Pregnancy and Type 2 Diabetes

Preparing for Pregnancy with Diabetes

Although having type 2 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 its full protective effect. This dose is only available on prescription from your GP.
  • Medication Review: Most of the medications used to treat type 2 diabetes are not safe to be used in pregnancy. Before you stop contraception you will need to have your diabetes medications reviewed and if necessary changed to insulin and or metformin both of which are licensed for use in pregnancy.
  • If you take other medications such as Dapagliflozin (taken for blood glucose), 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.
    • Start to check your glucose levels more frequently. Useful times to check are before and after meals, before bed and in the night (if taking insulin).
    • You may not be used to checking your glucose levels regularly so maybe start with 2-3 times per day varying the time and gradually build up to the full 4-7 times per day as it becomes part of your routine.
    • Don’t worry if your glucose are not in the target range 4,0 – 7.0 mmol/l to start with; we will work with you to optimise your management to get you there
    • Remember any improvement in glucose levels towards these targets will reduce risk.
  • 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:

Support

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: diabetes@nbt.nhs.uk for any questions and we encourage you to share your 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 if taking insulin you may find you are more at risk of hypos and will need to take greater care around hypo avoidance – please see section on hypoglycaemia
  • From 16 weeks you will notice your blood glucose or insulin requirements will start to rise as you become more insulin resistant

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

You may not be used to seeing what your glucose levels do after meals and you are likely to see your glucose levels rise above target.

As you start to make the changes to your diet for pregnancy, you will see these start to fall into range.

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 times to link carbohydrate types to times when your glucose are out of range to help you 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.

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 aggravate 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: 40-50g carbohydrate

✔ Mid-afternoon snack: 5-15g carbohydrate

✔ Evening meal: 40-50g carbohydrates

Carbohydrate awareness

We will give you portion guidance to help you keep to the recommended quantities of carbohydrate with meals and snacks.
Other sources of information to help you regulate your carbohydrate intake are:

  • Carbs & Cals book (Chris Cheyette & Yello Balolia, Publisher - Chello) is a useful supplement to regulating your carbohydrate intake. ISBN-10: 1908261153 / ISBN-13: 978-1908261151
  • MyFitnessPal App
  • Food Labels: use the “total carbohydrate” amount when working out how much carbohydrate is in the food.
  • Restaurant web sites: Nutritional information

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.

Breakfast choices:

✔ 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

Timing of meal time insulin – if taking insulin

When pregnant the absorption of insulin slows down and so it becomes even more important to give your meal time 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.

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.

Snacking

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.

It can feel tempting to choose sweeter, more refined carbohydrates especially if trying to avoid a hypo but these foods, 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
  • Olives
  • Vegetable pieces with humus, cream cheese or salsa dips.
  • Vegetable crisps
  • Avocado
  • 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.

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.

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 regularly can help with this. Email: diabetes@nbt.nhs.uk

Towards the end of your pregnancy

The increase in blood glucose and insulin requirements starts to level out as you reach the end of pregnancy (after 36 weeks) and you may notice your glucose levels are easier to regulate.

At 36 weeks we will discuss your diabetes management plan for during and after delivery.

Depending on what medication you took to manage your diabetes before pregnancy you may stop all insulin after delivery.

If you plan to breast feed you may need to continue on insulin as most diabetes medications are not safe for use when breastfeeding.

Vitamin supplements

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

Other medications

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 if you took metformin before you became pregnant you are likely to be advised to continue with this.

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). If you have any concerns around this please discuss with us and an information sheet about metformin is available from the clinic.

Hypoglycaemia ‘Hypos’

If you take insulin you may be at risk of hypoglycaemia – where the blood glucose level drops below 3.5 mmol/l.

“Mild” hypos, although not pleasant are not considered harmful to you or your baby.

Eating regularly and always including slow released carbohydrate with each meal and snack will reduce your risk of hypoglycaemia.

Common symptoms: hunger, anxiety, tremor, cold sweat, headache and change in vision.

Some people find their hypo warning symptoms change or are even lost during pregnancy so regular glucose monitoring becomes even more important if you take insulin.

It is important you let us know if you lose your hypo warning symptoms.

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.

Always:

  • Treat blood glucose levels below 3.5 mmol/l as a hypo regardless of whether you feel hypo or not.
  • Carry hypo treating foods (such as jelly babies, glucose tablets or 200ml carton smooth orange juice) on you when away from home; keep some in the car and by the bedside.
  • If you take insulin, check glucose levels before driving and ensure your glucose levels are “above 5 to drive”. See information leaflet on driving.
  • 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.

Hypo treatment

Take 15-20g quick-acting carbohydrate:

  • 4 jelly babies
  • Or 4 Lift ® glucose tablets
  • Or 1 Lift ® glucose juice
  • Or 200mls smooth orange juice

This should raise blood glucose levels quickly and symptoms should clear within 5-15 minutes, confirm with a blood glucose check.

Night time hypos

  • Aim for blood glucose levels to be around 6 mmol/l before bed.
  • If blood glucose is less than 5.0 mmol/l you should have a 10g carbohydrate snack before bed.
  • If you have been physically active towards the end of the day or you had a hypo earlier in the day and your blood glucose is less than 6.0 mmol/l before bed you should consider a 10g carbohydrate snack.

Nausea

Nausea or “morning sickness” can be a problem in pregnancy and can strike at any time of the day. The following suggestions may help but please mention this to us at your next appointment:

  • Avoid going long stretches of time without food.
  • Eat carbohydrate foods regularly throughout the day. Dry carbohydrate foods such as plain digestive biscuits and crackers like oatcakes or Ryvita may ease the nausea.
  • Try drinking fluids before or after meals and snacks rather than with them.
  • Avoid strong foods smells.
  • If you are unable to eat or drink without vomiting, you develop ketones, or feel unable to cope please contact your diabetes team or Day Assessment Unit urgently (see numbers at end of information sheet).
  • If you take insulin and are concerned about giving insulin when you may vomit, you can take half your meal time insulin before eating and the other half when you are sure you are not going to vomit.
  • If you are experiencing frequent hypos (blood glucose levels below 3.5 mmol/l) due to vomiting. Please contact a member of the diabetes team for advice.

Ketones

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.

Illness

If you are unwell your glucose levels are likely to run higher than usual and you will need more insulin to keep them in target range

If feeling unwell:

  • Monitor blood glucose levels every 4 hours.
  • Stay in close contact with the diabetes and pregnancy team for support and guidance.
  • Drink plenty of sugar free fluids or water (10-12 tall glasses daily).
  • If taking insulin, you may need to give giving additional rapid acting insulin to ‘correct’ high glucose levels, speak to your diabetes team about this.
  • You may also need to increase your background or overnight insulin temporarily.

Continue with normal eating pattern if possible.

If your normal diet is not tolerated try a light diet, taking smaller amounts of food more frequently i.e. every two to three hours.

Light diet:

  • cereal and milk
  • bread with soup or poached egg
  • crisp-breads with cheese
  • yoghurt, milk puddings,
  • milk and milk drinks eg Ovaltine, Horlicks

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.

Useful Contacts

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)

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:

Brunel building
Southmead Hospital
Westbury-on-trym
Bristol
BS10 5NB

0117 414 6420

www.nbt.nhs.uk/

© North Bristol NHS Trust. This edition published April 2021. Review due April 2023. NBT003274