Medical care and pregnancy - Diabetes Preconception

Patients with preexisting diabetes should be euglycemic during the critical period of organogenesis. Congenital abnormalities are increased if first trimester control is poor. Preconception and early pregnancy control of diabetes reduces the incidence of congenital abnormalities to the same rate seen in the general population.39 Patient education includes discussion of contraception, general issues of care during pregnancy, and the need for ongoing follow-up. Therapeutic alliances with diabetic women of childbearing age must start before conception. Preconception care of type I diabetic women results in earlier prenatal care, lower glycosylated hemoglobin levels, fewer antepartum hospitalizations and fewer hospital days, and decreased intensity and length of stay for newborns. A multicenter prospective study of women who received preconception care versus women who received only antepartum care showed cost savings of more than $(US)30,000 per patient.40 A study in the UK found that women attending a preconception clinic were more likely to be in a stable relationship and to be non-smokers. Preconception care improved outcomes and a 50% decrease in neonatal intensive care unit admission rate.41 For adolescent diabetics, developmental changes and parental control issues may clash; unprepared pregnancy is an increased risk for these young women. Physicians must educate both parents and patients about the risks of pregnancy. In this situation, one therapeutic goal may be the establishment of a negotiated agreement between adolescent and parents where graduated autonomy and responsibility for self-care are emphasized. Type II diabetic patients may not be identified in the medical care system before or during early pregnancy. Patients with gestational diabetes should demonstrate normalized glucose status at the six-week postpartum check-up. The identification of unrecognized type II diabetes is enhanced by careful followup of all women with a history of gestational diabetes. Screening for diabetes should be considered prior to conception in women with increased risk factors of obesity, unexplained fetal death, strong family history, and a history of macrosomic babies, especially in ethnic groups with a high prevalence of diabetes. This identification allows improved preconception and antepartum management critical to avoid increases in perinatal morality (4.1–6.6%) and congenital malformations (3.4–6.7%) over the general population.

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