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Pregnancy brings joy and anticipation, but for women with pre-existing diabetes, it also presents unique challenges that require careful management. Dr. Jennifer Lam-Rachlin joined us on the Healthful Woman podcast to discuss the importance of planning and monitoring to ensure healthy outcomes for both mother and baby.

Understanding Pregestational Diabetes

Both type 1 and type 2 diabetes are forms of pre-existing diabetes. The main difference between these is that type 1 diabetes is something a person is born with or develops early on, and their bodies are unable to produce or produces a significantly lower amount of natural insulin. Type 2 diabetes develops gradually and is not always detected for many years, which can pose risks if a woman has untreated diabetes and gets pregnant.

Pregestational diabetes or pre-existing diabetes is different than gestational diabetes, which develops during pregnancy as a response to new hormones produced by the placenta. Pregestational diabetes carries higher risks, primarily because elevated blood sugars are present during the earliest stages of fetal development. Poor glucose control before pregnancy or in the first trimester increases the likelihood of congenital anomalies, especially heart defects. Gestational diabetes, which emerges later in pregnancy, does not increase the risk of birth defects. Instead, the primary concerns involve excess fetal growth, an increased likelihood of preeclampsia, and the need for closer surveillance in the third trimester.

Preparing for Pregnancy with Pre-Existing Diabetes

For women with known diabetes who are planning to get pregnant, preconception care plays a crucial role in improving outcomes. Because of the high risk of birth defects with untreated diabetes, it is important for women to make sure their blood sugar levels are under good control before getting pregnant. The hemoglobin A1C is a standard test used to monitor blood sugar or glucose levels, and it can be used to determine whether a person is prediabetic or how severe their diabetes is. Achieving a normal A1C before conception is one of the most important steps toward a healthy pregnancy. Eye exams, kidney function assessments, heart evaluations such as EKGs, and screenings for neuropathy should also be performed to assess potential diabetes-related complications. Many women with diabetes also have other conditions, such as chronic hypertension, which should be controlled before pregnancy. As Dr. Lam-Rachlin emphasizes that “the better controlled [patients] are going through the pregnancy, the better the pregnancy outcome.”

Diabetes Treatment During Pregnancy

Dr. Lam-Rachlin generally recommends insulin as the preferred treatment. It is safe for the developing fetus because it does not cross the placenta, and it allows for precise adjustments. As Dr. Nathan Fox explains, “you can change the dose of insulin by 5%, by 10%…to have very small or fine effects or not overdo it. Whereas the pill, it’s hard to do that. So, if it’s not working and you increase their dose, they may end up having very low blood sugar the next morning.” Oral medications such as metformin or glyburide also have a high failure rate and may cause gastrointestinal side effects. Although many patients are initially apprehensive about insulin injections, Dr. Fox also provides reassurance about the tiny size of the needle, which is less painful than a routine finger-stick glucose test.

Pregnancy Care for Diabetic Patients

Throughout pregnancy, women with pregestational diabetes undergo additional monitoring to ensure fetal health. This often includes monthly ultrasounds to assess fetal growth, as diabetes can lead to babies who are either larger or smaller than expected, depending on whether blood sugar levels are too high or too low. Around 20 weeks’ gestation, a fetal echocardiogram is performed to evaluate the baby’s heart development, since the heart is particularly vulnerable to disruptions from high blood sugar early in pregnancy. Beginning around 32 weeks, biophysical profiles and other assessments help confirm that the baby remains healthy to prevent a stillbirth, another adverse outcome that can occur in women with pregestational diabetes. Many women safely deliver at full-term, with a preferred method of vaginal delivery.

Learn More on the Healthful Woman Podcast

To learn more about what pre-diabetic women can expect during pregnancy, check out Dr. Fox and Dr. Lam-Rachlin’s full discussion on the Healthful Woman podcast. If you have any questions or personally require advanced pregnancy care, we encourage you to schedule an appointment with us at our NYC office.

Maternal Fetal Medicine blogs are intended for educational purposes only and do not replace certified professional care. Medical conditions vary and change frequently. Please ask your doctor any questions you may have regarding your condition to receive a proper diagnosis or risk analysis. Thank you!