Steps to Prepare for a Healthy Pregnancy

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Steps to Prepare for a Healthy Pregnancy

Dear Dr. Nicholson: I have diabetes and would like to have a baby. How should I prepare for a healthy pregnancy?

Preparing before you conceive is one of the best steps you can take to have a healthy baby and a healthier you. A woman with diabetes who is planning pregnancy should consult with her healthcare team before she becomes pregnancy. In the field of obstetrics, these visits are termed preconception visits. Preconception health

18 refers to the health of the woman before she becomes pregnancy. Preconception visits provide an opportunity to make sure blood glucose levels are in optimal control, adjust medications, manage any associated medical problems, such as hypertension (i.e. high blood pressure), and to start folic acid supplementation which is recommended for all women considering pregnancy.  It is recommended that women begin to take folic acid supplementation (400 mcg per day) at least one month before conception. Preconception visits also provide an opportunity for women and their clinicians to talk about how diabetes can affect the pregnancy and how pregnancy can affect their diabetes. Women with diabetes who are considering pregnant should take the following steps:

Step 1:  Assemble your healthcare team:

Ideally, the healthcare team should consist of the following clinicians:

  • A primary care clinician  or endocrinologist who prescribes insulin
  • An obstetrician
  • Diabetes educator 
  • Nutritionist

Many women with diabetes have an established primary care clinician or endocrinologist who can help to inform glucose management throughout the pregnancy. The obstetrician provides expertise on what type of oral medications are acceptable for use in pregnancy and oversees maternal health, delivery of the infant and postpartum care.  A nutritionist can help you to plan healthy meals, discussing the number of appropriate calories, carbohydrates and snacks/meals throughout the day. The optimal number of calories depends upon the woman’s pregnancy weight and activity level. A diabetes educator can help you understand and achieve strict glucose control prior to conception to reduce the chance of complications for you or your bably.

Step 2:  Talk to your healthcare team about how diabetes can affect your pregnancy

During pregnancy, glucose levels in the mother’s blood crosses the placenta in order to provide energy for the baby. High blood glucose levels in the mother lead to high blood glucose levels in the developing baby. High blood glucose levels during pregnancy can cause serious medical consequences for the mother and baby: 

  • In early pregnancy, high glucose levels increase the risk of miscarriage and birth defects. These risks are highest when hemoglobin A1C is >8 percent or the average blood glucose is >180 mg/dL (10 mmol/L).
  • Infants exposed to high glucose levels in utero are at risk for metabolic abnormalities. In utero alterations to fetal metabolism due to prolonged glycemic exposure have life-long consequences for the newborn; namely an 8-fold risk of diabetes as well as chronic obesity and its associated complications.
  • As pregnancy progresses, high maternal blood glucose levels can cause the baby to become overweight or “over-sized.”  The baby's weight can be higher than average and increase the risk of complications during and after delivery. Women with large babies have a higher chance of having a cesarean delivery. Large babies are at risk for experiencing trauma during delivery and undergoing an admission to the neonatal intensive care unit (NICU).  Complications are much less likely to occur if maternal blood glucose levels are well-controlled.

3. Try to reach an optimal A1C

The American Diabetes Association Clinical Practice Guidelines for managing pre-existing diabetes (type1 and type2) recommends monthly A1C levels during pregnancy, beginning with the first prenatal visit. The goal is an A1C level of < 6.  The rationale for choosing this A1C level is that it is associated with the lowest rates of adverse events. In the first trimester, this means rates of congenital anomalies (2.5 to 4 percent) and miscarriage (15 percent) that are similar to the rates in the general population. Higher A1C values (≥6.1 percent) during pregnancy, especially in the third trimester, have been associated with a significant increase in risk of preeclampsia [17] and delivery of a large for gestational age infant.

4. Focus on having a healthy weight before pregnancy

About 1/3 (33%) of childbearing women aged 20–39 years are obese and 8% are extremely obese.   The National Heart Lung and Blood Institute (NHLBI) classifies overweight and obesity based on body mass index (BMI), defined as weight in kilograms divided by the square of height in meters (kg/m2) (8,9). 

 

Description of body mass index categories and Institute of Medicine recommendations for weight gain during pregnancy

Weight categories

BMI

Total weight

gain range (lbs.)

Weekly weight gain

(2nd & 3rd trimester)

Mean range in lbs/wk

Normal weight

18.5-24.9

25-35

1 (0.8-1)

Overweight

25.0-29.9

15-25

0.6 (0.5-0.7)

Obese

30 or greater

11-16

0.5 (0.4-0.6)

ttp://www.iom.edu/Reports/2009/Weight-Gain-During-Pregnancy-Reexamining-the-Gu... (last accessed 2-3-2014)

Women with diabetes should seek guidance from their providers on how to achieve a healthy weight prior to and during pregnancy.  Prior to pregnancy, women with diabetes should talk with their providers about how to reach the normal weight category. Once pregnancy occurs, women should talk with their healthcare team about how to gain an appropriate amount of weight during pregnancy. Several steps that women can take to achieve a healthy weight are listed below:

  • Ask your clinician to calculate and discuss your body mass index. Clinicians can access an on-line BMI calculator at the National Heart Lung Blood Institute (NHLBI) website (http://www.nhlbisupport.com/bmi/).  Your clinician can provide information on the amount of weight you can lose to achieve a healthy weight and health BMI.
  • After you become pregnant, ask your physician how much weight you should gain during pregnancy. The Institute of Medicine recently published guidelines for how much weight women should gain during pregnancy based on their body mass index just prior to pregnancy. Guidelines are listed in the table above and can be accessed at http://www.iom.edu/Reports/2009/Weight-Gain-During-Pregnancy-Reexamining-the-Guidelines.aspx
  • Assess all of your current leisure activities. Make a plan for increasing your activities. Investigate low resources such as the YMCA or find a friend and go for walks in the park. Be sure to include activities that you can easily bring your newborn after delivery. Current recommendations support moderate physical activity for 7 days a week.
  • Ask about farmers’ markets in your community, which can provide various choices for healthy eating at a reasonable price.
  • Assess your environment. Use an easily accessible computer at home, work, or your local library to identify low cost venues for physical activity that can be used throughout the year. For example, you may find a church near your neighborhood that has an indoor track or sponsors exercise classes.

5. Action Items for you and your baby:

  • Talk to your endocrinologist or health care provider about finding an obstetrician, diabetes educator and nutritionist to help you to become a healthy mom. If you don’t have a primary care provider, identify someone NOW before becoming pregnant.

  • Look at your calendar and plan what days you will  exercise

  • Start monitoring your blood glucose levels so that adjustments in your insulin or oral medications can be made before pregnancy. 

Dr. Nicholson is an Associate Professor in the Department of Obstetrics and Gynecology at the University of North Carolina at Chapel Hill. She is a board-certified obstetrician-gynecologist and a perinatal epidemiologist. Through funding from the American Diabetes Association (ADA), Dr. Nicholson has developed a postpartum-specific weight loss intervention, First WIND (Weight-loss Interventions after Delivery), for women at risk for type 2 diabetes which was piloted among urban-based women in Baltimore City. She was previously an investigator with the Johns Hopkins Evidence-Based Practice Center where she was the PI of the task report on Labor and Postpartum Management of Gestational Diabetes, funded through the Agency for Healthcare Research and Quality. Dr. Nicholson is a member of the ACOG National Committee on Health Care for Underserved Women, the US Preventive Services Task Force, and the NC Diabetes Advisory Council.