Prepregnancy counselling

Diabetic women have near-normal fertility unless they have persistently high blood glucose levels, or have renal impairment. Even then, conception can occur. Teenage girls should know that it is important to plan pregnancy when they do decide to have a family and that contraception should be used, if necessary, until then.

Congenital malformations used to be two to three times as common in diabetic pregnancies as in the general population. Then it was found that malformations were most likely in women with hyperglycaemia in the first 8 weeks of pregnancy, (for example women whose haemoglobin A1c was over 10 per cent). Maintenance of strict normoglycaemia reduces the likelihood of congenital malformation to near that of the non-diabetic population.

As few women know when they conceive, the usual strategy is to maintain contraception, adjust treatment to achieve normoglycaemia, and then stop the contraception. It is easier to use barrier methods here, as menstrual cycles may be erratic after stopping oral contraception and it is helpful to be able to date the last menstrual period if pregnancy occurs. Normoglycaemia is continued. It is hard work and means four times daily finger-prick glucose estimations, sometimes for years if conception is slow to occur.

Few women of child-bearing age will be taking oral hypoglycaemic drugs. This is more common in women of Asian and Afro-Caribbean origin. There is concern that these drugs may be associated with fetal malformation. Stop them and transfer the patient to insulin treatment.

The woman's fitness to withstand pregnancy and her prospects of healthy survival during the years in which her child needs her most must also be considered. Nowadays, women with severe tissue damage are surviving pregnancy with normal infants, but this requires nine months very intensive effort, and the harsh reality is that they may become severely disabled or die before their child grows up. Retinopathy can worsen in pregnancy and fundoscopy should be part of the pre-pregnancy screen as should assessment of renal function. Renal failure may also worsen considerably during pregnancy and such women should be managed jointly by obstetrician, renal physician, and diabetologist from pre-pregnancy onwards.

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