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ATLANTIC-DIPAtlantic Diabetes in Pregnancy
Pregnancy & DiabetesAn Information booklet for mothers with diabetes
Authors: Prof Fidelma Dunne and Dr Geraldine Gaffney. Edition 3, January 2015.
GalwayGalway University Hospital Newcastle Road, Galway
Ms Louise Carmody Pregnancy Service Coordinator Diabetes Day Centre Galway University HospitalNewcastle Road, Galway (091) 542039 or 086-249 5880 [email protected]
Professor Fidelma Dunne ATLANTIC DIP Principal Investigator Consultant Endocrinologist Diabetes Day Centre Galway University Hospital Newcastle Road, [email protected] Geraldine Gaffney ATLANTIC DIP Principal Investigator Consultant Obstetrician Galway University Hospital Newcastle Road, [email protected] Aoife EganResearch FellowEndocrinology & Diabetes Day CentreGalway University Hospital [email protected] Breda Kirwan Diabetes Nurse Specialist Diabetes Day Centre Galway University Hospital Newcastle Road, Galway Tel: Diabetes Help Line (091) 544698
Ballinasloe
Portiuncla Hospital Ballinasloe Ballinasloe, Co Galway
Professor Fidelma Dunne Consultant EndocrinologistMs Hilda Clarke, Diabetes Nurse Specialist Portiuncula Hospital Ballinasloe Co Galway [email protected]: 090 964 8362
Castlebar
Mayo General Hospital Castlebar, Co Mayo
Ms Marie Todd Diabetes Nurse SpecialistMs Maria Hobson Diabetes Nurse Specialist Mayo General Hospital Castlebar, Co Mayo [email protected] [email protected] Tel: (094) 9042389
Sligo
Sligo General Hospital The Mall Sligo
Dr Catherine McHugh Consultant Endocrinologist Sligo General Hospital The Mall, Sligo [email protected]
Letterkenny
Letterkenny General Hospital Letterkenny, Co Donegal
Ms Therese Gallacher ATLANTIC DIP Research Nurse Letterkenny General Hospital Letterkenny, Co Donegal 074-91-25888 [email protected]
Mullingar
Midlands Regional Hospital Longford Road, Mullingar Co. Westmeath
Dr Shu Hoashi Consultant Endocrinologist Midlands Regional Hospital Longford Road, Mullingar Co. [email protected]
Local and national contacts
Contents
Introduction 5
Personal Details 6
Useful Names and Numbers 6
Antenatal Care 7
Diabetes Explained 8
Trimester One 11
Trimester Two 13
Trimester Three 14
Risks to the unborn baby 16
Achieving good blood
glucose control 17
Eating for good health 19
Insulin Administration 24
Illness and diabetes 25
Hypoglycaemia
and pregnancy 26
Possible problems
during pregnancy 27
Labour and delivery 30
Following the delivery 32
Infant feeding 33
Risk of diabetes in the baby 24
Postnatal diabetes care 35
Planning a future pregnancy 36
Checklist for planning
a pregnancy 37
Weekly Checklists 38-77
3
4 5
Introduction Welcome to the Combined Antenatal and Diabetes Clinic. You have
been referred to this clinic for your pregnancy care because you have
diabetes and are pregnant, or because you have developed diabetes
during this pregnancy.
You will probably have questions you may wish to ask particularly about how
diabetes may influence the pregnancy for both you and the baby. This booklet
should answer many of your concerns as it is based on knowledge gained in
looking after pregnant women with diabetes. It highlights that you need ‘extra
care’ during pregnancy which will be provided by the combined diabetes and
obstetric team in order to achieve good control of your diabetes and careful
obstetric supervision.
There is a section about delivery of your baby, but remember that each person is
different and there may be some special points for you. There is information for
getting help in an emergency, and this booklet also serves as a daily record of
your blood glucose (sugar) readings. If you need insulin this can also be recorded
in your monitoring diary.
Please feel free to ask the doctor, midwife or nurse at the clinic if you have any
questions about your care.
PLEASE BRING THIS BookLET WITH YoU To EACH CLINIC VISIT
4 5
PLEASE BRING THIS BookLET WITH YoU To EACH CLINIC VISIT
Important telephone numbersGeneral Practitioner:
Obstetrician:
Antenatal Clinic:
Delivery Suite:
Diabetes Nurse/Midwife:
Combined Antenatal Clinic:
Social Worker:
Accident & Emergency Department
Pre-pregnancy Clinic:
6 7
Personal DetailsName:
Address:
Date of Birth:
Age:
Height:
Weight before pregnancy:
Age of onset of diabetes:
Usual dose/type of insulin before pregnancy:
Any special problems with diabetes:
Other medical problems (drug allergies etc.)
Diabetes Clinic:
6 7
Antenatal Care
Good Control of diabetes during pregnancy combined with good
antenatal care is known to reduce the risk for babies born to mothers
with diabetes and also reduce the risks for mothers. Because you have
diabetes or have developed diabetes during pregnancy you will have
hospital antenatal care and attend our antenatal diabetes clinic.
Antenatal Clinic VisitsThe clinic is run by a specialist team of staff which includes a physician, obstetrician, ultrasonographer, midwife, diabetic specialist nurse and dietitian.
You can expect to see these staff at your visits as required (at present a dietitian
is not available at these clinics and this will be arranged for outside of clinic times). Parentcraft classes are also available to provide you with further
information on all aspects of delivery and postnatal care.
Each clinic visit may last 1 – 2 hours but your booking or first visit usually takes a
little longer. A sample of blood may be taken from you at your visit to find out the level of glucose (sugar) in your blood and your average glucose (HbA1c test) level. This will be discussed with you as well as any changes in your diet or
insulin dose. You will be seen by an obstetrician who will check that all is well
with both you and your baby. You will have ultrasound scans to check the
baby’s wellbeing.
If you are on insulin treatment you will be seen at the Combined Clinic every two weeks. If you are treated with diet and exercise you will be seen every four weeks. Regular attendance is very important so
that we can closely monitor your diabetes and pregnancy. You will also have regular phone contact from your Diabetes Nurse Specialist between clinic visits.
8 9
Diabetes Explained
Diabetes mellitus is a condition where the amount of sugar in the blood becomes
too high and the body cannot use the sugar in food for energy.
Type 1 DiabetesThis type of diabetes develops when the body is unable to produce insulin, which
is a hormone that helps sugar enter the cells. It usually appears before the age of
40 and is treated by insulin injections, diet and exercise.
Type 2 DiabetesThis type of diabetes develops when the body still produces some insulin but
not enough, or when the insulin that is produced does not work properly (insulin
resistance). It occurs more commonly in people over the age of 40 who are
overweight. It is treated with diet and exercise alone or by diet, exercise and
tablets, or by insulin injections. Women with type 2 diabetes may need to take
insulin injections throughout their pregnancy to achieve normal blood glucose
levels. Such women can usually go back to their previous treatment after
pregnancy.
The main aim of treatment of both types of diabetes is to achieve normal blood
glucose and blood pressure levels. This, together with a healthy lifestyle, helps to
improve wellbeing for mother and baby and protect against long-term damage to
the eyes, kidneys, nerves, heart and major arteries.
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Diabetes diagnosed during pregnancy:Gestational diabetes (GDM) is a type
of diabetes that is diagnosed during
pregnancy (usually after 20 weeks
gestation). In some women, GDM occurs
because the body cannot produce enough
insulin to meet the extra needs of pregnancy.
In other women, GDM may be found before 20
weeks of pregnancy. In these women, the condition
most likely existed before pregnancy. There are
certain risk factors that make you more likely
to have GDM.
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The high glucose level in the blood may have been discovered because of the
presence of glucose in the urine, and is confirmed by a glucose tolerance test.
Gestational diabetes is usually treated by diet. In about 40% of women insulin
injections are required. A glucose tolerance test is arranged 6-12 weeks after
delivery to check that the glucose levels have returned to normal. Women with
GDM have an increased risk of developing Type 2 Diabetes during their lifetime.
This risk can be reduced by maintaining a normal weight. It is important to let your
doctor know that you have had GDM and ask him to check your blood glucose
every year, and before you try for any further pregnancy because you may develop Type 2 diabetes. You should be referred back to the antenatal
diabetes clinic as soon as you become pregnant again.
Risk factors for diabetes during pregnancy
l Age over 30 years
l being overweight
l Polycystic ovarian syndrome (PCOS)
l History of infertility
l Multiple pregnancies (twins/triplets)
l Family history of diabetes
l of non-Causcasian ethnicity
l History of miscarriages, stillbirth, neonatal death or a baby born with a congenital abnormality
l previous gestational diabetes
l delivery of a previous large baby
10 11
Trimester One (weeks 0 – 12)Your baby’s development:�Major organs are formed; nervous system begins to develop; eyes, ears and nose
take shape.
Clinic Visits:You will be seen at the Combined Antenatal Clinic every 2 weeks if you are on insulin treatment and every four weeks if you are treated with diet and exercise.Tests
�Ultrasound scan to measure baby’s growth and to confirm expected date of
birth.l �HbA1c (blood test to check long term sugar control) to establish glucose control
before your pregnancy; then every 2- 4 weeks to help maintain your control.
l� �Urine and blood tests to check for kidney problems.
l� �Eye examinations to check for retinopathy (changes in the eyes caused by
diabetes) – if there is any evidence of retinopathy you may be referred to
the Eye Clinic.
l� Blood pressure examinations
l� Examinations by your hospital doctor (obstetrician).
Insulin Needs:l� �If you have Type 1 diabetes, your insulin needs may go up and down
during this time.
l� Regular monitoring of blood glucose is vital to avoid hypos.
l� �You will be shown how to monitor your blood glucose if you do not
do so already
l� �If you have Type 2 diabetes or gestational diabetes, you may have to start
taking insulin injections during this period.
�
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Your Goals
l Check blood glucose 4-7 times per day: fasting then one hour after each meal.
l Aim for fasting blood glucose of between 4 and 5 mmol/l and an after meals blood glucose of between 4 and 7 mmol/l.
l Follow diet and exercise guidelines; stop smoking and alcohol.
l Contact your Diabetes Nurse Specialist, midwife or doctor if you have
particular problems with nausea and vomiting or any concerns.
l Make sure that you have a glucagon kit and that someone in your household knows how to use it.
l Attend all antenatal clinic appointments and phone your clinic or Diabetes Nurse Specialist if you have any questions or concerns.
l Take folic acid 5mgs for at least 12 weeks before pregnancy and
during the first 12 weeks of pregnancy.
12
12 13
Trimester Two (weeks 13 – 24)
Your baby’s Development:Body growth begins to catch up with head growth. Baby begins to hold head
erect and begins to move. Heartbeat becomes regular and brain becomes more
complex. Eyes are sensitive to light. Cannot yet breathe on its own.
Clinic Visits: You will be seen at the Combined Antenatal Clinic every 2 weeks if
you are on insulin treatment and every four weeks if you are treated with diet and
exercise.
Tests:l� Ultrasound at 18-22 weeks, to check for fetal wellbeing.
l�� Listening to the baby’s heart.
l�� �Measurement of fetal head and abdomen – ideally every four weeks, to
monitor growth of the baby.
l�� HbA1c every 2-4 weeks to monitor glucose control.
l�� �Blood pressure, kidneys and eyes are checked regularly to monitor any problems.
Insulin Needs:As the baby grows, your insulin dosage may increase.
Your Goals
l Check blood glucose fasting and 1 hour after meals.
l Aim for fasting blood glucose of between 4 and 5 mmol/l and an after meals blood glucose of between 4 and 7 mmol/l.
l Follow diet and exercise guidelines.
l��Attend all clinic appointments.
l Record baby’s movements and inform your doctorof any changes/concerns.
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14 15
Trimester Three (weeks 25 – 40)Your baby’s Development:Brain grows rapidly during this stage. As the baby continues to grow it places
more demands on your body.
Clinic Visits:You will be seen at the Combined Antenatal Clinic every 2 weeks if you are
on insulin treatment and every four weeks if you are treated with diet
and exercise.Tests:Regular Ultrasound examinations for fetal growth. More frequent scans may
be necessary if there are problems, such as the baby growing too large, the
baby growing too slowly, or if you have high blood pressure.
Insulin Needs:These may continue to increase and may reach up to twice the dose you needed before you became pregnant.
14 15
Your Goals
l Check blood glucose fasting and 1 hour after meals.
l Aim for fasting blood glucose of between 4 and 5 mmol/l and an after meals blood glucose of between 4 and 7 mmol/l.
l Follow diet and exercise guidelines.
l Attend all clinic appointments and contact your doctor if you have any concerns.
l Check 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 are concerned contact the hospital.
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Malformations:
According to current studies, the risk of malformation is greater in babies of
women who have diabetes, so it is most important that your diabetes
control is good both before becoming pregnant and in the early stages of
pregnancy. If HbA1c is less than 6.1% (43 mmol/mol) before pregnancy, risk is decreased considerably.
Increased size of the baby:In the later stages of pregnancy, if your blood glucose levels are too high, the
baby may be larger than average. This is caused by too much glucose and other
nutrients crossing from the mother to the baby, and may lead to difficulties at
delivery. If your blood glucose is within the normal range your baby is more likely
to be of normal size, and to be born at the normal time and in the normal way.
Your obstetrician will discuss with you the options for delivery. This will
depend not only on the size of the baby, but on factors such as blood
glucose, blood pressure and how the baby was delivered in any previous
pregnancy.
Increased risk of stillbirth/increased risk to the newborn baby:
According to studies, the risk of death from 28 weeks into your pregnancy to 27
days after birth (the perinatal period) is greater for women with diabetes than for
the general population. With good blood glucose control, this rate decreases
dramatically.
17
Achieving good blood glucose control
There are three main ways to improve your blood glucose control:
l�� Careful attention to your diet.
l�� Adjusting your insulin dose as necessary.
l�� Taking Exercise.
Targets to aim for:
Home blood glucose Target
Fasting between 4 and 5 mmol/l Before Meals between 4 and 5 mmol/l
1 Hour After Meals between 4 and 7 mmol/l
Average blood glucose Target (Previous 2-4 weeks)
HbA1c Below 6.0%
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Monitoring control of blood glucose:Glucose Monitoring:
You will be asked to measure your own finger prick blood glucose with a meter.
Blood glucose self monitoring puts you in control. If you have not done this before
we will teach you how to do it. You will be asked to measure your blood glucose
levels every day fasting and 1 hour after meals.
If you have Type1 diabetes you will need to monitor before and after each meal.
The results should be recorded at the back of this booklet. This will help you to see, for example, if your blood glucose is always high or low at a particular time
of day.
Long Term Glucose Average (HbA1c)Haemoglobin A1c (HbA1c) is a measure of the average blood glucose over the
previous month. It is measured at each clinic visit and the result discussed with
you. The aim is to keep it as close as possible to the range found in normal
non-pregnant people (less than 6.0%)
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Eating for good health
Healthy eating is important to help you to manage your diabetes and to
help the baby get the nutrients it needs.
Aim to:1. Eat a varied diet with regular meals and snacks.
2. Include starchy carbohydrate foods at each meal e.g. bread, cereals,
pasta, rice, potatoes.
Best choices are the high fibre varieties such as: Granary, multigrain or
wheaten bread, new or sweet potatoes, Basmati rice, porridge oats or high
fibre cereals and pasta.
3. Eat more fruit, vegetables and salad - aim for at least 5 portions
every day. One portion is:
• 1 medium fruit e.g. apple, pear, orange, banana
• 2 small fruit e.g. kiwi, plums
• 2 tablespoons tinned fruit (in natural juice)
• 3 tablespoons vegetables
• 1 cereal bowl of salad
Pulses such as peas, beans and lentils are a good source of fibre.
Use sugar free or diet soft drinks and sweeteners in hot drinks e.g.
Hermesetas, Canderel, Saccharin or Splenda.
Don’t be tempted by diabetic foods or drinks. They can be expensive
and can have a laxative effect.
20 21
5. Eat less fat. Fatty foods eg. fried foods, crisps, chocolate, cakes, and bis-
cuits are high in saturated fat and high in calories, which can make you gain
too much weight.
• Grill, boil, bake, microwave or casserole instead of frying.
• Choose lower fat dairy foods e.g. skimmed or semi-skimmed milk,
low fat cheese, low calorie / diet yoghurts.
• Choose lean meat, chicken and fish. Cut off any skin or visible fat.
• Use less butter and margarine and try reduced or low fat spread.
• Spread thinly on bread and do not add to potatoes or vegetables.
• Only use a small amount of oil in cooking.
Choose spreads and oils high in monounsaturates e.g. olive or rapeseed oil.
These are better for your heart.
7. Use less salt and reduce salty foods
Too much salt can cause high blood pressure and fluid retention. High blood
pressure can lead to stroke and heart disease.
• Try not to add salt to foods. Flavour food with pepper, mustard,
vinegar, herbs or spices.
• Do not use salt substitutes e.g. Losalt, Ruthmol, Solo.
• Limit ready meals and tinned and packet foods as they contain
a lot of salt.
Other Foods to help your Baby Grow:✔� Take a supplement containing 10 micrograms (400 international units) of
vitamin D daily during pregnancy.
✔�� Take folic acid supplements
20 21
✔�� Take folic acid 5mgs (available on prescription only) for at least 12 weeks
before pregnancy and during the first 12 weeks of pregnancy.
✔�� Include meat, fish and alternatives
Two to three servings per day of these foods are recommended in
pregnancy. These foods are high in protein & contain B vitamins, zinc
and iron. One serving is:
• 2 ounces (60g) cooked lean meat/chicken. Avoid high fat,processed meats like sausages, bacon, salami and corned beef.
• 3 ounces (90g) fish• 2 eggs
• 3 tblsp beans/ lentils/ pulses/ dahl
• 5-6oz tofu/soya protein.
✔�� Iron is important to help make the extra blood needed by you and your baby
� Good sources include red meat, chicken, fish, eggs, breakfast cereals
fortified with iron, beans, peas and lentils, dried fruit and green vegetables.
✔�� Vitamin C aids the absorption of non-meat iron.
Good sources include oranges, kiwis, berries, tomatoes, potatoes, peppers
and green vegetables. Try to have at least two servings of fruit or
vegetables rich in vitamin C everyday.
✔�� Calcium is important for healthy teeth and bones.
Good sources include milk, hard cheese and yoghurt. Aim to have three servings
of calcium rich foods everyday. If you are under 18 years or are carrying twins or more, aim for at least 5 servings daily. One serving is equal to:
• 200mls (one glass) milk
• 30 grams (size of a small matchbox) of cheese
• 125 grams (one average pot) of yoghurt.
Other sources of calcium include tinned fish, soya milk fortified with calcium, orange juice fortified with calcium, broccoli, seeds and beans.
✔� Eat oily fish once a week
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Omega 3 fats are derived from fish oils. These include oily fish such as
sardines, salmon, trout, herring and mackerel. These foods are important
for your baby’s brain and eye and nerve development.
Other sources of omega 3 fats include
• White fish eg. Cod and whiting,
• Some vegetable oils eg. Rapeseed, flaxseed, linseed and
walnut oils.
• Seeds such as sunflower, safflower, pumpkin and sesame.
Foods and Drinks to avoid or limit in Pregnancy• 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
• Avoid alcohol
Drinking too much alcohol during pregnancy can harm your baby. It also
affects your blood glucose levels and blocks absorption of nutrients.
‘Less is best’ when it comes to alcohol and it is better to avoid alcohol
completely until after baby is born.
• Avoid excess amounts of vitamin A
• Avoid cod liver oil supplements, and vitamin and mineral supplements
which contain vitamin A. Avoid liver, liver pate, liver sausage and faggotts.
• Avoid too much caffeine found in tea, coffee, high energy drinks, chocolateand cola. The
22 23
maximum recommended daily intake is 200 milligrams per day. This
is found in:
• Try to have no more than two mugs of coffee or four mugs oftea per day. De-caffeinated varieties of tea and coffee are widelyavailable. Avoid medications that contain caffeine.
• Herbal teas and herbal remedies: Try not to drink more than 2 cupsof fruit, mint or chamomile tea per day. Use teabags rather thanloose leaves, and try to make weak tea rather than strong tea.Avoid herbal remedies unless a qualified medical professional hasadvised that they are safe.
• Avoid shark, swordfish, marlin, tilefish, blue fin and king mackerel as
they may contain high levels of mercury. Limit tuna to 2 small cans or 1fresh tuna steak per week.
• Avoid raw or lightly cooked eggs and foods that contain them eg.
Home-made mayonnaise, ice-cream, cheesecake and mousse.
• Avoid unpasteurised milk and dairy products, including soft, mould-
ripened cheese eg. Camembert and brie and ricotta cheese.
• Avoid raw or undercooked meat, poultry, fish and shellfish including
smoked salmon and sushi.
• Avoid pre-cooked or ready prepared foods that do not require reheating
• Do not eat pate
• Do not eat unwashed fruit and vegetables.
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Insulin Administration
During pregnancy your insulin dose will often change considerably.
In the early months, some women find their need for insulin decreases.
on the other hand, from about week 20 onwards there is usually a need
to increase the dose of insulin, it could even double by the end of the
pregnancy. You will be encouraged to be involved with the changing of
the insulin dose as pregnancy proceeds. Your diabetes physician and
diabetes nurse specialist will discuss the insulin type and dose with you
to achieve the best possible blood glucose control.
The most usual way is to take three injections of rapid acting insulin given by
a pen before breakfast, lunch and the evening meal, combined with an
injection of long acting insulin taken at bedtime.
24 25
Illness and diabetes
When you are ill, particularly if you have a temperature, your blood
glucose will rise even if you do not eat.
If you are ill, contact your doctor or diabetes nurse as soon as possible for help.
Controlling your blood glucose is more difficult when you are ill and the staff will
be able to advise you.
If you are unable to eat, replace the carbohydrates you are missing by sipping
slowly on a still sweet drink such as fruit juice. Other sources of carbohydrate
include dry cereal, crackers and ice-cream.
l� Check your blood glucose frequently.
l� Never stop taking your insulin.
l� �Check for ketones in your urine frequently; if you have more than a ‘small’ level
of ketones, phone the hospital for advice.
Useful contact numbers are listed near the start of this booklet.
If you have repeated vomiting and/or a ‘large’ level of ketones in your
urine, go to hospital as soon as possible.
26 27
Hypoglycaemia and Pregnancy
Because the aim is for very strict blood glucose control, you may find
that you have more low blood sugars or ‘hypos’ when you are pregnant.
Hypoglycaemia is most common in the early weeks of pregnancy. Some
women may also lose awareness of hypoglycaemia, although many
women find that their pregnancy passes with few problems. There are
several steps you can take to try to avoid ‘hypos’ including:
l��
�Eat regularly – missed or late meals are the most common cause of
‘hypos’, so don’t get caught out.
l��
�Testing your Blood Glucose – at least 7 times a day and adjust your
food intake or insulin levels, as advised by your doctor.
l���Telling those close to you – friends, relatives and your children need to
know how to recognise a ‘hypo’ and how to help you
l�� �Carrying your dextro-energy tablets with you at all times. In addition, just in
case you have a severe ‘hypo’ and lose consciousness, you will be given a
glucagon kit. The diabetes nurse specialist will teach your partner or relative
how to inject you with glucagon to raise your blood glucose. This is the
opposite of insulin and brings blood glucose up within a few minutes. It may
be of great help in the middle of the night.
l�� �Taking care when you drive – if you need to drive, check your blood glucose
before you set off, carry extra glucose and try not to make a journey
before a meal.
Fortunately, unborn babies do not appear to be harmed by hypos.
26
26 27
Possible problems during pregnancy
Morning sickness:You may suffer from morning sickness (although it is called morning sickness it may happen at any time of the day). Some women find that eating a dry biscuit or drinking a glass of milk before getting up in the morning can help to prevent nausea. Other suggestions include identifying and avoiding foods which upset you and trying not be become over-tired.
Even if you cannot eat properly or are frequently sick, you still need to eat and take your insulin and test your urine for ketones. Very occasionally, if your morning sickness is particularly severe and you really cannot keep anything down or if you have ketones in your urine, you may need to come into hospital for a short period. Symptoms of morning sickness usually improve from around 16 weeks.
•� Eat dry toast/cracker/biscuit 20-30mins before getting up
•� Smaller, more frequent meals
•� Avoid fatty foods
•� Avoid spicy foods
•� Don’t drink liquids with meals
•� Get fresh air
•� Avoid the smell of cooking
•� Don’t lie down too soon after eatingas this can make nausea worse.
•� Ginger biscuits/ginger ale can help
•� Drink plenty of fluids
•� If taking fizzy drinks you should allowthem to go flat before drinking.Thiscan be done by pouring into glassand stirring quickly to remove the fizz
•� Sip fluids slowly using a small strawto make sure that you do nottake gulps.
•� Some people tolerate fluids bestwhen they are not too hot or too coldbut sometimes it is easier to takewarm/hot fluids or cold fluids with ice.
•� Try sucking on ice slowly; you caneven try freezing cordials to give themsome flavour.
•� If fluids are not staying down try fluidbased foods eg. Soup, jelly, custardor rice pudding.
•� Try taking fluids between meals andsnacks instead of with meals.
If you are still not holding down fluidsyou should attend your GP.
Some of the following suggestions might help with morning sickness:
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High GlucoseHigh blood glucose levels can lead to the formation of poisonous chemicals
(ketones) in the blood. Ketones can develop for example from a urinary tract
infection or gastroenteritis. If this is not treated (with extra insulin) the blood will
progressively become too acidic, a state that is known as ketoacidosis.
Ketoacidosis poses a very serious threat to the baby. However unlike hypos,
ketoacidosis does not come on in minutes – it takes several hours or days and
is preventable.
Pregnant women with diabetes should test their urine for ketones if:
l� on insulin therapy and blood glucose levels are high
l� you are ill for any reason
l� you are vomiting for any reason
If the test shows more than a ‘small’ amount of ketones, please phone for
advice and come to hospital early. Take plenty of fluids to drink and NEVER
SToP TAkING YoUR INSULIN.
Eye or Kidney Problems:If you already have retinopathy (eye disease) or kidney disease due to diabetes,
the extra physical demands of pregnancy could make these conditions worse.
Sometimes the damage is permanent but more often things return to the pre-
pregnancy state. Your eyes will be checked approximately once in each
trimester and more frequently if required.
Pre-eclampsia:Pre-eclampsia is a condition in which the mother develops very high blood pres-
sure, protein in the urine and fluid retention. It usually occurs in the last trimester
of pregnancy. This condition may harm the mother and baby and is often solved
by delivering the baby early. If it is too early to deliver the baby, then you may be
admitted to hospital and given drugs to control your blood pressure.
29
Premature labour:This term describes the onset of labour before the baby is fully developed and
ready to deliver. The earlier the baby is delivered (before 37-38 weeks) the more
likely he or she is to be admitted to the special care baby unit (SCBU)
for monitoring.
Polyhydramnios:This is a condition in which you retain more amniotic fluid (the liquid in which
your baby ‘floats’ throughout pregnancy) than normal. It may cause premature
labour. The condition can be improved by tighter blood glucose control in the
mother.
Exercise:Exercise (30 minutes per day) is an important way to keep healthy during your
pregnancy. If you have diabetes, exercise plays a vital role in keeping your blood
glucose under control before pregnancy. Pregnancy puts extra stress on your
heart and lungs, so it is best not to begin a hard exercise programme during
your pregnancy; gentle exercises,
such as walking and swimming
are best.
Gentle exercise is important
if you already have problems
with high blood pressure,
with your eyes, kidneys or
heart or nerve damage.
Your doctor will show you
the type of exercise plan
that best suits you.
30 31
Labour and Delivery
Because you have diabetes your labour and delivery will be closely moni-
tored. Although normal delivery at full term (40 weeks) is possible, and
is our aim, some women have their baby one or two weeks early. About
50% of diabetic mothers have a caesarean section. The best time and the
best way to deliver the baby will be discussed with you close to the time.
The decision will be based on a number of aspects such as the baby’s
health, your diabetes control, blood pressure and previous deliveries.
Most women are admitted to hospital the day before or very near the day
the baby is born.
If it is recommended that you have your labour induced, you will usually be
allowed to eat and drink initially as normal with close monitoring of your blood
glucose levels. Insulin will be given as required.
Once labour is established, a glucose and insulin infusion (drip) will be started and
your blood glucose will be measured frequently.
You will be asked to fast from the night before delivery if planned by caesarean
section. A glucose and insulin drip will be started before you go to theatre. When
the baby is born, his or her blood glucose will be tested frequently. Occasionally
babies of mothers with diabetes have a low blood glucose and it is recommended
to feed babies as soon as possible after birth and to feed frequently.
30 31
Following the delivery
Generally, your experience will be the same as other mothers. You will
be able to hold your baby, begin breast feeding if you choose to, and
enjoy the happy moments of first being together. But because you
have diabetes, doctors will take some extra steps to make sure
that you and your baby are off to a healthy start.
You:After delivery of your placenta (after birth), your insulin needs will drop
dramatically. You may be kept on an insulin/glucose drip for a few hours after
delivery and your insulin dose will be adjusted as needed. Your blood glucose will
be checked regularly after delivery until your levels stabilise. When you resume
your normal diet, you should also return to approximately your pre-pregnancy
insulin dose.
Your Baby:Babies born to mothers with well controlled diabetes before and during
pregnancy should have no more problems than those born to mothers without
diabetes. However some babies need to be admitted to the special care baby
unit. This is usually for help with breathing and blood sugar control because ba-
bies can develop low sugars in the first few days of life. If possible this is simply
managed by increasing the feeds the baby receives, but sometimes a glucose
drip is needed.
If your baby is well, he/she will stay with you in the ward. Early feeding of your
baby is encouraged (within 1 hour of birth). The baby’s blood glucose will be
checked prior to the second feed (at approximately 4-6 hours of age).
Within the first 24 hours after birth, doctors will check that your baby is healthy.
Some babies develop jaundice after birth, so your baby, may require treatment.
Phototherapy (light treatment) is usually enough depending on the condition of
your baby.
32
Infant feeding
Can I breast feed? YES. Breast feeding provides the best nutrition for your
baby, gives extra protection against infection (through your antibodies)
and helps you to develop a deep bond with your baby. Breastfeeding is
recommended in women with diabetes. Research shows that breastfed
babies are less likely to develop diabetes and obesity in the future and
breasfeeding also helps to keep the mother’s glucose levels under control.
It allows your body to use up some extra calories that were stored during
pregnancy. Losing weight after having the baby enhances overall health
and is one way to reduce your changes of developing diabetes in later
life life.
key points to remember when breastfeeding
l Early breast feeding is recommended within the first hour after delivery
as this helps to prevent low blood sugar levels in the baby.
l Your diet may need to be altered as your energy requirements will
increase when breastfeeding. Insulin requirements may drop by
up to 25%.
l You should take food prior to breastfeeding. This is to
avoid becoming hypoglycaemic. It is helpful to keep a snack nearby
in case the feeding is prolonged.
l Drink according to your thirst.
l If the baby is found to have low blood sugars, it may be necessary to
supplement breast feeds with expressed breast milk and formula milk
should a paediatrician recommend this but remember this may only be
for a short time and there is no reason why you should not continue to
breastfeed your baby.
33
34 35
Risk of diabetes in your baby
The chance of your baby developing diabetes in the future is relatively
low. It is important to remember that inheritance of diabetes involves both
genetic and environmental factors. Type 2 diabetes has a much stronger
family history than Type 1 but even this does not mean that
your child will definitely develop diabetes.
A simple figure to remember is that the chance of any baby developing
diabetes before the age of 20 years is around 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 Type 1 diabetes. If either parent has
Type 2 diabetes the risk of Type 2 diabetes in their children over their lifetime is
15/100. This risk increases further if both parents have Type 2 diabetes.
Vitamin DVitamin D is essential for good bone health. There is evidence that children and
adults in Ireland have low levels of Vitamin D.
All babies are advised to take a vitamin D3 supplement, but it is particularly
important for babies who have dark skin or who are breastfed. Babies should be
given a vitamin D3 only supplement. The supplement should not have any other
vitamins added (unless specifically recommended by your baby’s doctor).
The recommended dose is 5 micrograms (5μgs)
once a day from birth to 12 months.
You can buy vitamin D3 supplements from your
pharmacist. You do not need a prescription.
34
34 35
Postnatal diabetes care
While it is not necessary for you to have quite so perfect glucose levels
after pregnancy, good control is still very important.
The aim is to keep you healthy in the long term and regular home glucose
monitoring (aiming for pre meal sugars between 4-7mmol/l) is still a good idea.
If you have Type 2 diabetes, you should be able to return to your tablets soon
after delivery or after you have stopped breastfeeding.
If you have gestational diabetes, arrangements will be made for you to have an
oral glucose tolerance test at about 6-12 weeks after pregnancy to determine
whether you do or do not have diabetes outside pregnancy.
Healthy postnatal check-upContraceptive advice can be provided prior to discharge.
The combined oral contraceptive pill or long-acting progestogen injection are
unlikely to be used in the first 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 we will discuss your future plans and help you make
arrangements for whatever form of family planning you decide to use.
Make sure your cervical screen is up to date.
35
36 37
Planning a future pregnancy
Because of the importance of having good blood glucose levels at the very
early stages of the baby’s development, particularly around the time you actually
become pregnant, it is advisable to plan your pregnancy carefully. This often
means that some form of contraception is necessary while the insulin dose is
being adjusted to achieve the best control of blood glucose levels. Contraceptive
methods will be discussed with you and your individual needs considered.
Pre-Pregnancy Care (PPC) Clinical research undertaken as part of the Atlantic Diabetes in Pregnancy
Programme shows that having diabetes (type 1 or type 2) increases the risk of
complications for mother and baby. But this research has also shown that
planning and preparing for a pregnancy with your diabetes team can greatlyreduce that risk.
For women who have diabetes, pre-pregnancy care (PPC) is just as important as antenatal care.
l �Please think in advance and make sure that your blood glucose levels
are between 3.5 and 5.5mmol/l before meals before you stop your
family planning method.
l You should also ensure that you take folic acid daily for at least 12
weeks before you become pregnant as this has been shown to reduce
the risk of having a baby with spina bifida. Folic Acid 5mg is only
available on prescription.
l If your pregnancy is not planned, ask your family doctor to refer you
urgently to the antenatal outpatient clinic.
36 37
Pre-pregnancy care allows for a period of time for good blood glucose control
to be achieved before the pregnancy starts. It also allows time to deal with
hypoglycaemia, start folic acid and review medications that may not be safe
during pregnancy.
This time is also used to screen for and treat complications of diabetes mellitus
and to emphasise the importance of a healthy diet and moderate exercise in
pregnancy. An appointment can be made for pre-pregnancy care by calling your
local diabetes centre.
Checklist for planning a pregnancy
l �Use regular contraception.
l Seek the advice of your doctor before you become pregnant
l Have your eyes checked before pregnancy.
l Check any medications you take are suitable during pregnancy.
l Start taking folic acid at least 12 weeks before conception
l Monitor your glucose readings 7 times daily.
l Aim for blood glucose between 3.5 - 5.5 mmol/l before meals.
l HbA1c should be as near normal as possible (< 6.0%).
l Stop smoking
l Stop drinking alcohol
If you meet these requirements then you are ready for pregnancy.
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its)
Date
Pre
B’Fas
tPost
Pre
Lunch
PPost
Pre
Dinner
Post
Bed
Tim
eB’fas
tLunch
Dinner
Bed
Tim
eCommen
ts
Hb
AIc
Dat
e:
Wee
kly
Rec
ord
– W
eek
40
Notes
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Atlantic DIP 2015
E
Atlantic DIP 2015