The Management of Diabetes in Women Who Are Pregnant

Jennifer Smith RD, LD, CDCES

In this podcast, Jennifer Smith, RD, LD, CDCES, discusses the management of diabetes in women who are pregnant, including the changes women with diabetes should expect during pregnancy, post-partum, and while nursing, developing an action plan with patients, and the impact of technology in diabetes management. 

Additional Resource:
•    Diabetes Wise. Accessed September 17, 2023.

For more diabetes technology content, visit the Excellence Forum.



Jessica Bard:

Hello everyone and welcome to another installment of Podcast 360, your go-to resource for medical education and clinical updates. I'm your moderator, Jessica Bard with Consultant 360, a multidisciplinary medical information network. Diabetes can cause problems during pregnancy for women and their developing babies, registered and licensed dietician and certified diabetes care and education specialist Jennifer Smith is here to discuss changes women with diabetes can expect during pregnancy and postpartum, and the role of technology in diabetes management.

Jennifer Smith:

My name is Jennifer Smith and I'm a registered dietician and certified diabetes care and education specialist. I work with integrated diabetes services, a worldwide coaching service for those who are intensively managing their diabetes. You see people with type one and type two diabetes, all age ranges and I have a special interest in women's health and work with a lot of women through pregnancy.

Jessica Bard:

Jennifer, thank you so much for joining us on the podcast. Today we're talking about the management of women with diabetes during pregnancy and postpartum. To kick us off here, what kinds of changes should women with diabetes expect during pregnancy?

Jennifer Smith:

There are a lot of changes to expect certainly. Pregnancy and postpartum and women's health are a big part of what I work with in our practice, and so the major changes are going to be to the insulin dose. They are for someone with type one, especially, someone who may have type two may even have to transition into using insulin during their pregnancy. And even gestational diabetes, you may start out with some lifestyle changes and end up utilizing some type of medication to help.

So I think a big change that should be expected is a change to insulin dose need or medication need. And then the other changes, honestly, they focus a little bit more on the changes that come from the hormones that impact pregnancy and the continuing development of the baby and the pregnancy until delivery time. Right? And so those kinds of changes are sometimes a little bit more lifestyle. You may at certain times be a lot more fatigued.

You may at times feel back to your normal self. You may have nutrition needs that climb as your hunger level grows. At closing in on the end of the second and into the third trimester the baby is getting larger as it should, but because that baby's sitting on your digestive system essentially you may feel full, and you might not be able to eat as much at a time. So some changes might be more frequent intake of food to meet your nutrition needs when that wasn't your typical style prior to pregnancy.

So there are a lot of changes that you should definitely expect during pregnancy, but a big one specific to diabetes is the very significant change in insulin dose, which can be really surprising for many women, even if they've heard it before, can be very surprising as their needs escalate.

I mean, I know when I was pregnant with my first and I was changing all of my insulin to carb ratios, and one morning I looked at my bolus that was recommended from my pump and I couldn't believe the dose that it had suggested. I was like, "This can't be right. I never used this much insulin before for this meal." So that's just something mentally to kind of overcome.

Jessica Bard:

Yeah, and in that same vein with those changes, is there anything else that you wanted to mention about action plans with your patients and how you talk to them about those changes and things that they'll notice during pregnancy with their diabetes management?

Jennifer Smith:

Yeah. I think I'm always super excited when I get to work with somebody prior to conception because that's where that action plan starts, right? The understanding of I'm sitting here, I know my reaction to certain foods, I've got my standard intake, I've got my standard activity level, my insulin doses are working really well.

If they're not, that's the time that I usually work with somebody on really dialing in their medication doses to make sure that they're optimizing their blood sugar prior to conception, which can also enhance the potential of conceiving. So when I talk with women ahead of time, I can get them ready for what might end up happening.

If however, I get to start with somebody in the first trimester and we haven't worked together before, then that's a first place to start expect that at this point of pregnancy, this is going to be what you see, an increase in insulin sensitivity here leads into a little bit of stability. A climb in insulin essentially starts somewhere around 18 to 20 weeks, give or take woman to woman.

And so giving them information upfront for what to expect even if they're only six weeks pregnant at this point, an action plan so that they can see out into the future what will end up happening or where we're going to end up making likely adjustments to things. In visits I typically focus on the next couple of weeks before we have a chance to visit again, prepping them for the more immediate or short-term, what's going to change.

And then again, in those first visit or two, prepping them for what should look like happening as the months go forward and insulin resistance creeps up, increases, some big things definitely that can help. Again, preconception is the greatest place to kind of put some things into action, such as figuring out what most of your favorite foods to take in do to your blood sugar. Right?

Not only does it go along with understanding insulin action and getting your doses dialed in, but also what's the impact of this meal versus that meal? Something I often recommend is to take into consideration dinner, which tends to be for many families or many people, the most variable meal of the day. Maybe they've got a standard two or three things that they eat over and over for breakfast, kind of similar maybe for lunch, but dinnertime comes and it's sort of a, "I don't know, I was busy. I had to put something together quick."

Or, "We stopped and we got something and we brought it home." Or, "This meal was more planned." So action for them would be to sit down with their spouse, or significant other and figure out some of those dinner meals or there are meals that they're going to eat more together and then track ahead of time, "How do things look after this meal? Do I need to adjust something? Is it insulin timing that I need to change?

Is it using some of the smart features on an insulin pump or is it dosing medication in a different time or a different way?" So again, prior to pregnancy is the ideal time to create that action plan so that they know what's coming. And if they have that in place, as insulin needs to change through the course of the pregnancy, they don't have to resort to feeling like they can only eat lettuce in order to keep their blood sugar in the real tight pregnancy range. Right?

They have sort of a platform to work off of and that can help. I think another piece of that action plan is understanding activity or exercise in the whole grand scheme of pregnancy management with diabetes. Exercise, as we know even outside of pregnancy, enhances the action of insulin, making it work better for us. The more consistent the exercise is, the more sensitivity that we can keep in the picture, and that's very visible in pregnancy.

Those women who started out with a really good activity plan and continue it into pregnancy with potentially some changes that might be needed, again based on energy levels and ability and some minor restrictions that might be there from a pregnancy perspective for exercise, keeping that active sort of piece in the picture can make a really big difference on their overall insulin use or medication use and long-term into even delivery is improved.

For women who keep up with some type of active lifestyle, it improves flexibility. For many women, they've found that it improves the ability to have a more natural labor and delivery. So all of those things and even more get talked about. We often look in that action plan at the content of what might be eaten because food makes a really big impact as well, not only in preconception, ensuring you've got all the good nutrients that your body needs, but also in pregnancy, you're making another human. Right?

And so what that really means is making sure that your body has all the nutrition because all that nutrition then gets broken down and it gets passed into the baby. So make sure you've got a really good platform there to ensure you both get the needs that are important through that pregnancy and which also sets you up for the postpartum time as well.

Jessica Bard:

And I can only imagine the type of confidence that you help build in these patients with their diabetes management when they're pregnant. Having gone through it yourself, I'm sure that really helps instill some confidence in an action plan and everything else that we had just talked about. Now moving on to postpartum, how long could these changes that we mentioned continue into postpartum?

Jennifer Smith:

That's a great question because the postpartum time period is, it's a change in insulin need and sensitivity. That's the opposite of what the buildup in pregnancy is, right? The buildup of resistance, the buildup of an increase in insulin need. In the direct postpartum time, milk comes in. Pregnancy hormones, as soon as the baby and placenta are delivered, pregnancy hormones get, I guess washed out for lack of a better, easy way to kind of describe it.

And insulin needs to go down fairly quickly. I mean, it's not instantaneous in 10 minutes, but over the course of a couple of hours post-delivery insulin needs to shift down a lot. And so the expectation is that, for those who might be using insulin in pregnancy, the idea is to have some postpartum setup dosing strategy in place to enable it. Many women who are using an insulin pump have the ability to set up a secondary profile essentially for the pump to be able to deliver insulin.

Depending on what the insulin needs have changed through the pregnancy, many women double or even triple their insulin dose by preconception to the end of pregnancy or delivery. And so what we would look at is where were your needs preconception. Where did your insulin needs creep up to by the time of delivery? We par back their insulin needs for that post-delivery time period.

And then we may even reduce it slightly because in that direct couple of weeks right after delivery, it's what I would call the most sensitive time, honestly. There's a loss of all those pregnancy hormones, there's a switch over to lactation and nursing, which can also bring on a lot more sensitivity. And that's when women end up having a lot more struggle with low blood sugars versus the resistance and the higher blood sugars that they're fighting during the pregnancy.

So those are certainly considerations because the changes we make in pregnancy are different, but there are changes to expect postpartum and they can last a fair amount of time. I mean, depending on how long a woman nurses, that sensitivity can stay in the picture. And until weaning happens, and then post-weaning, another evaluation of insulin needs as activity level kind of creep back to normal or lifestyle, your day-to-day sort of changes back to the structure of including work if you were going to work. So it's another time of change just in a different way.

Jessica Bard:

You spoke about nursing just now. Anything else that patients with diabetes need to consider when nursing?

Jennifer Smith:

Because nursing, like I said, especially in the first several weeks post-delivery if milk comes in well, first milk is that colostrum. It's very liquidy, kind of like this yellowish sort of creamy kind of color. There's not a lot of it, and it's not meant to last for eons. It goes away pretty quickly once milk actually comes in. From a nursing perspective, one really important piece is hydration, making sure to stay well hydrated. Because if you are giving up liquid by nursing your child, your hydration needs to be high. Right?

So intake of fluids, especially water, is very important. The other component is while we don't necessarily continue to encourage such tight control, once the baby is born, those blood sugars should not be left just roller coaster up and down or remain elevated for fear of being low because now you're nursing. So changes to the insulin doses so that you can actually successfully nurse and keep your glucose levels in a good range to ensure that your body can produce milk and sustain that milk production as long as you plan to nurse your child.

What I've found in working with women is that for about the first three-ish months, give or take a little bit, tend to be a little bit more flexible in terms of your sensitivity to nursing and the insulin need in that time period. Many women end up, if they've had some good maternity leave, will end up going back to work after about three months, again, give or take, which brings in another consideration in nursing.

You might end up pumping and nursing at the same time, or you might end up exclusively pumping just to be able to provide breast milk to your baby, but you're not necessarily nursing. And so that might bring in a bit of a shift in what you see in terms of your glucose response. If you're finding that your nursing is creating low blood sugars initially in the postpartum time period, there are strategies certainly with again, the newer pumps on the market that allow you to essentially set a higher target to decrease the chance of lows.

Or if you're noticing that lower blood sugars are happening around a certain time of the day when you're nursing, you can expect it essentially with a trend and you can accommodate by taking a dose of insulin that's a little bit less. If it's happening after a meal and you're nursing after that meal, or if it's overnight, we might adjust the doses of insulin down for that time period. So a lot of it is still keeping up with your data.

It's still keeping up with looking trends, which for a new mother or a mother who has another child or two at home and now a newborn, can be a lot to take on. So I think that, a consideration in that postpartum time period is remembering to stay connected to your diabetes management care team so that they can also help as much as possible because you'll have new mommy or baby brain and the sleep loss brain and lots of things and it's really important that you've got somebody behind the scenes helping you look at things with kind of an unbiased eye.

Jessica Bard:

And I'm sure technology could also assist in that as well. What is the role of technology and how can that play in women with diabetes who are pregnant or postpartum?

Jennifer Smith:

Yeah. I mean, the first piece of technology that I think is really important in pregnancy as well as in the postpartum time period would be a continuous glucose monitor. Blood glucose monitors or finger sticks are a point of the real-time information, right? It's, "Right now what's my blood sugar?" But in the minutes after this or the hour after this, we have no ability to see where it's going. Is it going up? Is it staying stable? Is it dropping down? With nursing in the picture, what's happening?

So a continuous glucose monitor is the first line of technology that I would absolutely encourage women to ask for if they don't have it. The second line of technology that would be very beneficial is an insulin pump. That would be very beneficial to work with the continuous glucose monitor because all of the FDA-approved systems that are on the market today have some type of what's called an algorithm-driven insulin delivery system.

And so how the algorithm works in a simple way is it uses the continuous glucose data point that comes from the sensor and then the algorithm bases its decision in insulin delivery off of stability, rises in blood sugar, drops in blood sugar, things like insulin on board so that there's an assistive hand that helps with the micromanagement behind the picture.

And especially in pregnancy, because the algorithms aren't written for pregnancy, there has to be some use of them with a really qualified clinician who can help the woman navigate that. In the postpartum time period, however, these algorithm-driven insulin pump systems, they're most beneficial because they have a system of avoiding lows.

And so where we're most sensitive in this postpartum time period, and when nursing is in the picture, these systems can really be beneficial in avoiding very dangerous low blood sugars because of the way that they shift off insulin based on the decline or the drop in blood sugar or the predicted nature of where the blood sugar is going. So in terms of technology, I think those are pieces that would be very important to have in the picture.

For those who aren't using insulin pumps but might be using insulin, there are even insulin dosing sort of pens that are available, and they work with an app on the phone. So from another piece of technology, that can be beneficial because you can also share that data with your clinical team and they can help to evaluate the data, which includes CGM or continuous glucose information, and they can help to make suggested adjustments even if you're using injections and not the fancy technology of a pump essentially.

Jessica Bard:

Is there anything else that you'd like to add that you think that we missed?

Jennifer Smith:

I think from a more personal level, honestly, there's a piece of navigating pregnancy with diabetes. That means, from a clinical standpoint, it's important to still understand the individual. It's still really important to see the person navigating life while pregnant and that pregnancy should be, by deciding to have a child, pregnancy is this wonderful change of life for a woman. Right? It's a chance to welcome another person into their life and become a mom for the first time.

And that change or the joy in the change of pregnancy can sometimes get sort of overstepped because there's so much focus on managing diabetes in pregnancy. So I think it's important to help women or for women with diabetes to understand that you should still find enjoyment and love of being pregnant, and from a clinical standpoint, ensuring that their diabetes isn't the overwhelming thing that takes focus, taking away from just enjoying being pregnant.

Jessica Bard:

Couldn't agree more. I think that was very well said. Jennifer Smith, thank you so much for joining us on the podcast today. We really appreciate your time and everything that you do for your patience with diabetes.

Jennifer Smith:

Thank you so much for having me.

Jessica Bard:

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