Table 3 Summary of recommendations for preconception care among diabetic women

Members of the team may include an obstetrician, endocrinologist, family physician, diabetic educator and dietician

Complete a full medical and obstetric evaluation in the preconception period to assess risks

Evaluate and treat diabetic complications including:

Retinopathy (pre-existing retinopathy may progress rapidly in pregnancy and should be treated first before pregnancy)

Nephropathy (patients with pre-existing microalbuminuria are more likely to develop pre-eclampsia)

Neuropathy

Cardiovascular disease

Hypertension

Review all current medication use including complementary medication and change the following to a form of therapy which has less risk:

Angiotensin-Converting Enzyme (ACE) inhibitors

Angoitensin-II Receptor Blockers (ARB)

Statins

Diuretics

β-blockers

Assess level of metabolic control

Measure HbA1C monthly until control is achieved

HbA1C should remain below 7% (1% above normal value), lower if possible

Blood glucose management

Undertake blood glucose self monitoring with targets pre-meal of 4.4-6.1 mmol/l and 2 hour after meal of < 8.6 mmol/l

Maintain blood sugar within normal range without hypoglycaemia

Educate on hypoglycaemia awareness and management

Insulin should be prescribed to achieve target blood glucose levels

Use metformin as an adjunct or alternative

Counselling

Commence folate supplementation 5 mg daily pre-conceptually until 12 weeks gestation to prevent neural tube defects

Inform about risk of miscarriage, congenital malformation and perinatal mortality with poor metabolic control and unplanned pregnancy

Inform about how DM affects pregnancy and how pregnancy affects DM

Use effective contraception until target blood glucose control is achieved before conception

Encourage smoking cessation and reduction in alcohol intake

Encourage regular exercise and management of weight to achieve a BMI < 27

Encourage diet with high levels of complex carbohydrates, soluble fibre and vitamins and reduced levels of saturated fats

Contraindications to pregnancy

HbA1C >10%

Impaired renal function, creatinine > 0.2 mmol/L (increased risk of progression to dialysis during pregnancy)

Measure thyroid function in women with Type 1 Diabetes