Pregnancy and contraception in Women with Type 2 Diabetes

Women of child-bearing age with Type 2 diabetes are almost invariably overweight and have a high relative risk of arterial damage / thrombotic problems
Women who develop diabetes in pregnancy and revert to normal after delivery ( gestational diabetes ) are at high risk of developing Type 2 diabetes in later life

Contraception / pre-pregnancy management

Enquire :

as to need for contraceptive advice if pregnancy not intended

as part of Annual Review as to pregnancy intentions

Advice :

on barrier methods, or low-dose oral contraceptives if low arterial risk ( see above )

not to discontinue contraception until adequate metabolic control achieved

repeatedly the need for pregnancy planning

on the intensity of diabetic pregnancy management, and the risks to the fetus

If pregnancy is intended :

start folic acid

stop oral glucose-lowering drugs ( consider insulin therapy )

stop statins

optimize blood glucose control :

self-monitoring 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 )

assess and normalize ( <130/80 mmHg ) blood pressure :

replace ACE-inhibitors with methyldopa / nifedipine / labetalol

assess retina and treat as indicated

review education and repeat as needed

urge to stop smoking

Diagnosis of diabetes in pregnancy

If venous plasma glucose >6.0 mmol/l ( ł110 mg/dl ) at any time :

perform 75 g oral glucose tolerance test

manage as diabetes :

if	fasting plasma glucose ł7.0 mmol/l ( >125 mg/dl )
or	2-h plasma glucose ł7.8 mmol/l ( ł140 mg/dl )

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

self-monitored blood glucose

fasting :	3.5-5.5 mmol/l ( 65-100 mg/dl )
pre-pradial :	5.0-7.5 mmol/l ( 90-135 mg/dl )

glycated haemoglobin close to the upper limit of normal

food intake

weight controlling but 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

cessation of insulin therapy at delivery if started during pregnancy ( and no suspicion of Type 1 diabetes )

If diabetes before pregnancy provide advice for post-pregnancy blood glucose control

If diabetes diagnosed in pregnancy :

confirm remission at post-natal follow-up

advise patient / family doctor of need for regular arterial risk factor review for rest of life

Evaluate quality of care

monitor outcomes of pregnancy of women with diabetes

compare outcomes with other diabetes services

review any need for improvements in pregnancy care

Management of Diabetes during Surgery