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Type 1 Diabetes and Pregnancy: Preparing for Pregnancy

New York, NY, September 27, 2006 — When she was just coming to grips with a new diagnosis with type 1 diabetes, Maxine learned that she was in her second month of pregnancy. After consulting her nutritionist, she questioned whether two doses of insulin a day were enough to sustain her and the baby, when her blood sugars were surging to 220 each morning. Suppose she lost the baby? "I worry so much I can't even sleep," Maxine wrote to JDRF's Online Diabetes Support Team.

At a time when Maxine was faced with making considerable changes in her lifestyle to prepare for her new baby, she also had to become her own expert caregiver. A woman tending to both diabetes and pregnancy needs a proper education and the support of a team of professionals experienced in treating both conditions. "You can't recommend a goal of normal without providing the education and resources patients need to get there safely," says Lois Jovanovic, M.D., CEO & Chief Scientific Officer at the Sansum Diabetes Research Institute in Santa Barbara, CA. 

Proper planning is the best way to safeguard the health of the mother and her baby, but unfortunately lack of prenatal planning remains the norm for many women with diabetes. A recent British Medical Journal study found that for women with either type 1 or type 2 diabetes, the rate of major defects in infants born to these mothers - mainly health and nervous system defects - was more than twice that of the general population. The study also showed that the number of babies who died shortly after birth in this group was four times higher than in pregnancies carried by nondiabetic women.

Pre-pregnancy planning is key
The good news is that thousands of women with type 1 have normal pregnancies and healthy babies.  The key, of course, is making pre-pregnancy planning the goal. Experts recommend that a woman begin this process three to six months prior to conception if possible, working with her obstetrician and an endocrinologist to determine if it is safe to become pregnant. At this time she must get her hemoglobin A1C within normal ranges, to minimize risk of defects or spontaneous abortion. A woman with type 1 diabetes can't say, 'I'll wait until I'm pregnant and then I'll take care of myself,'" says Dr. Jovanovic. "She'll need to make blood sugar control her first occupation even before conception." 

A woman planning to conceive, or in the early stages of pregnancy, says Dr. Jovanovic, should ask herself—and her physician—the following questions to determine if she is ready for the "marathon run" of pregnancy.

Is my blood sugar safe enough so that there isn't increased risk of birth defects or spontaneous abortion? The fetus' heart, brain, nervous system, and other organs begin forming even during the first five weeks of pregnancy, before a woman can determine she is pregnant. Unless a woman is already in control of her blood sugar at the time of inception, birth defects can happen.

Are my eyes healthy? Pregnancy can irritate diabetic eye disease (retinopathy). A woman planning to become pregnant should therefore be tested for retinopathy. If the results show even a touch of retinopathy, an ophthalmologist with expertise in retinal disease should be added to her prenatal-care team.

Is my heart normal?  The heart must be in shape to endure the rigors of pregnancy. A woman with type 1 diabetes who is planning to become pregnant should undergo an exercise treadmill test and an EKG, and get assessed for a cardiovascular risk. Her disease puts her at higher risk for pregnancy-related complications such as strokes and heart disease.

Is my blood pressure normal?  High blood pressure significantly adds to a pregnancy's risks. Blood pressure medications, such as ACE inhibitors, are counter-indicated during pregnancy. As a result,  a woman planning to conceive should measure her blood pressure herself throughout a routine day in order to report to her physician any wide fluctuations. This self testing is in addition to testing blood sugar frequently—testing as many as 10 times a day—to see if levels fall within normal ranges and thus will mean that her hemoglobin A1C test will be normal or fall between 4.0 and 6.0%.

For many women the insulin pump is the best way to manage blood sugar levels before and during pregnancy. "The insulin pump makes pregnancy easier," says Jill Abelseth, M.D., an endocrinologist in Albany, New York. The pump site should be changed every two days and basal and bolus insulin continually adjusted. In addition, women should log their blood sugar readings to show their physician that they are within the goal range. Prior to conception, exercise, eating well to avoid low and high blood sugar, and taking prenatal vitamins and folic acids are all important strategies.

Education, blood monitoring, and new technologies that make it easier to achieve tight glucose control are improving prospects for women who want to have a baby.  When she first started as an endocrinologist, Dr. Abelseth recalls when she was doing rounds on women with type 1 diabetes and pregnancy in an outlying hospital. After her lecture, an older doctor got up and said, "You know what, honey. I just tell my girls they just can't get pregnant." 

"Back then, before we knew that good glucose control leads to healthy pregnancies, diabetes was thought to cause the poor outcome in pregnant women," recalls Dr. Abelseth. "My way of looking at it is that with motivation and proper care, a healthy pregnancy is to be expected."