Diabetes in pregnancy

Why does gestational diabetes occur?

During pregnancy, the placenta makes hormones that can make your body less responsive to insulin, which is the hormone that controls blood glucose levels. In gestational diabetes, your body can’t produce enough insulin to cope with this resistance, causing your blood glucose levels to rise. This leads to gestational diabetes.

Why should we take gestational diabetes seriously?

Managing gestational diabetes with healthy living and exercise is important to minimise the chance of complications occurring for both you and your baby.

Gestational diabetes can cause problems such as:

• Your baby growing larger than expected, this may lead to difficulties during the birth and increases the likelihood of needing induced labour or a caesarean section
• Polyhydramnios: Too much amniotic fluid (the fluid that surrounds the baby) in the womb, which can cause premature labour or complications at birth
• Premature birth: Giving birth before the 37th week of pregnancy
• Pre-eclampsia: A condition that causes high blood pressure during pregnancy and can lead to pregnancy complications if not treated
• Your baby developing low blood glucose or yellowing of the skin and eyes (jaundice) after they are born, which may require treatment in hospital
• The loss of your baby (stillbirth), though this is rare
• Newborn hypoglycaemia: Low blood glucose levels in your baby for the first 1 to 2 days after birth.

What are the long-term effects of gestational diabetes?

Gestational diabetes normally goes away after birth, but people who have had it are more likely to develop:

• gestational diabetes again in future pregnancies, up to 80% chance of it coming back in future pregnancies.
• type 2 diabetes a lifelong condition that can effect your heart, eyes, kidneys, feet and nerves.

Up to 50% of people who have gestational diabetes in pregnancy go on to develop type 2 diabetes within 5 to 10 years of giving birth in the UK. Whilst this is a worry, there are lifestyle changes that you can make to help to prevent you getting type 2 diabetes.

What are the symptoms of gestational diabetes?

Gestational diabetes does not usually cause any symptoms, most cases are discovered through a routine screening test for gestational diabetes during pregnancy.

Some people may develop symptoms if their blood glucose level gets too high (known as ‘hyperglycaemia’), such as:

• Increased thirst
• Needing to pass urine more often than usual
• A dry mouth
• Tiredness
• Blurred eyesight
• Genital itching or thrush

Please be aware: Some of these symptoms are common during pregnancy and are not necessarily a sign of gestational diabetes. Speak to your midwife or doctor if you are worried about any symptoms you may be experiencing.

What are the risks of gestational diabetes?

Several factors can increase your chances of developing gestational diabetes during pregnancy. These include:

• Having had gestational diabetes before
• Having had a baby that weighed 4.5 kg or more in a previous pregnancy
• Having a higher body weight, a Body Mass Index (BMI) above 30 kg/m2
• Having a first degree relative with type 1 or type 2 diabetes (a biological parent or sibling)
• Having a family ethnic origin with a higher risk of developing diabetes

Understanding these risk factors can help you to decide to take steps to reduce your risk of gestational diabetes in future pregnancies.

During your first antenatal appointment (also called a booking appointment) at around week 8 to 10 weeks of your pregnancy, your midwife will ask you some questions to find out if you have an increased chance of developing gestational diabetes.

If you have 1 or more risk factors for gestational diabetes you should be offered a screening test.

The screening test is called an oral glucose tolerance test (OGTT) which is usually done between the 24th and 28th week of pregnancy. If you have had gestational diabetes before in a previous pregnancy, you will be offered the OGTT earlier in your pregnancy and again between 24 to 28 weeks of pregnancy if the first test result is normal.

An oral glucose tolerance test measures how your body processes glucose and is usually done in the hospital pregnancy outpatient department.

It involves having a ‘fasting’ blood test in the morning- when you have not had any food or drink for 8 to 10 hours prior (though you can drink plain water).

You are then given a specific sugary drink to drink.

After resting for 2 hours, another blood sample is taken to see how your body is processing the sugary drink.

The Leeds Maternity Service Website provides more information on OGTT.

Also see for more information on glucose tolerance test

Healthy eating: Follow a balanced diet plan tailored to your needs. Your dietitian can help you to make changes to your diet so that it keeps your blood glucose levels stable.

Regular exercise: Physical activity helps control blood glucose levels. Ask your healthcare provider about the safest exercise routine for you.

Blood glucose monitoring: regularly check your blood glucose levels to ensure they remain within the target range set for you by your healthcare team.

Medication: in some cases, insulin injections or other medications may be necessary to manage blood glucose levels.

After pregnancy, Gestational diabetes usually goes away after your baby is delivered, but it’s important to attend your screening appointments to make sure it has gone away and to have yearly checks to make sure type 2 diabetes hasn’t developed.

• Gestational diabetes care pathway
• Gestational and pregnancy diabetes

If you’ve had gestational diabetes before and you are planning to get pregnant, make sure you get checked for diabetes, ideally before becoming pregnant – your GP can arrange this.

If you already have diabetes, you should be referred to a diabetes pre-conception clinic for support to ensure your condition is well controlled and your body is healthy before you get pregnant.

There is more information on the NHS Website about planning a pregnancy if you have type 1 or type 2 diabetes

In preparation for any future pregnancies, it is worth planning to be pregnancy ready. This means arranging to see your GP before stopping your contraception, so that they can review any medications you are taking for suitability in pregnancy, support you to make further lifestyle and diet changes, including weight loss if needed, help you to stop smoking, and start you on folic acid.

These “pregnancy ready” changes will help you have a healthy pregnancy and healthy baby.

If you have had gestational diabetes before in a previous pregnancy, there is a higher chance it will return in future pregnancies. If pre-pregnancy tests show you do not have diabetes, your midwife will ensure you are offered an oral glucose tolerance test early in your next pregnancy (around 12 weeks of pregnancy) and again between 24 to 28 weeks of pregnancy if the first test result is normal.

You should have a blood test to check for type 2 diabetes 6 to 13 weeks after giving birth, and once every year after that, if the result is normal. During these appointments, you will also be advised about things you can do to reduce your risk of getting diabetes, such as maintaining a healthy weight, eating a balanced diet and exercising regularly.

See your GP if you develop symptoms of high blood glucose levels, do not wait until your next test.

You should have the tests even if you feel well, as many people with diabetes do not have any symptoms.

‘Healthier You’: NHS National Diabetes Prevention Programme

Up to 50% of people diagnosed with gestational diabetes develop Type 2 diabetes within 5 years of the birth. Eating healthily and completing regular physical activity helps people to not only lose any excess weight gained during pregnancy but can also lower the risk of developing Type 2 diabetes.

The Healthier You NHS Diabetes Prevention Programme is available to help you to improve your health and wellbeing and reduce your risk of developing type 2 diabetes if you have previously had a diagnosis of gestational diabetes.

It is a free programme that provides participants with 13 friendly and supportive group-based sessions over nine months with a trained health coach. The sessions can be attended face-to-face at a local venue, remotely or through a digital App.

You will be able to self-refer whilst pregnant to be ready to start the programme after your pregnancy and in the Leeds area, you will be automatically referred to the programme if you have had gestational diabetes.

For more information, about the programme and how to sign-up

Please note: If you have been diagnosed with type 2 diabetes during or immediately after pregnancy you will not be eligible for this programme but there are other programmes and support that you can access.

Preventing gestational diabetes in future pregnancies and the development of Type 2 Diabetes following a diagnosis of gestational diabetes, involves adopting a life-long healthy lifestyle.

Here are some key things to consider:

1. Maintain a healthy weight
   • Before pregnancy: If you are planning to get pregnant, aim to reach a healthy weight before you conceive. Losing excess weight before conceiving can reduce your risk of developing diabetes and high blood pressure in pregnancy.
   • During pregnancy: Weight loss is not encouraged but eating a healthy balanced diet and doing regular physical activity will help to limit excessive weight gain.
2. Eat a healthy, balanced diet: Aim for a healthy balanced diet with plenty of fruit and vegetables, whole grains, fibre and lean sources of protein. Limit your sugar, saturated fat and salt intake as these can increase your risk of health problems and type 2 diabetes if you have too much. For more information on eating healthily
3. Stay physically active: Doing in regular physical activity before and during pregnancy can help manage weight, blood glucose levels and improve fitness. Aim for 150 minutes of moderate intensity physical activity per week which is just 30 minutes a day for 5 days (such as walking with the pushchair, parent and child physical activity classes or online workouts). Do muscle-strengthening physical activities on two days a week (such as housework, gardening and yoga). Break up long periods that you spend sitting and add physical activity into every day such as marching on the spot while you wait for the kettle to boil.More information on physical activity guidance for pregnancy, after birth and for general adults:
   • Pregnancy Guidance
   • Active Pregnancy
   • Birth to 12 months guidance
   • General adult guidance
4. Address unhealthy lifestyle habits and addictions: Refrain from drinking alcohol and smoking, not drinking alcohol and not smoking can significantly reduce your risk of developing type 2 diabetes and improve your longer-term health. Also, providing a smoke-free household for your baby and family will benefit their health and wellbeing.
5. Take care of your mental health and wellbeing: This includes getting enough sleep, managing your stress levels with self-help techniques, self-care and developing healthy habits.

Some research has suggested that babies of mothers who had gestational diabetes may be more likely to develop diabetes or become obese later in life. Adopting a whole family approach to healthy living can help reduce the chances of this.

“HENRY” is  a valuable resource to access and supports whole families in Leeds to make healthy choices and positive lifestyle changes

How you choose to feed your baby is personal to you and more information about the different methods of feeding  However, it is worth noting that breastfeeding offers many benefits specific to people who have had gestational diabetes or are at risk of developing type 2 diabetes, including:

Health benefits for the baby

• Lower risk of diabetes: Breastfed babies have a reduced risk of developing diabetes and becoming overweight or obese later in life.
• Immune system: Breastfeeding helps protect babies from allergic conditions, infections, asthma, and respiratory diseases.
• Stable blood glucose levels: For babies born with low blood glucose levels (hypoglycaemia), breastfeeding can help stabilize their blood glucose levels after birth.

Longer-term benefits

• Reduced obesity risk: Breastfeeding can lower the risk of obesity in childhood and adolescence.
• Lower risk of chronic diseases: It may also reduce the risk of developing hypertension, cardiovascular disease and other chronic conditions later in life.

Information about the Diabetes Maternity Service at Leeds Teaching Hospitals NHS Trust

Here you can find links to patient information leaflets on:

• Pre-pregnancy advice for women with pre-existing diabetes
• Pregnancy and type 1 diabetes
• Pregnancy and Type 2 Diabetes

The Leeds Diabetes Midwives can be contacted directly on the following team email:

• leedsth-tr.Diabeticmidwiveslth@nhs.net

It’s important to speak to your doctor’s surgery as soon as you start thinking about stopping your contraception. The earlier the better. About 6 to 12 months before you are thinking about having a baby is the best time.

Your Diabetes team can help make sure you are ready to conceive by helping you control your blood glucose levels, review any medication to make sure it is safe to take in early pregnancy and give you a prescription for the right dose of folic acid (5mg) while you are trying to get pregnant.

If you have another type of diabetes, you will usually be looked after in a similar way to women with type 1 or 2 diabetes. It’s best to speak to your diabetes specialist about planning your pregnancy.

Leeds has a team of diabetes specialist midwives. More information on diabetes specialist midwives

Things to do before you get pregnant:

• Use contraception until your diabetes is well controlled.
• Stop smoking and reduce alcohol.
• Tell your doctor that you are planning to have a baby so they can refer you to a specialist diabetes team at your local hospital to help you prepare for pregnancy.
• Eat a healthy diet and stay active.
• Aim for a BMI of less than 27, but losing any weight if you need to is beneficial.
• Start taking folic acid (5 mg) prescribed by your doctor and 10 micrograms of vitamin D every day, which can be bought in your local chemist or supermarket.
• Check your blood glucose regularly (aim for 5 to 7 mmol/L before meals, or follow the targets given by your Diabetes team).
• Ask your doctor to check that your diabetes medications are safe for pregnancy, most of the oral tablets except Metformin and all injectable medications (incretin hormones) are not suitable for pregnancy.
• Review your blood pressure and cholesterol, and make sure any medications are safe to take during pregnancy.
• Have your eyes (diabetic retinopathy) and kidneys (diabetic nephropathy) checked before getting pregnant.
• Know what to do about hypos, this is because you have reduced awareness in pregnancy and you may be at risk of having more hypos.
• Test for blood ketones if you have been given a ketone meter and asked to check for ketones by your diabetes team when you are unwell.
• Ask about a structured education programme to help improve your diabetes control.
• Type 2 diabetes LEEDS programme
• Type 2 diabetes (national programmes)
• Type 1 diabetes and other forms of diabetes: This is provided by the hospital, contact your hospital team or ask your doctor to refer you.
• Aim for a HbA1c of less than 48 mmol/mol (6.5%) if this is safe for you to do so
• Stop contraception once your HbA1c is below 48 mmol/mol (6.5%).
• When you have a positive pregnancy test, ask for an early referral to the pregnancy diabetes team at your local hospital.
• Continue taking folic acid until you are 12 weeks pregnant and vitamin D throughout your pregnancy and if you decide to breastfeed.
• Continue to monitor your blood glucose. Aim to keep your HbA1c around 48 mmol/mol throughout your pregnancy.

Resources

• Pre-pregnancy advice for women with diabetes
• Diabetes UK: Pregnancy and diabetes
• Leeds Teaching Hospitals NHS Trust: Pregnancy and type 2 diabetes
• Leeds Teaching Hospital NHS Trust: Pre-pregnancy advice for women with diabetes
• NHS: Gestational diabetes
• Diabetes UK: What is gestational diabetes, causes and symptoms