Questions and Answers About Diabetes and Pregnancy: Your Guide to Having a Healthy Baby

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2 Questions and Answers About Diabetes and Pregnancy: Your Guide to Having a Healthy Baby By Diabetes Care Program of Nova Scotia Pregnancy and Diabetes Subcommittee 2004

3 TABLE OF CONTENTS 1 INTRODUCTION...3 HOW TO USE THIS GUIDE...5 SECTIONS Preconception (before pregnancy)...yellow I have diabetes. Can I have a healthy baby?....9 How can I ensure the safest pregnancy possible for me and my baby?... 9 What is preconception care and why is it necessary?... 9 Who makes up my diabetes health care team? What should I do to prepare for pregnancy? What are the possible risks for me? What are the possible risks for my baby? What if I am already pregnant? Pregnancy...Green I am pregnant. What happens now? What should I do to keep my developing baby healthy? What tests can I expect during my pregnancy? What about hypoglycemia (low blood glucose) during my pregnancy? How should I treat hypoglycemia? What about hypoglycemia at night? What if I become sick during my pregnancy? How can I deal with the typical pregnancy complaints? Should I take any other medications while I am pregnant? Will I have to be hospitalized during my pregnancy? Delivery... Blue Will I deliver my baby early? Will I have a cesarean section? What will happen to my insulin during labor and after delivery? Will my baby need special care after delivery? What will the doctors check my baby for? How can my diabetes affect my baby at delivery? Breastfeeding...Salmon Should I breastfeed? What are the benefits to my baby? What are the benefits to me? What should I do if I want to breastfeed? Are there any risks associated with breastfeeding? How can I reduce the risk of infection?... 37

4 Postpartum (after delivery)... Cream What should I do now that my baby is born?...41 Is it possible to continue to exercise postpartum?...41 What are the possible long-term effects of my diabetes on my baby?...41 Will my baby have a chance of developing diabetes later in life?...41 Why do I need to worry about birth control?...43 What method of birth control is best for me? Conclusion... Lilac Conclusion...47 References...48 References APPENDIX A: Public Health Services, Resource Materials, and...53 Diabetes Education Centres in Nova Scotia APPENDIX B: Feedback...65

5 3 INTRODUCTION This booklet was produced for women who have diabetes before they become pregnant. This is referred to as preexisting diabetes - type 1 or type 2 (treated with insulin, diabetes pills, or diet only). If you have developed diabetes during your pregnancy (gestational diabetes), your doctor or other health professionals (nurses, dietitians, etc.) may be able to suggest other reading materials to better answer your specific questions. If you have diabetes, this booklet will help answer commonly asked questions and concerns you may have about pregnancy - before, during, and after delivery. It is hoped that the information in this booklet will result in an increased awareness among women with diabetes, their family members, and their health care providers about these issues and the impact they have on pregnancy outcomes. This increased awareness will have a positive influence on pregnancy outcomes in Nova Scotia for years to come. We hope you find this booklet helpful. Women with diabetes determined the ideas behind the development of this booklet and its content. This booklet is a guide and is not meant to replace information provided by health care professionals with an expertise and interest in diabetes. We encourage you to use this booklet to help you ask questions specific to your pregnancy. As this booklet is intended to address only diabetes-specific questions and concerns, more general information about pregnancy and breastfeeding can be found in the list of resources available from the Public Health Offices throughout Nova Scotia (see Appendix A, pages 53-54). In this section, you will also find a complete list of Diabetes Centres (DCs) in Nova Scotia with their contact numbers. To improve this guide and ensure we are meeting your needs, we encourage you to provide us with feedback. Please see contact information in Appendix C (page 63). We would appreciate your thoughts and ideas for future revisions. For more information about pregnancy and diabetes, contact your family doctor or other members of your diabetes health care team (nurse, dietitian, etc.).

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7 5 HOW TO USE THIS GUIDE There are five main sections in this booklet. A colored cover page separates each of the five main sections. This should help you to quickly locate the section(s) you are most interested in reading. Preconception (before pregnancy)...yellow Pregnancy... Green Delivery... Blue Breastfeeding... Pink Postpartum (after delivery)... Cream In each section, commonly asked questions and their answers have been identified. The table of contents will help you to locate specific questions. In addition to these sections, are appendices that provide you with the following: Public Health Offices (locations, services, and resource materials) Diabetes Centres in Nova Scotia (locations) Preconception Care Pamphlet Feedback (contact information)

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11 PRECONCEPTION (BEFORE PREGNANCY) 9 I have diabetes. Can I have a healthy baby? YES!! With tight control of your blood glucose levels before you become pregnant (in the preconception period), you can have a healthy pregnancy and a healthy baby. How can I ensure the safest pregnancy possible for me and my baby? The first step is to seek advice before you become pregnant. We call this preconception care and counseling. With more women seeking preconception care, great progress has been made in reducing the number of problems in the pregnancies of women with diabetes. What is preconception care and why is it necessary? Preconception care is very important to help prevent complications during your pregnancy and to ensure a healthy baby. The fact that you have diabetes increases the risk of your pregnancy. The goal of preconception care is to achieve near normal blood glucose levels 2 to 3 months before you become pregnant. This will reduce the risks to you and your baby. You can do this through changes in your diet, exercise/activity, and insulin regimen. It can take 3 months or more to achieve near normal blood glucose levels; so it is important to plan ahead. Your diabetes health care team will help you receive the level of care that you require. Preconception care consists of the following: Having a complete medical assessment for any preexisting complications caused by diabetes. Reviewing how and when to check your blood glucose, reviewing how and when to check your blood glucose meter to make sure it is working properly, adjusting your insulin at home, and achieving target blood glucose values. Learning about and following an appropriate exercise/activity routine to improve your physical fitness. Learning about and following an adequate meal plan that may include changing your energy intake (calories) to help you achieve a healthier weight before you become pregnant. Taking 0.4 to 1 mg folic acid (a specific B vitamin) daily in a multivitamin supplement during preconception period and up to 13 weeks gestation in addition to a diet high in folate. Obtaining information about coping with the more demanding routine required to help ensure a healthy pregnancy. Such demands include: laboratory blood tests; frequent visits to the diabetes health care team; activity, diet, and insulin changes; increased home blood glucose and urine ketone testing.

12 Who makes up my diabetes health care team? 10 Depending on your situation, the members of your diabetes health care team may vary. Your doctor will help arrange for you to see the most appropriate and available diabetes health care team members. The need for involvement and the extent of the involvement of various team members in your care may differ depending on your specific health care needs at different stages of your pregnancy. Diabetes health care team members may include: Your family doctor and/or obstetrician who specialize(s) in pregnancies at increased risk and is experienced in managing pregnancies of women who have diabetes. Your doctor will guide you as you try to achieve near normal blood glucose levels before your pregnancy. A doctor who specializes in diabetes care (endocrinologist, internist, etc.) and is familiar with managing diabetes before, during, and after pregnancy. A nurse (diabetes educator) who can advise and teach you how to manage your diabetes. Your nurse will help you to understand the effect your pregnancy will have on your diabetes. She/he will also help you improve your blood glucose levels through problem solving. A dietitian (diabetes educator) who will help you ensure your meal plan includes a variety of nutritious foods. This plan will also help to keep your blood glucose levels in a healthy range. You will also learn how to achieve a gradual weight gain during pregnancy and the benefits of breastfeeding as well as weight management after the baby is born. Other specialists may include the following: A physiotherapist who will discuss the benefits of an appropriate exercise/activity routine. He/she will also discuss body mechanics/posture to help you reduce the risk of back pain during pregnancy. A social worker who will help you deal with the changes that occur as a result of preparing for your pregnancy. This will help you better manage stress. The social worker will also help you identify and address any risks, problems, or barriers that may affect your emotional and physical health during your pregnancy. An eye specialist (ophthalmologist) who will help you deal with any changes to your vision. To ensure your eyes are properly cared for, a visit to your ophthalmologist before you become pregnant is recommended. A dentist who will help you care for any changes in your gums and teeth during pregnancy. YOU, the most important member, along with other members of your family. You have an active role to play as a member of the health care team. You will be responsible for nutritional management, self-monitoring of blood glucose and urine ketones, as well as keeping yourself mentally and physically fit through stress management and exercise/activity. Your spouse or partner and other family members and/or support persons are also an important part of the health care team. Their support and understanding of your health care needs before, during, and after pregnancy will decrease your stress and help you to manage your health care.

13 What should I do to prepare for pregnancy? 11 Tightly control your blood glucose to normal levels and watch it closely by checking your blood glucose levels regularly at home. Record your blood glucose carefully in a book provided by the diabetes health care team. Your insulin dose may need to change. Ideally, you and your diabetes health care team should aim for the following:* A1C levels less than 7% (less than or equal to 6% is optimal). (Note: This is the test that measures overall blood glucose control for the previous 2 to 3-month period.) Blood glucose levels before a meal less than 5.3 mmol/l. Blood glucose levels 1 hour after a meal less than 7.8 mmol/l. Blood glucose levels 2 hours after a meal less than 6.7 mmol/l. Pre-bedtime snack levels less than 6.0 mmol/l. * Not all women will be able to achieve these degrees of control. It is important to aim for the best possible control and to discuss this with your diabetes health care team. Arrange for a complete medical assessment and have your eyes checked by an eye specialist (ophthalmologist). Exercise regularly; be active. This will help you reduce stress, manage your blood glucose, and provide a sense of general well being. Get enough rest. Follow your meal plan and eat a variety of nutritious foods. Use foods with little or no nutritional value sparingly. You may want to start to use a meal plan that is appropriate for the early stages of your pregnancy before you become pregnant. This will help you to keep your blood glucose levels in control once you become pregnant. Start taking 0.4 to 1 mg of folic acid (a specific B vitamin) each day in a multivitamin supplement in addition to a folate-rich diet. This will reduce the risk of neural tube (spinal) defects in your baby. Your dietitian can help you with this and also help you choose foods that are good sources of folate (green leafy vegetables, beans, peas, orange juice, wheat germ, nuts, etc.). Try to attain and maintain a healthy weight before you become pregnant. Take steps to manage stress as stress can affect your blood glucose levels. Gather as much information about diabetes and pregnancy as needed to make you feel comfortable. Talk to your spouse/partner about your feelings and concerns as well as their feelings and concerns. This may help to reduce your stress. Remember to ask questions and discuss any concerns with members of your health care team. If you are on insulin, continue to take as prescribed. If you are taking diabetes pills, your doctor or diabetes specialist should switch you to insulin if you are planning a pregnancy. If you are taking high blood pressure medication, discuss this with your physician to ensure it is safe during pregnancy.

14 Prepare for the demands of pregnancy. To make sure you have a successful pregnancy, you will require frequent check-ups and more tests than women without diabetes. Practice the general principles of good health. These include avoiding smoking and second hand smoke, alcohol, and unnecessary drugs. Talk to someone with diabetes who has experienced preconception care and pregnancy. Your diabetes health care team should be able to arrange this for you. 12 What are the possible risks for me? There are some risks that you should be aware of and that you should discuss with your diabetes health care team. Planning for pregnancy and achieving near normal blood glucose levels before becoming pregnant reduces the chances of developing complications. Some of the possible risks for you include: Hypoglycemia (low blood glucose): Blood glucose levels below normal (less than 4 mmol/l). Low blood glucose levels are more common with the tighter blood glucose control recommended during pregnancy. Frequent testing of your blood glucose helps to identify patterns of when lows occur. This will make it easier to adjust various aspects of your diabetes management such as diet, insulin, and exercise routine. Mild hypoglycemia is not harmful, but being aware of mild symptoms of low blood glucose can help prevent more serious symptoms. Hyperglycemia (high blood glucose): Blood glucose levels above normal (greater than 5.2 mmol/l before meals; greater than 7.7 mmol/l at 1 hour; and greater than 6.6 mmol/l by 2 hours after eating). High blood glucose levels increase the risks for you and your baby and should be avoided if possible. However, high blood glucose levels are expected at times and diabetes management should be adjusted as necessary. Ketoacidosis (ketones and high glucose in the blood): The breakdown of body fat into acids occurs when there is not enough food or insulin to provide energy for the body. This is a serious, but rare, complication in pregnancy and needs to be treated right away by medical staff to avoid loss of the pregnancy. Worsening of Established Chronic Diabetes Complications: It is important to be assessed and treated as required for diabetes complications before and during your pregnancy. Eye problems (retinopathy) can worsen during pregnancy. The risk is increased with poor blood glucose control and can occur up to 1 year after delivery. Eye problems can be treated during pregnancy if necessary. Kidney problems (nephropathy) and nerve disease (neuropathy) vary in severity and should be discussed with your doctor. Heart disease (cardiac disease) may be reason to avoid pregnancy in a woman with diabetes and should be discussed with your diabetes health care team.

15 There are other things that can happen in any pregnancy but occur more often when a woman has diabetes. Some of these are: Pregnancy Induced Hypertension (PIH): High blood pressure caused by your pregnancy. This complication may occur in any pregnancy but is a higher risk if the woman has diabetes (especially those with type 2 diabetes). Your doctor will check your blood pressure and your baby s well-being at each visit. Urinary Tract Infections: Infection in your bladder and/or kidneys. While this complication is seen in pregnant women who do not have diabetes, it is more common in women with diabetes. Glucose in the urine contributes to the growth of bacteria that causes infection. Maintaining good blood glucose control will help prevent this. Urinary tract infections are treated with antibiotics. Preterm (early) Birth: Delivering your baby before it is due (before 37 weeks gestation). This also occurs in women who do not have diabetes. However, you can help prevent it with good diabetes management. Miscarriage: Loss of the pregnancy before 20 weeks gestation. This is a problem also faced by women who do not have diabetes. It is more common in women with diabetes who do not have tight blood glucose control. Cesarean Section: Delivery of the baby through an incision in the abdomen and uterus. This method of delivery may be necessary for many reasons. Women with diabetes sometimes deliver this way if the baby is large or vaginal delivery is not possible for other pregnancy-related reasons. 13 What are the possible risks for my baby? Babies born to women who do not have tight control of their diabetes have a higher risk of complications and birth defects. Some of the possible risks for your baby include: Prematurity: Birth before 37 weeks gestation. Babies are often born early if there is a problem with the mother or baby. It is now common for women with diabetes to have their pregnancy go to 40 weeks gestation or full term. Macrosomia (large baby): The term used to describe babies who grow larger than normal. This happens in response to the mother s high blood glucose levels especially after meals. The baby stores this extra sugar as fat. A very large baby may be more difficult to deliver and is more likely to experience temporary problems at birth. Birth Defects: Infants of women with poorly controlled diabetes in early pregnancy are at a higher risk of developing birth defects. Taking folic acid in a multivitamin supplement before you become pregnant and during the first 13 weeks of pregnancy can reduce the chance of your baby having a spinal defect.

16 The following complications are most apparent at the time of delivery. A more detailed explanation of these can be found on pages 30 and 31 of the Delivery section. Neonatal Hypoglycemia (low blood glucose in the newborn): Your baby is at risk for developing temporary low blood glucose levels after birth and will need to be monitored carefully. This can be easily treated. Respiratory Distress Syndrome (difficulty breathing): Immature lung development. This causes temporary problems with your baby s breathing. This is more common in babies born prematurely. Jaundice (yellow color of the skin caused by a build up of bilirubin in the blood). See page 30. Hypocalcemia (low blood calcium). See page 31. Tight control of blood glucose levels, especially before pregnancy and in the early weeks of pregnancy, decreases the risk of problems for both you and your baby. Nearly all diabetes-related problems can be prevented with tight control of blood glucose levels before and during your pregnancy. 14 What if I am already pregnant? Many problems can still be prevented with good diabetes management practices during the remainder of your pregnancy. Your diabetes health care team will guide you through your pregnancy and after delivery.

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19 PREGNANCY 17 I am pregnant. What happens now? Every woman experiences physical and emotional changes during pregnancy. You will probably experience extra stress due to the demands of your developing baby, managing your diabetes, and your increased appointments with your doctor and/or members of your diabetes health care team. If you have negative feelings about your pregnancy, your diabetes health care team can offer support. What should I do to keep my developing baby healthy? You need to achieve and maintain tight blood glucose control, get enough rest, exercise, follow your meal plan, and manage your stress. Your pregnancy will have an affect on your diabetes control, and you will have to make some changes in how you manage your diabetes. Your diabetes health care team will help guide you as needed with some or all of the following factors. Insulin adjustments: During your pregnancy, your body will be rapidly changing as your baby develops and grows. These changes will affect your blood glucose levels. You will have to adjust your insulin doses throughout your pregnancy. Most women need to make frequent changes to their insulin regimen. The number of injections you take each day may have to increase. Many women feel better on this routine and choose to continue it even after their pregnancy. During the first three months of your pregnancy, blood glucose control may be more unstable than usual and nighttime hypoglycemia (low blood glucose) is common. As your pregnancy progresses, you will have to increase how much insulin you take. Your insulin needs may double or even triple. Your higher insulin needs do not mean your diabetes is getting worse. It is the changes in the hormones made by the placenta and the demands of the growing fetus that cause the increase in your insulin requirements. The placenta is the organ that attaches to your uterus and supplies oxygen and nourishment to your baby. It also removes waste products. To make these insulin changes, you will have to test your blood glucose levels more often. If you are unsure how to adjust your own insulin dose(s), ask your doctor or other members of your diabetes health care team to help you. Blood Glucose Monitoring: You will have to increase the number of times you test your blood glucose level each day. It is common for women who are pregnant to test at least 4 times a day. You may be asked to check your blood glucose one hour after meals as this blood glucose value has been found to be more closely related to the size of the baby. You should keep track of your blood glucose levels. By testing regularly and writing the results in your diabetes diary, you can better see patterns develop to manage your diabetes. Remember to bring your meter or diabetes diary/record book to all appointments with your diabetes health care team. Your meter should be checked with a lab for accuracy at least every six months before pregnancy and more often during pregnancy.

20 Ketone Monitoring: Ketones occur when there is not enough food or insulin to provide energy for the body as in the case of an illness. Fat is then broken down into acids and ketones. This results in a higher level of ketones in your blood and urine with resulting acidosis (too much acid in the blood and tissues). This can cause problems for you and your baby. If your ketones are too high or are present on a regular basis, your diet may need to be changed to give you the energy that your body requires. More food may need to be added, and/or your night snack may need to be changed. Your dietitian will help you make adjustments in your meal plan. Your diabetes health care team can decide how often and when you should check your urine for ketones. Nutrition: You need to seek nutritional advice and counseling from your dietitian. Such counseling will help you develop a meal plan to follow during your pregnancy. This plan will meet both your needs and the needs of your growing baby. Good nutrition is necessary for the health of your baby. It is important to take charge of your own nutrition and understand that how and what you eat affects the health of your developing baby. Your meal plan will include three meals a day and two or more snacks. You may be asked to restrict the amount of carbohydrate you consume at breakfast. The carbohydrate you consume during the rest of the day will be measured, and your insulin will be adjusted to prevent hyper or hypoglycemia. You will need to eat a well balanced diet with extra protein, calories, calcium, iron, fiber, and folate. The extra nutrients are necessary to meet the needs of your growing baby and to prepare your body for the demands of the pregnancy. Your dietitian will help you adjust your meal plan to meet your needs and your baby s needs. She/he will also help ensure you have a healthy weight gain. Exercise/Activity: Exercise is safe during pregnancy. Your exercise/activity routine might have to change to help control your blood glucose levels and to accommodate your growing baby. All pregnant women with uncomplicated pregnancies are encouraged to participate in aerobic and strength conditioning exercise. Your doctor and/or physiotherapist can help you determine if you can participate in physical activities during pregnancy. Exercise/activity is good for you and your baby. It helps to lower your blood glucose levels and improve your circulation and heart function. Exercise can also give you a feeling of well-being and help prepare your body for the demands of pregnancy. Specific exercises can help reduce leg or back pain and reduce discomfort associated with the later stages of pregnancy. To maintain aerobic conditioning and a good fitness level, brisk walking, stationary cycling, cross country skiing, and swimming or aqua fit classes are recommended. These activities will minimize your risk of loss of balance and potential fetal trauma. Exercise at a comfortable intensity where you are still able to talk and always in a safe setting where there is no danger of falling. The best time to exercise is dependent on the type of insulin you use and your blood glucose levels prior to the activity. You should avoid exercise/activity during peak periods of insulin action. In order to prevent low blood glucose, it is important to coordinate your exercise/activity program with your meals and insulin. Do not begin exercise/activity if your blood sugar levels are too low or too high and/or if ketones are present. It is important to check your blood glucose levels before, during, and after exercise/activity. Blood sugar levels can continue to drop 12 to 18 hours following exercise. The most appropriate time to exercise can be discussed with your health care provider. 18

21 Listen to your body. If pregnancy is causing you to slow down, change your exercise/activity routine to one that makes you feel better. Your physiotherapist and/or doctor can help you with this. Frequency of Appointments: The frequency of appointments will increase. You may be required to have weekly tests. You will have tests done to monitor your diabetes, and you will also have tests to monitor your baby as she/he grows and develops. 19 What tests can I expect during my pregnancy? Tests to Monitor Your Diabetes Careful monitoring of your blood glucose levels and health status is necessary to allow your diabetes health care team to recommend adjustments in your treatment. The following table shows the expected frequency of testing for women with preexisting diabetes during pregnancy. Test A1C (Glycated Hemoglobin) Blood glucose Ketones Urine test for culture and sensitivity. (Test for urinary tract infection.) Kidney function 24-hour urine clearance and total protein. Eye status Thyroid Stimulating Hormones (TSH) Frequency Initially and every 3 months. Reviewed during appointments with the diabetes health care team. Self-testing at home, usually 4 or more times a day. Each trimester (three times during your pregnancy) your meter should be compared with the lab sample to ensure your testing method is accurate. Urine and/or blood ketone levels tested 1 to 2 times a week, more frequently as indicated; for example, during sickness, if blood glucose greater than 10 mmol/l, weight loss occurs, etc. Each trimester. Each trimester. First trimester and then as necessary according to the eye specialist. Repeat 1-year postpartum. Those with type 1 diabetes require assessment of this thyroid test in the first trimester unless completed in the past year.

22 Tests to Monitor Your Baby 20 You will undergo two types of testing to monitor your baby during your pregnancy - diagnostic testing and fetal surveillance testing. These are tests to evaluate the health of the developing baby. Diagnostic Tests Diagnostic testing is done during the first half of the pregnancy. The purpose is to detect structural or genetic disorders in the baby. Not all of these tests are done routinely but should be discussed with your doctor. Maternal Serum Screening: This is a blood test done between 15 and 20 weeks gestation that shows if your baby is at risk for developing problems such as spinal abnormalities. It only indicates if there is a problem; it cannot identify what the problem is. Further tests are needed if this test is positive. Amniocentesis: This is a common test. It may be done early in the pregnancy to assess the risk of developing genetic disorders. It may also be done later in the pregnancy before 38 weeks gestation to assess the baby s lungs. This will show if the lungs are developed enough for her/him to breathe on their own. It is performed by taking a sample of the amniotic fluid that surrounds the baby. If recommended for you, this test and the procedure will be explained by your doctor. Ultrasound: This test shows a picture of your developing baby. It can be used to determine the age, the position of the baby in the uterus, the outline of the body structure and organs, and the number of babies present. It will also be used to track your baby s growth and development. You will probably have an ultrasound early in your pregnancy to confirm your due date and check for abnormalities. You may have one or two more during your pregnancy to check the baby s structure and possibly to measure the size of the baby. Fetal Surveillance Tests Fetal surveillance tests are done later in the pregnancy and usually continue until birth. These tests can help to detect problems with your baby, but you must understand that no test can assure that a baby will be perfectly healthy. These tests are used to evaluate the health of your developing baby. Different doctors prefer to use different tests. Discuss with your doctor which tests are best for you. All methods are designed to provide similar information. Your doctor may use one or more of the following tests: Kick Counts: You will be asked to count the number of times you feel your baby move during certain times each day. If you detect a change in the pattern of your baby s movement, you should notify your diabetes health care team. This counting is usually started after 28 weeks gestation.

23 Biophysical Profile (BPP): This is also called a planning score. This test uses an ultrasound to evaluate your baby s movement, muscle tone, chest movements, and the amount of amniotic fluid surrounding her/him. This test is often done weekly after 28 to 32 weeks gestation. 21 Emotional Support It is important to involve your partner and/or other supporting individuals in your pregnancy. Support is needed to achieve tight blood glucose levels and will make it easier for you to adapt to your diabetes and pregnancy lifestyle. You will be better motivated if you receive support from your partner and/or significant others. You should be encouraged to accept help from others and feel free to express any frustration, fear, anger, or anxiety you may be having related to your pregnancy and diabetes. Your diabetes health care team is there for you - ask questions! What about hypoglycemia (low blood glucose) during my pregnancy? It is important that you are aware of hypoglycemia and that you know how to treat it. Regular blood glucose testing and recording of the results are necessary in preventing and managing hypoglycemia. You may be required to test your blood glucose more often if you have changing blood glucose levels or if you cannot feel the symptoms of hypoglycemia. Always carry/wear your diabetes identification. The pregnancy value for hypoglycemia is lower than that used in the non-pregnant or preconception period and is now defined as 3.3 mmol/l.* Signs and symptoms of hypoglycemia will develop when there is not enough glucose in the blood to allow your body to function normally. Symptoms of hypoglycemia may include: shakiness/tremors hunger, nausea blurred vision sweatiness headaches confusion palpitations dizziness feeling tired, anxious, or afraid Hypoglycemia may be caused by: Taking too much insulin (insulin errors). Not eating enough food. Not adjusting your insulin or food intake when you are active. Consuming alcohol (not recommended when pregnant). Too much unplanned exercise/activity. It is important to eat your meals and snacks on time to help prevent hypoglycemia. You should watch for the patterns of hypoglycemia so you can better plan and prevent recurrence. It is very important that you treat hypoglycemia properly. Over-treating will cause your blood glucose levels to become too high. If possible, check your blood glucose to confirm the presence of low blood glucose before treatment. *This value will be determined on an individual basis with members of your diabetes health care team. They will take into consideration your degree of control as well as safety and comfort issues.

24 How should I treat hypoglycemia? 22 Hypoglycemia may be mild, moderate, or severe. Each has different symptoms and each needs to be treated in a special way to avoid over-treating. Mild and Moderate Hypoglycemia: The symptoms of mild hypoglycemia do not interfere with normal activity but may cause shaking, palpitations, anxiety, hunger, sweating, nausea, and tingling. With moderate hypoglycemia, in addition to the symptoms of mild hypoglycemia, you may experience trouble moving and doing simple tasks. You may also behave inappropriately, but you should still be alert enough to help yourself. If you are feeling confused or irrational, you may need help with treatment. The treatment of mild or moderate hypoglycemia consists of eating or drinking 15 grams of glucose or sucrose. The best sources are glucose tablets, sugar (3 teaspoons/15 ml), juice or regular soft drink (3/4 cup/ 175 ml), Lifesavers (6), or honey (1 tablespoon/15 ml). This will produce an increase of blood glucose of 2.1 mmol/l in 20 minutes. Wait 15 minutes and retest blood glucose level. Re-treat with another 15 grams of carbohydrate if the blood glucose level remains below 4.0 mmol/l. If the next meal or snack is less than 1/2 hour away, have your meal or snack right away. If the meal or snack is more than 1 hour away, take a 15 grams portion of carbohydrate immediately (see the table below) as well as 1 protein choice. Have your meal or snack at the regular time. EXAMPLES OF 15 grams PORTIONS OF CARBOHYDRATE 250 ml (1 cup or 8 oz) glass of milk 175 ml (3/4 cup or 6 oz) glass juice 175 ml (3/4 cup or 6 oz) regular soft drink 4 Dextrosol or Dextro Energy tablets 3 teaspoons (15 ml) sugar 3 sugar cubes 1 tablespoon (15 ml) pasteurized corn syrup or honey 6 Lifesavers (1 = 2.5 grams carbohydrate) *NOTE: If you are still experiencing symptoms 30 minutes after treatment, test your blood glucose again. If your blood glucose is less than or equal to 3.3 mmol/l, take another 15 grams of carbohydrate. It may take up to 15 to 20 minutes for blood glucose levels to be near normal. You can resume normal activity once you have treated mild or moderate hypoglycemia. If driving, you should wait 15 to 20 minutes before proceeding.

25 Severe Hypoglycemia: Although this happens rarely, you and your family members should know how to treat this form of hypoglycemia. The symptoms of severe hypoglycemia include confusion, seizures, and/or coma. A relative or friend must know what to do before it happens. Treatment is the same in pregnancy as when you are not pregnant. You will need help from others to treat severe hypoglycemia. If you are conscious, consume 20 grams of carbohydrate preferably as glucose tablets. Wait 15 minutes and retest your blood glucose level. Re-treat with another 15 grams of carbohydrate if your blood glucose level is less than 4 mmol/l. If your meal or snack is due, be sure to eat it. If a meal is more than 1 hour away, a snack of 15 grams of carbohydrate and a protein source is recommended. If you are unconscious, you should be treated with glucagon. Speak with your diabetes health care team about the role of glucagon by injection, where to purchase glucagon, and how to use it. Glucagon is a hormone produced by the pancreas. Once injected, it helps to raise your blood sugar by releasing the stored sugar in your liver. Caregivers or support persons should call for emergency services, and the episode should be discussed with the diabetes health care team as soon as possible. 23 What about hypoglycemia at night? Nocturnal hypoglycemia If you have low blood glucose at night, talk to your diabetes health care team. Possible Causes: Delayed response to intense exercise. Too much insulin before supper or bedtime snack. Not enough carbohydrate and protein in the night snack. Night snack eaten too early. Symptoms: Nightmares. Headaches when you wake up. An unusually restless sleep. Unusually clammy skin. Treatment: If you suspect that you are experiencing hypoglycemia during the night, you may need to test your blood glucose at 3 a.m. Your bedtime snack should be taken later in the evening, or you may need two snacks. The snack should contain at least 25 grams of carbohydrate. You may also need to take intermediate- or long-acting insulin later in the evening. Hypoglycemia in any degree does not always mean you should reduce your insulin dose. With the help of your diabetes health care team, you should determine the cause of your hypoglycemia and the best way to prevent it. Remember that the way you treat your low blood glucose is very important; you do not want to over-treat.

26 What if I become sick during my pregnancy? 24 Aside from the normal signs and symptoms associated with pregnancy, you may become sick with the flu, a cold, etc., during your pregnancy. It is very important to keep tight control of your blood glucose while you are sick. The following are some guidelines on managing your diabetes when you are sick. Monitoring It is important to check your blood glucose regularly at home to determine your need for additional rapid- or short-acting insulin during the time you are sick. Blood glucose and blood or urine ketones should be checked every 4 hours, 24 hours a day. More frequent checks will be required if: You are vomiting. You are unable to follow your meal plan. You have moderate to large ketones present. You have a blood glucose greater than 10 mmol/l. You should continue to check your blood glucose as long as it is greater than or equal to 10 mmol/l. You should check for urine ketones as long as they are present. You should continue to monitor your blood and urine if your regular meal plan cannot be followed. Insulin Adjustment You should never stop taking your insulin when you are sick. Insulin should be adjusted as needed. Your diabetes health care team can help you make the appropriate adjustments. Adequate Intake If you have trouble eating solids, take a 10 to 15 grams portion of carbohydrate in the form of liquid or soft foods every 1 to 2 hours. If blood glucose levels are greater than 10 mmol/l and you are vomiting, you can wait up to 4 hours to eat. Blood sugar levels must be monitored at least every 2 hours. Take extra fluids (e.g., water, clear broth, sugar-free Kool Aid, sugar-free soft drinks, etc.) to prevent dehydration and help with the removal of ketones in your urine. Contacting a Health Professional It is important that you contact a member of your diabetes health care team immediately when: You have been vomiting for more than 4 hours or have more than 5 diarrhea bowel movements in one day.

27 Ketones are still present and high blood glucose levels persist even after insulin adjustments. You develop hypoglycemia during illness (blood glucose levels less than or equal to 3.3 mmol/l). You have been unable to eat or drink anything for 4 hours. Your illness lasts longer than 24 hours, is very severe, or worsens. If you have any questions or concerns about sick day management, contact a member of your diabetes health care team and they will be able to help you. 25 How can I deal with the typical pregnancy complaints? Morning Sickness: Nausea and vomiting are very common symptoms of early pregnancy. Because you have diabetes, nausea and vomiting may affect your insulin dose. If you are taking insulin and experience nausea and vomiting, keep taking your insulin. The following are some tips for controlling nausea: Eat some dry crackers or a piece of toast before getting out of bed. Eat small meals every 2 1/2 to 3 hours. Avoid caffeine. Avoid fatty and spicy foods. Drink fluids (e.g., water, clear broth, sugar-free Kool Aid, sugar-free soft drinks, tea, etc.) between meals, not with meals. Take prenatal vitamins after dinner or at bedtime. Always carry food for snacks. Have a snack containing carbohydrate and protein before bed. Your nausea may also be a symptom of hypoglycemia (low blood glucose); therefore, it is essential that you check your blood glucose levels often. It is also important that you carry food with you at all times to treat hypoglycemia or nausea. Constipation: Constipation often becomes a problem during pregnancy because your intestinal muscles relax, and the growing baby puts more pressure on your intestines. The following are some tips to help with constipation: Drink plenty of liquids (sugar-free). Eat high-fiber foods including whole grain breads, bran cereal, raw fruits, and vegetables. Get plenty of exercise/activity. If the problem persists, discuss it with your doctor. Cravings: Many women experience strange cravings during pregnancy. You may no longer like foods you once loved, and you may crave foods you normally would not eat. It is important to try to fit these new cravings into your meal plan. Your dietitian can help you with this.

28 Should I take any other medications while I am pregnant? 26 Any medication you take during pregnancy will not only affect you but also your unborn baby. During pregnancy you should avoid smoking, the use of alcohol, herbal supplements, and illicit drugs such as marijuana and cocaine. The following are some guidelines to follow when taking medication during pregnancy: Tell your doctor what drugs you normally use (including caffeine, tobacco, and prescription and nonprescription drugs including herbal supplements). Ask for advice about their use during your pregnancy. Even if your doctor agrees with you about taking a nonprescription drug during pregnancy, read the label carefully and look for any warnings about use during pregnancy. If you think labor is about to begin, do not use any medications unless you are instructed to do so by your doctor. Ask your pharmacist for additional information on any drugs you may be concerned about. Will I have to be hospitalized during my pregnancy? It is possible that you may have to go into the hospital if your blood glucose levels are not well controlled. Being admitted to the hospital can increase your level of stress. It may be helpful to view your hospitalization as an escape from a difficult situation. Depending upon your circumstances, the length of your hospital stay will vary. During your stay in the hospital, you should try to keep yourself busy by visiting the day room, exercising, or doing volunteer work at the hospital. Your diabetes health care team can help arrange this for you.

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31 DELIVERY 29 Will I deliver my baby early? The timing of your delivery depends on how well controlled your blood glucose levels were during your pregnancy and how well your baby is growing and developing. Control of your blood glucose levels is important right up until you deliver your baby. Will I have a cesarean section? Women with diabetes have cesarean births (assisted delivery through an incision in the abdomen) more often than women without diabetes. However, due to the use of home blood glucose monitoring and intensive therapy (frequent injections and fine tuning of insulin dose with food and exercise), more women with diabetes are able to continue their pregnancy to their intended due date (term). This also helps to reduce the chances of having a very large baby. By keeping your blood glucose near normal throughout the pregnancy, you can reduce the need for a cesarean section. What will happen to my insulin during labor and after delivery? The goal during labor and delivery is to maintain your blood glucose levels near normal. This will result in changes to your insulin dose. If labor is to be started by induction (labor started by your doctor using induction drugs), you may be instructed not to take your insulin the morning you are scheduled for the induction. Your blood glucose will be checked hourly and may be maintained by an intravenous (IV) insulin drip and dextrose (sugar) solution. If you are delivering your baby by cesarean section: You will be asked to have nothing to eat or drink overnight unless you have a low blood glucose reaction (hypoglycemia). Your cesarean section should be scheduled for early in the morning. For this reason, your breakfast and morning insulin will not be given. Your blood glucose will be checked prior to the cesarean section and an IV started. Different IV solutions will be used during and after the delivery to help stabilize your blood glucose levels until you are able to eat. Insulin will be given as required. After delivery, your insulin requirements will decrease and your insulin dose will have to be adjusted. Your blood glucose levels will be monitored carefully. Your doctor will help you adjust your insulin, and you should monitor your insulin and blood glucose carefully for some time after the birth of your baby. If you go into labor: Your blood glucose will be checked every 2 hours. This will help determine your need for insulin or a sugar solution to help keep your blood glucose near normal.

32 Will my baby need special care after delivery? 30 Due to the nature of your pregnancy and the risks associated with it, your baby will receive special care immediately after delivery. You will still have a chance to see your baby, but holding your baby may be delayed. Your doctor will check to make sure that your baby is okay. If there is a special care unit in the hospital where you are delivering, your baby will be taken to this unit. You will have opportunities to visit, hold, and touch your baby on a regular basis. A tour of the special care unit may be helpful in preparing you for what will happen to your baby after delivery. Touring this unit and/or discussing the special care your baby will receive will help reduce some of the stress you might experience at the time of delivery. Ask your diabetes health care team if a tour can be arranged. What will the doctors check my baby for? As with all newborns, your doctor will check to see if your baby has any physical abnormalities, ensure there are no injuries caused by the delivery, and that her/his breathing, colour, and heart rate are normal. Your baby will also be observed for risks related to your diabetes such as low blood glucose. How can my diabetes affect my baby at delivery? The most common complications are low blood glucose (hypoglycemia), immature lungs (respiratory distress syndrome), and jaundice (hyperbilirubinemia). Neonatal Hypoglycemia: Refers to low blood glucose levels in the baby shortly following birth. This occurs in the baby who has been exposed to high blood glucose levels from her/his mother. As a result of this high blood glucose, the baby s pancreas makes extra insulin. Once the umbilical cord is cut, the source of glucose from your body stops. Therefore, the baby s blood glucose can drop after birth. Your baby s blood glucose levels will be tested frequently after birth so treatment can begin immediately if her/his glucose levels are low. If it is necessary to watch for the signs and symptoms of low blood glucose in your baby, the nursing staff will explain these to you. The first feeding may be given by one hour of age to prevent hypoglycemia. The treatment of hypoglycemia is to feed your baby or to start IV glucose as needed. Jaundice (yellow colour of the skin): Jaundice (a build-up of bilirubin in the blood) is common in newborns and causes the skin to turn yellow. It may occur earlier or be more severe in a baby whose mother has diabetes. Signs to look for: Early skin changes such as yellow colouration. Sleepiness. Shows no interest in feeding. Contact your nurse or doctor if you notice any of these signs.

33 Respiratory Distress Syndrome (immature lungs): Occurs when the lungs of the infant are not fully mature at birth, and the baby has trouble breathing on her/his own. As mentioned before, this is more common in babies born prematurely. If this happens, your baby will be given oxygen and other assistance to breathe until her/his lungs are ready to do the work on their own. Mild cases do not result in long term breathing problems. Hypocalcemia: Refers to a low level of calcium in the blood of the newborn baby. There is a greater chance of this occurring in a baby of a mother with type 1 diabetes who had difficulty controlling blood glucose levels. The treatment for hypocalcemia is to give calcium supplements until the level of calcium returns to normal. 31

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37 BREASTFEEDING 35 Should I breastfeed? Yes, if you can! But don t feel guilty if you cannot. Breast milk is the best source of nutrition for all babies. It is recommended that women, including those with diabetes, breastfeed. One of the main advantages of breastfeeding is that it naturally lowers the mother s blood glucose levels without increasing insulin needs. Glucose is used as energy to produce the milk. Fasting blood glucose levels are lower in women who successfully breastfeed. What are the benefits to my baby? Attachment with the mother. Helps protect the baby from infection. Provides the baby with the best nutrition for growth and digestion. May help prevent your child from developing diabetes later in life. What are the benefits to me? Attachment with your baby. Prolonged breastfeeding (longer than six months) may promote weight loss as it uses fat stores accumulated during pregnancy. Controls uterine bleeding after delivery. Economical (no formula cost). Time saving (no preparation). Decreased insulin needs. What should I do if I want to breastfeed? Before Delivery Attend a breastfeeding class in your community. Ask your diabetes educator to introduce you to a woman with diabetes who has recently breastfed her baby. She can help answer any questions you may have. Discuss with a diabetes educator possible obstacles to breastfeeding.