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Our Senior Moderator, Sara Owens, writes: High-risk does not always mean you have or will develop complications. It does mean that your provider feels you have a higher likelihood of developing a complication then other patients. But even if you are high-risk, you may have a very uncomplicated pregnancy. It just means that your provider is aware of higher potential for complications and should provide appropriate monitoring in case complications do arise. Medically complicated means that you or baby or both have known underlying conditions or problems that may mean some changes to your care. Your doctor may recommend running extra tests for either or both of you, seeing a higher level provider, and/or delivering by a certain point or in a certain way. Should I be considered high-risk after preeclampsia? If my doctor says I am high-risk, does that mean they expect me to have complications again? Yes, if you have had preeclampsia or another hypertensive disorder of pregnancy, you should be considered high-risk in all subsequent pregnancies. Again, you may have a completely uncomplicated pregnancy, and in fact, most women who have had preeclampsia do have uncomplicated pregnancies the next time. If your doctor says you are high-risk, it does not always mean they expect you will have complications, but it should mean they will be prepared in case anything changes. What does a high-risk pregnancy look like? This is going to be very individual. Your provider can review your obstetric history, fetal outcomes, underlying conditions, and so on and give a personalized monitoring and assessment plan for you. They can also decide if they want to refer you to a higher level of provider or hospital, and they can create a plan for delivery. High-risk has a very wide range. For women who deliver at term, where baby and mom recovered quickly, no underlying conditions, high-risk may just mean their regular OBs do the recommended baseline testing and are just aware of their history and ready to act if anything changes. Except for baseline testing and perhaps home BP monitoring, their subsequent pregnancies may not look especially different from a low risk pregnancy. For women who delivered preterm, who lost a baby, and/or who have certain underlying conditions, their subsequent pregnancies may be a little more busy. It is common for those women to have extra visits, sometimes with Maternal Fetal Medicine specialists or other specialists like cardiology. They may also have more ultrasounds, more NSTs, more lab work. This chart is from the US's ACOG. It talks about the recommended monitoring and testing for women with a history of preeclampsia. There is leeway for individual situation, especially in the third trimester. Your plan will look specific to you! Here is our list of preconception questions to ask as well. My doctor said I am not high-risk and they will just proceed "as normal" unless anything changes. This may be a matter of wording choice. As discussed above, you should be considered high-risk, but if your circumstances do not warrant extra tests and such, your pregnancy may not look very different from low risk. Use the above chart to discuss with your doctor how they will ensure that you and baby receive appropriate monitoring and any necessary care. My doctor says I only need some baseline labs and a couple of ultrasounds. I see other women going to MFM, going for NSTs, and so on. Is my doctor doing enough to make sure baby and I are safe? Or My doctor wants me to come in twice a week for two months, wants me to see MFM, etc. That seems like a lot – do I really need all of that? Again, this is going to depend on your situation. Ask your doctor what they feel is appropriate for your clinical situation, as outlined in the chart. Ask your doctor what their concerns are for you and this baby and this pregnancy. Ask them what impact the results of certain tests would or would not have on your care and delivery plan. Informed consent means that you should be able to understand your doctor’s reasoning, and they should be able to understand your concerns, and in the end, you should both be comfortable with the plan and approach. Here are some posts that can help you have a productive conversation with your doctor about how your care should look: • This post is about concerns when your doctor doesn't listen. • This post is about what good care looks like in the context of preeclampsia. • This post has suggestions to help you advocate for yourself. • This post explains how to keep mothers safe. • This post goes over what is the role of the MFM. I just discussed the plan with my doctor, and that made the fear a little too real, and now I am worried and scared. Hugs – pregnancy after preeclampsia is stressful, for sure. Many of us can relate to how you are feeling, and we are always here to listen and to lend a virtual shoulder. But we also recommend keeping your doctor informed about how you are feeling, emotionally as well as physically. They can help, by discussing pregnancy-safe anxiety meds and when those might be warranted. They can also refer you to a mental health professional who can help you develop some coping techniques for anxious moments. Postpartum.net also has some excellent resources. Specific information for those living in the UK In the UK, as you don't have direct access to either an OB or MFM, your pregnancy will usually be placed on the appropriate pathway when you book in with the community midwife. They will complete a risk assessment and score you on risk, which will include details of past pregnancies, losses and personal data. Your NHS trust will have a specific pathway detailing what your care looks like if you are high-risk, so make sure to ask your midwife. They will provide you with a list of appointments and with whom when booking in. If needed, you will be referred to MFM departments at a larger hospital if your pregnancy becomes medically complicated.

Our Senior Moderator, Sara Owens, writes: Pregnancy causes a natural increase in insulin resistance. For some women, this goes a bit further than it should, and your body needs some assistance to keep your blood sugars down to a safe range. When this happens after about 20 weeks of pregnancy, it is considered gestational diabetes, caused by the placenta, which is why most women do a glucose tolerance test, where you drink a set amount of a sugary solution and then have your blood checked, in the 24-28 week range. If you were diabetic, or borderline diabetic, before pregnancy, or if you have had GD in a previous pregnancy, your doctor may start you on a diabetic diet right away and/or may do glucose testing early to check for undiagnosed pregestational diabetes. How is diabetes managed in pregnancy? Typically, it is managed with a diet that balances carbohydrates with proteins and fats, in order to keep your blood sugar at a consistent, acceptable level. Exercise may be recommended as well. Some women will take Metformin (a pill), and some will take insulin at various points in their day. Do I need to eliminate ALL carbs? No! You'll need to balance carbs with fat and protein, and you may especially need to watch simple carbs such as are found in sweets, but extremely low carb may not actually be beneficial for your numbers or for your body or baby in general. How often should I test? Ask your doctor, but typically, you will be testing first thing in the morning (fasting), preferably before you do too much walking around, and after each meal. How long after a meal should I test? It is usually one hour or two hours from first bite of food. Some doctors will have a preference for which, so if they do, follow their instructions; if they don't specify, pick one and stick to it. What about snacks and beverages? You should take the carb (sugar) contents of all snacks and beverages into consideration. A high sugar snack may have an ongoing effect on your later mealtime numbers that day. My doctor wants me to take insulin. Does it hurt? Is it difficult to inject yourself? Insulin is injected into subcutaneous fat, which does not have a lot of nerve endings, so it is pretty painless (probably less painful than the finger sticks). There may be a tiny sting, but you may not feel it at all. It may take a bit of "psyching up" to do it to yourself at first, but it should not be physically difficult. Your insulin should come with instructions and/or the doctor's office should go over instructions with you. If you're unsure, you can ask for a nurse visit so they can show you. If possible, the pens make it very easy. *It is important to read the instructions, though, for YOUR insulin -- some need to be inverted and rolled in order to mix properly, and some should NOT be.* Insurance may cover the insulin and needles, as well as the meter, strips, and lancets, but you will probably need to purchase alcohol pads to clean the injection site before injecting. Typically, you should rotate injection sites as well as fingers for the finger sticks. What do I eat? Typically, proteins and non-starchy vegetables are low in carbs. Whole grains are typically better than white grains. Berries may have less effect on sugar numbers than other fruits. You will likely need to watch your consumption of desserts, sweet snacks, bagels, pretzels, etc. and take care to eat those things in moderation and/or alongside fat/protein. Milk can spike some people's sugars, and you will likely need to watch your intake of sweetened drinks. You can ask your doctor if sugar substitutes are acceptable options. You may find that you can handle more carbs in the afternoon/evening than you can in the morning, or vice versa. It may also be beneficial to find substitutes that fulfill cravings without the carbs -- for instance, salted almonds instead of pretzels, cucumber slices with salsa instead of chips, or mashed cauliflower instead of potatoes. If you are new to diabetes and counting nutrients, you may want to ask for a visit to a registered dietitian with experience with diabetes in pregnancy. They can help you with some target carb/protein counts for meals and snacks. You should take as many notes as you can about what you eat, how you feel, and what your blood sugar numbers are, while you are figuring out what works for you. Every body, and even every pregnancy, will be different, so what works for you may not work for someone else or even for you next time. What numbers are good numbers? Is there a number that would be considered emergency level? This is really important to ask your doctor based on your situation. ACOG recommends that fasting numbers for pregnant women be 95 or lower, 140 or lower one hour after eating, and 120 or lower two hours after eating.Within those ranges, ask what would be considered too low for you, meaning you should consider increasing your carbs. Will my diabetes affect baby? Poorly controlled diabetes in pregnancy can lead to health problems for baby. It can cause babies to be larger than their genetic norms, and it can also be one cause of polyhydramnios (high amniotic fluid). Keeping your diabetes under control is really important for baby's optimal health, as well as your own. Will I need extra testing because of diabetes? Your doctor may recommend a fetal echocardiogram for preexisting diabetes as well as baseline diabetes labs. Your doctor may also recommend extra NSTs, fluid checks, growth ultrasounds, and BPPs to keep an eye on baby's size and well-being. As appropriate, you may be referred to MFM, ophthalmologist, dietitian, endocrinologist, cardiologist, and/nephrologist, especially for preexisting diabetes. Will I need to delivery early because of diabetes? ACOG says that delivery timing should be based on how well-controlled your diabetes is, whether you need meds for controlling it, whether it is gestational or pregestational, and whether there are additional complications. For well-controlled diabetes, up to 40+6 may be possible, but for poorly-controlled diabetes, 36 weeks may be recommended, or earlier if there are significant complications. Will I need a c-section? ACOG says that if the fetal weight is estimated to be over 4500 grams (about 10 pounds), your doctor should discuss risk vs. benefit of c-section delivery. What should I expect for baby after birth since I had diabetes? They may need to check baby's glucose several times in the first day or so after birth, especially if you were on insulin. Low glucose in a newborn can be managed if detected, so baby will be healthy. If breastmilk feeding is important to you, you may wish to ask about the hospital's protocol for managing low glucose ahead of time so that you are prepared to feed baby in the appropriate interval before the glucose tests, hand expressing or pumping for feeding with a spoon or syringe if baby is not ready to nurse effectively. Will I end up with diabetes for life if I had GD? Women who have had GD are at higher risk for developing type 2 diabetes later in life, but this does not mean you are doomed. This means that postpartum, your OB or PCP can check to see if you are still diabetic, and they can keep an eye on your a1c and fasting sugars as time goes on, so that if things do change, you can discuss medication and/or lifestyle changes. If you do develop type 2 diabetes, there are plenty of options for managing it as well. Does GD increase my risk for preeclampsia? Yes. GD is caused by a placenta that is a bit odd, as is preeclampsia; if the placenta is odd in one way, it is more likely to be odd in another way. However, plenty of women with GD or preexisting diabetes do not get preeclampsia, and plenty of women get preeclampsia without having diabetes. Having a risk factor just means that you are more likely, not that you definitely will or will not have preeclampsia or other complications. If you've had diabetes of any type in pregnancy, feel free to share about your experience and management in this thread!

What are the different types of urine protein testing, and what do they mean? • Dip Test -- a strip is dipped into a single sample, and the color is compared to a chart; can be done in office • Spot Test -- the amount of protein in a single sample is measured in a lab • 24 Hour Urine -- you collect all urine for 24 hours, and the lab measures the amount of protein in the full amount of urine • Protein Creatinine Ratio (PCR) -- the lab measures the amount of protein in a single urine sample, like with the spot test, but also measures the amount of creatinine in a single urine sample and compares them together to approximate the 24 hour urine. You can read more about lab work associated with preeclampsia in this post.