Preparing for Pregnancy with Diabetes
Although having type 1 diabetes makes your pregnancy higher risk, with the right preparation you can reduce this risk and have the best pregnancy experience and outcome for you.
Considerations for pregnancy:
- Allow yourself 6-12 months as it can take time to get everything in place
- Continue with effective contraception until you are “pregnancy ready”. The website www.fpa.org.uk has lots of information on contraception options
- Start taking 5mg Folic Acid for 3 months before starting trying for a pregnancy: Folic acid is a B vitamin that helps with brain and spinal cord development and it takes 3 months for it to build up to it’s full protective effect. This dose is only available on prescription from your GP.
- Medication Review: Insulin is safe for pregnancy. If you take other medications such as Dapagliflozin, ACE inhibitors (taken for blood pressure) or statins (taken for high cholesterol) these will need to be changed to pregnancy safe options.
- Make sure your eye and kidney checks are up to date
- Blood glucose levels:
- Aim to get your HbA1c as close to 48mmol/mol as possible without causing problematic hypoglycaemia. If you use a glucose sensor aim to get at least 70% of your glucose time in range (3.9-10mmol/L). Remember any improvement in glucose levels towards these targets will reduce risk.
- Start to check your glucose levels more frequently; useful times to check are before and after meals, before bed and in the night.
- Healthy weight: being at a healthy weight before pregnancy will help reduce risk. Please ask if you would like support with weight management.
- If your HbA1c is greater than 86mmol/mol it is advised that you avoid pregnancy.
Already pregnant! – don’t panic, start taking 5mg Folic Acid, if you haven’t already and get in touch with the pregnancy team.
Other useful sources of information include:
- NHS Choices
We have a team of doctors, nurses, dietitians and midwives experienced in supporting women with diabetes and pregnancy.
We can see you regularly in clinic:
Preconception clinic: We will review you in our dedicated preconception clinic and arrange further support as necessary.
Antenatal Clinic: Once pregnant we can review you as often as required; usually every 2-4 weeks.
Email Support: firstname.lastname@example.org for any questions and we encourage you to share your pump / glucose sensor / glucose meter upload with us to support you with your glucose management.
What to expect in pregnancy
Once pregnant you may notice quite early on that your diabetes and glucose management is different:
- Up to 8 weeks you may notice your glucose running higher and / or being more variable.
- 8-16 weeks you will become more insulin sensitive and will need to take greater care around hypo avoidance – please see section on hypoglycaemia
- From 16 weeks you will notice your insulin requirements will start to rise as you become more insulin resistant. Towards the end of pregnancy you may be taking 3-4 times the amount of insulin compared to the start of pregnancy. You will also find the balance of insulin changes to needing more with your meals and less background or basal.
A key change to glucose levels in pregnancy is that they tend to swing up more after meals, especially after breakfast.
The following guidance is to help you keep your glucose levels in target.
Glucose targets for pregnancy:
✔ On waking and before meals less than 5.3mmol/l
✔ 1 hour after meals less than 7.8mmol/l
✔ At least 70% time in range (3.5-7.8mmol/l)
✔ Less than 25% above range (greater than 7.8mmol/l)
✔ Less than 5 % below range (less than 3.5mmol/l)
✔ Less than 1% below 3.0mmol/l
You may find you start your pregnancy closer to 50% time in range; we will work closely with you to steadily increase this time and remember every 5% more time spent in range has been shown to reduce risk.
Please see Top Tips information leaflet for using sensors in pregnancy.
https://abcd.care/dtn/CGM has some very useful webinars how to set up your sensor and how they can be used during your pregnancy. There are also some personal stories from women who have used sensors in pregnancy.
When working to achieve at least 70% time in range it will become important to keep the post meal and overnight glucose in target as well as the pre-meal and pre-bed.
What you eat and drink will become more important to achieve this.
It is also important that you eat a healthy balanced diet: https://www.nhs.uk/start4life/pregnancy/healthy-eating-pregnancy/ is a useful source of information.
Optimising blood glucose levels at meal times
Eating the right type of carbohydrate
Carbohydrate foods have a direct impact on your blood glucose so being careful with the type of carbohydrate eaten will become very important.
You may notice carbohydrates that have been fine before now don’t work well in pregnancy and you will need to find alternatives.
It is likely that the range of carbohydrates you are able to eat will become more limited so make the most of the whole range of carbohydrates that can be eaten and get variety from the foods that have minimal impact on your glucose such as protein and vegetables.
The table below lists those foods that many women find need to be avoided with suitable alternatives.
You may find it helpful to keep a food diary at different stages during your pregnancy to identify carbohydrate types and impact on glucose if out of range. This can help to make better choices.
REFINED CARBOHYDRATES TO AVOID (High GI)
- All white breads: loaf, rolls, pitta, naan, non-traditional baguette, croissant, chapattis, Panini, wraps.
- White flour based foods: Cakes, biscuits, Cream crackers, water biscuits, Ritz, Tuc, Yorkshire pudding, dumplings, Pizza, Pastry (pies, pasties, quiche, sausage rolls, spring rolls). Breaded and battered foods e.g. fish fingers, battered fish.
- Low fibre and sugar coated breakfast cereals: Cornflakes, Rice Krispies, Special K, Sugar Puffs, Cocoa Pops, sweetened muesli.
- Rice, pasta, grains: No types need to be avoided.
- Processed potato products: Oven chips, French Fries, Smiley faces, waffles, Croquettes, frozen roast potatoes, instant potato, ready meals with instant potato topping.
- Processed savoury snacks: Hula Hoops, Quavers, Pringles, Monster Munch, French Fries, Skips, baked crisps.
- Cold drinks: Fruit juices and smoothies, full sugar squash and fizzy drinks. Lucozade.
- Sugar: Sugar, glucose, maltose, dextrose, honey, treacle and syrup.
- Preserves: Jam, marmalade, Honey, Lemon curd, maple syrup, chocolate spread
- Sweets / Desserts: Melon, Mango, Pineapple, dried fruit, sweets, chocolates, mints, sweet puddings and ice cream, tinned fruit in syrup.
- Condensed, evaporated milk.
- Ready meals/stir in sauces/take away: Some ready meals and sauces contain significant amounts of sugar, for example sweet and sour sauces, jar or packet Chinese sauces. Chinese takeaway. Tomato soup, Baked Beans, tinned spaghetti.
- Bed-time and Malted drinks such as Ovaltine, Horlicks, drinking chocolate.
TRY INSTEAD (Low GI)
- High fibre breads: Rye bread and sourdough bread have the lowest GI. Whole-wheat, stoneground, granary and multi-grain varieties of breads have lower GIs. Chapattis made with whole meal flour. Freezing bread first can help lower the GI.
- Oatcakes, whole-wheat crackers and crisp-bread e.g. Ryvita, Cracker wheat. Wheatmeal Digestives, Hobnobs, Hovis biscuits (one or two).
- High fibre cereals: Porridge oats (Jumbo). Most women don’t tolerate any cereal in pregnancy. You may tolerate small amounts of some high fibre cereals earlier in pregnancy: All Bran, Bran Buds, Shredded Wheat.
- The best rice is basmati. Brown rice and whole-wheat pasta may give benefit. Cooling rice, pasta and potato after cooking and then eating cold or re-heating will lower the GI. Couscous, Bulgur wheat, semolina, tapioca, Quinoa.
- Home cooked potatoes – boiled is best. Small baked potato, mash. Sweet potato, yam, cassava.
- Sliced potato crisps, for example Walker’s or Kettle crisps. Ryvita snacks, vegetable crisps, salted or natural popcorn.
- Sugar free squash, Sugar free carbonated drinks. Water.
- Artificial sweeteners if a variety are used and in small quantities. Splenda, Sweetex, Hermesetas, Nutrasweet, Candarel, Stevia.
- Marmite, Vegemite, Peanut Butter (if no allergies).
- Fresh fruit, tinned fruit in natural juice (juice drained off), sugar free jelly, yogurt, “fromage frais” (under 15g total carbohydrate / pot).
- Crème Fraiche, cream.
- Tomato-based pasta sauces. Tomato-based/dry curries. Reduced sugar baked beans (drain off sauce).
- Cadbury’s Highlight, Ovaltine Options, cocoa powder.
Timing of bolus insulin
When pregnant the absorption of insulin slows down and so it becomes even more important to give your bolus insulin before eating.
In early pregnancy give insulin 15-20 minutes before eating.
As your pregnancy progresses this time will need to gradually extend to 30-45 minutes.
Think about how you can structure your day to help you achieve this. Maybe use the alarm function on your phone (to alarm 20 minutes before you are due to eat or 20 minutes after you have bolused) and giving insulin for breakfast on waking if it takes 20 minutes to get ready for breakfast.
Eating the right amount of carbohydrate
Carbohydrate is an important part of a healthy balanced diet providing you with a useful source of energy for your body and essential vitamins, minerals and fibre.
It is important to eat enough carbohydrate to keep your diet nutritionally balanced but not too much to challenge your glucose levels.
Women who eat more than 200g carbohydrate per day tend to see more glucose readings out of target.
Diets containing less than 120g carbohydrate tend to be more nutritionally inadequate.
Glucose levels are more likely to stay in target when carbohydrate is spread over 3 smaller meals with carbohydrate snacks mid-morning and afternoon.
The amount of carbohydrate that you tolerate is likely to change as your pregnancy progresses and we will review this with you at your clinic appointments.
You may find the carbohydrate amounts below a good place to start.
✔ Breakfast: 15-20g carbohydrate
✔ Mid-morning snack: 5-15g carbohydrate
✔ Lunch: 50g carbohydrate
✔ Mid-afternoon snack: 5-15g carbohydrate
✔ Evening meal: 50g carbohydrates
Getting breakfast right
Glucose levels tend to swing up much more after breakfast and so you will need to be much more careful with both the type and amount of carbohydrate at this meal.
Most women find 15-20g carbohydrate works well at this time of day.
Breakfast cereal of any kind will cause glucose levels to rise above target.
✔ 1 slice whole-wheat toast with a topping e.g. poached or scrambled eggs / mushrooms / tomato / cheese / ham / bacon / avocado OR
✔ 1 small pot yoghurt with one chopped fruit or cup of berries OR
✔ 25g jumbo porridge oats mixed raw with crème fraiche and 1 cup berries OR
✔ 40g jumbo porridge oats cooked with water and single cream added to taste.
This can be repeated 1.5-2 hours later.
Being active immediately after eating
Getting up and being active for 10-15 minutes after eating can make your post meal glucose level up to 2mmol/l lower and so can really help achieve the post meal glucose target.
This can be going for a walk or being active around the house or work place.
Avoid being inactive immediately after eating.
Think about how you can structure activity in your day to time with after meals and what your options are. e.g. timing a meal before the nursery / school run.
Bulking up meals with more protein and vegetables / salad
Eating more protein foods such as lean meat, fish, chicken, cheese, eggs, tofu, Quorn, pulses and vegetables will fill you up more and stop you feeling hungry when limiting carbohydrate portions. These foods also delay the post meal glucose rise and help avoid post-meal hypos.
Accurate carbohydrate counting
If you think 10g carbohydrate can increase glucose by 2-3 mmol/l, being as accurate as you can with carbohydrate counting can really help achieve those tight glucose targets for pregnancy.
Weighing food is the most accurate but there are a number of useful resources to help with carbohydrate counting:
- Carbs & Cals book or app (Chris Cheyette & Yello Balolia, Publisher - Chello)
- Food Labels: use the “total carbohydrate” amount when working out how much carbohydrate is in the food.
- Restaurant web sites: Nutritional information
Some women simplify their meals keeping carbohydrate foods separate, avoiding mixed meals such as risotto or pasta bakes and keeping to one carbohydrate choice at a time.
Snacking between meals can be helpful to avoid post meal hypos, help manage hunger and optimise nutrition.
Making snack choice healthy, high in fibre and avoiding refined forms of carbohydrate helps to keep glucose levels stable between meals.
Snacks eaten for the following reasons will not need to be covered with insulin:
- Snacks eaten within 2 hours of a meal to avoid post meal hypos.
- Snacks to avoid hypos – when sensor reading below 6 mmol/l with arrows down (see sensor handout – avoiding hypos)
- To cover significant activity
It can feel tempting to choose sweeter, more refined carbohydrates such as cake/ biscuits especially if trying to avoid a hypo but these foods, even if covered with insulin, make it difficult to keep the next pre meal glucose in target.
Try to carry healthy snacks with you when away from home in case you get hungry.
Healthier snacks containing 10-15g carbohydrate:
- 1 fruit
- 2 whole-wheat crispbreads or oatcakes with low fat cream cheese
- Small pot yogurt
- 3-5 small squares 70% coco solids chocolate
The following snacks contain minimal carbohydrate and can be eaten any time without needing insulin:
- Natural nuts / mixed seeds
- Vegetable pieces with humus, cream cheese or salsa dips.
- Vegetable crisps
- Cherry tomatoes
- Cubes of cheese (try with cocktail onion or gherkin)
- Sun blushed or sun dried tomatoes
- Cooked meats
- Sugar free jelly
- Corn on the cob
- Boiled egg
Avoid eating carbohydrate late in evening
Overnight can be as much as a third of your day so getting glucose levels as near normal pre bed and overnight makes all the difference to achieving that 70% time in range.
Women report that their glucose are better when they eat their evening meal before 7.30 pm and if they get hungry in the evening that’s when they reach for the carbohydrate free snacks.
Stay in touch
It can be challenging to keep up with the changes in insulin requirements over the course of your pregnancy.
Sharing your glucose data and pump upload (if on a pump) regularly can help with this. Email: email@example.com
Insulin requirements towards the end of pregnancy
Many women find their insulin requirements increase less and may even stabilise as they reach the end of their pregnancy.
This is partly due to growing insulin resistance starting to level out but also because they find they can’t eat as much!
Please let us know if you start to have more hypos or are having to significantly reduce you insulin doses.
At your 36 week appointment we will discuss your insulin regime for during and after delivery.
Insulin requirements return to pre-pregnancy levels almost immediately after delivery so it is important to keep a record of your recommended post-delivery insulin regime so you know what to change to.
If you use an insulin pump it can be helpful to pre-programme this with your pre pregnancy doses. It may be useful for your birth partner to be familiar with your pump and glucose sensor so they can make changes if you don’t feel able.
A word on weight gain
The body becomes more efficient at using energy from food during pregnancy and most women find they don’t need to eat more than usual until the last three months of pregnancy.
Your appetite and rate of weight gain are generally good guides as to whether you are getting enough energy from your diet.
It is not helpful to gain too much weight as this can make you more insulin resistant making blood glucose control more difficult.
If you are concerned that you are gaining too much or too little weight we can discuss this at your clinic appointment.
You may need to make more changes to cover activity up to 16 weeks to avoid hypos (as you are more insulin sensitive); you may need to reduce insulin or eat extra carbohydrate for activity you wouldn’t normally make changes for before you were pregnant. After 16 weeks you may need to gradually make less change for activity as you become more insulin resistant. Use your sensor glucose to help guide you. As you become more insulin resistant extra activity will become a useful tool to keep your glucose levels in target especially after meals.
Continue to take 5mg Folic Acid until 12 weeks pregnant when you can stop.
All pregnant women are recommended to take a pregnancy specific vitamin and mineral supplement. This will provide the recommended additional amount of Vitamin D for pregnancy (10 micrograms per day).
Aspirin: for most women we will recommend taking 150 mg Aspirin daily from 12 to 36 weeks to reduce the risk of pre-eclampsia.
Metformin is a tablet usually used to treat Type 2 Diabetes and is increasingly being used in pregnancy. It works by making your body more sensitive to insulin, making it more effective; this can be particularly helpful towards the end of pregnancy when insulin requirements are raised.
Metformin is a medication that crosses the placenta. There have been a number of good studies to show it can be used safely in pregnancy and it is recommended for use in pregnancy by NICE (National Institute for Clinical Excellence). An information sheet about metformin is available from the clinic.
When working to achieve the tight glucose targets for pregnancy it is likely you will experience more hypos than usual, especially in the first 16 weeks when you are more insulin sensitive.
“Mild” hypos, although not pleasant and inconvenient are not considered harmful to you or your baby.
You may find your hypo warning signs change and they can become more subtle during pregnancy making it important to monitor your glucose levels more frequently.
You are more at risk of having a severe hypo in the first 16 weeks of pregnancy and will need to be more careful to avoid hypos.
If you lose your hypo awareness or have a severe hypo (where you need 3rd party assistance to treat) it is important to let us know.
You will hopefully find the information you get from your glucose sensor helpful to avoid many hypos – please read this section in the sensor information leaflet.
Some things to keep in mind for hypos:
- Treat blood glucose levels below 3.5mmol/l (4mmol/L if any degree of hypoglycaemia unawareness) as a hypo.
- Carry hypo treating foods (such as glucose tablets, jelly sweets, Lift – glucose juice) on your person when away from home; keep some in the car and by the bedside.
- Check glucose levels before having a daytime nap, especially in the afternoon, to ensure you are at a safe level as this is often when glucose levels drop low. If your sensor is showing glucose below 6mmol/l with arrows down have a carbohydrate snack and ensure your glucose is stable before you sleep.
- Keep an “in date” Glucagon injection kit at home (in the fridge). Glucagon is a hormone that prompts the liver to release glucose and when injected will treat a hypo if you are unconscious and unable to eat or drink. This is available on prescription from your GP. It is important that someone in your household is trained to give Glucagon and we are happy to provide this training.
- Hypoglycaemia and Driving. Driving with a low blood glucose level is potentially dangerous and there are regulations from the DVLA to be aware of. In order to drive safely you must have good hypo awareness and check your glucose level before driving, this must be more than 5.0 mmol/L to safely drive. https://www.diabetes.org.uk/guide-to-diabetes/life-with-diabetes/driving#test
Hypo Treatment: see flow chart
ALWAYS use a finger stick glucose check to confirm your hypo and show your recovery from a hypo as this is the most accurate measurement.
Sensor glucose is 5-10 minutes behind your blood glucose level.
After a hypo your sensor can still be showing a low glucose when your blood glucose is recovering and back in range; if you use the sensor glucose you are more likely to over treat your hypo resulting in a higher glucose later and you can find yourself on that glucose roller coaster.
Hypoglycaemia avoidance: 5g quick acting carbohydrate
- Lift Shot (previously Glucojuice): 1/3rd of a bottle
- Smooth orange juice: 50 ml
- Lift glucose tablets: 1
- Glucose tablets: 2
- Jelly babies: 1
Hypoglycaemia avoidance / Treatment: 10g quick acting carbohydrate
- Lift Shot (previously Glucojuice):2/3rds of a bottle
- Smooth orange juice: 100 ml
- Lift glucose tablets: 2
- Glucose tablets: 3
- Jelly babies: 2
Hypoglycaemia treatment: 15g quick acting carbohydrate
- Lift Shot (previously Glucojuice): 1 bottle
- Smooth orange juice: 150 ml
- Lift glucose tablets: 4
- Glucose tablets: 5
- Jelly babies: 3
Night time hypos
- Aim for glucose levels to be around 6.0 – 6.5mmol/l before bed (unless guided otherwise by your team).
- If you see arrows down on your sensor, work to stabilise them before going to sleep to avoid hypos in the night
- If you have been physically active towards the end of the day or you had a hypo earlier in the day and your glucose is less than 6.5mmol/l before bed you should consider a 10g carbohydrate snack.
Pregnant women are more likely to produce ketones and this can be part of the changes that normally occur in pregnancy.
Showing small amounts of ketones at times, especially if you have gone a long stretch without eating e.g. overnight, with glucoses in the normal range is not a cause for concern.
Showing ketones regularly and losing weight can be a sign that you are not eating enough.
Test for ketones using a blood ketone meter if your glucose levels are running above 10mmol/l (on 2 consecutive occasions) or you are unwell.
In the same way high ketone levels are not good for you they are not good for your developing baby.
Sick Day Rules (SDR)
If feeling unwell or your glucose levels are persistently running above 10mmol/l check for ketones (using a blood ketone meter) and start following the Sick Day Rules – See sheet at end.
✔ Check glucose and ketone levels more frequently – see sheet.
✔ Drink plenty of carbohydrate free fluids to avoid dehydration (100mls per hour or 2.5 litres per day).
✔ If you can, continue to eat regularly.
✔ If your appetite is poor try a light diet with small amounts of carbohydrate; 20g carbohydrate with insulin every 2-4 hours (yogurt, milk, soup, fruit juice, biscuits, toast, plain ice-cream, fruit).
Make emergency contact if:
- Blood ketones above 3mmol/l,
- Ketones remain above 1.0mmol/l after 6 hours
- Glucose running above 10mmol/l for more than 6 hours
- You continue to vomit / unable to keep fluids down
- Having problematic hypos
Nausea or “morning sickness” can be a problem in pregnancy and occur at any time of the day. The following suggestions may help but please mention this to us at your next appointment. You can also discuss medication options with your GP.
- You may struggle to follow the dietary guidelines for pregnancy whilst struggling with nausea. Make a list of foods you can manage and bring to clinic so we can discuss how best to cover with insulin.
- Avoid going long stretches of time without food.
- If you are concerned you may vomit after eating take 1/3 to 1/2 your mealtime insulin dose before eating and the rest after once you are confident you will keep it down.
- Eat carbohydrate foods regularly throughout the day. Dry carbohydrate foods such as toast, oatcakes or Ryvita may ease the nausea.
- Try drinking fluids before or after meals and snacks rather than with them.
Reasons to contact Day Assessment Unit
- Two consecutive blood ketone reading above 1.0mmol/l
- Vomiting continuously - it may be necessary to admit you to prevent dehydration.
- Pain or feeling unwell for an unknown reason.
- Bleeding or water loss from the vagina.
- Any combination of:
- Loss of, significant reduction or change in baby movements.
- Significant fall in insulin requirements (more than 10% reduction in insulin requirements).
- Increased frequency of hypos.
See contact numbers at end of leaflet.
Any eye disease present may worsen during pregnancy. The National Eye Screening Programme will be informed following your first appointment and you will be contacted by them regarding screening in pregnancy. If you are concerned about this, please ask at your next appointment.
If you attend the eye clinic you should inform them of your pregnancy as you may need to be seen more frequently.
You should seek an urgent assessment if you experience blurred vision, flashes of light, new floaters or a change in vision.
This can be a sign of changes to your eyes or indicate pre-eclampsia is developing (high blood pressure in pregnancy).
Your kidney function will be checked during your pregnancy by blood and urine tests. Any kidney disease present may worsen during pregnancy. If you are concerned about this, please ask us at your next appointment.
This will be measured at every appointment to screen for pre- eclampsia (high blood pressure in pregnancy) and to monitor pre-existing blood pressure problems.
Obstetric Care During Pregnancy
Pregnancy in women with diabetes is classed as ‘High Risk’.
Your pregnancy will be closely monitored by the obstetric team by the use of scans and foetal monitoring for the growth and well-being of your baby. NHS Choices website has a link for specific advice about pregnancy.
It is important to continue to see your community midwife throughout your pregnancy for routine antenatal care.
Day assessment unit 0117 414 6906
Appointments 0117 414 6923
Diabetes Midwife 0117 414 6929
(08:00 to 15.00 Mon- Fri) (answer machine)
Diabetes Specialist Nurse 0117 414 6420
(08:00 to 15:00 Mon- Fri) (answer machine)
Additional information for women on insulin pumps
- To ensure optimal absorption of insulin replace your cannula every 2 days for the duration of your pregnancy. As your pregnancy progresses you are likely to need to place your cannula towards the sides of your abdomen and on your flank for comfort as your skin becomes more stretched.
- From 36 weeks place your cannula on the sides of your abdomen (above hips) and towards your back so that it doesn’t get in the way at delivery.
- If you are on an insulin pump the aim is for you to continue to manage your glucose levels using your pump throughout the delivery. Your insulin requirements during labour are likely to remain similar to what they were at the end of your pregnancy.
- You are aiming to keep your blood glucose levels between 4 and 7mmol/l through labour so that your baby arrives in the best condition and reduces the chance of low glucose levels (neonatal hypoglycaemia) after delivery.
- If for any reason you don’t feel able to manage your own glucose levels during labour or your glucose levels are running outside the range 4 to 7mmol/l you can be changed to a “variable rate intravenous insulin infusion” (insulin through a vein) to maintain optimal glucose levels.
Pump Sick Day Rules Flow Sheet
Flowchart for managing unexplained hyperglycaemia using an insulin pump:
If you or the individual you are caring for need support reading this leaflet please ask a member of staff for advice.
How to contact us:
0117 414 6420
© North Bristol NHS Trust. This edition published April 2021. Review due April 2023. NBT003274