Planning a Pregnancy With Type 2 Diabetes

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Planning a Pregnancy With Type 2 Diabetes
February 1, 2007
Kurt Ullman
DOC News

© 2007 American Diabetes Association

Early assessment and teamwork enhance healthy outcome

Molly has type 2 diabetes and a new desireÛto start her family. The bad news is that studies show the offspring of women with diabetes are at increased risk for congenital anomalies and the women themselves are at increased risk of miscarriage. The good news is that her request for preconception care will help lessen the likelihood that these problems will occur.

"Before anything else, counsel the patient on the role of high glucose in causing problems early in the pregnancy, such as early fetal loss or malformation," says John Kitzmiller, MD, a diabetologist and consultant to the Maternal Fetal Medicine Program at the Santa Clara Medical Center in San Jose, Calif. "It is also important to stress to the woman that she should not become pregnant until excellent glycemic control has been established. This should include continuing or starting methods to prevent pregnancy."

EARLY ASSESSMENT IMPORTANT

The early steps in preconception care include assessments of patients' concerns regarding both type 2 diabetes and pregnancy. Start with a complete history and physical examination.

"A very important part of good care is the history," says Virgilio Licona, MD, associate medical director of Plan de Salud del Valle, Inc., in Fort Lupton, Colo., and a member of the board of directors of the American Academy of Family Physicians. "I am going to want to know the duration of the diabetes, what treatments and medications she is taking, and what her [glycated] hemoglobin A1C levels have been to understand her level of glucose control. The American Diabetes Association guidelines and the literature suggest <7%, but I would get as close to 6% as possible."

The clinician should review any current medications the patient may be taking. The safety of most oral antidiabetic agents in pregnancy has not been established, and it is controversial whether any should be used during the actual pregnancy. In most cases, this will require changing the medication regimen to insulin. However, the timing of this change is not yet well established.

"If they have concrete plans to become pregnant, I would consider starting them on insulin prior to conception," says Sagi Mathew, MD, assistant clinical professor of family medicine at Indiana University School of Medicine in Indianapolis. "This all comes back to the needs of the patient, and many folks do not like the idea of taking shots until absolutely necessary. I can understand the idea of getting them stabilized on oral medications as long as they have adequate A1C levels."

As with any woman who is pregnant or trying to become pregnant, clinicians should look at all of the medications the diabetic patient is taking and their safety during and after conception, making changes as needed.

A general screen for the major complications of diabetes should be completed. This includes a urine check for microalbuminurea, a dilated retinal examination by an ophthalmologist with experience in diabetic eye disease, an electrocardiogram to assess cardiac or peripheral vascular disease, and a neurological exam for signs of autonomic neuropathy.

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