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 and avoiding pregnancy until they have good HbA1c control
- the need for regular self-monitoring and monthly HbA1c measurements prior to pregnancy with any improvement in HbA1c being encouraged
- the fact that being pregnant with diabetes will require more frequent monitoring and interventions, with frequent contacts with healthcare professionals
- the increased risk of pregnancy complications associated with diabetes
- hypoglycaemia and the treatment options of hypoglycaemia
- hyperglycaemia – how to check for ketones at home (for those with Type 1 diabetes) and what to do if unwell (for every woman with diabetes)
- the need to check that current 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
- smoking cessation advice
- cutting down or cutting out alcohol
- the importance of losing excess weight prior to conception.
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.
Women planning a pregnancy should have a medical, dietetic, educational, drug, obstetric and gynaecological history taken. Metformin may be used together with, or in place of, insulin during preconception and throughout pregnancy. All other blood glucose lowering medications should be stopped before pregnancy and replaced with insulin. If the woman is taking any other medication that is not recommended in pregnancy – eg ACE inhibitors, statins, diuretics or beta-blockers – steps should be taken to remedy this before conception, or as soon as pregnancy is confirmed.
Diabetic complications should be assessed and treated if indicated. A baseline retinal examination and assessment of microalbuminuria (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 her 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 the target (ie less than 48mmol/mol) should be encouraged taking into account the risk of hypoglycaemia. Women with HbA1c above 86mmol/mol should be strongly advised to avoid pregnancy because of the associated risks.
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 give a glucose result that is a plasma value. Plasma values are approximately 11 to 12 per cent higher than whole blood values.
Blood glucose targets* during preconception should be:
- a fasting blood glucose level of 5-7 mmol/l and
- a blood glucose level of 4-7 mmol/l before meals at other times of the day.
Those who choose to test after meals should aim for blood glucose levels of 5-9 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.
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, as appropriate. 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 other contact details for adjustment of insulin doses and other aspects of treatment. Once the woman has achieved stable glycaemic control (assessed by monthly 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.
*This recommendation is from the new NICE guidelines for the management of diabetes in pregnancy. NICE recommmends that women with diabetes who are planning for pregnancy should aim for the same blood glucose levels recommended for all adults with Type 1 diabetes. These target ranges are taken from the updated NICE guidelines for Type 1 diabetes which is due for publication in August 2015.