Summary of main points for women with diabetes considering a pregnancy:
Women with diabetes of childbearing age should be informed about:
- the importance of carefully planning a pregnancy with advice from their diabetes care team
- how pregnancy and labour can affect and be affected by their diabetes
- the need for effective contraception
- the need for optimising blood glucose control prior to and during pregnancy with any improvement in HbA1c being encouraged
- hypoglycaemia and the treatment options of hypoglycaemia
- hyperglycaemia - how to check for ketones and what to do if unwell
- the need to check that medications are suitable for use in pregnancy
- their baseline retinal (eye) and nephropathy (kidney) results
- the advantages of healthy eating and taking folic acid supplements in an appropriate dose
- stop smoking advice
- cut down or cut out alcohol
- the need to be a healthy weight for your height.
Diabetes and contraception
Information on pregnancy and contraception should be given to all women with diabetes of childbearing age. There are no contraceptive methods that are specifically contraindicated in women with diabetes. Methods with proven high degrees of effectiveness are to be preferred.
Preconception care
Women planning a pregnancy should have a medical, dietetic, educational, drug, obstetric and gynaecological history taken. If the woman is taking any medication that is not recommended in pregnancy – eg ACE inhibitors, diuretics or beta-blockers – steps should be taken to remedy this before conception.
Diabetic complications should be assessed and treated if indicated. A baseline retinal examination and assessment of albuminuria (protein in urine) should be performed pre conception. Diabetic retinopathy, if present, can accelerate during pregnancy. All women with diabetes should be made aware of the requirement to have regular retinal examinations during pregnancy. Untreated cardiovascular disease is associated with a high mortality, and should be excluded.
The woman should have access to members of the multidisciplinary team appropriate to her needs: diabetologist, obstetrician, psychologist, specialist diabetes dietitians, specialist diabetes nurses and special diabetes midwives. The woman with diabetes (and partner) should be included as members of the team, be involved in decisions about their care and be offered the opportunity to make choices by provision of appropriate and sufficient information.
Blood glucose control should be optimised to prevent congenital malformations. Any improvement in HbA1c towards normal (ie less than six per cent) should be encouraged and if possible HbA1c should be less than seven per cent taking hypoglycaemic risk into account. Women with HbA1c above 10% should be advised to avoid pregnancy.
Goals should be jointly set with the woman for self-monitored glucose, having established that the woman can use her blood glucose meter to produce results that are +/-0.5 mmol/l when compared to a reference technique. Such quality assurance methods should be available through the hospital laboratory.
Diabetes UK realises that in addition each blood glucose monitoring system will vary by at least 10 per cent from a reference value. Individual meters will also vary from the method mean. These figures must therefore be interpreted locally and individually.
All blood glucose meters in the UK use whole blood to measure blood glucose levels. Some meters give the result in terms of whole blood glucose, others in terms of plasma glucose, which can be 12 per cent higher. For women considering pregnancy, achieving tight blood glucose control is vital. Diabetes UK suggests that this group is aware of the range their blood glucose results will be in. They should contact their meter manufacturer to check which type of result their meter gives.
- Before meals capillary whole blood glucose less than 5.6 mmol/l
capillary plasma glucose 4.4- 6.1 mmol/l
- Two hours after meals capillary whole blood glucose less than 7.8 mmol/l
capillary plasma glucose less than 8.6 mmol/l
The following should all be discussed in detail:
- diet, including folic acid supplements
- general health measures – particularly smoking and alcohol awareness, if pertinent
- the local programme of pregnancy care
- the effect of diabetes on pregnancy and of pregnancy on diabetes.
Counselling should be provided about the:
- risk of congenital malformations
- risk of obstetric complications
- effect of pregnancy on diabetic complications.
Hypoglycaemia
The Diabetes Control and Complications Trial showed that attempts to achieve tight glycaemic control in people with Type 1 diabetes increases the risk of severe hypoglycaemia. Severe, frequent or unexplained episodes of hypoglycaemia are due to a number of factors, including:
- hypoglycaemia unawareness
- insulin dose errors
- excessive alcohol intake.
There is no evidence that such hypoglycaemia is an independent risk to the developing human embryo. The mother, however, is clearly at risk, and the woman with diabetes contemplating pregnancy should have that explained to her. Means of prevention and treatment (GlucoGel and glucagon) should be provided to her and her family. It is essential to include family members and friends of the patient in the education.
After the initial visit, the woman should have access to phone or personal contact details for adjustment of insulin doses and other aspects of treatment. Once the woman has achieved stable glycaemic control (assessed by HbA1c) that is as good as she can achieve, she can then be counselled about the risk of malformations and spontaneous abortions. When she wishes, contraception can be discontinued. If conception does not occur within one year, the woman and her partner’s fertility should be assessed.
Reviewed April 2008