Pregnancy and Type 1 Diabetes: Preconception through Third Trimester

Lots of preparation went into planning my pregnancy (especially diabetes related). This blog post will cover pre-conception, conception, and each trimester.

Preconception

Prior to becoming pregnant, I acted like I was. I treated my diabetes like I was already pregnant to ensure that I was used to the tight control that pregnancy and diabetes requires. My goal was to stay between 65-90 fasting, and always below 120 after meals. I was able to achieve this by eating low carb (<30g carbs per day), lots of proactive management, and motivation. Preconception, I was using vial and syringe for injecting insulin and using Tresiba, Novolog, and Regular insulin. Please know, tight control is possible no matter what method you choose, injections or pump.

Conception

My conception A1C was 5.2%. I was happy with it, but knew I wanted to be lower during pregnancy. Around fertilization time, I specifically knew something was going on in my body when I had pesky high blood sugars.  I had a weekend a few days past ovulation where my sugars were resistant and elevated. I was in the 150-160s for about a day and a half which is very high for me. No matter how low carb I ate, or how often I corrected, I stayed elevated. It finally went down, and that’s when the exhaustion started. I work in higher education admissions, so I blamed the fatigue on all the crazy traveling I was doing. So if you ask me if my blood sugar gave any indications of pregnancy, I would say yes. The period of time with resistant blood sugars was not normal for me and coincided with fertilization.

First Trimester

Around week 6 of pregnancy, I had my first endocrinology appointment. I discussed with my doctor that I would be continuing to eat low carb during the entire pregnancy, which she fully supported, although she did say that low carb has not technically been studied in pregnant women. Honestly, I did not care if there were studies or not. I knew the consequences of high blood sugars on babies and women when diabetes is out of control. The only way I could maintain normal blood sugars was by eating low carb (this is still true)! My OB was also supportive of me eating this way.

I was given targets of: fasting 60-90, one hour after meal <130, and two hours after meal <120. I was able to maintain this fairly easily with eating low carb and being very reactive to any blood sugars that got close to 100.

At week 12, my A1C was 4.9%. I FINALLY hit the 4’s, my goal! According to my Dexcom reports, my average blood sugar was 86 with a standard deviation of 18 during the first three months of pregnancy.

By week 14, I started to use an insulin pump. I was previously using Tresiba for long-acting and Novolog for short-acting. I wanted to use a pump during pregnancy because I felt like I could react quicker and could make adjustments to basal insulin at any second instead of waiting an entire day for the next dose. I choose the Medtronic 670G, but with a Dexcom CGM. I did not use automode or their sensor. I only used the pump to deliver insulin.

FATIGUE. My goodness, honestly, I think the first trimester was the hardest in terms of debilitating symptoms. I didn’t have any nausea or morning sickness, but I was so incredibly tired. I don’t think I cooked one meal, thankfully my husband picked up my slack.

One thing I did notice in the first trimester is that I was very insulin sensitive. I didn’t have a lot of lows, but I didn’t require as much insulin for certain meals as before pregnancy.

Around week 16, I had to increase my basal insulin for the first time though. My A1C was also measured at 4.7%. In the beginning, they tested my A1C every 3-4 weeks.

In the first trimester, I had an OB appointment once ever 4 weeks. I saw my endocrinologist once.

The 20 week anatomy scan was so exciting! We learned she was growing well and on track, at 11oz and in the 39th percentile. We did however learn that we shared a single umbilical artery. Usually the umbilical cord has two arteries, but ours only had one. This can lead to growth issues, but it is the most common umbilical abnormality and usually doesn’t lead to issues (thankfully for us, it wasn’t a problem).

Second Trimester

The fatigue finally waned, yes! The horrible hormonal acne that I had finally stopped too. The second trimester was glorious and I finally felt like myself, minus a growing belly.

At 25-26 weeks, I had to increase my basal again. I was up 13 units in basal compared to pre-pregnancy rates and was really curious how much more I would have to increase until I had my baby. Spoiler alert: I increased my levels again, but overall, my insulin needs didn’t change too dramatically. Total daily insulin remained under 60 units a day. Again, I attribute this to eating low carb.

I still stick to my mantra that low carb saved my life and made pregnancy super easy (honestly). My A1C was 4.5%. Dexcom data showed that my average was 86 and 18, ironically the same as the first three months of pregnancy. My entire diabetes and OB team kept reassuring me that I faced no higher risks because of my diabetes! This was really reassuring because with diabetes, we are automatically higher risk. Essentially, I was being treated like someone without diabetes.

I don’t say these things to boast or make anyone feel bad. I say it because I really think it’s important that all women with diabetes know that having a healthy and normal pregnancy is possible!

I had a growth ultrasound at 26 weeks and baby girl was doing great; she weighed just under 2 pounds and was in the 33rd percentile. I mention her size because I think it’s really important that women with diabetes know that having “normal” size babies is possible, we aren’t all doomed to have huge babies like the medical world makes us believe. With good control, babies can grow at a normal, healthy rate.

In the second trimester, I saw my OB every 3 weeks, and my endocrinologist once.

Third Trimester

Week 29 of my pregnancy was interesting. I started to hit another round of resistance (actually around week 28). I noticed an increase in bolus insulin and not as much in basal. Meaning I took insulin for a meal and ended up needing much more than I anticipated (even while eating low carb)! It’s important to note that insulin needs can change both for basal and bolus (short and long acting).

At my 30 week Endo appointment, my doctor commented on how my A1C was the best she’d ever seen (4.5%) and was astounded. I was so proud of myself, but also sad that her reaction was so surprised and somehow even skeptical. I hope that by sharing my journey I can empower other women to reach for the stars during pregnancy with diabetes.
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I was 30 weeks pregnant when COVID hit the news. Lots of my pregnancy was shrouded in this uncertain and yucky time. I barely saw my family, I didn’t see friends. I wasn’t able to have a baby shower. I had to stop going to my yoga classes. I had to resort to an online birth course. I stressed about the possibility of having to give birth alone. Even thinking about it now sends me down a rabbit whole on all of the things that I missed out on (and now what my baby is missing out on). Anyway…

My basal insulin finally changed again around 30-32 weeks. My bolus (mealtime) insulin needs also increased, but only in the evening. For a low carb dinner, I often needed 10 units where prior to pregnancy I might have only needed 3 units. It was a hard mental game to inject so much insulin and feel confident that it‘s correct, especially because it was so much more than I had ever taken before! It’s so important to remember that we need what we need, and that’s ok!

At 32 weeks I had my first BPP ultrasound (biophysical profile)! They look at fluid levels, big movement, small movements, and the baby doing practice breathing. I had them weekly from 32 weeks until delivery. It‘s an added bonus to see baby every week. It is standard for women with diabetes to have BPP appointments once per week starting at 32 weeks.

COVID put a real hamper on my OB care. My doctor and the clinic she was at started doing rotations where they were working in the hospital and clinic for a few weeks, then off for a few weeks. So at the very end of my pregnancy, I was meeting with different doctors quite often. This was so frustrating because I really wanted continued, consistent care. One doctor I met with at 36 weeks was convinced that I needed to have my baby that week because my blood pressure was slightly elevated. I have white coat hypertension and it’s often high at appointments, but at home it is normal. So it was frustrating to have to explain this to someone who never saw me previously but was trying to dictate the rest of my pregnancy based on one 20 minute office visit. Thankfully, I was able to see my regular OB later that week and she was fine with letting me go longer as none of my lab results indicated preeclampsia, which is quite common among women with diabetes, and usually accompanies high blood pressure.

I stopped getting my A1C checked. In the beginning it was fun to see the 4s, but toward the end, I didn’t want to get more blood work done if I didn’t have to. The last A1C I did was 4.7%. Again, COVID hit and I was limiting my visits and time at the clinic as much as possible.

Around 37 weeks, my OB helped schedule my induction, May 10th – Mother’s Day! We decided to induce at 37.6 weeks because of the slight risk of developing gestational hypertension (high blood pressure during pregnancy). Because my A1C was around 4.5%-4.7% the entire pregnancy, this was not actually a deciding factor on when to induce; however, having diabetes in and of itself poses a microvascular risk, even with great control. This was a really hard pill to swallow. Even with great control during pregnancy, prior management (or lack thereof can make its impact years later). So we decided to induce at 37.6.

In the third trimester, I saw my OB at least once per week, and starting at 32 weeks, I had two appointments per week (one BPP, and one office visit). I did not see my endocrinologist.

Final Thoughts

I get asked about my diet during pregnancy quite often. I ate low carb the entire pregnancy (and had been for years prior). By low carb, I mean healthy, fibrous, non-starch vegetables, berries, lots of protein, and healthy fat. I skip out on added sugars, starches, grains, flours, and pasta. Honestly, it’s nothing crazy. Simply nutrient dense, whole foods.

I was able to maintain such tight control because I was proactive in responding to changing blood sugars. If I started to approach 100, I corrected. I found that if I got close to 120, I became quite resistant and it was hard to get back down below 100. Reacting early was very helpful. Early action and eating low carb were two very big reasons why I never went over 170 mg/dl my entire pregnancy!

35. That’s how many appointments I had throughout my pregnancy. I saw my endo twice. This is definitely not the case for most people. I am very autonomous in my diabetes care and did not feel the need to see my endocrinologist. Again, this is abnormal. Most people meet with their diabetes team on a monthly basis.

I’m always open to chatting. If you’re reading this and have questions, please send me an email via the contact page. I would love to provide support, motivation, and anything else you need!

Check out my birth story!