Pregnancy and T1D

Planning for baby

Whether you’ve just started planning, or are looking ahead, gathering information is the first step to ensuring a safe and healthy pregnancy with T1D.

Many people choose to work with a team that includes an endocrinologist, primary care doctor, diabetes nurse educator, dietitian and an OB-GYN, ideally, if possible, one who has experience with T1D pregnancies. Your healthcare team will assess you for possible complications and review your current medications. It is also recommended to have an ophthalmological evaluation by a vision care specialist during planning and throughout pregnancy to screen for retinopathy.

Creating a pregnancy plan is the next step. It is recommended to begin taking a multi-vitamin supplement with folic acid at least 3 months prior to conception. Most experts recommend maintaining an HbA1c at or below 7% (ideally ≤6.5%) before you conceive and HbA1c at or below 6.5% (ideally ≤6.1%) throughout your pregnancy. It’s also important early in the planning stages to consider wearing a CGM or Flash GM if you don’t already. These devices will provide additional insight into blood-glucose patterns, helping you maintain healthy blood-glucose levels.

Read more about the CONCEPTT study and CGM use during pregnancy.

The excitement combined with well-intended advice from friends and family can make pregnancy feel overwhelming. This is true for anyone, but especially true when you are pregnant and living with a chronic disease like T1D. Making plans and having the appropriate care team can help you feel more in control over your T1D management while you are pregnant.

What to expect during the pregnancy

Keeping your blood glucose levels within target, trying to ensure an appropriate weight gain and adequate lifestyle, and, if necessary, antihypertensive (high blood pressure) treatment such as low-dose aspirin can reduce the risk of pre-eclampsia, pre-term delivery, and other adverse pregnancy and neonatal outcomes for pregnant people with T1D.

*Even with use of diabetes technologies like CGMs and insulin pumps, the target of more than 70% time in range in pregnancy (TIRp 3·5–7·8 mmol/L) is often reached only in the final weeks of pregnancy, which is too late for beneficial effects on pregnancy outcomes. Hybrid closed-loop (HCL) insulin delivery systems are emerging as promising treatment options in pregnancy.

(*Source)

Aim to keep your blood glucose within target range. Blood glucose levels that remain high during pregnancy may cause the baby to grow too large (macrosomia) or harm the early development of organs and lead to potential birth defects. The recommended target blood glucose values are:

• Fasting and preprandial <5.3 mmol/L
• 1 hour postprandial <7.8 mmol/L
• 2 hours postprandial <6.7 mmol/L

These targets may be reassessed by your care team if severe hypoglycemia occurs during pregnancy.

Knowledge is power. This includes knowing the risks that accompany T1D and pregnancy. People with T1D can have a safe pregnancy and a healthy baby, but it’s important to monitor for any potential complications that could worsen throughout pregnancy, such as high blood pressure, vision loss, and kidney disease. Your OB-GYN, endocrinologist and other healthcare providers will work with you to monitor your T1D management closely to address any changes or increase in complications/risks.

T1D may increase other potential risks and complications include :

• Preeclampsia – high blood pressure that can damage the liver and kidneys.
• Insulin resistance – when insulin is less effective at lowering your blood glucose.
• Miscarriage.
• Macrosomia – a larger-than-average baby. This can lead to a more difficult delivery.
• Birth defects that may affect your baby’s heart, brain, spine, kidneys, digestive system, limbs, and mouth.

While this list of potential complications is intimidating, these are complications that can occur in any pregnancy. So, while there is increased risk compared to those without T1D, it’s important to note that it’s not marked, especially if T1D is well managed. Evidence strongly suggests that optimization of blood glucose levels prior to and in early pregnancy can significantly reduce these risks.

Be aware of any changing insulin needs. Your insulin needs may change throughout your pregnancy. Low blood glucose (hypoglycemia) can be common in pregnancy when you have T1D. Make sure to have frequent check-ins with your health care team about how much insulin you need and how often you need it.

Creating a birth plan and preparing for delivery

Having a well-considered birth plan is something you should consider when becoming pregnant with T1D. In women with uncomplicated pre-existing diabetes, induction should be considered between 38–39 weeks of gestation. Induction prior to 38 weeks of gestation should be considered when other fetal or maternal indications exist, such as poor glycemic control   Whether or not to have one and how in-depth to make your birth plan is a very personal choice, and you are the best judge of that. A birth plan is, in essence, a wish list of how you would like your baby to arrive into the world. Sometimes this is an official document, and other times it is a discussion that you may have with your healthcare providers and family members. Regardless of the formality, it can help parents-to-be feel better prepared during labour.

Of course, no one lives in a perfect world, and in reality, only a few birth plans are followed fully. Yet, for someone pregnant with T1D, a big part of the birth process is diabetes management. It is important to discuss blood glucose management with your medical team to plan how it will be managed from the time you arrive at the hospital until the time that you leave, and what you will do to ensure these plans are followed. During labour and delivery, it is recommended to keep blood glucose levels between 4.0 – 7.0 mmol/L.

What questions do you want your birth plan to answer:

First, talk with your support team about what your ideal plan would be. Discuss your concerns about pain management, birthing options and using a midwife or doula. There are so many questions surrounding childbirth that you may want to get answers in advance, and the best way to figure out what options are right for you is by doing research and seeking information from your medical team and endocrinologist and other healthcare providers who know you well.

Below are a few questions that can help to get started. You can build on this list as you develop your birth plan:

• Do I want to receive pain medication at any time during labour, or do I prefer to give birth naturally? Will the pain medication impact my glycemic control?
• Who will manage my T1D during the labour and delivery (my partner, my OB-GYN, someone else?)
• Will I be able to wear my insulin pump during labour and delivery?
• Who will monitor my insulin pump during labour and delivery?  (Note: you may want to plan to have your partner or someone accompanying you during labour to manage your pump and CGM during labour and delivery)
• Do I want to breast-feed or formula feed?
• If my baby experiences a low blood glucose level after delivery, what are my options?
• Who are the people I want present in the room during my child’s birth? Are there any restrictions on how many people can be there?
• If there is an emergency, who will make medical decisions on my behalf or my child’s behalf if I am unable to do so?
• After birth, do I have any plans for the umbilical cord blood and/or placenta, to be stored or encapsulated?

Bring your OB-GYN and any other healthcare providers you would like included into the discussion and explain your wants and needs. Work together with your medical team to plan for both an uneventful birth and one that may deviate from expectations.

Remain flexible and open to changing the plan to accommodate any emergencies. The most important end result is health for everyone, and the goal of your medical team is to help you achieve that.

Planning for delivery with your diabetes team

First, ask your obstetrician or midwife if there is a hospital protocol in place for when someone with T1D gives birth and more specifically, if there is a protocol for those who use insulin pumps and flash or continuous glucose monitors (Flash GMs and CGMs).

Can I wear my CGM during labour?

You may be using a continuous glucose monitor (CGM) during the course of your pre-pregnancy and pregnancy months. This can be a very useful tool to help monitor the ever-changing insulin needs of a pregnant body, and may improve blood glucose management, leading to better health outcomes. However, the ability to use a CGM during the actual birth process depends on the delivery method and the individual hospital.

Check with your medical team to see if you will be able to keep your CGM on during labour. If you are having a C-section, your OB-GYN may require that the sensor be removed before surgery.  Ask your OB-GYN about their protocol and where they prefer you to wear it (so it doesn’t get in the way) and be sure to voice your preferences.

You will also want to be aware of any protocols (such as removal of insulin pump, a certain type of insulin that must be used, an insulin drip that must be used, etc.) that do not align with your birth plan. This may require some pre-labour discussions to ensure you remain on current medications throughout the birth experience.

It is also important to discuss your plans for managing any change in insulin dose just prior to and immediately after birth, during your hospital stay, and once you go home.

Take a copy of these instructions and bring them with you to the hospital. Make sure your endocrinologist and obstetrician have a copy for their charts as well.

Having this information will serve as a great source of comfort if the hospital experience becomes hectic or other aspects of the birth process feel out of your control.

Most importantly, make sure that you and your healthcare team are in agreement about how your diabetes will be managed both during and after the birth of your child.

With T1D, even the best-laid plans can change at a moment’s notice. It is good to have a plan for how you’d like your delivery to unfold, but there is always much that cannot be controlled. Whether or not the delivery goes exactly as planned, know that you are in good hands with your medical team throughout the birth process.

How giving birth differs when you have T1D

Your birth experience will be similar to those who do not have T1D. However, one main difference is that your blood glucose levels will be monitored very closely throughout the entire birthing process. If you are not using a continuous glucose monitor (CGM), this will mean you might experience a lot of finger pricks throughout the labour.

This kind of close monitoring is required to ensure that your blood glucose remains within the target range (4.0-7.0 mmol/L) as the physical and emotional stress of labour can potentially increase your blood glucose. If you do experience a high or a low during labour your medical team will give you the necessary amount of insulin or glucose needed to return to your target blood glucose.

If you were to experience a complication during a vaginal birth that would require a C-section, your consumption of food or drink may further complicate the delivery of your baby. This is why it is important that blood glucose levels are closely monitored during labour.

Although it differs slightly across individuals, your insulin requirements will drop dramatically either just before or immediately after you give birth. In fact, many return to their pre-pregnancy insulin requirements at this time. This is dependent on several factors, so your experience may differ from others who have given birth with T1D.

Early feeding of baby will be encouraged immediately after birth to reduce the risk of hypoglycemia for the baby. Breastmilk is encouraged for a minimum of 4 months to reduce the risk of developing diabetes. Exclusive breastfeeding for a minimum of 6 months is recommended by the World Health Organization.

Will I pass type 1 on to my baby?

It is natural for people with T1D to worry about the possibility of passing the disease on to their children.

On average, the risk is about fifteen times greater for someone with a relative, like a parent, who has the disease compared to the general population risk (~0.4% chance).

But there are many factors that impact your child’s risk of T1D, including:

• Sex
• Race/ethnicity
• Where you live (the disease is more common in countries further from the equator)
• How old you were when you developed T1D
• The presence of diabetes-related autoantibodies in your body
• Whether one or both parents have the disease
• Your age when the baby is born (if you are carrying the baby)
• Having certain immune system disorders in addition to T1D

It is important to remember that one’s genetic makeup is not the only factor at play. In fact, >85 percent of people with T1D have no family history of the disease.

In Canada, the only T1D screening available is for those with relatives with T1D. As a parent with T1D, your child will be eligible for screening through TrialNet.  Breakthrough T1D, through its partnership with CIHR, is currently funding a Canada-wide T1D Screening Research Consortium to research and support the potential implementation of population-wide screening.

“Being pregnant and managing type 1 diabetes is no easy feat. From fluctuating hormone levels and carbohydrate ratios to food cravings and rapidly changing insulin needs, pregnancy becomes a lot more complicated for a person living with T1D. That said, after two healthy pregnancies, I know that with preparation, patience, and grace it is possible. Equip yourself with the knowledge, tools and support system to feel confident that you too can handle the extra mental load of being pregnant. Your body and your baby will thank you”

— Anne Marie MacDonald, mother of two who has lived with type 1 diabetes for over 35 years.

https://guidelines.diabetes.ca/cpg/chapter36#sec2

https://www.cdc.gov/diabetes/library/features/type-1-and-pregnancy.html