Diabetes is a metabolic condition in which the body cannot utilize the glucose obtained from food for the production of energy. With this condition, there is either no insulin production or not enough insulin production to make blood glucose reach the cells, resulting in accumulation of glucose in the blood or high blood sugar levels. Diabetes is caused by the pancreas not producing enough insulin or cells in the body not responding properly to the insulin produced. There are 3 types of diabetes:
- Type 1 – The body does not produce enough insulin. It is also known as insulin-dependent
- Type 2 – The cells become insulin resistant or non-responsive to the insulin produced by the body. It is also called non-insulin dependent diabetes.
- Type 3 – Gestational diabetes occurs in pregnant women who have no previous history of diabetes but develop high glucose levels during their pregnancies., , 
Gestational diabetes is a common and serious complication of pregnancy, representing 3.3% of all live births. Diabetes can cause problems in pregnancy for both women and the developing fetus. It is necessary to control diabetes during pregnancy to prevent birth defects to the developing baby and avoid serious complications to the mother. 
Glucose levels and Pregnancy
High glucose levels can have major side effects on the fetus. At conception and in the first trimester, elevated glucose levels (hyperglycemia) increases the risk of fetal malformations. A potential birth complication of high glucose levels during pregnancy (especially in the later stages) is macrosomia. This condition is characterized by a newborn being significantly larger than an average baby; it may also put the baby at risk for metabolic complications., 
Considerations Before Planning Your Pregnancy
Diabetes can be preexisting in women before pregnancy, known as pregestational diabetes. If you have pregestational diabetes, here’s a look at some things to consider before planning your pregnancy:
- Pregestational diabetes – If you are a woman with type 1 or type 2 diabetes and are planning to start a family, you should plan your pregnancy as much as possible. That’s because in the early weeks of pregnancy (usually by the 7th week since your last period) most of the fetus’ primary organs have already formed. Hence, to avoid the risk of fetal malformations and miscarriage, it is important to control glucose levels prior to getting pregnant and to plan your pregnancy accordingly. , , 
All women of reproductive age with type 1 and type 2 diabetes should consult their diabetes health care (DHC) team at least 6 months prior to conceiving to receive advice on the following:
- Birth control – oral contraceptives that increase blood pressure and platelet aggregation should be avoided in women with diabetes and associated risk factors like hypertension, angiopathy, smoking or age (above 35 years). 
- Proper glycemic control – during fasting periods, blood sugar levels should be between 60–119mg/dl; 1 hour after mealtimes, blood sugar should fall between 100–149 mg/dl for optimal diabetes management and nutrition. , 
- Controlling A1C levels – glycated hemoglobin A1C should be less than 7% to avoid spontaneous abortion, congenital abnormalities, the progression of retinopathy (damage to blood vessels of the retina), preeclampsia (high blood pressure and high protein in the urine occurring in the 20th week of pregnancy or later). , 
- Avoiding drugs that are potentially harmful to the embryo, such as statins, ACE inhibitors, and ARB’s.
- Supplementing the diet with multivitamins, especially folic acid (5mg) at least 3 months pre-conception and up to 12 months postpartum (or till breastfeeding is discontinued).
- Drug interactions – Women who have pregestational diabetes and also PCOS (polycystic ovarian syndrome) may continue on metformin but should be advised about possible side effects. , 
Self-Care Guidelines for Pregnant Women With Diabetes
You should take extra care of yourself during pregnancy. It is important for you and your baby’s health to keep your blood sugar levels in check throughout these nine long months.
Be sure to assemble a Diabetes healthcare team (DHC) that includes the following health professionals:
- A trained primary care doctor experienced in managing pregnant women with diabetes.
- A registered dietician
- A diabetes educator
- An obstetrician who is thoroughly trained in high-risk 
During pregnancy, your body is changing. This means managing your diabetes will require more work. Try to stay in the target range to avoid complications. The target range may vary in different healthcare systems. Consult your DHC team to set your customized targets. The American Diabetes Association suggests the following optimal levels for pregnant women:
- Before a meal and bedtime – 60–99 mg/dl
- After a meal (12 hours after meal) – 100–129 mg/dl
- A1C – less than 6%. , ,
In addition to staying in these target ranges as closely as possible, be sure to check your blood glucose levels frequently (at least 6–8 times per day). The number of times you check your blood sugar will ultimately be determined by your DHC team.
Managing Insulin and Oral Diabetic Pills During Pregnancy
Insulin is the first drug choice for glucose control during pregnancy as it does not cross the placenta. Oral medications used for diabetic control cross the placenta and can affect the fetus to varying degrees. This is why oral pills are usually avoided.
Pregnant women with type 1 diabetes need to change their insulin dosing as their body’s need for insulin goes up, especially during the last three months of pregnancy. The hormones secreted by the placenta may counteract the action of insulin, so more is usually needed.
For pregnant women with type 2 diabetes, oral pills must be discontinued. Making the switch to insulin is recommended by most doctors. While planning the treatment, the doctor will need to consider the role of insulin resistance in women with type 2 diabetes. , , 
For women experiencing the symptoms of gestational diabetics, diet control and physical exercise will usually keep glucose levels under control. If it doesn’t, then the doctor will typically recommend insulin for the duration of the pregnancy. 
Managing Your Food Intake During Pregnancy
A well-monitored and controlled diet plan is necessary to keep your blood glucose levels in check. The focus should be on the quality of food you’re getting rather than the quantity. The meal plan should include the following food sources:
- Nonfat dairy products
- Whole grains
- Lean meats
A diet rich in these foods can help you maintain healthy blood sugar levels and also provide proper nutrition to both you and your baby.
Work with your dietician to monitor and maintain your weight and body mass index (BMI) throughout your pregnancy as obesity along with diabetes can complicate the outcomes of treatment planning. , 
Incorporating Exercise Into Your Routine During Pregnancy
Exercise is an important part of your treatment plan. Regular exercise aids in the maintenance of blood sugar levels in people with diabetes. Rest assured that most forms of physical activity are considered safe and beneficial for pregnant women with diabetes as it helps your muscles better utilize the glucose in your blood, helping to keep your levels in check. Some safe exercises that you may want to try out include:
- Low-impact aerobics
As a word of caution, it’s important to avoid exercise if you are suffering from any of the following complications:
- High blood pressure
- Eye, heart or kidney problems
- Vascular or nerve damage
In these cases, be sure to consult your DHC team before doing any form of physical activity.
Avoid participating in any strenuous physical activity during pregnancy that puts pressure on your abdomen or poses an increased risk of falling on your abdomen. , 
Preparing for Delivery and the Postpartum Period
During the later stages of the third trimester, your health team will carefully monitor your health and that of your baby to decide the safest date and method of delivery. As an added incentive to take extra care of yourself at this time, keep in mind that well-controlled blood glucose levels give you the best chance of reaching full term. 
Your DHC team will take the following factors into consideration to decide the safest time and method to deliver your baby:
- Blood glucose levels and control
- Blood pressure
- Kidney function
- Any other diabetes complications like retinopathy, heart problems, etc., 
During delivery, your doctor will keep monitoring your blood glucose levels. You may be put on an insulin drip to compensate for the insulin drop in the early stages of labor. Your insulin will be monitored frequently up to 24–72 hours post-delivery to ensure you do not suffer from any complications. , 
Post-delivery, your body will be trying to recover from the pregnancy and heavy load you’ve carried over the last nine months. During this transitional period, you may experience glucose mood swings, hyperglycemia, and hypoglycemia, which can contribute to postpartum depression. It is extremely critical that you keep a close watch on blood glucose levels during this vulnerable period. , 
Women with type 1 diabetes should be screened for postpartum thyroiditis with TSH at 6–8 weeks postpartum. 
Consult your doctor to revisit your medication plan post-pregnancy. For women with type 2 diabetes, you may follow the same treatment regimen you were on before pregnancy. For women with gestational diabetes, diabetes will typically go away if blood glucose levels were kept under control through proper meal planning and regular exercise. Many women with gestational diabetes develop type 2 diabetes later on; it’s especially important for these women to consult with their health team and get regular checkups every 1–3 years. , 
Breastfeeding and Diabetes
There is no reason women with diabetes cannot breastfeed. However, you should consult with your doctor while using any oral medications for diabetes control. Also, it is important for you to prevent low blood glucose levels during breastfeeding. You can prevent lower blood sugar by consuming a light snack and drinking plenty fluids before and during nursing. Keep in mind that breastfeeding your baby is also a good way to reduce maternal obesity. , 
Planning Future Pregnancies
As long as you have no complications, no additional diseases, and your metabolic state is normal, carrying another baby should be a safe option for you. In some cases, however, your health care team may recommend proceeding with caution or avoiding getting pregnant until accompanying disorders are well-managed. Getting pregnant while struggling to manage your diabetes poses a risk to your health and that of your unborn baby. For pregnancy planning, it is suggested to conceive within the first ten years of the onset of your diabetes or before the development of any vascular complications. , 
- “Diabetes Fact sheet N°312,” WHO, 2013.
- Diabetes Mellitus (DM): Diabetes Mellitus and Disorders of Carbohydrate Metabolism: Merck Manual Professional. Merck Publishing, 2010.
- “CDC – Diabetes and Pregnancy.” [Online]. Available: https://www.cdc.gov/pregnancy/diabetes.html. [Accessed: 25-Jan-2018].
- “Diabetes During Pregnancy: Symptoms, Risks, and Treatment.” [Online]. Available: http://americanpregnancy.org/pregnancy-complications/diabetes-during-pregnancy/. [Accessed: 25-Jan-2018].
- Thompson, H. Berger, D. Feig, R. Gagnon, T. Kader, E. Keely, S. Kozak Bsn, E. Ryan, M. Sermer, and C. V. Pdt, “Clinical Practice Guidelines Diabetes and Pregnancy Canadian Diabetes Association Clinical Practice Guidelines Expert Committee,” Can. J. Diabetes, vol. 37, pp. S168–S183, 2013.
- Australia, “Pre-existing diabetes and pregnancy,” 2017.
- “Before Pregnancy: Women and Diabetes.” [Online]. Available: http://www.diabetes.org/living-with-diabetes/complications/pregnancy/before-pregnancy.html?referrer=http://www.diabetes.org/living-with-diabetes/complications/pregnancy/after-delivery.html. [Accessed: 25-Jan-2018].
- “FUEL METABOLISM IN DIABETIC PREGNANCY.”
- “Diabetes in pregnancy: management Diabetes in pregnancy: management from preconception to the postnatal from preconception to the postnatal period NICE guideline Y Your responsibility our responsibility,” 2015.
- “2. Management of Diabetes in Pregnancy General Principles for Management of Diabetes in Pregnancy,” Diabetes Care, vol. 39, pp. 94–98, 2016.