INTRODUCTION
Type 1 diabetes in pregnancy is a high-risk state for both the woman and her fetus. Rates of miscarriage, perinatal loss and major congenital malformation are increased at least two to threefold.
Type 2 diabetes is becoming more common in this age group and management of pregnancies in people with type 2 diabetes should follow the same intensive program of metabolic, obstetric and neonatal supervision.
AIM
An optimal outcome may be obtained in diabetic pregnancy if excellent glycaemic control is achieved before and during pregnancy. Good pre-pregnancy planning is thus essential. Effective contraception, allowing a planned pregnancy, is therefore important.
CONTRACEPTION
Contraception should be discussed on an individual basis with all women of childbearing age with diabetes. In general, the contraceptive advice for a diabetic woman should follow that in the general population but with the following caveats:
- The combined OCP should be avoided in women with complications or risk factors for vascular disease or over 35 years of age. Progesterone-only preparations may be suitable in these women.
- Women using the intrauterine contraceptive device should be advised that they might be at increased risk of infection.
In women with complications or vascular risk a value judgement must be made which balances the risk of complications with the need to avoid pregnancy. The levonorgestrel releasing intrauterine device (e.g. Mirena coil) may be particularly suited as it is as effective as sterilisation and produces low circulating hormone levels.
PRE-PREGNANCY CARE
Infants whose mothers receive dedicated multidisciplinary pre-pregnancy counselling show significantly fewer major congenital malformations (approximating to the rate in non diabetic women) compared to infants of non-attendees. They also have fewer immediate problems and are kept in special care for shorter periods.
All women with diabetes who are planning a pregnancy should be seen at a Multidisciplinary Clinic involving a endocrinologist, obstetrician, diabetes nurse specialist, and dietician. They should be seen with their partners if possible and provided with written information.
- Full medical, obstetric and gynaecological history.
- Check thyroid function.
- Review current medications.
- STOP: ACE Inhibitors, A2 Blockers, Statins, Review anti diabetic medication and likely stop all but metformin and insulin. Women on other agents may need replacement with insulin. Contact the local Diabetes Secondary Clinic immediately as soon as pregnancy confirmed.
- Prescribe Folic Acid 5mg daily for at least 1-month pre conception and for 1st trimester.
- Screen for complications.
- Advice on diet and weight reduction if relevant and strongly discourage smoking and refer to smoking cessation if appropriate
- Instruct partners to recognise and treat hypoglycaemia with glucagon if necessary.
- Support improvements in glycaemic control including access to structured education where appropriate and consideration of optimal monitoring and insulin delivery.
Women who are well controlled and free from complications should take 1 month’s folic acid prior to stopping contraception and keep a record of periods. Others should spend additional time optimising control and having complications investigated and treated.
Women should perform a pregnancy test if there is a lapse of 5 weeks between periods and contact their Diabetes Specialist Nurse if positive.
ANTE-NATAL CARE
Care should be hospital based, from a multi-disciplinary team. Women generally attend every 2 to 4 weeks until 30 weeks and then every 1-2 weeks thereafter.
POST NATAL CARE
- Insulin requirements fall dramatically after delivery- reduce dose to pre-conception dose.
- In breast feeding mothers reduce this further and encourage higher blood sugars than pregnancy.
- Discuss contraception after delivery (usually prior to hospital discharge).
- All women should be reviewed at the clinic in 6 weeks.