Blood Glucose Management. The first step is to choose blood glucose targets for your pregnancy. The targets given in the box on page 370 are an example. Talk to your health care team about how to personalize blood glucose target ranges to your health and your lifestyle.

In the first trimester, targets are designed to help you minimize the risk of birth defects or miscarriage. In the second and third trimesters, the targets will help to prevent your baby from growing too large. If you have trouble staying in the range, or if you have frequent or severe hypoglycemia, talk to your health care team about revising your treatment plan or your targets.

Women with type 2 diabetes usually need to use insulin during pregnancy. So may many women with gestational diabetes.  Women who use insulin will find that they need to increase their insulin dose over the course of the pregnancy to reach these targets. You may also need to make adjustments in the kind of insulin you take and how often you inject. Usually, the amount of insulin you take increases with each trimester.

This is because the hormones of pregnancy, which increase in effect over time, create more and more insulin resistance. Some women need to increase their insulin dose by as much as two or three times, especially in the last trimester. This does not mean that your diabetes is getting worse.  You and your provider need to decide together when and how to make any changes in your insulin schedule or dose.

Food and Exercise. Your eating habits may need to change during pregnancy to help you stay on target. And you also will want to make sure that you are eating foods that provide adequate nutrition for you and your baby. You will probably have a visit with your dietitian even before you become pregnant. In general, choose nutritious foods that are part of any healthy eating plan. Women with gestational diabetes may be able to manage their blood glucose levels more effectively by limiting their carbohydrate intake to 35 to 40 percent of calories.

Your dietitian will help you tailor your meal plan to your recommended weight gain. A weight gain of 22 to 32 pounds over the 9-month period is normal. Women who are underweight to begin with may be advised to gain more. And women who are very overweight may be advised to limit their weight gain.
Checking your urine for ketones each morning will help you know if you are getting the carbohydrates and insulin you need.

Eating five or six small meals a day may help your efforts to stabilize your blood glucose. This eating pattern may also help with “morning sickness,” which is often worse when the stomach is empty. Morning sickness is not limited to mornings, and nausea can occur day or night,  often accompanied by vomiting. If you have morning sickness, there are some dietary steps you can take to feel better.  It can help to keep some starch, such as Melba toast, rice or popcorn cakes, or saltines or other low-fat crackers, close at hand to eat if you become nauseated. Some women find it helps to prevent morning nausea when they eat a small snack at bedtime or before they get up in the morning.

It is important to maintain physical activity during pregnancy,  as long as your overall health permits it.  Being fit prepares you for the physical stress of labor and delivery and the busy days that follow. It is usually safe to continue with any exercise you were doing regularly before pregnancy.

But pregnancy is not the time to take up any new, strenuous activities.

Glucose Monitoring.  You will probably need to check your blood glucose levels several times each day. If you take insulin, you may monitor before and after meals and at bedtime. If you have type 2 or gestational diabetes and are managing it through meal planning and regular exercise,  you will need to check more frequently than you are used to.

You may want to check your blood glucose at these times:

  once before each meal

  1 to 2 hours after each meal

  at bedtime

  during the middle of the night, around 2 a.m.

If you take insulin and keep your blood glucose levels near normal, you are more likely to have episodes of low blood glucose. During pregnancy, a blood glucose of 70 mg/dl is considered to be a low blood glucose. In addition, your early warning symptoms of hypoglycemia may change. Some women develop hypoglycemia unawareness during pregnancy.

You may have less shaking and sweating and more rapid development of drowsiness or confusion.  Monitoring frequently helps you know whether you are close to being low. There is no evidence that hypoglycemia is dangerous for the baby. But, a hypoglycemic episode can be dangerous for the mother-to-be.

In addition to testing before and after exercise, always check your blood glucose before you drive. Be prepared for severe low blood glucose by carrying a glucagon kit and training several people you see daily how to use it.

Obstetrical Care. Because of the risks to you and your baby, you’ll need more frequent visits to your obstetrician, perhaps every two weeks for the first part of your pregnancy and weekly during the last month. The reason for these visits is to make sure that your baby is developing as expected and that you stay in good health. You will be screened for neural tube defects early in pregnancy (around weeks 15 to 18) by measuring the concentration of alpha-fetoprotein in your blood. You’ll need an ultrasound test early in your pregnancy (to show when your baby was conceived) and several more throughout your pregnancy to follow the baby’s growth. A fetal echocardiogram may be done around the middle of your pregnancy. Other monitoring includes counting your baby’s movements for an hour each day and fetal movement and heart rate monitoring during the last 6 to 12 weeks of pregnancy. These tests help ensure your baby’s well-being and will assist your health care team in deciding when to deliver your baby.

—
Martha M. Funnell, MS, RN, CDE
Michigan Diabetes Research and Training Center
University of Michigan Medical School
Ann Arbor, Michigan

Robert M. Anderson, EdD
Michigan Diabetes Research and Training Center
University of Michigan Medical School
Ann Arbor, Michigan

Shereen Arent, JD
National Director of Legal Advocacy
American Diabetes Association

American Diabetes Association Complete Guide to Diabetes