People with type 1 diabetes have healthy pregnancies all the time — but the planning starts earlier than for most people. The American Diabetes Association’s 2026 Standards of Care recommend aiming for an A1C below 6.5% before conception if you can get there without significant lows, a dilated eye exam before pregnancy, a medication review (especially blood-pressure and cholesterol drugs), and staying on effective contraception until your team agrees you are ready.
The order matters more than the speed
Why the months before conception carry the most weight
Most of a baby’s organs form between roughly weeks 5 and 8 of pregnancy — often before people have had a first prenatal appointment, and sometimes before they know they are pregnant. The ADA’s pregnancy chapter explains that the risk of certain birth differences (including heart, brain, and spine differences) rises with higher A1C in the first 10 weeks, and that an A1C below 6.5% is associated with the lowest risk.
That is why diabetes guidance puts so much emphasis on before. You can absolutely adjust once you are pregnant, but glucose levels in the first two months cannot be redone later. Planning lets you arrive at that window already steady.
This is not a reason for fear. Studies that link A1C to outcomes are about averages across many people, and the ADA notes those associations are tangled up with other factors. The useful takeaway is simple: the closer to target you are at conception, the more of the risk you have already reduced.
The A1C goal — and what “as safely as possible” means
The ADA’s Recommendation 15.3 says to aim for glucose “as close to normal as is safely possible,” ideally an A1C under 6.5% (48 mmol/mol), to lower the risk of congenital anomalies, preeclampsia, large babies, and preterm birth. The word safely is doing real work there. Pushing A1C down by stacking up frequent or severe lows is not the goal.
Once pregnant, targets tighten. The ADA lists fasting glucose under 95 mg/dL and either a one-hour post-meal value under 140 mg/dL or a two-hour value under 120 mg/dL, with an ideal pregnancy A1C under 6% — relaxed to under 7% if that is what it takes to avoid lows. Knowing this ahead of time helps you see why your team may start nudging settings before you conceive.
If your A1C is well above goal right now, that is information, not a verdict. It usually means building in more runway: more frequent check-ins, technology changes, and staying on contraception a little longer. In the UK, for example, NICE guidance advises people with diabetes to avoid pregnancy when HbA1c is above 86 mmol/mol (10%) — a reminder that the plan is to get closer first, not to try harder at an unsafe starting point.
The preconception checklist, in plain English
The ADA recommends that care before conception be “interprofessional” — endocrinology, maternal-fetal medicine, a dietitian, and a diabetes care and education specialist — and that standard preconception care be expanded for people with diabetes. Here is what that tends to include, based on the ADA’s Table 15.1:
| Check | Why it matters before pregnancy |
|---|---|
| Dilated eye exam | The ADA notes a high risk of new or worsening retinopathy during pregnancy. It recommends an exam ideally before pregnancy and in the first trimester, then as indicated through the first postpartum year. |
| Kidney tests (creatinine, urine albumin-to-creatinine ratio) | Existing kidney involvement affects which medications are safe, how blood pressure is managed, and how closely pregnancy is monitored. |
| Thyroid test (TSH) | Thyroid conditions are listed among the comorbidities to evaluate and treat before conception. |
| Lipid panel and blood pressure | Sets a baseline and flags medications that need changing (see below). |
| Foot exam; ECG if indicated | Part of the full complications screen. The ADA suggests an ECG from age 35 for people with cardiac symptoms or risk factors. |
| Prenatal vitamin | The ADA recommends at least 400–800 μg of folic acid plus 150 μg of potassium iodide before conception. Some national guidelines (such as NICE in the UK) use a higher prescription folic acid dose for diabetes — ask which applies to you. |
It also includes screening for sexually transmitted infections and the usual preconception items, like vaccines. If you have not done a general preconception sweep yet, the TTC checklist covers the parts that are not diabetes-specific.
Medications to review before you stop contraception
Insulin itself is the backbone of diabetes treatment in pregnancy. The medications that need attention are usually the other ones people with long-standing type 1 diabetes often take:
- ACE inhibitors, ARBs, and mineralocorticoid receptor antagonists. These are often prescribed to protect the kidneys or lower blood pressure. The ADA recommends they be stopped before conception and avoided in sexually active people not using reliable contraception. Your prescriber will decide what replaces them and when — do not drop them on your own, because kidney and blood-pressure protection still matters.
- Statins and other lipid-lowering drugs. The ADA says that in most circumstances these should be stopped before conception, with some exceptions (for example, familial hypercholesterolemia) decided case by case.
- GLP-1 or GIP/GLP-1 medications, sometimes used alongside insulin for weight. The ADA says these should be discontinued before pregnancy and contraception used while taking them. Semaglutide’s label advises stopping at least two months before a planned pregnancy.
- Anything else you take regularly — thyroid medication, antidepressants, migraine or acne treatments, supplements. Bring the full list. (If migraine treatment is part of your list, see migraine medications while trying to conceive.)
Pregnancy with diabetes also usually involves low-dose aspirin later on to lower preeclampsia risk. The ADA recommends it starting at 12–16 weeks for people with type 1 or type 2 diabetes, and the U.S. Preventive Services Task Force lists pregestational diabetes as a high-risk factor. Your obstetric team will prescribe it — there is nothing to start before you conceive.
CGM, pumps, and automated insulin delivery
Technology is one place the 2026 Standards are especially clear. The ADA recommends continuous glucose monitoring for pregnant people with type 1 diabetes (Recommendation 15.11), noting that CGM can reduce the chance of a large-for-gestational-age baby and newborn low blood sugar. Pregnancy-specific CGM goals for type 1 diabetes are more than 70% of time between 63 and 140 mg/dL, with less than 4% of time below range.
For automated insulin delivery (AID, sometimes called hybrid closed loop), the ADA recommends systems that have pregnancy-specific glucose targets (Recommendation 15.19) and says systems without them “may be considered” with experienced teams and workarounds (15.20). The ADA also notes that most FDA-approved AID systems lack pregnancy-specific algorithms and that their lowest available target sits above the pregnancy fasting range.
Practically, that means the preconception window is a good time to ask:
- Is my current CGM and pump setup the one you would want me on in pregnancy?
- If I use AID, what target can my system reach, and what will we change once I am pregnant?
- Should I switch systems before conceiving, so I am not learning new hardware in the first trimester?
- How do I share CGM data with you between visits?
- What is the plan if a sensor or pump fails at night?
One more data point: the ADA says estimated A1C and the CGM “glucose management indicator” should not be used in pregnancy as stand-ins for a lab A1C. Your team will rely on lab A1C plus your CGM metrics.
First-trimester lows and other early surprises
Many people expect insulin needs to climb in pregnancy, and they do — later. Early on, the ADA notes that many people with type 1 diabetes have lower insulin requirements and a higher risk of hypoglycemia in the first trimester. Nausea, smaller meals, and tight targets can combine into more frequent lows, sometimes before you have told anyone you are pregnant.
- Make sure glucagon is current and that a partner or housemate knows how to use it.
- Ask in advance how your team wants you to handle early basal and bolus changes.
- Set CGM alerts you will actually hear at night.
- Plan for nausea days: what you will eat or drink to treat a low if regular food will not stay down.
Retinopathy deserves a mention here too. The ADA describes a high risk of new-onset or worsening retinopathy during pregnancy, which is why eye exams continue during pregnancy rather than happening once.
The human side: planning without perfectionism
Type 1 diabetes already asks for constant attention. Layering “and now the numbers affect a future baby” on top can make every high reading feel like a failure. A few things that help people stay steady:
- Think in trends, not single readings. A1C and time-in-range are averages for a reason. One bad night is not a pregnancy outcome.
- Share the load. A partner can learn to read CGM data, refill supplies, and handle overnight alarms. If you have a partner, bring them to a preconception visit.
- Ask for diabetes education support, not just prescriptions. The ADA lists a diabetes care and education specialist and a dietitian as part of the team for a reason.
- Name burnout early. Diabetes distress is real, and pregnancy planning can amplify it. Mental health support is part of preconception care, not a detour from it.
And if conception takes a while, the usual timelines apply. Diabetes does not mean you need to wait longer than anyone else to ask for help; see when to see a fertility specialist.
Frequently asked questions
What A1C should I have before trying to conceive with type 1 diabetes?
The ADA’s 2026 Standards of Care recommend aiming for an A1C below 6.5% (48 mmol/mol) before conception if it can be reached without significant hypoglycemia. Your diabetes team may set an individualized goal.
Do I need an eye exam before getting pregnant?
Yes. The ADA recommends a dilated eye exam ideally before pregnancy and again in the first trimester, then as indicated during pregnancy and for a year after birth, because retinopathy can start or worsen in pregnancy.
Should I stop my blood pressure or kidney medication before trying?
Do not stop it on your own. The ADA recommends that ACE inhibitors and ARBs be stopped before conception, but your prescriber should plan the switch and time it with your contraception so your kidneys and blood pressure stay protected.
Can I use my insulin pump or automated insulin delivery system in pregnancy?
Often yes. The ADA recommends CGM for pregnant people with type 1 diabetes and recommends AID systems with pregnancy-specific glucose targets. Systems without them may be considered with an experienced team. Ask your team before conceiving whether your current system is the right one.
Why are my blood sugars lower in early pregnancy?
The ADA notes that many people with type 1 diabetes need less insulin and have a higher risk of hypoglycemia in the first trimester. Keep glucagon current, set CGM alerts, and ask your team in advance how to adjust doses.
Sources & guidance
- ADA Professional Practice Committee. 15. Management of Diabetes in Pregnancy: Standards of Care in Diabetes—2026. Diabetes Care 2026;49(Suppl 1)
- ADA: Blood Glucose & A1C — Diagnosis
- U.S. Preventive Services Task Force: Low-Dose Aspirin Use for the Prevention of Preeclampsia (2021)
- Cambridge University Hospitals NHS: Diabetes and pregnancy (NICE NG3-based patient guidance)