Pregnant with Type 2 diabetes: what good care looks like
When pregnancy arrives unplanned, women with Type 2 diabetes often find themselves behind on preparation they were never told about. Consultant obstetrician Dr Manju Chandiramani explains what good care looks like from here.
Many pregnancies are not planned. They arrive on a Tuesday morning, in a bathroom, with a test that was not supposed to be necessary yet. For women living with Type 2 diabetes, that moment carries a particular weight: not just the news itself, but the sudden awareness of everything they have been told, or not told, about what a pregnancy with diabetes is supposed to require. The 5mg folic acid they are not taking. The HbA1c that has not been optimised. The medication review that never happened.
Adaeze found out she was pregnant when her glucose levels started behaving strangely, climbing for no apparent reason despite her usual insulin doses. A nurse initially reassured her that it was unlikely to be pregnancy. Then the test came back positive. She was already past the point at which the preparation is supposed to begin.
She is far from alone. Across the women Diabetes Africa has spoken to as part of its work with maternity and diabetes teams in South East London, the same story surfaces again and again: the pregnancy that arrived before the conversation did. Amara had developed gestational diabetes with her first baby and gone on to be diagnosed with Type 2. Nobody referred her to a preconception clinic. Nobody told her there was one. By the time she found out she was pregnant again, she was back in the UK from Nigeria, specifically because the level of care she needed was not available where she had been living. “It just felt very,” she said, searching for the word, “‘you’ve got this, you’ve been on this, sort yourself out.'”
This is the reality that Manju Chandiramani sits with every week. A consultant obstetrician at Guy’s and St Thomas’ NHS Foundation Trust, with a particular focus on diabetes and pregnancy, she is often the person women meet at the point when preparation is no longer possible in the way it was meant to happen. When she thinks about unprepared women arriving in her clinic, her response is not what one might expect from someone steeped in protocols and clinical benchmarks.
“It’s not the woman’s fault,” she says. “The system was built to treat, not prepare.”
That said, what happens next matters enormously. And there is a great deal that can go right. Women with Type 2 diabetes who are already pregnant, or who are trying to conceive, will typically be seen by what is called a diabetes and pregnancy team: an obstetrician, a diabetes physician or specialist nurse, a midwife, and in many centres a dietitian, working in coordination. At a centre like Guy’s and St Thomas’, NICE guidelines recommend these professionals be available at the same appointment, so the woman is not shuttling between departments. The goal, as Manju describes it, is sustained attention on two things at once: the woman’s health and the baby’s, from the first booking appointment through to the postnatal period.
It’s not the woman’s fault. The system was built to treat, not prepare”
Dr Manju Chandiramani
“The big things are to ensure her ongoing health and her baby’s health throughout the pregnancy,” she says. In practice, that means blood glucose control, diet and lifestyle, and monitoring of the longer-term health markers that pregnancy can affect (kidneys, eyes, blood pressure) and as the pregnancy progresses, increasing attention on how the baby is growing and developing.
That is more appointments than most women expect. More letters, more blood tests, more Wednesdays spent at the hospital. Adaeze, who was travelling from Croydon to St Thomas’ every week, describes it as simply becoming the rhythm of her pregnancy. Her manager got used to not seeing her online on Wednesday afternoons. The appointments, she found, were less daunting once she understood what each one was for.
What can be done, starting now.
Even when preparation before conception was not possible, there are things that make a significant difference once a pregnancy is confirmed or being planned.
Blood glucose control is the most important. In pregnancy, the targets are tighter than outside it; the team will typically be aiming for an HbA1c below 48 mmol/mol before conception, with close monitoring throughout. The reason the first trimester matters so much is that the baby’s organs, including the heart, are forming in those weeks. Good blood glucose control during that window reduces the risk of complications in ways that cannot be achieved later in the pregnancy. For women already pregnant, the work of improving control begins at the first appointment, not before it.
Folic acid at the right dose is the other non-negotiable. The standard over-the-counter dose of 400 micrograms is not sufficient for women with diabetes. The recommended dose is 5mg, available on prescription. For women in the first twelve weeks, it is not too late to start. For women thinking about a future pregnancy, starting now is the whole point.
Medication review happens quickly once a woman is booked in. Some medications used to manage Type 2 diabetes are not safe in pregnancy. Semaglutide, for instance, increasingly prescribed as part of Type 2 management, should ideally be stopped several months before conception. For women who are already pregnant, the team will act fast. “Amara” described her medication being reviewed within days of her first appointment at St Thomas’.
Eye and kidney checks are part of the early picture too, since pregnancy can affect both. These are not signs of trouble. They are the baseline from which the team works.
The thing nobody warns you about.
“It’s suddenly a lot more than she thought her pregnancy was going to involve,” Manju says, with a candour that feels worth recording. She is right, and it is worth naming honestly. If the women around you had uncomplicated pregnancies, this will look different. The monitoring, the appointments, the conversations about risk; they can feel relentless, particularly when pregnancy on social media tends to look radiant and uncomplicated.
Adaeze describes the early weeks as emotionally draining. Her HbA1c was high when she found out she was pregnant, and her consultant was direct about the need to bring it down quickly. “I understand that she was a bit firm with me because she just wanted the best for me and my baby. But at that time it was really emotionally draining.”
Her HbA1c came down from 70 to the twenties by the time her son was born. He grew at the right pace and the right weight. The monitoring was not a sign of danger. It was why things went well.
Manju’s framing is worth holding onto: “We have all of the building blocks that we need to know how to keep her safe.” The appointments are not a record of what went wrong before the pregnancy. They are the protection.
Culture, food and the conversations that matter
For many women, and particularly for those whose families carry strong traditions around pregnancy, food and what the body needs, the clinical picture is only part of what shapes the experience. Shola Oladipo, a dietitian and CEO of Food for Purpose who works closely with Manju’s team, puts it plainly: in many African and Caribbean communities, a new pregnancy is held privately at first. Announcing it too early is thought to invite bad energy. Coming to a first appointment and being met immediately with a list of risks can feel, she says, like exactly the wrong kind of attention at exactly the wrong moment.
“The messaging has to start with positivity for our people,” she says. “Celebrate with me.”
There is also the pressure of the matriarchs: the aunties, the grandmothers, the women whose knowledge of what a pregnant body needs is passed down through generations and is not always aligned with clinical guidance. Some of that knowledge contains real wisdom. Some of it needs updating. Women often arrive at their appointments carrying both and not knowing which is which.
Adaeze’s regular dietitian, who was herself of African heritage, understood this instinctively: she worked with what Adaeze actually ate, adjusting portions rather than replacing dishes entirely. The locum who covered during her pregnancy had no such frame of reference. Adaeze eventually stopped going to those appointments.
For women navigating both a complex pregnancy and a set of cultural expectations about how pregnancy should look and feel, finding a team that can hold both is not a luxury. It is part of the care.
Manju was asked, at the end of a conversation about all of this, what she would want a woman with Type 2 diabetes reading this to know.
“Push your healthcare team to help you optimise everything,” she said. “Declare to your healthcare team that you are hoping to have a family and you would like to be signposted to as much as you can be. It’s your journey. And there are people who are really devoted to improving your care in pregnancy. Demand to see a specialist if you feel you’re not getting what you need.”
There are also, she might have added, people working to change the system so that fewer women have to demand it in the first place. That work is slower. But it is happening.
Diabetes Africa works with NHS trusts and healthcare professionals to improve pregnancy outcomes for women living with diabetes, with a particular focus on Black women and culturally sensitive care. Names of women interviewed as part of Diabetes Africa’s research have been changed to protect their privacy. Visit diabetesafrica.org to find out more.
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