Preconception Care of Women with Diabetes
• All diabetic women of child-bearing potential should be counseled about the risks of unplanned pregnancy.
• The use of appropriate contraception should be discussed until metabolic control is achieved and conception is attempted.
• The desired outcome is to lower glycated hemoglobin to as to achieve maximum fertility and optimal embryo and fetal development.
• Practical self-management skills essential for glycemic control and preparation for pregnancy include:
— using an appropriate meal plan;
— timing of meals and snack;
— planning physical activity;
— choosing time and site of insulin injections;
— using carbohydrate and glucagon for hypoglycemia;
— reducing stress, coping with denial;
— testing capillary blood glucose;
— self-adjusting insulin doses.
Initial visit
• A complete history and physical assessment is imperative, including: duration and type of diabetes; acute and chronic complications; diabetes self-management; concomitant medical conditions and medications, particularly thyroid disease; menstrual and pregnancy history; contraceptive use; and support system including family and work environment.
• An initial individual educational evaluation session with members of diabetes management team to review current management and develop a comprehensive treatment plan.
• Detailed physical examination including: blood pressure, dilated retinal examination, cardiovascular examination for those with diabetes for more than 10 years or other coronary artery disease (CAD) risk factors or with complications of diabetes, neurological assessment, and pelvic exam including pap smear.
• Laboratory evaluation including: in-office blood glucose and urine ketone testing and the following may be included: glycated hemoglobin, baseline assessment of renal function, serum thyroid stimulating hormone and/or free thyroxine in women with Type 1 diabetes.
• Management plan to be discussed with patient, including: risk of congenital anomalies and means of prevention, fetal and neonatal complications, maternal complications, contraception, cost implications of care, and preventing complications.
• SMBG goals:
— Preprandial: 70-100 mg/dl
— Postprandial: 1 hour, less than 140 mg/dl
2 hours, less than 120 mg/dl
Continuing care
• At each visit, evaluation of progress in achieving goals.
Visit frequency
• Patient should be seen at approximate monthly intervals.
• Weekly telephone contact should be considered.
• After glycemic control is achieved, glycsolated hemoglobin should be repeated at six- to eight-week intervals until conception occurs.
• If conception does not occur within one year, reassess patient from fertility standpoint.
• Monitor self-management techniques and modify as necessary.
Special considerations
• Hospitalization: Occasionally it may become necessary to hospitalize individuals for initiation of intensive therapy or for treatment of illnesses and acute diabetic complications.
• Hypoglycemia: It is imperative to explain the risks associated the hypoglycemia along with means of prevention and treatment offered.
• Retinopathy: The risk of accelerated diabetic retinopathy during pregnancy should be discussed with the patient and follow-up ophthalmologic examination should be anticipated during pregnancy for all women with diabetes.
• Hypertension: Pregnancy-induced hypertension is a potential problem for women with diabetes. Aggressive monitoring and control of hypertension in preconception state is imperative. ACE inhibitors, beta-blockers, and diuretics should be avoided in women contemplating pregnancy.
• Neuropathy: Peripheral neuropathy may be exacerbated by pregnancy.
• Cardiovascular disease: The presence of coronary artery disease suggests a high mortality rate during pregnancy. Evidence of CAD should be sought in any women who has had diabetes for more than 10 years or in the presence of complications.
• Early pregnancy management: Confirm pregnancy by laboratory assessment at earliest possible time and address the following: meal plan for optimal vitamin and mineral intake, modification of meal plan to address nausea and vomiting, gestational weight goals, prevention of fasting hypoglycemia, insulin adjustments to achieve target glucose control, quality control in SMBG, and psychosocial concerns.
Source: American Diabetes Association, Alexandria, VA. Full text can be found on the Internet at: http://www.diabetes.org/ DiabetesCare/Supplement199/S62.htm.
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