy for your fetus. Ketones occur when there is not enough insulin in your system, during illness or with weight loss. If ketones are present, you may test either your urine or blood (using a special meter) every four hours and take fast-acting insulin according to your doctor's recommendations until ketones are gone. If you are ill, or your tests indicate high levels of ketones, or ketones persist, call your doctor or diabetes nurse educator right away.

Other Tests
In addition to monitoring your blood glucose, your doctor will also want to measure your blood pressure, your thyroid level, test your urine for protein and have your eyes assessed by an eye specialist in each trimester.

Managing Diabetes in the Second Trimester

Nutritional needs
During the second trimester, your nutritional requirements increase. We recommend you discuss your changing needs with a dietitian. You can also find information on nutrition during pregnancy at the Health Canada Web site.

Continued blood glucose and urine ketone testing provide ongoing information useful in making changes to your diabetes management. For more about these tests please review the information in the first trimester section.

There are also a number of routine screening tests often used during pregnancy to help monitor your health and progress of the pregnancy.

Insulin Adjustment
Around 20 weeks' gestation, you will begin to need more insulin. Continued blood glucose monitoring and insulin adjustments are necessary to prevent elevated blood glucose levels.

An average weight gain of about 9lbs (4kg) is expected in this trimester.

Discomforts of the Second Trimester
Although morning sickness often ends by the second trimester, other discomforts may occur. Constipation is common in pregnancy because your intestinal muscles relax.

Drinking plenty of water may help, but avoid fruit juices as these can raise blood glucose. For more information about relieving constipation and other discomforts of pregnancy visit our Pregnancy Health Centre.

Managing Diabetes in the Third Trimester

Nutritional needs
You may prefer more frequent, small meals at this time. Again it is important to consult with a dietitian to ensure that you are obtaining adequate nutrition and eating a variety of foods that you enjoy.

Weight increases steadily at this stage. If your weight was at a healthy level prior to pregnancy, you can expect about 1/2 - 1 lb. (1/2 kg) weight gain weekly. If you suddenly gain a lot of weight or notice swelling, you should contact your doctor.

Medical Visits
During this last trimester the baby's growth and development are closely monitored. You can expect further ultrasounds, weekly biophysical profiles that use ultrasound to assess fetal activity and amniotic fluid, and non-stress tests that monitor the baby's heart rate. All of these tests are done on an outpatient basis.

Daily assessment of the baby's activity by the mother is often started after 28 weeks. This involves counting movements made by the baby each day.

Insulin Adjustment
You can expect your blood glucose to rise in this trimester, which will often necessitate a significant increase in insulin. Many women find they need to triple their insulin dose. Close to the end of your pregnancy, your insulin dose may start to level out. Should the total amount of insulin decrease by more that 15 percent, contact your physician. This may be an indication that you are ready to deliver.

The Birth and Afterwards

Some women with diabetes go into labour on their own and others need to have labour induced. This is a decision your doctor will make with you. Your doctor will take into consideration the baby's size, your blood glucose level, blood pressure and overall health. Labour is induced for the majority of women with diabetes around 38 weeks, at which time the baby is mature. Waiting until 40 weeks means that the baby grows larger and this can increase the likelihood of a caesarean section.

Insulin needs during the birth vary. You will be given insulin intravenously if you have type 1 diabetes. Some women with type 2 diabetes do not need insulin at this time. Often during active labour, no insulin is necessary for women with either type 1 or type 2 diabetes.

After the birth, insulin is not usually restarted until blood glucose rises approximately above 10mmol/L. You and your doctor can determine this.

A caesarean section is more likely if your baby is large. However, about 50 percent of women with type 1 diabetes are able to give birth vaginally.

Once your baby is born, the baby's blood glucose level will be checked. If the blood glucose is low because the baby has had to produce more insulin in response to your elevated blood glucose levels, sugar water (by bottle or intravenous), breast milk or formula will be given to raise the baby's blood glucose to normal. Your baby's pancreas will soon adapt and produce less insulin. Often the baby is kept in the nursery or neonatal intensive care unit until the blood glucose reaches a normal level.

If your baby is born prematurely or is very large, he or she is more likely than full-term or smaller babies to develop Respiratory Distress Syndrome. This means the lungs may be immature and the baby may need to go to the neonatal intensive care unit for assessment and oxygen. There is also an increased risk of higher levels of bilirubin or jaundice in babies born to women with type 1 diabetes. This situation is not life-threatening and is easily treated.


If you are able to breastfeed, it is a healthy choice for you and your baby. Breast milk provides your baby with natural immunity. There is a theory that the introduction of cow's milk before 6 months of age may increase the risk of a child developing type 1 diabetes. This is just a theory and has not been proven, however the Canadian Pediatric Association recommends not giving your child cow's milk until 9 to 12 months of age. Breast-feeding also facilitates maternal weight loss and lowers blood glucose. During this time, when you are getting little sleep, eating irregularly and hormones are fluctuating, you will find your blood glucose will also fluctuate.

Breast-feeding places extra nutritional demands on your body, even more than when you were pregnant. If you do not increase your food intake at this time you are at greater risk for hypoglycemia. In order to make sure you are eating well while breast-feeding, you should increase your caloric intake by about 500 calories per day. This can be done by drinking a glass of milk each time you breast-feed your baby. This provides you with the extra fluid that your body needs and with extra carbohydrates to prevent your blood glucose from going too low. Discussing your needs with a dietitian will provide you with alternative ideas if you find it difficult to drink milk.

Being aware of the symptoms of hypoglycemia and treating promptly with sugar or juice is important, especially now that you have a baby who depends upon you. Be aware of the subtle changes to the signs and symptoms of hypoglycemia and have juice or candy with you at all times. To prevent hypoglycemia, check your blood glucose often and record the results. Testing and recording will help you and your diabetes team to determine your insulin needs. Make sure you are eating regular snacks.

By continuing to take care of yourself at this busy time, you will be better able to enjoy your new family. As your family grows older, you, as a mother, will find that new demands are placed on you. You may go through periods of time where your diabetes management is not a priority. If diabetes management takes a back seat, it's certainly worth the effort to get back on track.


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