Type 1 Diabetes
Type 1 Diabetes develops when the pancreas fails to produce any insulin. It usually develops over a short period of time. The main symptoms are weight loss, feeling thirsty and passing a lot of urine during the day and night. The only treatment for this type of diabetes is insulin, and this treatment with insulin is for life.
In this section:
Pre Pregnancy Care
Soon after conception, even before you know you are pregnant your baby's brain, spinal cord, heart and other organs begin forming. If you have poor blood glucose control during the earliest days of pregnancy, your risk of miscarriage and your baby's risk of birth defects increases. Controlling your blood glucose level is the best way to prevent diabetes complications, so when you are preparing for pregnancy, even months before you conceive, blood glucose control is very important.
Most women with diabetes have a normal pregnancy resulting in a healthy baby. However, having diabetes does increase the chances of serious complications for both mother and baby. Planning and preparing for a pregnancy with your diabetes team can substantially reduce that risk. For women with diabetes therefore, pre-pregnancy care (PPC) is essential.
Pre-pregnancy care allows for a period of time for blood glucose control to be optimised before the pregnancy starts, dealing with hypoglycaemia, starting folic acid and reviewing medications that may not be safe during pregnancy. This time is also used to screen for and treat complications of diabetes and emphasise the importance of a healthy diet and moderate exercise. It is advisable that you plan your pregnancy carefully and use contraception during this period while your insulin is being adjusted to achieve the best control of blood glucose levels.
Checklist for planning a pregnancy
- Contact your GP and local Diabetes Clinic if you are thinking about getting pregnant and make an appointment
- The diabetes team will review your diabetes treatment, changes will be made to your treatment to get the best possible control of your diabetes before stopping contraception
- Use reliable contraception until it is safe for you to conceive
- You should stop smoking and avoid alcohol
- Your Diabetes team will review your medications for blood pressure and cholesterol
- Ask for a dietary review, and arrange to see a Dietician to plan for your ideal weight, and try to achieve it
- Your GP /Diabetes team will prescribe 5mgs of folic acid
- Your GP /diabetes team will check your Rubella status
- Your GP / Diabetes team will check kidney function, thyroid function and schedule an eye examination
- Eat a healthy diet
A healthy and balanced diet helps ensure that in the event of pregnancy, a woman of childbearing age will be in good health throughout the pregnancy and will be able to provide the unborn infant with the nutrition needed to develop properly.
- Keep blood glucose levels in good control. This reduces the risk of pregnancy problems for mother and baby.
- Cut out alcohol.
- Take 5mg of folic acid before conception.
- Enjoy a wide variety of foods from the five food groups
- Pay attention to serving sizes - choose smaller portions and add plenty of vegetables and salad.
- Include wholemeal breads, cereals, potatoes, pasta and rice to provide energy for a healthy weight.
- Eat at least five servings of vegetables every day.
- Use low-fat varieties of milk, yoghurt and cheese - choose milk and yoghurt more often than cheese.
- Include lean meat, poultry and fish (oily is best) daily, and remember that peas, beans and lentils are good alternatives.
- Use polyunsaturated and monounsaturated spreads and oils sparingly - reduced-fat spreads are best.
- Confectionery, savoury snacks, and biscuits are rich in calories, fat, sugar and salt and should be avoided.
- Drink plenty of water.
- Grill, bake, steam or boil food instead of frying or deep frying.
- Prepare and store food safely.
- Limit salt intake
Women of childbearing age should aim to consume a nutritionally adequate diet. Such a diet should contain foods from the five main foods groups every day.
Healthy eating guidelines for women of childbearing age:
Healthy cooking practices
Vitamin D is needed for strong healthy bones and may protect against heart disease and cancer. Most people do not get enough vitamin D. Choose oily fish one to two times a week as a good way to get vitamin D. A daily vitamin D supplement of 200 IU per day is recommended.
Physical activity is an important part of preparing for your pregnancy. Discuss exercise and an exercise plan that best suits you with your doctor. Choose activities that you enjoy such as walking or swimming that you can make part of your daily routine.
If you haven't been active for a while, start slowly and build up gradually. Gentle exercise is important especially if you have problems with high blood pressure, with your eyes , kidneys or nerves in feet.
Remember physical activity affects blood sugar levels so be sure to check levels after any activity.
Treatment (Targets, HYPOS)
The main ways to improve your blood glucose control are diet, exercise and adjusting your insulin dose if necessary.
Targets to aim for with home blood glucose target
- Fasting below 5.3mmol/l
- Before meals below 5.3mmol/l
- 1 hour after meals below 7.8mmol/l
Haemoglobin A1c(HbA1c) is a measure of the average blood glucose over the previous 3 months, which is measured periodically and discussed with you at clinic visits, aiming to keep levels as close to the range found in healthy non pregnant women (less than 6.0%/42 mmol/mol).
Pre Pregnancy Care
In this section:
Good control of diabetes during pregnancy combined with good antenatal care is known to reduce the pregnancy risks for babies and mothers. With Type 1 diabetes you will need to have hospital antenatal care and attend a specialist antenatal clinic to meet the needs of your pregnancy and diabetes.
Trimester 1(weeks 0-12) In your baby's development, major organs are formed, the nervous system begins to develop and eyes, ears and nose take shape.
You will have visits to the Clinic every 2-4 weeks, where you will have an ultrasound scan to confirm your expected date of birth. You will be reviewed by the diabetes team, weight and blood pressure will be checked. A specialised blood test known an ‘HbA1c’, which can assess how well glucose levels are being controlled will be done, and will be repeated periodically throughout your pregnancy. Urine and blood tests will be done to check for kidney problems. Eye examinations will be carried out to check for retinopathy (changes in the eyes caused by diabetes). You will also be reviewed and examined by your Obstetrician at each visit.
InsulinWhen you have Type 1 diabetes and are pregnant your insulin needs will change during this time. You will be at risk of hypoglycaemia in the early morning especially. Regular monitoring of blood glucose is vital to avoid this. Your insulin will need to be adjusted weekly.
- Take folic acid 5mgs for the first 12 weeks of pregnancy
- Follow diet and exercise guidelines
- No smoking and no alcohol
- Check blood glucose 7 times a day: fasting before each meal and 1 hour after each meal
- Aim for fasting blood glucose not any higher than 5.3mmol/l and after meals blood glucose not higher than 7.8mmol/l
- Make sure that you have an in date glucagon kit and that someone else in your household knows how to use it
- Attend all antenatal clinic appointments and phone your clinic or diabetes nurse specialist if you have any questions or concerns. If you have nausea and vomiting, always phone your Diabetes team for advise.
Trimester 2(weeks 13-24) At this stage your baby's body growth begins to catch up with the head growth. Baby begins to hold its head up and move. Your baby's heartbeat becomes regular and its brain becomes more complex. Your baby cannot yet breathe.
At this stage of your pregnancy, you will have clinic visits every 2 weeks. At these visits you will have your weight and blood pressure checked, you will also have a urine test and an eye check . A HbA1c will be checked periodically to monitor glucose control. An ultra sound will be done at 18-22 weeks to check for foetal well being. The foetal head and abdomen will be measured on the ultra sound scan to monitor the growth of your baby. As your baby grows, your insulin requirements will increase and adjustments will be made to your doses weekly, in conjunction with your diabetes team, to ensure glucose control is kept within strict limits.
- Check blood glucose 7 times a day, fasting and 1 hour after meals
- Aim for fasting blood glucose no higher than 5mmol/l and 1 hour after meals no higher than 7mmol/l
- Follow diet and exercise guidelines
- Attend all clinic appointments
- Record baby's movements and inform your doctor of any changes or concerns you may have
Trimester Three (weeks 25-40) Your baby's brain is growing rapidly at this stage, and as your baby continues to grow more demands are put on your body. Your visits to the clinic will be every 2 weeks until 36 weeks and from then on every week. At these visits all the previous checks will continue to be done. you may require more frequent ultra sound scans for examination of foetal growth, in case your baby is growing too large, or not growing enough, or if you have high blood pressure.
Your insulin needs will continue to increase and may reach twice the dose you needed before you became pregnant.
- Continue to be as they are listed above in your second trimester.
- Check also that your baby moves at least 10 times each day. If you have less movements or a change in your baby's movements' pattern, or if you are in any way concerned contact the hospital.
Foods to help your baby grow
- Take a supplement 10micrograms of Vitamin D daily during pregnancy
- Take folic acid for 12 weeks before pregnancy and during the first 12 weeks of pregnancy
- Iron is important to make the extra blood needed by you and your baby. Good sources red meat, chicken, fish, eggs, cereals fortified with iron, beans ,peas and lentils and green vegetables
- Vitamin C aids the absorption of non meat iron. Sources include oranges, kiwis berries, tomatoes, potatoes, peppers and green vegetables
- Calcium is important for healthy teeth and bones. Good sources include milk, hard cheese and yogurt
- Eat oily fish once a week, Omega 3 fats are derived from fish oils. Sources include sardines, salmon, trout, herring and mackerel. These are important for your baby's brain and nerve development.
What to avoid:
- Food and drinks to avoid or limit during pregnancy
- Raw and cooked foods should be kept separately to avoid contamination.
- Avoid pre cooked meals that do not require reheating.
- Avoid raw or under cooked meat, poultry, fish and shellfish including smoked salmon and sushi.
- All foods should be eaten before their use-by date
- Avoid liver, liver pate and liver sausage.
- Avoid excess amounts of vitamin A.
- Avoid too much caffeine found in tea, coffee, chocolate and cola.
- Avoid unpasteurised milk and dairy products, including soft and mould ripened cheese e.g. Camembert and ricotta cheese
- Avoid raw or lightly cooked eggs and foods that contain eggs e.g. home made mayonnaise, ice cream and mousse
- Make sure food is always handled in a hygienic manner and do not eat unwashed fruit and vegetables
A diabetic diet is a healthy diet. The following are the guidelines you should follow:
- Follow a healthy balanced diet.
- Eat regular meals with small amounts of high fibre carbohydrate food at each meal.
- Eat plenty of vegetables and limited fruit
- Avoid added sugars in your diet.
- Include a small breakfast everyday.
Breastfeeding can protect you and baby against diabetes, obesity and other illnesses. Ask your doctor, midwife or dietician for more information.
1. Follow a healthy balanced dietWhat is a healthy diet?
A healthy diet is a balance of foods from all the food groups. Your diet should be low in fat, low in sugar and salt, rich in wholegrains, fruits, vegetables and calcium. You should eat a well balanced diet to stay healthy and support baby's growth. Be sure to follow guidelines for food safety during pregnancy.
The pyramid below shows how much of each food you need every day. The dietician can make a meal plan that suits your own needs.
2. Eat regular meals with small amounts of high fibre carbohydrate food at each meal.
There are three basic nutrients in food: carbohydrate, protein and fat.
Carbohydrates provide us with most of our energy. Carbohydrate foods turn into sugar (glucose) after you eat them. It is important that these foods are eaten in the same quantity and at regular times throughout the day. This will help you keep the amount of sugar in your blood steady and energy levels up. Choose high fibre, whole grain options as they release the energy (sugar) more slowly. High fibre, whole grains also contain more vitamins and minerals, can help prevent constipation and keep hunger at bay.
Protein is essential for your baby's development and can help keep hunger at bay. Protein is found in meat, chicken, fish, eggs, peas, beans, lentils, tofu, nuts and cheese and will not turn to sugar when you eat them. Speak with your dietician about the right amount for you.
Fats do not turn to sugar but should be limited in your diet. One special fat (omega-3) should be increased in your diet. Omega-3 fats have been shown to improve baby's brain development and are important to heart health. The best source is oily fish e.g. salmon, trout, mackerel, sardines, kippers and herring. Aim for 1 to 2 portions of oily fish per week. Vegetarian sources of omega-3s include soya, walnuts and rapeseed oil.
The following are types of carbohydrates foods:
Examples of high fibre starchy foods are:
- Breakfast cereals: porridge oats, All-Bran®, Shredded Wheat®
- Breads, baps, rolls, pitta: wholegrain, granary, wholemeal, rye, oat bran, chapatti.
- Grains: brown rice, basmati rice, millet, whole barley, quinoa.
- Pasta: macaroni, spaghetti, couscous, semolina or noodles - try whole-wheat versions.
- Crisp breads: rye crisp bread, wholegrain crackers, oatcakes.
- Potatoes: new potatoes, sweet potatoes or yams.
Milk and yogurt are good sources of calcium for strong bones and teeth. Choose yogurts with no added sugar (diet or light). Limit your milk to no more than 3 glasses of 200ml each daily as too much milk can make your blood glucose levels too high. Your dietitian will advise you on the best type of milk for you.
Fruit is a healthy food, but it is high in natural sugars. A portion of fruit is either one very small piece of fruit or half of a large piece of fruit. Do not eat fruit that has been canned in syrup. It is best to avoid fruit juices. Avoid dried fruits such as raisins, sultanas, dates and apricots.
Discuss recommended portions with your Dietician or Diabetes Nurse Specialist.
3. Eat plenty of vegetables
4. Avoid added sugars in your diet:
Sugar & sugary foods (e.g. chocolates, sweets, toffees, cakes, honey, jam, marmalade, normal fizzy drinks, sugar/chocolate coated breakfast cereals etc)are absorbed quickly by the body, which can cause your blood sugar level to rise rapidly. It is therefore best to avoid these foods and to choose low sugar alternatives.
Avoid foods labelled "diabetic" (chocolates, sweets and jams) or made with sugar alcohols like sorbitol, malitol, xylitol. They are often high in fat and can cause wind, bloating and diarrhoea if you eat a lot of them.
Sugar in Medication: Some medicines like medicines for heartburn and constipation contain sugar. Make sure all the medications you are taking are sugar free. Speak with your doctor or pharmacist about sugar-free options that are safe in pregnancy.
5. Include a small breakfast every day
Blood glucose levels tend to be higher in the morning time. You may need to limit the amount of carbohydrate you take at breakfast and you must avoid added sugars.
Remember... NO JUICE!
- 1 Shredded Wheat® biscuit or 40g All-Bran® sticks and 200 ml low-fat milk.
- 30g dry porridge made on water.
- 1 slice wholegrain or granary toast and 125g diet yogurt.
- 2 thin slices wholegrain or granary toast and 30g light cheddar cheese and tomato slices.
- 1 slice wholegrain or granary toast and 1 poached egg and 2 dessert spoons reduced-sugar baked beans and a half of grilled tomato/mushrooms and 1 grilled rasher (fat trimmed)
Summary: Putting it all together
To keep your blood glucose levels under control and meet your needs for pregnancy you should:
- Eat three meals and some snacks spaced evenly over the day. Smaller portions of carbohydrates eaten more often can keep your blood glucose levels steady and prevent over-eating.
- Avoid added sugars and sugary foods.
- Include a small portion of starchy carbohydrate at each meal (wholegrain bread, brown rice, pasta, new potatoes, sweet potatoes, high fibre cereals)
- Limit fatty or fried foods and take-aways.
- Do not skip meals. You may find yourself eating too much at the next meal because you are overly hungry. Drink plenty of water and other sugar-free drinks throughout the day to stay hydrated. This will help prevent constipation.
- Avoid alcohol
- Avoid excess amounts of vitamin A
- Avoid cod liver oil supplements, and vitamin and mineral supplements which contain vitamin A.
- Avoid liver, liver pate, and liver sausage.
- It is recommended that pregnant women should limit their caffeine intake to less than 200mg a day. There may be a slight risk that too much caffeine will affect your baby's birth weight and in some cases cause miscarriage.
- Caffeine is found naturally in a range of foods such as coffee, tea and chocolate. It is also added to some drinks especially to so called 'energy drinks'.
Caffeine content of some foods and drinks:
- 1 average mug of instant coffee 100mg
- 1 mug of filtered coffee 140mg
- 1 mug of tea 75mg
- 1 can of regular/diet cola drinks up to 40mg
- 1 can of energy drink up to 80mg
- 1 bar of chocolate (50mg) up to 50mg.
- Avoid shark, swordfish, marlin, tilefish, ray and King mackerel as they may contain high levels of mercury. Limit tuna to 2 small cans or 1 fresh tuna steak per week.
- Avoid raw or lightly cooked eggs and foods that contain them e.g. home-made mayonnaise and mousse.
- Avoid unpasteurised milk and dairy products, including soft, mould-ripened cheese e.g. Camembert and brie.
- Avoid raw or undercooked meat, poultry, fish and shellfish.
- Avoid pre-cooked or ready prepared foods that do not require reheating
- Do not eat pate
- Do not eat unwashed fruit and vegetables
- Avoid herbal remedies.
FOOD SAFETY TIPS:
- Food should always be handled, stored and cooked in a hygienic manner.
- Keep raw & cooked foods separate to avoid contamination.
- Eat all foods before their use-by date.
- Follow manufacturers instructions for storage and preparation/
- Wash all fruit and vegetables before eating.
- Defrost frozen meat thoroughly before cooking.
- Never re-heat foods more than once.
- Always wear gloves when gardening or handling cat litter.
Exercise (30 minutes a day) is an important way to keep healthy during your pregnancy. Pregnancy will put extra stress on your heart and lungs so it is best not to begin with a hard exercise programme. Choose exercises that you will enjoy such as walking or swimming and always discuss your exercise plan with your doctor who will advise you the type of exercise plan best suited for you. If you haven't been active for a while start slowly and build it up gradually. Remember physical activity affects blood glucose levels so always check your blood glucose after any activity. .
Treatment (Targets, Hypos)
During your pregnancy your insulin dose will change considerably, often decreasing at the beginning of your pregnancy, increasing during it and possibly doubling by the end of your pregnancy. This will all be discussed with you and closely monitored by your Diabetes Nurse Specialist and Doctor.
If you are ill, particularly if you have a temperature, your blood glucose will rise even if you do not eat. Always contact your doctor or diabetes nurse for help. Your blood glucose is more difficult to control when you are ill and the staff will be able to advise you. Check you blood glucose frequently; never stop taking your insulin.
Your diabetes team will discuss the importance of checking for ketones in your blood. Ketones are strong acids that build up in your body and can lead to diabetic ketoacidosis. Ketones are therefore an essential warning signal. If you detect ketones in your blood you must phone your Diabetes Team for medical advice.
Hypoglycaemia and Pregnancy
Hypoglycaemia can occur if your blood sugar drops to a low level. Common symptoms of hypoglycaemia include:
Hypoglycaemia is most common in the early weeks of pregnancy. As you are aiming for very strict blood glucose control you may have more low blood glucose levels or ‘hypos' than usual (a blood glucose level of less than 4mmol/l).
To avoid episodes of hypoglycaemia you will need to:
Possible problems during pregnancy
Morning Sickness is very common in pregnancy, usually improving after about 16 weeks. Some women find eating a dry biscuit or a glass of milk before getting up in the morning can help to prevent the nausea.
Diabetic Ketoacidosis (DKA)
High blood glucose levels can lead to the formation of ketones in the blood, if not treated the blood will progressively become too acidic, a state known as ketoacidosis. Ketoacidosis poses a very serious threat to your baby. It takes several hours or days to come on but is preventable. You must test your urine for ketones if you are vomiting for any reason, or are feeling ill or if your blood glucose levels are high.
Problems with your eyes
If you have retinopathy(eye disease) or nephropathy(kidney disease) they will be monitored closely throughout your pregnancy as sometimes these conditions deteriorate.
Pre-eclampsia is a condition where the mother develops very high blood pressure, protein in the urine and fluid retention. This occurs usually in the last trimester of pregnancy. If this happens you will be admitted to hospital and given drugs to control your blood pressure and you may require early delivery of your baby.
Polyhydramnios occurs when you retain more amniotic fluid (the liquid in which your baby floats throughout pregnancy) than normal. This can happen when your diabetes control is not good and it can cause pre-mature labour (onset of labour before the baby is fully developed).This condition can be improved by tighter blood glucose control in the mother.
Labour and Delivery
Because you have diabetes, your labour and delivery will be closely monitored. Although normal full term delivery is usually possible some women will deliver their baby early, and about 50% of diabetic mothers will have a caesarean section. Decisions regarding delivery will be discussed with you and will be based on a number of factors such as your baby's health, your diabetes control, your blood pressure and previous deliveries. Once labour is established a glucose and insulin drip will be started and your blood glucose measured frequently. If you are going to have a caesarean section, a glucose and insulin drip will be started before you go to theatre.
After the delivery of your placenta, your insulin requirements will drop dramatically. You will be kept on an insulin/glucose drip for a few hours, and your blood glucose will be checked regularly until your levels stabilise.
When your baby is born, his/her blood glucose will be tested frequently. Babies born to mothers with well controlled diabetes prior to and during their pregnancy should have no more problems then those born to mothers without diabetes. Sometimes babies will need to be admitted to the special care baby unit, usually for help with breathing or because of low blood glucose levels. Where possible, this is managed by increasing the feeds your baby receives, but sometimes the baby may need a glucose drip.
Some babies develop jaundice after birth, so may require treatment. Phototherapy (light treatment) is usually enough depending on the condition of your baby.
In this section:
Generally your experience will be the same as for any new mother; however the doctors will take some extra steps in monitoring you both due to your diabetes.
After the delivery of your placenta, your insulin needs will drop dramatically. You may be kept on an insulin drip for a few hours after delivery, with your blood glucose being checked regularly until your levels stabilise.
Within the first 24 hours after birth, a paediatrician will check that your baby is healthy. Babies born to mothers with well controlled diabetes prior to and during their pregnancy should have no more problems then those born to mothers without diabetes. Sometimes babies need to be admitted to the special care baby unit, usually for help with breathing or blood glucose control. Where possible this is managed by increasing the feeds your baby receives, but sometimes a glucose drip is needed. Early feeding of your baby (within the first hour) is encouraged.
Some babies develop jaundice after birth, and your baby may require treatment for this. Phototherapy (light treatment) is usually enough, depending on the condition of your baby.
Early feeding of your baby (within the first hour) is encouraged. Breast feeding provides the best nutrition for your baby; giving him/her extra protection against infection and helps you to develop a deep bond with your baby. Breast feeding is recommended in women with diabetes, with research showing that breastfed babies are less likely to develop diabetes and obesity in the future. It also helps keep the mothers glucose levels under control, and it allows your body use up some extra calories that were stored during pregnancy.
Points to remember when breastfeeding
- Early breastfeeding, within the first hour of delivery is recommended to help prevent low blood glucose levels in the baby.
- Your diet may need to be altered as energy requirements will increase when breastfeeding.
- Insulin requirements may drop by up to 30%.
- You should eat before breastfeeding to prevent becoming hypoglycaemic, and keep a snack close by in case the baby feeding goes on longer than expected.
- Drink according to your thirst
- If your baby is found to have low glucose levels, it may be necessary to supplement breast feeds with expressed breast milk or formula milk if recommended by your paediatrician. This may only be for a short time.
The risk of your baby developing diabetes in the future is relatively low. Inheritance of diabetes involves both genetic and environmental factors. The risk of any baby developing diabetes before the age of 20 is about 1 in 1000.If either parent has Type 1 diabetes the risk of one of their children developing diabetes is 3-9/100 and increases further if both parents have diabetes.
Vitamin D is essential for good bone health. Evidence in Ireland suggests that children and adults have low levels of vitamin D; all babies are advised to be given a D3 supplement with no other vitamins added to it.
Treatment After Delivery
It is important that you meet with your Diabetes Team for postnatal review sometime between 6-12 weeks after delivery.
Good glucose control after your pregnancy is very important to keep you healthy in the long term and while not as strict as during your pregnancy ,regular glucose monitoring is still a good idea(aiming for pre meal blood glucose levels between 4-7mmol/l).An appointment will be made for you to attend the diabetes clinic for postnatal review at 6-12 weeks post delivery.
Contraceptive advice can be provided prior to discharge. The combined oral contraceptive pill or long-acting progestogen injection can be used after 6 postnatal weeks. Progestogen only oral contraceptive pill can be used safely in the first 6 weeks. IUD (Coil) can be inserted after resumption of menstruation. At your postnatal visit your future plans will be discussed and advice given about family planning and contraception. Make sure your cervical screen is up to date. This will also be discussed at your postnatal visit 6-12 weeks after delivery.