Pregnancy planning and management in young women with diabetes
Dear Colleagues,
This bulletin discusses the importance of pregnancy planning and maintaining optimal blood glucose control before and during pregnancy to achieve the ultimate outcome that every parent hopes for, a healthy baby.
For a young woman with diabetes, pregnancy can be a challenging time that requires adequate planning and more intense diabetes self-management efforts.
The following information is based on an ISPAD conference presentation 2018 by Prof Ethel Codner from Chile, ISPAD (2018) and ADA guidelines (2019) and lists some educational resources specific to young women with diabetes. A section on Diabetes in Pregnancy is also available in the Pocketbook for the Management of Diabetes in Childhood and Adolescence in under-resourced countries (IDF&LFAC, 2017 page 52 English version).
Pre-conception Care
It is crucial that preconception counseling should occur at the onset of puberty and/or 3-6 months prior to a planned pregnancy. According to the 2018 ISPAD guidelines (Chapter 17), this should include:
Awareness of the importance of a planned pregnancy ((explain that blood glucose levels (BGLs) are the same in the baby as the mother, discuss risk of high and low BGLs))
Advice, where applicable, on methods of avoiding pregnancy (see Table 1) and sexually transmitted infections (STIs) for all adolescents. Advice should be adapted to different countries, cultures and religions and delivered in a culturally sensitive manner
Prevention of hypoglycaemia (including during and after intercourse)
Advice on genital hygiene, vulvovaginal candidiasis and menstrual disorders
Discussion with the young person and partner regarding the small genetic risks of diabetes to their offspring (3.6-8.5% if father has type 1 , 1.3-3.7% if mother has type 1) (Mayer-Davis et al, 2018)
Aim for HbA1c levels of <6.5% (<48mmol/mol) as recommended by ADA (2019) and NICE (2015) guidelines
Strongly advise women with diabetes whose HbA1c level is above 10% (86 mmol/mol) not to get pregnant because of the associated risks (NICE, 2015)
Table 1: WHO Medical Eligibility Criteria for Contraceptive use in Patients with Diabetes
Blood glucose levels are the same in the foetus as in the mother at a very early stage when the young woman might be unaware that she is pregnant. At 4 weeks the baby is the size of a pea but already has a head with its brain forming, eyes, bumps that will be arms and legs, and a heart is pumping blood. Evidence shows that the higher the BGLs at conception and the first weeks of pregnancy, the higher are the risks of congenital malformation; perinatal mortality and serious adverse outcomes (Jensen et al, 2009; see Table 2).
Table 2: Adverse outcomes of pregnancies in women with type 1 diabetes
Contrary to some beliefs, high BGLs will not prevent the woman from conceiving. A study by Codner (2011) showed that girls ovulate and can fall pregnant with HbA1c levels as high as 10-12% (86-108mmol/mol) (see Figure 1).
Screen for retinopathy and nephropathy (first trimester) as these can be exellerated by pregnancy
Once or twice monthly medical follow up to monitor BGL control. Ideally cooperative management by an obstetrician and physician with special experience in diabetes and pregnancy.
Increase frequency of glucose testing (> 4 times if strips availablle)
Tighted target blood glucose levels (ADA 2019 guidelines) to:
Fasting and pre-meal <95 mg/dl (<5.3 mmol/L)
1-hr post prandial <140mg/dl (7.8 mmol/L) or
2-hr post prandial <120mg/dl (6.7 mmol/mol)
HbA1c target 6.0% (42mmol/mol) but may be relaxed to < 7% (53mmol/mol) to prevent hypoglycaemia (ADA, 2019)
Understanding the importance of good control throughout pregnancy to avoid foetal macrosomia (large baby), hypoglycaemia and ketoacidosis (increased risk of perinatal mortality).
It is very important that, where available, the delivery of the baby should be in a hospital that is able to provide expert maternal and foetal care. The newborn needs to be monitored closely for hypoglycaemia during the first few days after delivery.
Despite the challenges of managing BGLs during a time of physical and hormonal changes, we have received many reports and pictures of young women who have delivered healthy babies. Undoubtedly, an optimal pregnancy outcome relies on the support of a dedicated health care team that provides education, encouragement and expert clinical care to the young woman and her family.
We would love to receive your stories and pictures of pregnancy outcomes in LFAC supported young women, with permission.
Jensen DM, Korsholm L, Ovesen P, et al. Periconceptional A1C and risk of serious adverse pregnancy outcome in 933 women with type 1 diabetes. Diabetes Care 2009; 32: 1046-8
Schneider MB, Umpierrez GE, Ramsey RD, Mabie MC, Bennett KA. Pregnancy (2003) Complicated by Diabetic Ketoacidosis. Maternal and fetal outcomes. Diabetes Care Mar; 26(3): 958-959. Available from https://care.diabetesjournals.org/content/26/3/958
