P O S I T I O N S T A T E M E N T

Preconception Care of Women With

DIABETES AND CONGENITAL provider who is familiar with contracep- The model of diabetes preconception
MALFORMATIONS — Major con- tive prescribing practices, using the same and early pregnancy health care described
genital malformations remain the leading guidelines that apply to women without in this document is interactive. It includes
cause of mortality and serious morbidity diabetes. Because unexpected failure of four main elements: 1) patient education
in infants of mothers with type 1 or type 2 contraception can lead to such serious about the interaction of diabetes, preg-
diabetes. Several studies have established complications for the infant of a woman nancy, and family planning; 2) education
an association between elevated maternal with diabetes, the focus should be on in diabetes self-management skills; 3)
glucose or glycohemoglobin levels during methods with proven high degrees of ef- physician-directed medical care and lab-
embryogenesis and high rates of sponta- fectiveness. oratory testing; and 4) counseling by a
neous abortions and major malforma- mental health professional when indi-
tions in newborns. Clinical trials of cated to reduce stress and improve adher-
PRECONCEPTION CARE
preconception care to achieve stringent ence to the diabetes treatment plan. All
PROGRAM — To prevent excess
blood glucose control in the preconcep- four elements are important for patients
spontaneous abortions and congenital
tion period and during the first trimester to achieve the level of sustained glycemic
malformations in infants of diabetic
of pregnancy have demonstrated striking control necessary to prevent excess con-
mothers, diabetes care and education
reductions in rates of malformations com- genital malformations and spontaneous
must begin before conception. This is best
pared with infants of diabetic women who abortions.
accomplished by a multidisciplinary team
did not participate in preconception care.
that includes a diabetologist, internist, or
(For further discussion, see the American
family practice physician skilled in diabe- SPECIFIC GOALS OF
Diabetes Association technical review on
tes management; an obstetrician familiar TREATMENT — The desired out-
this subject [1].) Unfortunately, unplanned
with the management of high-risk preg- come of the preconception phase of care
pregnancies occur in about two-thirds of
nancies; diabetes educators, including a is to lower A1C test values to a level asso-
women with diabetes, precluding ade-
nurse, dietitian, and social worker; and ciated with optimal development during
quate preconception care and leading to a
other specialists, as deemed necessary. organogenesis. Epidemiological studies
persistent excess of malformations in
Ultimately, the woman with diabetes indicate that A1C test values up to 1%
their infants. To minimize the occurrence
must become the most active member of above normal are associated with rates of
of these devastating malformations, stan-
the team, calling upon the other members congenital malformations and spontane-
dard care for all women with diabetes
for specific guidance and expertise to help ous abortions that are not greater than
who have child-bearing potential should
her achieve her goal of a healthy preg- rates in nondiabetic pregnancies. How-
include 1) counseling about the risk of
nancy and newborn. ever, rates of each complication continue
malformations associated with un-
The primary purpose of these guide- to decrease with even lower A1C test lev-
planned pregnancies and poor metabolic
lines is to define the elements of a precon- els. Thus, the general goal for glycemic
control and 2) use of effective contracep-
ception care program. This program management in the preconception period
tion at all times unless the patient is in
should be sufficient to minimize congen- and during the first trimester should be to
good metabolic control and actively try-
ital malformations and thereby substan- obtain the lowest A1C test level possible
ing to conceive.
tially reduce health care costs. This without undue risk of hypoglycemia in
document describes the recommended the mother. In particular, levels that are
DIABETES AND intensive outpatient treatment plan, ⬍1% above the normal range are desir-
CONTRACEPTION — There are no based on risk assessment, health promo- able. Practical self-management skills es-
contraceptive methods that are specifi- tion, and intervention, and outlines effec- sential for attaining this level of glycemic
cally contraindicated in women with dia- tive team work strategies to implement control in preparation for pregnancy are
betes. Thus, the selection of a method for the plan before and during early preg- the same skills required for any insulin-
an individual patient should be made by a nancy. based self-management program:
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
● Use of an appropriate meal plan
The recommendations in this article are based on the evidence reviewed in the following publication: ● Self-monitoring of blood glucose
Preconception care of diabetes, congenital malformations, and spontaneous abortions (Technical Review).
Diabetes Care 19:514 –541, 1996. (SMBG)
Approved 1995. Most recent review/revision, 2000. ● Self-administration of insulin and self-
Abbreviations: CAD, coronary artery disease; SMBG, self-monitoring of blood glucose. adjustment of insulin doses

DIABETES CARE, VOLUME 26, SUPPLEMENT 1, JANUARY 2003 S91

● Treatment of hypoglycemia (patient ogist or other eye specialist knowledge- relationship between preconception
and family members) able about diabetic eye disease care and prevention of malformations.
● Incorporation of physical activity ● Cardiovascular exam for evidence of ● Selection of antihyperglycemic ther-
● Development of techniques to reduce cardiac or peripheral vascular disease. apy. Insulin should be prescribed for
stress and cope with denial If found, patients should have screen- type 1 and type 2 diabetic patients, be-
ing tests for CAD before attempting cause the safety of currently available
INITIAL VISIT pregnancy to assure they can tolerate oral antidiabetic agents is not assured
the increased cardiac demands. during early pregnancy.
Medical and obstetrical history ● Neurological exam, including examina- ● Establishment of plan to achieve low-
A complete history is imperative before tion for signs of autonomic neuropathy risk glycemia. The main tool for assess-
planning for pregnancy. This should in- ing the risk of malformations in the
clude, but not be limited to, questioning Laboratory evaluation infant is the maternal A1C test result.
for the following: The evaluation should focus on assess- Two steps are recommended for
ment of metabolic control and detection achieving a low-risk concentration
● Duration and type of diabetes (type 1 or of diabetic complications that may affect (⬍1% above the normal range, lower if
type 2) or be affected by pregnancy: possible).
● Acute complications, including history
of infections, ketoacidosis, and hypo- ● A1C test 1. Set goals for self-monitored glucose.
glycemia ● Serum creatinine and urinary excretion Successful preconception care pro-
● Chronic complications, including reti- of total protein and/or albumin (albu- grams have used the following pre-
nopathy, nephropathy, hypertension, min-to-creatinine ratio or 24-h excre- and postprandial goals:
atherosclerotic vascular disease, and tion rate). Patients with protein
autonomic and peripheral neuropathy excretion ⬎190 mg/24 h have been Before meals:
● Diabetes management, including insu- shown to be at increased risk for hyper- capillary whole-blood glucose
lin regimen, prior or current use of oral tensive disorders during pregnancy. 70 –100 mg/dl (3.9 –5.6 mmol/l),
glucose-lowering agents, SMBG regi- Patients with protein excretion ⬎400 or
mens and results, medical nutrition mg/24 h also are at risk for intrauterine capillary plasma glucose
therapy, and physical activity growth retardation during later preg- 80 –110 mg/dl (4.4 – 6.1 mmol/l)
● Concomitant medical conditions and nancy. No specific treatments are indi-
medications, thyroid disease in partic- cated, but patients should be counseled 2 h after meals:
ular for patients with type 1 diabetes about these risks. Since patients should capillary whole-blood glucose
● Menstrual/pregnancy history; contra- not take angiotensin-converting en- ⬍140 mg/dl (⬍7.8 mmol/l) at 2 h,
ceptive use zyme (ACE) inhibitors during preg- or
● Support system, including family and nancy, these assessments should be capillary plasma glucose
work environment carried out after cessation of these ⬍155 mg/dl (⬍8.6 mmol/l) at 2 h.
drugs.
An initial individual educational evalua- ● Measurement of serum thyroid stimu- There are no data to suggest that postmeal
tion session with a diabetes educator, a lating hormone and/or free thyroxine glucose monitoring has a specific role in
registered dietitian, and, when needed, a level in women with type 1 diabetes be- preconception diabetes care beyond what
psychosocial expert is valuable. Members cause of the 5–10% coincidence of hy- is needed to achieve the target for A1C.
of the patient’s immediate family should per- or hypothyroidism Thus, a focus on preprandial monitoring
participate in this session. In conjunction ● Other tests as indicated by physical is recommended initially to assist patients
with the primary physician, these profes- exam or history in self-selection of insulin doses.
sionals will review the patient’s current
management plan and develop a compre- Management plan 2. Implement the treatment plan and
hensive treatment plan. The initial management plan should in- monitor A1C levels at 1- to 2-month
clude the following components: intervals until stable. Then, counsel
Physical examination patient about the risk associated with
Diabetic retinopathy, nephropathy, auto- ● Counseling about the risk and preven- her level. If she does not achieve a low-
nomic neuropathy (especially gastropare- tion of congenital anomalies; fetal and risk level of ⬍1% above the upper
sis), and coronary artery disease (CAD) neonatal complications of maternal di- limit of normal, consider modification
can be affected by or can affect the out- abetes; effects of pregnancy on mater- of the treatment regimen, including
come of pregnancy. Thus, physical exam- nal diabetic complications; risks of addition of postprandial glucose mon-
ination should give particular attention to obstetrical complications that occur itoring. It is important to note that gly-
the following: with increased frequency in diabetic cemic goals may need to be modified
pregnancies (especially hypertensive according to the patient’s recognition
● Blood pressure measurement, includ- disorders); the need for effective con- of hypoglycemia and risk of severe
ing testing for orthostatic changes traception until glycemia is well- neuroglycopenia. Outpatient manage-
● Dilated retinal exam by an ophthalmol- controlled; and the cost-benefit ment is the appropriate forum for

S92 DIABETES CARE, VOLUME 26, SUPPLEMENT 1, JANUARY 2003

achieving preconception glycemic with standard indications for that ther- mentioned above, the presence of pro-
goals. apy. Thus, a baseline dilated comprehen- teinuria in excess of 190 mg/24 h before
sive eye examination is necessary before or during early pregnancy is associated
CONTINUING CARE — After the conception, and women with pre-existing with a tripling of the risk of hypertensive
initial visit, patients should be seen at 1- diabetes should be counseled on the risk disorders in the second half of pregnancy.
to 2-month intervals depending on their of development and/or progression of di- ACE inhibitors for treatment of mi-
mastery of the management program and abetic retinopathy. In settings in which a croalbuminuria should be discontinued
the presence or absence of coexisting retina specialist is unavailable, other ex- in women who are attempting to become
medical conditions. Frequent phone con- perienced examiners may be acceptable. pregnant.
tact for adjustment of insulin doses and Follow-up ophthalmological examina-
other aspects of the treatment regimen is tion should be anticipated during preg- Neuropathy
advised as well. Once the patient has nancy for all women with diabetes. The presence of autonomic neuropathy,
achieved stable glycemic control (as- particularly manifested by gastroparesis,
sessed by the A1C test) that is as good as Hypertension urinary retention, hypoglycemic un-
she can achieve, then she can be coun- Hypertension is a frequent concomitant awareness, or orthostatic hypotension,
seled about the risk of malformations and or complicating disorder of diabetes. Pa- may complicate the management of
spontaneous abortions. If the risk as well tients with type 1 diabetes frequently de- diabetes in pregnancy. These complica-
as the status of maternal diabetic compli- velop hypertension in association with tions should be identified, appropriately
cations and any coexisting medical condi- diabetic nephropathy, as manifested by evaluated, and treated before conception.
tions are acceptable, then contraception the presence of gross proteinuria. Patients Peripheral neuropathy, especially com-
can be discontinued. If conception does with type 2 diabetes more commonly partment syndromes such as carpal tun-
not occur within 1 year, the patient’s fer- have hypertension as a concomitant dis- nel syndrome, may be exacerbated by
tility should be assessed. ease. In addition, pregnancy-induced hy- pregnancy.
pertension is a potential problem for the
SPECIAL CONSIDERATIONS woman with diabetes, particularly when Cardiovascular disease
proteinuria in excess of 190 mg/day is Untreated CAD is associated with a high
Hypoglycemia present before conception or in early mortality rate during pregnancy. Evi-
It is clear from the Diabetes Control and pregnancy. Aggressive monitoring and dence of CAD should be sought according
Complications Trial that attempts to control of hypertension in the preconcep- to the American Diabetes Association
achieve normal glycemic control in pa- tion period is advised, if—for no other consensus statement on the diagnosis of
tients with type 1 diabetes increase the reason—to reduce the risk of worsening coronary heart disease (2). Successful
risk of severe hypoglycemia. The occur- diabetic nephropathy or the development pregnancies have been undertaken after
rence of severe, frequent, or unexplained of retinopathy or clinical atherosclerosis. coronary revascularization in women
episodes of hypoglycemia may be due to a ACE inhibitors, ␤-blockers, and diuretics with diabetes. Exercise tolerance should
number of factors, such as defective coun- should be avoided in women contemplat- be normal to maximize the probability
terregulation, hypoglycemia unaware- ing pregnancy. that the patient will tolerate the increased
ness, insulin dose errors, and excess cardiovascular demands of gestation.
alcohol intake. There is no solid evidence Nephropathy
that such hypoglycemia is an indepen- Baseline assessment of renal function by Early pregnancy management
dent risk to the developing human em- serum creatinine and some measure of At the earliest possible time after concep-
bryo. There is, however, clear risk to the urinary protein excretion (urine albumin- tion, pregnancy should be confirmed by
mother. Thus, it is imperative that this to-creatinine ratio or 24-h albumin excre- laboratory assessment (urinary or serum
risk be explained to the woman with dia- tion) should be undertaken before B-hCG). The woman should be reevalu-
betes contemplating pregnancy and that conception and followed at regular inter- ated by the health care team to reinforce
means of prevention or ultimate treat- vals because of the potential impact of goals and methods of management,
ment be provided to her and her family. pregnancy on proteinuria and the impact which should remain essentially stable
Inclusion of family members and close as- of renal insufficiency on fetal growth and throughout the first trimester.
sociates of the patient in both education development. Women with incipient re-
and management is imperative. Frequent nal failure (serum creatinine ⬎3 mg/dl or
contact with the patient for readjustment creatinine clearance ⬍50 ml/min) should References
of the treatment program is integral to the be counseled that pregnancy may induce 1. Kitzmiller JL, Buchanan TA, Kjos S, Combs
prevention of severe hypoglycemia. a permanent worsening of renal function CA, Ratner R: Preconception care of diabe-
in ⬎40% of patients. In subjects with less tes, congenital malformations, and sponta-
neous abortions (Technical Review).
Retinopathy severe nephropathy, renal function may Diabetes Care 19:514 –541, 1996
Diabetic retinopathy may accelerate dur- worsen transiently during pregnancy, but 2. American Diabetes Association: Consensus
ing pregnancy. The risk can be reduced permanent worsening occurs at a rate no development conference on the diagnosis
by gradual attainment of good metabolic different from the background. There- of coronary heart disease in people with
control before conception and by precon- fore, it should not serve as a contraindi- diabetes (Consensus Statement). Diabetes
ceptual laser photocoagulation in women cation to conception and pregnancy. As Care 21:1551–1559, 1998

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