Although a goal of <48 mmol/mol is desirable, there appears to be a linear relationship between HbA1c level and adverse perinatal outcomes suggesting that any reduction in prepregnancy HbA1c while avoiding excessive hypoglycaemia is likely to be beneficial.
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Women with type 1 diabetes (T1DM) or type 2 diabetes (T2DM) planning a pregnancy should aim for an HbA1c as low as possible without excessive hypoglycaemia.
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Women should be offered advice on weight management prior to pregnancy in line with guidance from the Royal College of Obstetricians and Gynaecologists and national programmes (for example, A Healthier Future: type 2 diabetes prevention, early detection and intervention framework). This is likely to be of particular benefit to women with type 2 diabetes or prior GDM when planning pregnancy
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Advise women that HbA1c <48 mmol/mol can minimise risk of perinatal mortality and morbidity but should not be used a strict threshold for access to assisted conception services. An individualised approach should be used.
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Other risk factors such as body mass index (BMI), smoking, hypertension and level of diabetic retinopathy should be taken into account when individualised HbA1c targets are being considered.
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Pregnancy should be avoided if HbA1c >86 mmol/mol.
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Referral of women with T2DM who are planning a pregnancy to secondary care for optimisation of their diabetes should be considered, including the possibility of the use of CGM if preconception glycaemic targets are not being met. If not already being used, this is an opportunity to further consider medication to lower cardiovascular risk.
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Diabetes and obstetric teams should take opportunities to engage with all women with pre-existing diabetes early in pregnancy irrespective of their attendance at prepregnancy counselling clinics. This should be as soon as possible after a positive pregnancy test, ie before the formal ‘booking’ appointment takes place.
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All medications should be reviewed prepregnancy for suitability in pregnancy and women should be advised to take 5 mg folic acid for at least 3 months prior to conception and throughout the first trimester.