Postpartum Care for Women with Diabetes

What will happen after birth?

Many changes occur after birth including loss of weight and a return to normal physical activities. Many mothers also experience emotional "ups and downs" as their hormone levels return to pre-pregnancy levels. Insulin needs will be lower than they were during pregnancy and within a few weeks after delivery, insulin doses should return to pre-pregnancy levels.

Patients who have diabetes before becoming pregnant sometimes have difficulty returning to their normal dietary routine after delivery. It is often not easy to adhere to a rigorous schedule for meals and snacks when caring for a new baby. It is critical that good monitoring and eating habits be maintained for optimal control.

If gestational diabetes requiring insulin developed during pregnancy, the physician will probably discontinue insulin treatment after delivery and monitor a few blood sugars before releasing you from the hospital.

Most of the time (>90%) gestational diabetes will resolve after pregnancy, however, some women have persistently high blood sugars and require postpartum treatment. Fasting blood sugars should be drawn at the 6 to 8 weeks postpartum visits.

• If the fasting sugar is > 125 mg/dl or a random sugar is > 200 mg/dl (on two occasions), overt diabetes needing treatment is present.
• If the fasting sugar is 111 - 125 mg/dl, a 2-hour oral glucose tolerance test should be administered with a 75-gram glucose load for further evaluation.
• If the fasting sugar is < 111 mg/dl, the diabetes has resolved but a screening test should be performed every year particularly if insulin was required during the pregnancy since up to 60% of women will develop overt diabetes later in life.

Breast feeding

Mothers with diabetes can breast feed their children and, like for all nursing mothers, caloric needs must be carefully adjusted. Approximately 500 calories per day should be added to the pre-pregnancy diet, which covers the extra energy needed for milk production. If breast feeding continues for longer than 3 months, a further increase in calories may be needed.

A record of glucose levels must be kept because breast feeding moms who have pre-gestational diabetes will be more prone to hypoglycemia, particularly in the nighttime hours between the bedtime snack and breakfast. A snack may be needed before nighttime breast feeding

If an oral medication was prescribed to control blood sugars before pregnancy and the doctor switched to insulin during pregnancy, insulin may still be needed while breast feeding Oral medications should not be taken while breast feeding without approval of the doctor.

Birth Control

Birth control choices should be discussed with the doctor or nurse before discharge from the hospital. Choosing the safest and best time to have a child is one of the keys to planning a successful pregnancy for the woman with diabetes. Ideally, a physician will be seen in the preconception period (prior to conception of the baby).

No form of contraception is specifically contraindicated in women with diabetes, however the usual indications and contraindications for each form should be considered. Contraceptives containing only progesterone (e.g. the minipill, Norplant, Depo-Provera) may make sugar control more difficult or have a negative effect on the cholesterol and lipids. In addition, there is some evidence that in women who had gestational diabetes, using a contraceptive with only progesterone may increase the chance of developing overt diabetes later in life.

Remember, pregnancy is possible soon after giving birth. Even if there has been no menstrual period, ovulation may still occur. Some people believe that breast feeding a baby will prevent pregnancy…. Beware, this is not true!