Preconception care of women with diabetes

• Diabetes UK •

• A medical, dietetic, educational, drug, obstetric and gynaecological history should be taken

A woman with diabetes of childbearing age should be informed about:

• The need for effective contraception
• The importance of carefully planning a pregnancy with advice from her diabetes care team
  • she (and her partner) should be included as members of the team, be involved in decisions about her care and be offered the opportunity to make choices by provision of appropriate and sufficient information
  • GPs and practice nurses need to be proactive in delivering care and advice
• How pregnancy and labour can affect and be affected by her diabetes
  • counselling should be provided about the risk of obstetric complications and the effect of pregnancy on diabetic complications
• The need for optimising blood glucose control before and during pregnancy
  • aiming for an HbA_1c of below 6.1% (43 mmol/mol) if safe
• goals for self-monitored glucose levels should be set jointly with the woman
• some blood glucose monitors give the result in terms of whole blood glucose, others in terms of plasma glucose; the woman should check with the meter manufacturer to be sure which her meter displays
• optimum levels are:
  • capillary whole blood glucose:
    before meals <5.9 mmol/l; 1 hour after meals <7.8 mmol/l
    
  • capillary plasma glucose:
    before meals 4.4–6.1 mmol/l; 1 hour after meals <8.6 mmol/l

• Hypoglycaemia and the treatment options for hypoglycaemia
  • attempting to achieve tight glycaemic control in people with diabetes increases the risk of severe hypoglycaemia; this is a problem for the mother rather than the developing embryo
  • means of prevention and treatment (glucose gel and glucagon) should be provided to the woman and her family
  • it is essential to educate family and friends
• The need to check that medications are suitable for use in pregnancy
  • if the woman is taking any medication not recommended in pregnancy, e.g. ACE inhibitors, diuretics or beta-blockers, steps should be taken to remedy this before conception
  • women on certian oral hypoglycaemic agents should be transferred onto insulin
  • metformin may be used before and during pregnancy, as well as or instead of insulin
• Her baseline retinal and nephropathy results
  • she should be made aware of the requirement to have regular (at least in each trimester) retinal examinations
  • cardiovascular disease should be excluded
• The advantages of healthy eating and importance of taking 5 mg folic acid daily, prior to conception through to the end of the 12th week of pregnancy
• The advantages of healthy eating and importance of taking folic acid supplements in an appropriate dose
• Stopping smoking, cutting down or cutting out alcohol and the need to be a healthy weight for her height
• After the initial visit:
  • the woman should have access to phone or personal contact for adjustment of insulin doses and other aspects of treatment
  • once she has stable glycaemic control that is as good as she can achieve, she can be counselled about the risk of malformations and spontaneous abortions when she wishes contraception can be discontinued; if conception does not occur within 1 year, her and her partner's fertility should be assessed

full guidelines available from…
Diabetes UK, 10 Parkway, London NW1 7AA (Tel –020 7424 1000)
http://www.diabetes.org.uk

Diabetes Uk. Care Recommendations: precomception care for women with diabetes. 2002, updated 2010