Women with type 2 diabetes can achieve successful pregnancy outcomes through careful planning, optimal blood glucose control, and specialist multidisciplinary care. Preconception counselling ideally begins at least three months before conception, allowing time to optimise glycaemic control, review medications, and address any diabetes-related complications. The National Institute for Health and Care Excellence (NICE) recommends structured preconception care for all women with diabetes to reduce risks to both mother and baby. With appropriate medical support, medication adjustments, and enhanced antenatal monitoring, most women with type 2 diabetes can expect healthy pregnancies and positive outcomes. Early engagement with joint diabetes and antenatal services provides the foundation for safe pregnancy management.

Planning a Healthy Pregnancy with Type 2 Diabetes

Women with type 2 diabetes can have successful pregnancies with careful planning and medical support. Preconception care is essential and should ideally begin at least three months before attempting to conceive. The National Institute for Health and Care Excellence (NICE) recommends that all women with diabetes receive structured preconception counselling to optimise their health and reduce potential risks to both mother and baby.

During the planning phase, your healthcare team will assess your current diabetes control, review your medications, and screen for any diabetes-related complications such as retinopathy, nephropathy, or cardiovascular disease. Achieving optimal glycaemic control before conception significantly reduces the risk of congenital abnormalities and pregnancy complications. Target HbA1c levels should ideally be below 48 mmol/mol (6.5%) before conception if this can be achieved safely. Women with HbA1c above 86 mmol/mol (10%) should be strongly advised to avoid pregnancy until their diabetes control improves, as the risk of complications is very high. Use reliable contraception until glycaemic targets are met and all medications are optimised for pregnancy.

Key preconception steps include:

• Starting high-dose folic acid supplementation (5 mg daily, available on prescription) from before conception until 12 weeks of pregnancy to reduce neural tube defect risk

• Reviewing and stopping diabetes medications that are not safe in pregnancy, including SGLT-2 inhibitors and GLP-1 receptor agonists (some GLP-1 RAs require a washout period before conception—check with your diabetes team)

• Switching to pregnancy-safe options such as insulin and, if appropriate, metformin

• Optimising blood pressure control and changing to pregnancy-safe antihypertensive medications if needed

• Achieving a healthy body weight where possible

• Stopping smoking and avoiding alcohol

• Ensuring rubella immunity and cervical screening are up to date

Your GP or diabetes specialist nurse can refer you to a joint diabetes and antenatal clinic, where a multidisciplinary team including obstetricians, diabetes specialists, and specialist midwives will coordinate your care. Early engagement with specialist services provides the foundation for a healthy pregnancy and allows time to address any concerns or optimise your diabetes management before conception occurs.

Preconception guidance is based on NICE NG3: Diabetes in pregnancy. For medicine-specific advice, consult the British National Formulary (BNF), MHRA/EMC Summaries of Product Characteristics (SmPCs), or the UK Teratology Information Service (UKTIS/BUMPS).

Managing Blood Sugar Levels Before and During Pregnancy

Maintaining tight glycaemic control throughout pregnancy is crucial for maternal and foetal wellbeing. Pregnancy alters insulin sensitivity, with increasing insulin resistance developing from the second trimester onwards due to placental hormones. This means diabetes management requires frequent adjustment and intensive monitoring throughout the pregnancy journey.

Self-monitoring of blood glucose becomes more rigorous during pregnancy. NICE guidance recommends testing fasting blood glucose and one hour after every meal. If you are on insulin, you will also need to check before meals and at bedtime, and occasionally overnight, as advised by your specialist team. Target blood glucose levels are stricter than in non-pregnant individuals:

• Fasting: 5.3 mmol/L or below

• One hour after meals: 7.8 mmol/L or below

• Before meals (if on insulin): 4.0–5.9 mmol/L

These tighter targets help minimise the risk of macrosomia (large baby), polyhydramnios (excess amniotic fluid), and neonatal complications. However, they must be balanced carefully against hypoglycaemia risk, particularly in the first trimester when insulin requirements may actually decrease.

Continuous glucose monitoring (CGM) or flash glucose monitoring is routinely offered to women with type 1 diabetes during pregnancy. For women with type 2 diabetes, CGM may be considered on an individual basis, particularly for those on intensive insulin regimens or with problematic hypoglycaemia, though availability depends on local commissioning and clinical need.

Dietary management remains fundamental, with referral to a specialist dietitian recommended for all pregnant women with diabetes. A balanced diet with controlled carbohydrate portions, distributed across three meals and two to three snacks daily, helps maintain stable glucose levels. Regular physical activity, as tolerated and unless contraindicated, also supports glucose control and overall pregnancy health.

Women should be educated about recognising and treating hypoglycaemia promptly, keeping fast-acting glucose readily available at all times. If you are unwell, vomiting, or your blood glucose is persistently high (e.g., above 11 mmol/L), check your blood ketones. Seek urgent medical advice if ketones are positive, as this may indicate diabetic ketoacidosis, which requires emergency treatment.

Monitoring guidance is based on NICE NG3: Diabetes in pregnancy. For patient-facing advice, see NHS: Diabetes and pregnancy, and Diabetes UK resources on hypoglycaemia in pregnancy.

Medication Changes and Safety in Pregnancy

Most oral diabetes medications are not recommended during pregnancy, necessitating significant treatment changes during the preconception period. Metformin is the exception and may be continued or initiated during pregnancy, though it crosses the placenta. Current evidence suggests metformin is safe in pregnancy, and NICE guidelines support its use, particularly in women with polycystic ovary syndrome or those requiring additional glycaemic support alongside insulin.

Other oral hypoglycaemic agents, including sulphonylureas (glibenclamide has a limited role in gestational diabetes when insulin is declined, but is not routinely used for pre-existing type 2 diabetes), SGLT-2 inhibitors, DPP-4 inhibitors, and GLP-1 receptor agonists, should be discontinued before conception due to insufficient safety data or known risks. Stop SGLT-2 inhibitors and GLP-1 receptor agonists before planned conception; some GLP-1 RAs require a specific washout period—check the Summary of Product Characteristics (SmPC) or consult the UK Teratology Information Service (UKTIS). These agents should also be avoided during breastfeeding unless specifically advised by your specialist.

Insulin therapy becomes the mainstay of treatment for most women with type 2 diabetes during pregnancy when lifestyle measures and metformin alone prove insufficient. Insulin does not cross the placenta and is safe for the developing baby. Women typically require a basal-bolus insulin regimen, using:

• Isophane insulin (NPH) as the first-line basal (background) insulin; insulin detemir is an acceptable alternative. If you are already well controlled on insulin glargine before pregnancy, your team may consider continuing it after discussing the risks and benefits.

• Rapid-acting insulin analogues (such as insulin aspart or insulin lispro) before meals

Insulin requirements change dramatically throughout pregnancy. First trimester needs may decrease, increasing hypoglycaemia risk. From approximately 16 weeks onwards, insulin resistance increases progressively, often requiring substantial dose increases—sometimes doubling or tripling by the third trimester. Close liaison with the diabetes team ensures timely adjustments.

Other medication considerations include:

• Discontinuing ACE inhibitors and angiotensin receptor blockers (used for blood pressure or kidney protection) due to foetal toxicity—alternative antihypertensives such as labetalol, nifedipine, or methyldopa are prescribed instead. Thiazide diuretics should also be avoided or changed in pregnancy.

• Reviewing statin therapy, which should be stopped before conception

• Starting low-dose aspirin (75–150 mg daily) from 12 weeks' gestation to reduce pre-eclampsia risk in women at high risk, including those with pre-existing diabetes

Women should never adjust or stop medications without consulting their diabetes team, as both hyperglycaemia and abrupt medication changes carry significant risks.

Medication guidance is based on NICE NG3: Diabetes in pregnancy and NICE NG133: Hypertension in pregnancy. For detailed medicine information, consult the BNF, MHRA/EMC SmPCs (insulin detemir, isophane insulin, insulin aspart, insulin lispro, metformin, labetalol, nifedipine, methyldopa, aspirin, SGLT-2 inhibitors, GLP-1 RAs), and UKTIS (BUMPS) patient information leaflets.

Monitoring and Antenatal Care for Diabetic Pregnancies

Pregnancies complicated by type 2 diabetes require enhanced surveillance and specialist antenatal care. Women should be seen in a joint diabetes and antenatal clinic regularly throughout pregnancy, with the frequency tailored to your glycaemic control and stage of pregnancy—appointments often increase to every one to two weeks later in pregnancy. This multidisciplinary approach ensures coordinated care between obstetricians, diabetes physicians, specialist midwives, and dietitians.

Retinal screening is essential, as pregnancy can accelerate diabetic retinopathy. NICE recommends digital retinal photography:

• At the first antenatal appointment (unless performed within the previous three months)

• At 28 weeks' gestation

• If retinopathy is identified at booking, an additional assessment at 16–20 weeks is required

• More frequent screening may be necessary if pre-existing retinopathy is present or if progression occurs

Any sight changes should be reported immediately, as rapid progression occasionally occurs.

Renal function monitoring includes:

• Baseline assessment of serum creatinine and estimated glomerular filtration rate (eGFR)

• Urinary albumin-to-creatinine ratio (ACR) measurement

• Regular monitoring throughout pregnancy, particularly in women with pre-existing nephropathy

Foetal surveillance is intensified to detect complications early. Ultrasound assessments include:

• Early dating scan

• Detailed anomaly scan at 20 weeks (four-chamber heart view particularly important)

• Serial growth scans from 28 weeks (typically every four weeks) to monitor foetal growth and amniotic fluid volume

• Umbilical artery Doppler studies if growth concerns arise

HbA1c monitoring is recommended at booking and at 28 weeks' gestation, with additional measurements if clinically indicated. Interpretation differs from non-pregnant values due to increased red blood cell turnover.

Blood pressure monitoring at every antenatal visit is crucial, as women with diabetes face increased pre-eclampsia risk. Urine should be tested for protein at each appointment, with any new proteinuria prompting further investigation. Women are advised to be alert for pre-eclampsia symptoms including severe headache, visual disturbances, epigastric pain, or sudden swelling, and to seek immediate medical attention if these develop.

Monitoring guidance is based on NICE NG3: Diabetes in pregnancy and the NHS Diabetic Eye Screening Programme pregnancy pathway.

Reducing Risks and Complications During Pregnancy

Type 2 diabetes increases the risk of several pregnancy complications, but optimal glycaemic control significantly reduces these risks. Understanding potential complications enables early recognition and prompt management, improving outcomes for both mother and baby. Women with pre-existing diabetes also have an increased risk of stillbirth, which is why planned timing of birth is recommended.

Maternal complications include:

• Pre-eclampsia: Risk is two to four times higher in women with diabetes. Low-dose aspirin from 12 weeks reduces this risk.

• Polyhydramnios (excessive amniotic fluid): Related to foetal hyperglycaemia causing increased foetal urination. May cause discomfort and increase preterm labour risk.

• Urinary tract infections: More common and require prompt antibiotic treatment.

• Diabetic ketoacidosis: Rare in type 2 diabetes but can occur, particularly with concurrent illness. DKA can develop at lower glucose levels in pregnancy. Check blood ketones if you are unwell, vomiting, or if glucose is persistently high, and seek urgent assessment if ketones are positive. DKA requires emergency hospital treatment.

• Increased caesarean section rate: Related to foetal size and other complications.

Foetal and neonatal complications include:

• Congenital abnormalities: Risk increases with poor periconceptional glycaemic control, particularly affecting cardiac and neural tube development.

• Macrosomia (birth weight >4.5 kg): Caused by foetal hyperinsulinaemia in response to maternal hyperglycaemia, increasing birth injury risk.

• Intrauterine growth restriction: May occur with maternal vascular complications.

• Preterm birth: More common, sometimes iatrogenic due to complications.

• Neonatal hypoglycaemia: Occurs as the baby's insulin production adjusts after delivery.

• Respiratory distress syndrome: Slightly increased risk even at term.

• Neonatal jaundice and polycythaemia: Require monitoring and occasional treatment.

Risk reduction strategies include:

• Maintaining target blood glucose levels throughout pregnancy

• Attending all scheduled antenatal appointments

• Taking prescribed medications as directed

• Following dietary advice and remaining physically active

• Monitoring foetal movements from 28 weeks and reporting any reduction immediately (see RCOG patient information on reduced foetal movements)

• Avoiding smoking and alcohol completely

• Managing concurrent conditions such as hypertension

Women should contact their diabetes team or maternity unit immediately if they experience reduced foetal movements, vaginal bleeding, regular contractions, rupture of membranes, severe headache, visual disturbances, persistent vomiting, or positive ketones. Early intervention often prevents complications from progressing.

Complication guidance is based on NICE NG3: Diabetes in pregnancy. For red-flag advice, see NHS: Pregnancy and diabetes – warning signs and RCOG: Reduced fetal movements (patient information).

Postpartum Care and Long-Term Health After Delivery

The immediate postpartum period requires careful diabetes management as insulin requirements drop dramatically after placental delivery. Women on insulin typically need to reduce their doses immediately to approximately pre-pregnancy levels (or even lower) to avoid hypoglycaemia. Blood glucose monitoring should continue frequently in the first few days, with doses adjusted according to readings and in consultation with the diabetes team.

Delivery planning for women with pre-existing type 2 diabetes typically involves:

• Offering elective birth between 37+0 and 38+6 weeks' gestation, even if glycaemic control is good and there are no other complications, to reduce the risk of stillbirth and other adverse outcomes

• Earlier delivery if maternal or foetal complications arise

• Induction of labour or planned caesarean section depending on individual circumstances

• Continuous foetal heart rate monitoring during labour

• Blood glucose monitoring every hour during labour, maintaining levels between 4–7 mmol/L with intravenous insulin and dextrose if necessary

Neonatal care includes blood glucose monitoring for the baby within two to four hours of birth and before subsequent feeds for at least 24 hours. Babies should be encouraged to feed as soon as possible after birth. The neonatal team will monitor for hypoglycaemia, jaundice, and respiratory problems, with most babies remaining with their mothers unless complications arise.

Breastfeeding is strongly encouraged and provides numerous benefits for both mother and baby, including improved neonatal glucose stability and potential long-term metabolic benefits. Women can safely breastfeed while taking metformin and insulin. SGLT-2 inhibitors and GLP-1 receptor agonists should be avoided during breastfeeding unless specifically advised by your specialist. Those breastfeeding should be aware of increased hypoglycaemia risk and may need to consume a snack before or during feeds.

Contraception discussion should occur before hospital discharge, as another pregnancy soon after delivery carries additional risks. Contraceptive choice should be individualised using the Faculty of Sexual and Reproductive Healthcare (FSRH) UK Medical Eligibility Criteria (UKMEC). Combined hormonal contraceptive methods may not be suitable for women with vascular disease or other diabetes-related complications; discuss options with your healthcare team.

Long-term follow-up is essential:

• Diabetes medications are reviewed at six weeks postpartum, with many women returning to pre-pregnancy oral agents (if appropriate and not breastfeeding)

• HbA1c should be checked at the postnatal review

• Women with type 2 diabetes should receive annual diabetes reviews including retinal screening and renal function assessment

• Lifestyle advice regarding diet, physical activity, and weight management supports long-term health

• Future pregnancy planning should involve preconception counselling again, as each pregnancy requires the same careful preparation

If you experience any suspected side effects from your diabetes or other medications, report them via the MHRA Yellow Card Scheme (available at yellowcard.mhra.gov.uk or via the Yellow Card app).

Postpartum and delivery guidance is based on NICE NG3: Diabetes in pregnancy (intrapartum and postnatal care). Contraception advice is based on FSRH UK Medical Eligibility Criteria (UKMEC) for Contraceptive Use. For breastfeeding safety, consult the BNF and MHRA/EMC SmPCs for SGLT-2 inhibitors and GLP-1 RAs.

Frequently Asked Questions