Pregnancy and contraception in Women with Diabetes

Avoid destroying the normal experience of pregnancy through overzealous application of medical technology
But good blood glucose control from before conception is critically important

Contraception

Enquire :
		as to need for contraceptive advice if pregnancy not intended
Advice :
		on barrier methods, or low-dose oral contraceptives if low arterial risk ( see above )
		not to discontinue contraception until adequate metabolic control achieved

Pre-pregnancy management

Enquire as part of Annual Review as to pregnancy intentions :

emphasize repeatedly the need for pregnancy planning

educate about diabetic pregnancy, including risks to fetus

Start folic acid 400 痢 daily

Stop statins

Optimize blood glucose control :

targets:	pre-prandial 3.5-5.5 mmol/l ( 65-100 mg/dl )
	post-prandial 5.0-8.0 mmol/l ( 90-145 mg/dl )

recommend highly purified human / pork insulin preparations

Assess and normalize blood pressure :

replace ACE inhibitors with methyldopa / nifedipine / labetolol

Assess and normalize blood pressure :

Assess retina and treat as indicated

Review education and repeat as needed

Urge to stop smoking

Pregnancy care

Organize joint obstetric care in a designated centre
		include a diabetologist, a diabetes teaching nurse, a dietician, an obstetrician, a midwife, and a neonatologist
Provide support for continuing good blood glucose control :
		frequent review ( every 1-2 weeks )
		appropriate educational support
		regular self-monitoring of blood glucose with reliable system
		target blood glucose as close to normal as possible, while avoiding hypoglycaemia
	fasting blood glucose :3.5-5.5 mmol/l ( 65-100 mg/dl ) post-prandial blood glucose :5.0-8.0 mmol/l ( 90-145 mg/dl ) glycated haemoglobin close to the upper limit of normal
		multiple insulin injection regimen with highly purified human / pork insulin
		food intake
	adequate to maintain maternal and fetal nutrition frequent small meals may facilitate improved blood glucose control
Examine eyes each trimester
Provide regular obstetric care :
		ultrasound examination early and repeated for dates and fetal malformation
		fetal monitoring in later stages
		frequent antenatal review
Provide a normal safe delivery :
		deliver at term unless obstetric or diabetes risk
		deliver vaginally unless obstetric or diabetes risk
		provide optimal neonatal care :
	access to specialized neonatal intensive care neonatologists warned of expected delivery
		good blood glucose control during / after labour
		IV infusion of glucose and insulin with frequent blood glucose measurement
		rapid return to pre-pregnancy insulin requirements at delivery
Provide easily accessible advice for post-pregnancy blood glucose control
Caution about hypoglycaemia risk if breast feeding; may need further insulin dose reduction

Management of Diabetes during Surgery