Type 1 Diabetes And Pregnancy

What is type 1 diabetes?

Type 1 diabetes is a chronic autoimmune condition in which the pancreas is unable to produce any insulin or produces insufficient levels. This often leads to problems as insulin is a crucial hormone in the body’s creation of energy.⁴ Glucose (blood sugar) is the main component in energy production and it comes from food that dominantly contains carbohydrates (carbs) and sometimes protein as well. 

Normally, carbs are broken down into glucose when leaving the intestine to the liver and will go to the body’s cells through the bloodstream and create energy. Before glucose enters the body’s cells, it has to pass insulin which acts as the gatekeeper. This insulin is produced by beta cells in the pancreas and these beta cells can detect an excess of glucose in the blood. If an excess of glucose occurs (usually after a meal), it will send insulin to maintain the glucose. However, all this does not happen in both type 1 and type 2 diabetes.⁹

Furthermore, type 1 and type 2 diabetes are different in diagnosis  in treatment. Type 1 diabetes is usually diagnosed in childhood and does not relate to obesity; however, it is associated with an increase in ketone levels when diagnosed. Meanwhile, type 2 diabetes is commonly diagnosed in those over 30 years old’s and is correlated with excess body weight, as well as high blood pressure and/or cholesterol levels when diagnosed.⁵

The UK is one of the countries with the highest rate of type 1 diabetes in the world, with around 400,000 people living with type 1 diabetes and 29,000 of them are children. Surprisingly, approximately 4% of new cases have been diagnosed annually.⁷

Symptoms

Occasionally, the diabetes symptoms are mild so they go unnoticed. Normally, people will urinate frequently, will long for a drink and food, and experience exhaustion, blurry vision, cuts and/or bruises that heal with difficulty. Type 1 diabetics will lose some weight although they consume lots of food, whereas type 2 diabetics will feel tingling, pain or numbness in their hands and feet.¹

Furthermore, type 1 diabetes tends to appear suddenly and in some cases, diabetic ketoacidosis (DKA) will happen before the diagnosis is made.¹

Causes and risks

The cause of type 1 diabetes is autoimmune devastation of insulin production in the pancreas which consequently causes absolute insulin deficiency. Furthermore, the risk factors that affect type 1 diabetes are genetic and environmental.¹⁴

Type 1 diabetes is a polygenic inheritance disease; hence, there will be a 6-7% risk of developing this disease for siblings of type 1 diabetes person. The risk of a child of type 1 diabetic  is about 1-9%. Furthermore, certain environmental factors that trigger the pancreatic beta cells in autoimmunity development are diet, vitamin D exposure, higher Body Mass Index (BMI), islet inflammation due to the early-life exposure to viruses and the plunge of the intestine’s microbiome diversity.¹⁴

What are the risks of becoming pregnant when you have diabetes?

The risks of having type 1 diabetes while pregnant vary by pregnancy trimester.¹²

The possible risks that could happen in the first trimester of pregnancy (0-12 weeks) are divergent. Poor blood sugar can cause improper development of the baby that results in various birth defects such as cleft lip and abnormal heart structure. These risks depend on the mother’s HbA1c levels when pregnant.¹²

In the second and third trimesters (13-42 weeks), the baby will receive more glucose through the placenta due to poor glucose control, which consequently makes the baby’s weight larger than average. This condition can contribute to delivery complications, in which the size of the baby's head is disproportionate; therefore, the labour process will be stuck.¹² When the baby’s size is larger-than-average, a C-Section tends to be the option for delivering the baby. However, when it comes to diabetes, they will take longer to recover from a C-section.² Moreover, a C-section for an overweight baby is commonly done early between 37-38 weeks and six days of pregnancy using induction labour and will result in the baby being born prematurely.¹² Premature babies are vulnerable and can suffer various complications such as breathing and heart problems, brain haemorrhage and intestinal and vision problems.²

Furthermore, in early pregnancy, there will be a risk of miscarriage and fetal loss and a risk of stillbirth in later pregnancy (more than 24 weeks).¹² The baby can also develop a low blood sugar (hypoglycemia) condition after birth due to the mother’s uncontrollable blood sugar. The blood sugar which flows through the umbilical cord to the baby is cut and the blood sugar supply from the mother stops. Afterwards, the baby has a sudden situation where there is no more blood sugar supply and a lack of blood sugar (hypoglycemia) which should be observed for several hours after birth.²

Preparing for pregnancy when you have diabetes

Before the pregnancy

Know the risks and possible complications

As explained previously, there are plenty of risks associated with  type 1 diabetes. However, some risks can be avoided while others can be reduced if the mother plans ahead and looks for support from their GP.⁶

Involve your doctor or specialist nurse

The GP, nurse and/or midwife should be involved in the pregnancy planning as diabetes is a risk for pregnancy. These health practitioners can give advice and pre-conception clinic referrals. The information that will be given regarding pregnancy with type 1 diabetes specifically is regarding maintaining the blood sugar level, the suitable medicine to take during pregnancy, and the possibility of risks as well as how to tackle them.⁶

Keep your HbA1C and blood sugar in the target range

HbA1c is a test to measure the blood sugar attached to the haemoglobin within 3 months.¹⁰ Measuring the HbA1c level before planning to be pregnant is a good treatment as it will reveal whether the diabetes is controlled or not. This result will help the health practitioner plan the treatment during and after pregnancy.¹² 

The ADA recommendation for HbA1c levels for women planning a pregnancy should be as close to the target pregnancy as possible (A1c < 6.0%) without significant hypoglycemia.⁸

Check your medications are all safe for pregnancy

Women with diabetes who plan to get pregnant and have previously had diabetes therapy like insulin should discuss this with their GP. Some diabetes therapies are not safe for babies such as statins, ACE inhibitors, and medicine which treat blood pressure.⁶

Take folic acid

Regarding the risk to the baby’s development, folic acid therapy is advised and will be given by the General Practitioner (GP) to increase the chance of the baby developing normally.¹²

Get your eyes and kidneys checked out

Diabetes complications can affect the eyes and kidneys, examples being diabetic retinopathy and diabetic nephropathy. These complications can be avoided if women are screened and in some cases, they may need to be referred to a specialist.⁶

Get as much advice as possible

It is also possible to stay informed about diabetes and pregnancy through information provided by diabetes support helplines. This information has been provided by professionals and can be found easily on the Internet.⁶

Does diabetes affect fertility?

Type 1 diabetes is an autoimmune disease in which an insulin deficiency occurs.¹⁶ This condition can cause the female ovaries to create the sex hormones at a less than usual capacity or something they do not create any of the hormones; therefore, type 1 diabetes in females may affect their fertility.¹¹

During pregnancy

During pregnancy, women with type 1 diabetes are advised to make a diabetes management plan with their GP and midwife. The plans include control of the HbA1c level on target during pregnancy until labour; otherwise, the risks will happen unexpectedly.³

Moreover, regular exercise is  advised to keep control of blood sugar as well as maintain a balanced food intake. It is advised to do at least 30 minutes of moderate-intensity physical activity for a minimum of 5 days/week by doing a walk, swimming or even playing with children actively. It is also advised  to not drink alcohol and smoke, since both harm the body and can aggravate the diabetes risks and complications. Meanwhile, drinking and/or smoking while pregnant can cause breathing problems, miscarriage, prematurity, and low birth weight, and can affect the child’s physical and mental development.¹⁵

Keep your HbA1C and blood sugar within the target range by

• Eating Healthily
• Remaining Active
• Not Drinking Alcohol
• Not Smoking

Where and how to give birth

In hospital is best

The National Health Service (NHS) guidance implies that pregnant women with type 1 diabetes can have a natural birth. However, it suggests that labour should take place in hospitals as many things need to be considered. According to the risks like the disproportionate size of the baby’s head- which could possibly cause congested labour and require an urgent C-Section- the hospital is the best place to plan the birth with type 1 diabetes. Premature labour could also happen as a result of the risk of an overweight baby, which potentially endangers the baby’s health. Hence, a Neonatal Intensive Care Unit (NICU) may be  needed to stabilise the baby after delivery which is only available in the hospital.³

Insulin administration during labour

Regardless of the delivery methods, there will be an increase in blood sugar during labour which will suddenly decrease immediately after the delivery. Therefore, the insulin therapy might change according to the birth plan and the doctor will give the therapy using the insulin pump or Continuous Glucose Monitor (CGM).³

After delivery

Breastfeeding

Breastfeeding for women with type 1 diabetes can be good as it helps reduce the body’s extra weight which is gained during pregnancy. Other benefits of breastfeeding regardless of whether one has type 1 diabetes are: decreased risks of high blood pressure, ovarian cancer and breast cancer. Breastfeeding is similar to doing exercise since it is an energy-consuming activity. Therefore, breastfeeding could possibly cause low blood sugar and it is crucial to intensively observe signs of low blood sugar.³

Summary

Type 1 diabetes is an autoimmune disease caused by less or even no insulin production by beta cells in the pancreas. The common symptoms are urinating frequently, craving food, feeling thirsty all the time, tiredness, blurry vision, cuts and/or bruises that are hard to heal and loss of  weight although consuming lots of food. If women with type 1 diabetes get pregnant, there will be several risks for both their pregnancy and their babies such as miscarriage, premature labour, low birth weight and birth defects and there is a tendency to require a C-section. Therefore, due to the risks, it is better that women who have type 1 diabetes consult with their GP and midwife to plan their pregnancy as well as throughout their pregnancy as they will need  to control their food intake and diabetes therapy, regular exercise, and plan their diabetes management with the healthcare practitioner.