Planning and good A1C
It is vital that women who have either type 1 or type 2 diabetes avoid unplanned pregnancies. This is because the high blood sugars associated with diabetes can damage the baby in the days immediately following conception when the baby’s organs are being formed. Women should avoid pregnancy until their glycaemic control is within the recommended target levels and they have been assessed for the presence of any complications that need to be treated before pregnancy.
Babies born to mothers with poorly controlled diabetes are at higher risk of congenital malformations, stillbirth and neonatal death than babies born to women in the general population. “If somebody has an HbA1c above 60 mmol/l we would strongly discourage them from becoming pregnant. The higher the A1c the higher the risk of congenital abnormality,” said Rita Ford, Advanced Nurse Practitioner.
“By the time most people discover they are pregnant the baby is generally formed. A process called organogenesis occurs in the first six to eight weeks after conception. Most women don’t realise they are pregnant during most of that time. During this time all of the baby’s organs are formed and the foundation for later growth is laid down,” said Rita Forde.
Good control before pregnancy
Women who have type 1 diabetes and are planning to become pregnant need to establish good glycaemic control and an A1c (long-term blood sglucose level) of under 7% for three months in a row before they become pregnant. Women who have type 2 diabetes should aim to get their A1c down to 6.5%.
If a woman is planning to have a baby, the first thing she should do is let her health-care providers know and see what they have to offer. “It is much easier for people to achieve good glycaemic control with a little bit of help. It is hard work – if it was easy everybody would have good glycaemic control.
The first thing she should do is inform her diabetes nurse or her clinic that she plans to have a baby. The big thing then is to avoid pregnancy until your glycaemic control is within target and you have been assessed for any complications that might need to be treated before you get pregnant.
Care during pregnancy
When a woman has achieved good glycaemic control and has no other complications and then actively tries to become pregnant, she should then be very observant for when she might become pregnant.
When a woman with diabetes has confirmed her pregnancy she will be transferred to the diabetes-obsteteric clinic at her local maternity hospital.
In the three major maternity hospitals in Dublin, the Coombe, the Rotunda and the National Maternity Hospital, the consultant endocrinologists from the Mater hospital hold a combined diabetes clinic with an obstetrician once a week. Each hospital also has specialist diabetes midwives and dietitians at these clinics. After the baby is born, the mothers return to their normal clinic for their diabetes care.
Women need extra folic acid
Women with diabetes need a higher dose of folic acid before pregnancy because their babies are considered at a higher risk of developing the neural tube defects that folic acid can minimise.
Women attending the pre-pregnancy diabetes clinics who are finding it difficult to conceive will be referred on for fertility treatment sooner rather than later.
Eating Well and pregnancy
If you have diabetes and you are thinking about having a baby it is very important to attend the pre-conception clinic so that you can optimise your blood sugars before you become pregnant. If you plan your pregnancy, attend a pre-conception clinic or at least discuss pregnancy with your GP, it can help you avoid any complications during early pregnancy. Early assessment can help you to:
• Improve how you manage your diabetes
• Assess your diet and lifestyle
• Manage your day-to-day blood glucose levels
• Manage your A1c (long-term blood glucose levels)
• Make sure your eyes are healthy.
• Tighter control of blood glucose
Your blood glucose control needs to be much tighter during pregnancy, so you may need to check your blood sugars more frequently and your medications may need to be changed or discontinued. Pregnancy is a time of constant change and a good varied, balanced diet throughout, will help to provide a variety of nutrients for both you and your growing baby. Some nutrients, however, are in higher demand during pregnancy and at different stages of the pregnancy.
If you have diabetes and you are planning a pregnancy or are already pregnant you should take 5mg daily supplement of folic acid for at least 10-12 weeks before you become pregnant and up until the 10-14th week of your pregnancy. This helps to prevent neural tube defects like spins bifida and hydrocephalus. Women who have diabetes need a higher dose of folic acid during pregnancy than women who don’t. You should also try to eat some folic acid or folate rich foods most days. These include dark green leafy vegetables, beans, peas, lentils, oranges, and fortified breads and cereals.
Iron is a mineral that is needed for the healthy development of new blood cells. It is very important in the growth of the foetus, especially in the last six months of your pregnancy.
If you eat an iron rich diet from the start of your pregnancy you can help to prevent anaemia. Include iron rich foods in your diet most days such as:
• Lean red meat – beef
• Poultry – Chicken, Turkey
• Oily fish – salmon, trout, sardines
The iron in green leafy vegetables, fortified breakfast cereals, breads, eggs, peas, beans and lentils is not as well absorbed in the body as iron found in meats. But if you also eat food rich in vitamin C such as unsweetened fruit juices, salads, green vegetables and fruits at mealtimes, it will help you to absorb iron. Tannins in tea, coffee and darker beverages like some herbal teas or cola drinks, red wine can make it more difficult to absorb iron so try and limit how much of them you drink. Some of you may be on iron supplements, as recommended by your doctor.
Calcium and Vitamin D
Calcium and vitamin D work together in the body and are essential for the growth of bones and teeth. Calcium is very important for both mother and baby in pregnancy. It is needed for growth of new bone but also to protect the mother’s bones during pregnancy and later in life.
High calcium foods
Include 3 portions of high calcium foods in your diet every day. These can include:
Milk – fortified brands are best
Cheese – full fat or low fat
Other good sources of calcium and vitamin D include:
Oily fish such as salmon
Tinned sardines or other fish
Green leafy vegetables
Fortified orange juice
Olive oil-based margarines
You should also try to spend some time outdoors in the sunshine to allow the sun to make vitamin D in your body. This is especially important if you have dark skin or you usually cover your skin. Also note – wearing high factor sunscreen or a moisturiser with high SPF may also reduce the body’s ability to produce vitamin D
Omega-3 fats are essential for the development of the baby’s brain and eyes. The best way to get enough of these healthy oils is to eat oily fish such as salmon, mackerel, trout, sardines, pilchards and herring one to two times per week. If you do not like fish, you can still get omega-3 fats from oils such as rapeseed or linseed oil and from nuts and seeds, fortified eggs, milks, juices, breads and yoghurts.
Don’t lose weight!
You should not lose weight in pregnancy! If you need to lose weight, do so at least three months before you become pregnant so that you do not limit your nutritional intake near to or around the time you become pregnant. If you are overweight during pregnancy you may be increase the risk of developing blood pressure problems so you should start your pregnancy at a healthy weight. Everyone gains weight during pregnancy. This is natural and is needed to support the growing foetus, placenta, increased blood volume and fat stores. How much you gain is again very individual, in general expect to gain anything from one to two stone (7kg-14kg). This generally occurs in the second half of your pregnancy, so if you don’t put on much weight in the first three months do not worry.
Regular gentle physical activity, such as walking or swimming, will help you gain healthy weight during pregnancy. If you have raised blood pressure, speak with your doctor or midwife before beginning any physical activity.
Remember that the extra energy needed in pregnancy can be easily be made up with just an extra 200-400kcal per day which is equivalent to one-two pieces of fruit, one pint of milk or two pieces of toast. If you are concerned that you may be gaining too much or too little weight, ask your GP or a dietitian for advice.
This is the nausea and vomiting that affects women generally in the early stages of pregnancy. It can be more severe for some. If you have diabetes and are on medication or insulin, you may find it very difficult to eat and drink; take your medication; and maintain your blood sugar levels. However, try to eat small amounts of carbohydrate rich foods such as dry crackers, plain biscuits, bread, cereals, breadsticks or fruit juices. These can help keep your blood glucose levels up and prevent hypos (very low blood sugar readings). Try to eat first thing in the morning and have regular snacks and plenty of fluids. Consult your doctor if this nausea becomes severe and you are having frequent hypoglycaemic events.
Foods to avoid:
• Cod liver oil supplements because they have very high levels of vitamin A
• Soft boiled or raw eggs. Remember some sauces, desserts and mayonnaises may contain raw egg so always read the label or ask the chef
• Soft-moulded or unpasteurised cheeses. If in doubt check the label or avoid.
• Liver and all types of pate
• Raw fish and sushi
• Smoked fish, however, you can eat it cooked
• Shellfish such as oysters, mussels and prawns should be avoided unless they are part of a hot meal and have been thoroughly cooked.
• Undercooked or reheated meats
• Soft whipped ice-cream
• Shark, marlin, or swordfish
• Limit tuna intake to one-two tins (140g) per week or one fresh tuna steak per week
• Avoid peanuts if there is a family history of allergies
• Never eat foods past the ‘use by date’
• Limit caffeine intake to 1-2 cups of coffee a day or 2-4 cups of tea a day. No more than 200mg caffeine a day is advisable.
**Remember that chocolate, coke, some energy drinks, certain cold or flu remedies and some herbal teas also contain caffeine.
**Always remember basic food hygiene advice to follow especially during pregnancy to avoid unwanted germs, infections and food borne illnesses.
If you are planning to become pregnant it is best to avoid all alcohol before conception, during and after pregnancy (if breastfeeding). The smallest amounts of alcohol can affect the unborn baby and alcohol can make your blood glucose much harder to control. It is also a high source of calories and contains little nutrition.
If you have a very healthy, balanced and varied diet in general, you do not need a vitamin supplement (except folic acid). However, if you are a very fussy eater and avoid a large range of foods or food groups, then you may benefit from taking a multivitamin that is suitable for pregnant women. If you are uncertain, speak with your doctor or dietitian, who can advise you. When you are pregnant it is important always to check with a pharmacist or doctor whether or not any vitamin or herbal product or supplement is safe to take during pregnancy. Just because a product is ‘natural’ does not mean it is safe. Give your child the best possible chance and eat a healthy, varied diet from the start!