Healthy management of type 1 diabetes in pregnancy begins before conception
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Susan Weiner, MS, RDN, CDCES, FADCES, talks with Jennifer Smith, RD, LD, CDCES, to discuss steps women with type 1 diabetes can take to prepare for a healthy pregnancy.
Weiner: Are women of childbearing age typically educated about pregnancy management before conception? What should they know?
Smith: From the start of menstruation through perimenopause, women of childbearing age are undereducated about pregnancy management. A chronic health condition such as type 1 diabetes brings another level of management to ensure a healthy mother and child.
Women should know how their overall health before conception affects their baby’s development. Diabetes care for women of childbearing age should focus on overall glucose management with low variability and more time in range rather than meeting an HbA1c goal.
Women should have a goal for meeting glucose targets prior to conception. Teaching women how hormone levels change during their menstrual cycle is vital to glucose and insulin management and helps them to realize that insulin doses may need to be adjusted based on the time of their cycle. Tracking this is a valuable tool whether preventing or planning a pregnancy.
If a woman is planning a pregnancy, discussion should focus on what that will mean in terms of insulin adjustment along the way. Risks for hyperglycemia and hypoglycemia, benefits of physical activity, and how insulin needs will fluctuate as pregnancy progresses are all important points to highlight. This early education should also include a basic discussion around labor and delivery and postpartum management.
These topics are on the minds of most women even prior to conception because of social media and the rabbit hole of misinformation online. Most information on social media focuses on poor outcomes rather than the benefits of a proper plan for labor, delivery and postpartum/nursing.
Support should continue after pregnancy, during a time of additional hormone fluctuation.
Weiner: How is pregnancy planning approached with teenagers and college-aged women, who may be more concerned with avoiding pregnancy than conceiving?
Smith: Clinicians who work with women in this age group should start the conversation early, at the start of menstruation, in an age-appropriate manner with a parent or guardian at the visits to ensure they also understand the impact of glucose management on regulation of the monthly cycle.
While most adolescents and women in college would prefer to prevent pregnancy, many are not educated about how use of hormonal contraception can affect glucose control with more fluctuations, weight change and insulin requirements. Tracking tools can help with analysis of data from month to month. This information makes it much easier to plan for adjustments. Ensuring the tools a woman uses — glucose monitors, insulin pumps and other technologies — are used correctly will allow for optimized health even while they aim to prevent pregnancy.
Weiner: What are some challenges that women with type 1 diabetes may face in preparing for pregnancy?
Smith: Glucose targets are a big challenge. Meeting targets for pregnancy should be a goal in at least the 3 months leading up to conception. This allows enough time to get used to hitting the tighter target range. When these targets are not met early in the preconception time, the focus on tightening up to the range for healthy pregnancy can be daunting, particularly in conjunction with symptoms that can arise during the first trimester. Preconception time should be used as a way to practice pregnancy targets.
A second challenge is the proper use of technology for diabetes management. Monitoring glucose levels with the technology used today provides a lot of information on a continual basis. The changes that happen in early pregnancy will create variance in glucose levels. Prior to pregnancy this can mean more time is needed to evaluate data. This requires more check-in time with a health care provider to ensure adjustments are fine tuned.
A third challenge is healthy body weight. Optimizing weight goes hand in hand with dietary assessment to ensure overall nutrition needs are met. It also ensures that insulin doses have been optimized for a good base to titrate insulin as needs change in pregnancy.
Another challenge could be associated with a diagnosis the woman wasn’t prepared to receive. When initially aiming for pregnancy, some women with type 1 diabetes are not able to get pregnant easily. If management wasn’t optimal prior to conception, it may be that cycles are irregular and timing of conception is off. It could also be that a woman with high insulin needs before conception was not properly diagnosed with [polycystic ovary syndrome], which decreases likelihood of conception unless properly managed.
Weiner: What are some simple starting tools/goals for a woman preparing for pregnancy?
Smith: As educators, we must consider each woman individually — her literacy/numeracy, learning style and basic understanding as well as what technology she uses and how well she is using it. It is also important to consider timing in identifying goals. Consider how far from the pregnancy glucose targets she is currently. This would help provide a starting point in discussion for a timeline of action items before trying to conceive.
The list might include the following:
- Find a good team of physicians and educators to work with as there will be frequent visits.
- Explain optimal glucose levels in pregnancy target range.
- Assess for a baseline on other health factors, such as retinopathy, neuropathy, cardiovascular disease and nephropathy.
- Consider continuous glucose monitoring if the woman is not already using this technology. CGM should be a standard of care in all pregnancies with diabetes, not just type 1 diabetes.
- Evaluate and adjust insulin doses to ensure a good base for adjusting in pregnancy.
- Ensure proper use of insulin delivery device.
- Discuss nutrition and its impact on overall health, glucose management and development of the baby.
- Provide referral to a registered dietitian/certified diabetes care and education specialist who works with pregnant women.
- Establish a timeline of action to allow progression to improved management. Seeing how change makes a difference prior to pregnancy can help ensure the ability to stick with goals as glucose and insulin levels shift.
- The JDRF Pregnancy Toolkit is a free PDF that covers many points a woman considering pregnancy could use to prepare.
For more information:
Jennifer Smith, RD, LD, CDCES, is director of lifestyle and nutrition at Integrated Diabetes Services in Wynnewood, Pennsylvania. She can be reached at jennifer@integrateddiabetes.com.
Susan Weiner, MS, RDN, CDN, CDCES, FADCES, is co-author of The Complete Diabetes Organizer and Diabetes: 365 Tips for Living Well. She is the owner of Susan Weiner Nutrition PLLC and is the Endocrine Today Diabetes in Real Life column editor. She can be reached at susan@susanweinernutrition.com; Twitter: @susangweiner.
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