Years ago, women with diabetes were discouraged from becoming pregnant because there were too many risks involved. Today, however, women with type 1 diabetes or type 2 diabetes are almost as likely to have a healthy baby as women without diabetes.

Having diabetes does pose certain risks during pregnancy, such as a greater chance of miscarriage, stillbirth and birth defects. It can also worsen some diabetic complications in expectant mothers, such as high blood pressure and eye disease. However, these risks can be greatly reduced through monitoring and control of glucose (blood sugar).

Because of the risks associated with diabetes and pregnancy, women with diabetes who would like to become pregnant should first have a complete physical examination to help identify any complications that may jeopardize the health of the mother or baby. Women with diabetes should also receive preconception counseling and care to learn about the general risks of pregnancy and the specific risks associated with diabetes.

Most diabetic complications of pregnancy can be prevented by achieving and maintaining near-normal glucose levels. This can typically be achieved through:

• Proper diet
• Regular exercise
• Control of insulin (a hormone that regulates glucose)
• Watching for signs of dangerous fluctuations in glucose

Because of the level of care required for the mother and baby during and after delivery, home births are not generally recommended for women with diabetes. Diabetic women can generally deliver vaginally providing that glucose levels are normal, that there are no complications and that the baby is not oversized. Otherwise a Caesarean delivery (C-section) may become necessary. Regardless of whether the baby is delivered vaginally or through C-section, glucose is carefully monitored during labor, and most women with good glucose control during pregnancy have a healthy baby.

The relationship between the new mother and the medical team does not end with birth. Many new mothers with diabetes experience glucose swings after delivery. They may rely on their medical team for care and advice about how to predict bodily changes, especially if they are breastfeeding their infant.

Many women with diabetes can nurse successfully. However, those who take certain medications should speak with their physician before nursing because many over-the-counter and prescription drugs, including some diabetes medications, can pass into breast milk in varying quantities. It is important for nursing mothers with diabetes to continue to monitor their glucose because they may develop hypoglycemia, which can harm mother and baby.

Diabetes increases the risk that a pregnant woman will develop preeclampsia, a condition involving high blood pressure and excess protein in the urine. In addition, nondiabetic women can develop temporary pregnancy-induced diabetes, which is known as gestational diabetes.

In decades past, women with diabetes were discouraged from becoming pregnant because they faced increased risk of complications, including miscarriage, stillbirth and birth defects in the baby. This is no longer the case.

Some women with diabetes and serious complications may still be advised by their physician to avoid pregnancy for their own safety. However, diabetic women who control their glucose (blood sugar) before and during pregnancy are almost as likely to have a healthy baby as those without diabetes. This applies to women with type 1 diabetes, type 2 diabetes and lesser-known forms of diabetes, such as latent autoimmune diabetes of adulthood (LADA) and maturity-onset diabetes of the young (MODY).

Data indicate that diabetes in the mother complicates 2 to 3 percent of all pregnancies but may underestimate the prevalence, according to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Some recent studies suggest that diabetic complications during pregnancy are a growing problem because increasing rates of obesity are causing diabetes to develop more often and at an earlier age. Type 2 diabetes, by far the most common form of diabetes, was once rare during the childbearing years but has become more common in young adulthood.

Sometimes women who do not have diabetes develop the condition during pregnancy. This is called gestational diabetes. Women with gestational diabetes and their babies have many of the same risks as other diabetic women. However, because gestational diabetes typically occurs during the third trimester of pregnancy, after the embryo becomes a fetus, some of the risks associated with nongestational diabetes are reduced. Risk factors for gestational diabetes may include:

• Being over age 25
• Having a family history of diabetes
• Being overweight
• Being a member of an ethnic or racial group with a high occurrence of diabetes (e.g., black American, Hispanic, Asian and Native American)

Women at increased risk for gestational diabetes should be tested for the condition between their 24^th and 28^th week of pregnancy.

In any type of diabetes, strict management of glucose levels is essential prior to conception and during all stages of pregnancy. This is because glucose fluctuations throughout a pregnancy can cause complications for the expectant mother and the fetus. Uncontrolled glucose is especially dangerous during the first six to eight weeks of pregnancy when the baby’s organs are forming.

Expectant mothers with diabetes have to visit their physician more frequently than women without diabetes. Women with mild diabetes or exceptional glucose control can often carry their baby to term without any issues. However, many healthcare providers prefer to schedule an early delivery of babies with diabetic mothers, typically around 38 to 39 weeks.

Because of the level of care required for the mother and baby during and after delivery, home births are not generally recommended for women with diabetes. As long as glucose levels are normal, there are no prior complications and the baby is not oversized (a condition called macrosomia), a woman with diabetes can usually deliver vaginally. If complications occur, however, a Caesarean section (C–section) may become necessary. Regardless of which delivery method is used, glucose is carefully monitored during labor, and most diabetic women who maintain good glucose control during pregnancy have a healthy baby.

For any parent, having a baby is a considerable financial investment. However, women with diabetes and their partners should be prepared to pay additional expenses associated with good glucose control, even if they have medical insurance coverage. These expenses may include:

• More frequent visits to the physician.
  
  
• Nutritional counseling.
  
  
• Extra glucose test strips. Some pregnant women with diabetes must perform glucose monitoring seven or more times a day.
  
  
• Extra ketone strips. Pregnant women with diabetes may be advised by their physician to monitor ketones (a waste product found in urine) frequently.
  
  
• Insulin (a hormone that regulates glucose). Women with type 2 diabetes who take oral diabetes medication (antidiabetic agents) are usually switched to insulin injections by their physician to help ensure the safety of the fetus. There are costs associated with taking insulin, such as syringes and training.

  

• Additional medical and laboratory tests. Depending on the physician and the patient’s risk factors, women with diabetes may be more likely to undergo additional ultrasounds or procedures such as amniocentesis. In amniocentesis, a needle is inserted through the woman’s abdomen to draw a fluid sample from the amniotic sac surrounding the fetus.

Diabetes poses special challenges for women who want to become pregnant. Any woman with diabetes who is considering having a baby should therefore first have a thorough physical examination. A preconception physical exam typically includes a dietary evaluation and a drug, obstetric, gynecological and medical history, as well as laboratory tests, to help identify any risks that may jeopardize the health of the mother or baby. If a patient has diabetic complications such as heart disease or high blood pressure, these conditions should be treated prior to conception.

Additionally, if a woman is taking certain medications that are not recommended during pregnancy, such as ACE inhibitors or diuretics, the physician may suggest alternatives and discuss any other steps that must be taken before conception.

It is also important for women with diabetes to receive prepregnancy counseling. Preconception information and support should be provided by the woman’s physician as well as the following healthcare professionals:

• An obstetrician (a physician who cares for women during and immediately after pregnancy) trained to handle high-risk pregnancies.
  
  
• A neonatologist (a physician who specializes in the treatment of newborns) or pediatrician (a physician who specializes in the treatment of children) experienced in treating babies of diabetic mothers.
  
  
• A registered dietician who can develop and alter a patient’s meal plan as nutritional needs change during and after pregnancy.
  
  
• A diabetes educator to help the patient manage diabetes during pregnancy.

Preconception care, which is designed to minimize birth defects, teaches women about the pregnancy risks to mother and baby. Evidence indicates that enrollment in a preconception diabetes care program may reduce the higher prevalence of birth defects and miscarriages that occur in women with diabetes. Diabetic women should ask their counselor about their preconception glycemic goals (an A1C of 7 or lower is typical; see glycohemoglobin test). The counselor will also review the following diabetes self–management skills:

• Meal planning
  
  
• Testing and interpreting glucose (blood sugar) levels before and after meals
  
  
• Adjusting insulin (a hormone that regulates glucose) when necessary

• Treating hypoglycemia (low glucose) if it occurs
  
  
• Making appropriate lifestyle modifications, such as diet and exercise

In addition, the counselor will discuss issues that affect all pregnant women, such as taking supplements of folic acid before conception to reduce neural tube defects (birth defects that affect the brain and spinal cord), and the effects of smoking and alcohol on a fetus. It is often helpful to include the woman’s partner in preconception discussions.

The goal for diabetic women who would like to become pregnant is to achieve near-euglycemia, or close-to-normal glucose levels before conception. Glucose irregularities can alter the mother’s metabolism and produce changes in the intrauterine environment where the baby grows.

Tight control of glucose is important during all stages of pregnancy. However, uncontrolled glucose is especially dangerous during the first six to eight weeks of pregnancy when the baby’s organs are forming the most. Because women do not typically realize that they are pregnant for up to a month after conception, women with diabetes should take extra care to plan their pregnancy, and thus reduce the risk of fetal abnormalities. For this reason the American Diabetes Association (ADA) recommends that women control their glucose levels for three to six months before trying to conceive.

Good prenatal care is especially important in light of recent research findings that babies of low birth weight or high birth weight who later develop diabetes may be more likely to die of diabetic complications.

Although pregnancy is no longer discouraged among most women with diabetes as it once was, pregnant women with diabetes should be aware of the risks to the fetus and child. For instance, some evidence suggests that offspring of mothers who did not exercise tight control of glucose (blood sugar) during pregnancy have an increased risk of speech difficulties, poor eye-movement coordination, socialization problems, chromosomal defects and eating disorders. Other risks that may be associated with maternal diabetes include:

• Miscarriage. Women with diabetes have a greater risk of miscarriage than women without diabetes. However, this risk can be decreased by controlling glucose at conception and during the first trimester of pregnancy.
  
  
• Increased risk of birth defects. Research varies on how much maternal diabetes raises the likelihood of congenital malformations. According to the American Diabetes Association (ADA), the rate of major birth defects in babies of mothers with pre-existing (nongestational) diabetes ranges from 0 to 5 percent among women who receive preconception care to 10 percent among women who do not receive preconception care. Increased odds of birth defects are due to ketones (a waste product) and excess glucose (blood sugar) passing through the placenta to the developing baby, according to the ADA.
  
  
• Intrauterine growth restriction (IUGR). Individuals with diabetes have an increased risk of angiopathy (blood vessel disease) and nephropathy (kidney disease). For unknown reasons, the fetus of a woman with either of these conditions may be unable to achieve its potential size as predicted by genetics. IUGR is associated with increased risk of the following perinatal (the period around childbirth, which lasts from five months before to one month after delivery) complications:
  
  
• Fetal mortality (death) and morbidity (injury or disease)
• Premature birth
• Fetal compromise during labor
• Physician-induced early labor
• Caesarean delivery (C-section)
  
  
• Neonatal morbidities. Infants born to mothers with diabetes also have an increased risk of dying from the following conditions:
  
  
• Respiratory distress syndrome (RDS). A respiratory (related to breathing) disease that affects newborns.
  
  
• Hypoglycemia. Low blood glucose.
  
  
• Hyperbilirubinemia. A condition characterized by an excess concentration of bile pigment (bilirubin) in the blood.
  
  
• Hypocalcemia. Insufficient calcium in the blood.
  
  
Neonatal mortality is associated with maternal hyperglycemia (high blood glucose) during the second and third trimesters of pregnancy. It is vital that expectant mothers with diabetes carefully manage their glucose levels during this period.


• Oversized baby (macrosomia). Babies born to mothers with type 2 or gestational diabetes (diabetes that occurs during pregnancy) are two to three times more likely to have macrosomia, or oversized bodies. Macrosomia in infants is sometimes defined as a birth weight that exceeds 9 pounds (about 4 kilograms). Therefore, women with diabetes are three to four times more likely to have a C-section than nondiabetic women. Also, those who deliver vaginally are more prone to shoulder dystocia (a condition in which the positioning of the infant’s shoulders makes delivery difficult) than nondiabetics. Macrosomia can also stem from maternal hyperglycemia during the second and third trimesters of pregnancy, providing yet another reason for tight glucose control during all stages of pregnancy.
  
  
• Jaundice. For unknown reasons, babies of women with diabetes are also more likely to experience jaundice, a condition in which old red blood cells accumulate because the body cannot process them fast enough. Jaundice, characterized by yellow skin, typically disappears quickly with proper treatment.
  
  
• Increased risk of diabetes in offspring. Children of mothers with type 2 diabetes or gestational diabetes have a significantly higher risk of developing obesity, prediabetes and type 2 diabetes than those with nondiabetic mothers. A child born to a parent with type 1 diabetes has a slightly higher risk of developing type 1 diabetes than the child of a nondiabetic. This risk varies depending on whether the mother or the father has diabetes and on the age of the mother.

Pregnancy also poses certain risks to expectant mothers with diabetes. Minor risks may include polyhydramnios (excess amounts of amniotic fluid during pregnancy, which may cause a distended belly), edema (swelling) and the development of skin infections, yeast infections and urinary tract infections. A main concern of many women with diabetes who are contemplating pregnancy is that pregnancy can worsen some diabetic complications, including:

• Hypoglycemia and hyperglycemia. Low or high levels of glucose (blood sugar).
  
  
• High blood pressure (hypertension). Pregnancy can cause elevated blood pressure to escalate even further. In addition, women with diabetes are up to five times as likely to develop preeclampsia (also called toxemia), a condition characterized by high blood pressure, excess protein in the urine (proteinuria) and, often, fluid retention.
  
  
• Diabetic retinopathy. An eye disease that damages blood vessels in the retina.

• Autonomic neuropathy of the stomach. Nerve damage of the stomach caused by diabetes (see Gastroparesis).
  
  
• Diabetic nephropathy. A disease that impairs kidney function.
  
  
• Cardiovascular diseases such as atherosclerosis, heart conditions and stroke.

Women can reduce their risk of such complications by controlling their glucose and otherwise adhering to the diabetes management plan devised by their physician.

Most diabetic complications of pregnancy can be prevented through tight glucose (blood sugar) control. There are a number of ways in which a pregnant woman with diabetes can achieve normal or near-normal glucose levels. These include:

• Eating a healthy diet. Women with diabetes who are pregnant or plan on becoming pregnant should consult their dietician or diabetes educator about a healthy meal plan. Poor eating habits can cause glucose levels to fluctuate, which places mother and fetus at risk for complications. A weight gain of 22 to 32 pounds over the course of pregnancy is considered normal. Underweight women may be advised to gain more than 32 pounds, whereas overweight women may be advised to gain 15 pounds or less. Eating between five and six small meals a day may aid in stabilizing glucose levels as well as alleviate morning sickness (nausea that often accompanies pregnancy).
  
  
• Exercising regularly. Consistent physical activity has proven benefits for individuals with diabetes, including improved glucose control. It also prepares expectant mothers for the physical stress that accompanies labor and delivery. It is generally not a good idea for women with diabetes to begin a new strenuous exercise regimen during pregnancy. Expectant mothers with diabetes should consult their physician about which activities are safest during pregnancy and other exercise guidelines.
  
  
• Controlling insulin (a hormone that regulates glucose). A woman’s insulin needs fluctuate during pregnancy. They may decrease during the early stages because the rapidly growing fetus is tapping into the body’s glucose reserves at a great rate. After this period, insulin needs tend to increase because hormones made by the placenta can lead to insulin resistance. Many pregnant women with type 1 diabetes may require intensive insulin therapy, which may involve:
  
  
• Taking additional insulin
• Taking a combination of various types of insulin
• Adjusting insulin doses according to glucose levels, diet and exercise
• Checking glucose levels more frequently
  
  
Women with type 2 diabetes who take oral medication (antidiabetic agents) are usually switched to insulin during pregnancy because the safety of oral medications for expectant mothers and unborn babies has not been established. The safety of these medications during nursing is still being studied. Recent research suggests that metformin, a biguanide, passes through breast milk but does not appear to harm the baby. Clinical trials are exploring greater use of antidiabetic agents during pregnancy. Patients are advised to consult their physician for details about the safety of medications during pregnancy and breastfeeding. 

During labor, a woman’s insulin needs generally drop. Most women with diabetes will not require any insulin during labor and up to 72 hours after delivery.

• Performing regular glucose monitoring and ketone tests, as advised by the individual’s physician.

• Watching for signs of hypoglycemia (low blood glucose), hyperglycemia (high blood glucose) and diabetic ketoacidosis (a serious condition characterized by extremely high glucose, insufficient insulin and ketosis).

Pregnant women with diabetes should immediately contact their physician if any of the following occurs:

• Vaginal bleeding
• Sharp pain in the back
• Pain or burning during urination (dysuria)
• An infection
• Dizziness or fainting
• Rapid weight gain
• Swelling (edema) of the face, hands or feet
• Severe nausea accompanied by hyperglycemia
• A decrease in the baby’s movement

Women who have prediabetes or normal glucose may be able to help prevent type 2 diabetes by breastfeeding. Research involving about 157,000 women from the Nurses’ Health Study and the Nurses’ Health Study II found that the longer participants breastfed, the more they reduced their risk of becoming diabetic.

The relationship between the new mother and the medical team does not end with the birth of the baby. For many new mothers with diabetes, the period after labor is characterized by odd swings in glucose (blood sugar). New mothers may turn to their medical team for care and advice about how to predict bodily changes, especially if they are breastfeeding their infant.

Many women with diabetes nurse their baby with great success. In addition, babies who are breastfed for a minimum of three months are less likely to develop type 1 diabetes than those who are given formula. Although breastfeeding is beneficial for women with diabetes, it may make glucose fluctuations somewhat difficult to predict. Women with diabetes who choose to breastfeed must be well-informed about their caloric needs for the production of milk as well as how to adjust insulin while nursing. It is also important to note that women who take certain medications should speak with their physician before nursing because many over-the-counter and prescription drugs (including some diabetes medications) can pass into breast milk in varying quantities.

Women are likely to be tired for the first few weeks after they bring their baby home from the hospital. They may also experience increased stress and odd sleep patterns, which may lead to sleeping through snack or mealtimes. Women with diabetes should make every effort to eat regularly because hypoglycemia (low blood glucose) can be very dangerous to mother and baby.

Nursing mothers with diabetes can help prevent hypoglycemia by adhering to guidelines recommended by their physician, which may includes such steps as:

• Having a snack before or while nursing.
  
  
• Drinking sufficient fluids (women should plan to sip water or a caffeine-free beverage while nursing).
  
  
• Keeping something to treat hypoglycemia nearby while nursing so they do not have to interrupt a feeding to treat plummeting glucose levels.

Women who nurse use and require more calories. The foods and beverages that they consume have a direct effect on their milk supply and glucose levels. It is essential for all new mothers with diabetes, especially those who breastfeed, to work with their physician or dietician to devise a healthy meal plan.

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about pregnancy and diabetes:

1. Is it safe for me to have a baby?
   
   
2. What sort of glucose control should I have before becoming pregnant, and for how long?
   
   
3. Do I also need to improve control of my blood pressure, cholesterol or anything else before becoming pregnant?
   
   
4. How can my diabetes affect my pregnancy, and how can my pregnancy affect my diabetes?
   
   
5. If I don’t have diabetes before pregnancy, am I at risk of gestational diabetes?
   
   
6. Am I at increased risk of preeclampsia and eclampsia?
   
   
7. Which other pregnancy complications might my baby and I be at increased risk of?
   
   
8. What monitoring tests will I need to have, and how often?
   
   
9. What are my glucose and glycohemoglobin targets during my pregnancy?
   
   
10. Will my baby be at increased risk of obesity, prediabetes, diabetes or other complications later?
    
    
11. If I take diabetes pills, will I need to switch to insulin?
    
    
12. In what other ways might my pregnancy alter my use of medication?
    
    
13. Do I need to have my baby in a hospital?
    
    
14. Can you recommend an obstetrician or neonatologist experienced in diabetes?
    
    
15. Will I be able to have a vaginal delivery, or will I likely need a C-section?
    
    
16. How can I increase my chances of a safe pregnancy and delivery?
    
    
17. What exercises should I do during my pregnancy, and are there any I should avoid?
    
    
18. What sort of diet should I follow during my pregnancy? Do you recommend I see a dietician?