Preconception Care for Women with Diabetes

Becoming a parent is a major commitment filled with challenges, rewards and difficult choices. Having diabetes should not keep any woman from enjoying pregnancy and expecting a good outcome but it can certainly make the challenges and choices more difficult.

By making plans and positive changes now, before pregnancy, an invaluable investment in personal health, as well as that of the future baby, will be made. The ability to cope with the stresses of pregnancy, labor, and delivery is also enhanced by preconception care (medical care before pregnancy).

Preconception care helps to ensure that the mother and fetus are not exposed to environmental factors that could be harmful during pregnancy. Many women do not know that they are pregnant until several weeks after conception. The early weeks of pregnancy are the most crucial for the baby as its vital organs are developing. Certain substances such as cigarettes, alcohol and medications may interfere both with the ability to become pregnant and with the normal growth and development of the baby after conception.

A preconceptional visit with a health care provider, preferably a physician who is experienced in caring for pregnant women with diabetes, will be extremely helpful. A preconception visit should involve review of your family and medical history, your current medications, diet, and lifestyle and your past pregnancy history (if applicable).

A fair amount of time will be spent reviewing the diabetes treatment plan, any complications which have developed since you were diagnosed with diabetes and how these may be affected by pregnancy. This is your chance to ask questions, seek advice or discuss any concerns. It is always helpful to bring your significant other so that his concerns may also be addressed.

General Issues

Family History

Some medical conditions are more prevalent in certain families and the risk of their transmission to the child may be higher. Some examples include hypertension (high blood pressure), epilepsy (seizures) and mental retardation.

Certain genetic disorders can also be inherited and, if they run in the family, genetic counseling may help to predict the chances of having an affected baby. Some of these diseases may be detected before or early in the course of pregnancy. It is sometimes possible to learn if the baby has a specific disease before birth. These disorders include:

• Thalassemia
• Tay-Sachs disease
• Sickle cell disease
• Hemophilia
• Muscular Dystrophy
• Cystic fibrosis
• Huntington chorea
• Fragile X (mental retardation)

Medical History

Besides diabetes, other medical conditions requiring special care during pregnancy such as high blood pressure, asthma or a history of deep venous thrombosis may by present. Pregnancy puts extra demands on the body and certain problems that are well controlled before pregnancy can become more difficult to manage after becoming pregnant.

Some medicines that can safely be taken in the absence of pregnancy may actually prevent pregnancy or be harmful to the growing baby after conception. Allergies, prior surgeries, or accidents will also be discussed.

Gynecological History

A good gynecological history includes questions about when menses started, their regularity, and discussion of any history of abnormal PAP smears [a screening test for cancer of the cervix] as well as a history of vaginal infections or sexually transmitted diseases [e.g. herpes, gonorrhea, chlamydia].

Some women who have Type 2 diabetes may be overweight and have very irregular menstrual cycles. These women may have a condition known as Polycystic Ovarian Syndrome (PCOS). PCOS makes if more difficult to become pregnant and medical help from an obstetrician/gynecologist or a reproductive endocrinologist may be needed to achieve pregnancy.

Past Pregnancies

A problem occurring in a past pregnancy does not necessarily mean that it will happen again, although special attention and care may be needed during the next pregnancy. A careful review of the obstetric history (prior pregnancies) is critical to understanding how the body may react to the stresses of pregnancy.

Many women are worried that if they had a previous miscarriage they will have trouble maintaining a healthy pregnancy. This is not necessarily true, as approximately one in five women have undetected miscarriages. Most of these women go on to have normal pregnancies the next time around.

There may be a correctable reason for a prior miscarriage such as having poor blood glucose control, being exposed to a potentially harmful medication like an oral diabetes medication, an anti-cholesterol drug or some blood-pressure drugs.

Medications

The physician will ask about any medications currently taken, including over the counter (bought without a prescription) products such as aspirin, antihistamines, diet pills etc. Some of these medicines can be harmful to the fetus and should be avoided around the time of conception. Other medications should absolutely be avoided during pregnancy. The doctor may opt to discontinue them or choose an alternative medicine that is safer.

Examples of medications to avoid:

• Accutane [Isotretinoin a Vitamin A derivative] - for acne. 
• ACE inhibitor [e.g. lisinopril, captopril] - for high blood pressure or to protect the kidneys. 
• Zocor, Lipitor - to lower high cholesterol. 
• Coumadin - a blood thinner.

Environmental Exposures

Some substances found in the environment, or in the work place, may make it more difficult to become pregnant, increase the risk for miscarriage, or contribute to other problems during pregnancy. If there are "toxic" substances (chemicals, radiation, radioactive substances, toxic fumes) in the work environment take extra care to avoid them. However, the effects of most chemicals in our environment are unknown.

Women planning a pregnancy who are exposed to radiation in the work place should ask for monthly readings that show radiation exposure. The amount of radiation in a chest X-ray is not sufficient to harm a pregnancy but radiation used to treat diseases such as cancer is usually at much higher doses and may be harmful. Ask the doctor or a genetic counselor about this risk before getting pregnant!

Infections

Infections may be harmful to both the mother and the baby and in some cases may cause serious birth defects. Some may be prevented with vaccinations before pregnancy. Even if immunizations were received as a child, it may be necessary to repeat some of them. Blood tests can check for immunity to some diseases. A period of three months between most immunizations and conception should elapse to ensure safety.

• Immunizations (needed based upon risk factors):
• Tetanus-diphtheria booster [every 10 years]
• Measles, mumps, rubella [once if not immune]
• Varicella [chicken pox]
• Hepatitis B vaccine*
• Influenza vaccine*
• Pneumococcal vaccine*

Other infections that may be harmful to pregnancy include those transmitted by sexual contact, sexually transmitted diseases [STDs]. These can affect the ability to become pregnant or harm the baby after conception. Some common STDs are chlamydia, gonorrhea [GC], genital herpes [HSV], and human immunodeficiency virus [HIV].

Substance Use

Using illegal drugs, drinking alcohol, or smoking are addictive behaviors and can harm both the mother and the fetus. If a baby is exposed to these substances in the first few weeks of pregnancy, (even before a positive pregnancy test) they can cause damage that can last a lifetime, or result in miscarriage.

Smokers should seriously consider quitting before conception for the sake of their own health and that of the unborn child. The same is true for drinkers and abusers of other drugs. Alcohol can be devastating to the fetus, as seen in fetal alcohol syndrome, and the acceptable level of exposure is not currently known. Ask your health care provider for help. It takes time and patience to quit a bad habit and professional help is very important.

Later Childbearing

Most women in their mid 30s are able to have normal healthy pregnancies. As a woman ages however, her risk for certain medical and obstetric problems may increase such as hypertension, multiple gestations or increased risk for having a cesarean delivery.

Another concern that many older women have is the increased risk of having a baby with a birth defect. The chances of having some birth defects do increase with age and women 35 or older are usually offered testing for genetic disorders early in pregnancy.

What Should My Blood Sugar Values Be?

When planning a pregnancy it is best to optimize blood sugars as much as possible before attempting conception.

Goals for blood glucose control before and during pregnancy:

What should I know about my diabetes before I become pregnant?

1. What is my Hemoglobin A1c level? A test which measures how good the blood sugar control has been for the past 6 to 8 weeks. Ideally it should be < 6% before conception.
2. Do I have diabetic retinopathy [disease in the back of my eyes in the retina]?
3. Do I have neuropathy [disease of my nerves]?
4. Do I have gastropathy [problems with slowing down of my gastrointestinal tract]? This can be a problem in the first trimester when women are sometimes prone to nausea and vomiting.
5. Is my thyroid function normal? 10-20% of women may have borderline thyroid disease, which may impair fertility, and if untreated during pregnancy may lead to developmental delay in the baby.
6. Am I on any medications for my diabetes that could be harmful to my baby if I become pregnant?

Types of Insulin

Different types of insulin vary by how quickly they start to work and by how long they last. Ultra fast-acting insulin (Humalog ® or Novolog ®) should be taken immediately before mealtime and begins working immediately. It does not last as long as Regular insulin which is also fast-acting but should be taken about 30 minutes prior to a meal. NPH, Lente and Ultralente all have a slower peak of onset and a longer duration of action. Different types of insulin are often combined in order to get the benefits of rapid action and long-lasting effects.

Most insulin pumps now use Regular, Novolog® or Humalog® insulin. Certain patients may benefit from insulin pump therapy in order to optimize blood sugar control before pregnancy. Click here for more information on types of insulin.

Nutrition and Pregnancy

Before becoming pregnant, it is important to eat a balanced controlled diet so that the mother and baby can have a healthy start with the needed nutrients. A balanced diet is a basic part of good health at all times but especially just prior to and during pregnancy.

The foods eaten become the main source of nutrients for the baby. As the baby develops and places new demands on the mother's body, more nutrients and calories will be needed.

There may be unique dietary needs that should be met before becoming pregnant. It is advisable to consult with the physician, diabetes educator or dietitian before conception to discuss special needs (see below). Changes in the current diet and meal plan may be needed. Click here for more information on nutrition and diabetes.

1. Are you eating a well balanced diet?
2. Are you trying to lose weight?
3. Are you a vegetarian?
4. Do you have an eating disorder?
5. Have you been told you have anemia?

Folic acid may help prevent certain birth defects (neural tube defects, spina bifida, cleft lips and palates). The United States Public Health Service recommends that all reproductive age women take at least 0.4 mg of folic acid daily to reduce the risk of these problems. Certain foods such as leafy, dark green vegetables, citrus fruits, dried beans and bread have folic acid.

By taking one prenatal vitamin a day, most women will get sufficient folic acid. Women who have given birth in the past to a baby with a neural tube defect, should take one prenatal vitamin and an extra 4 mg of folic acid per day for up to 1 month before pregnancy and for 3 months after conception. This will substantially decrease the chance of it ever happening again. Some physicians recommend that all pregnant women with diabetes contemplating pregnancy should take the extra folic acid preconception.