Counseling and Preconception Care Recommendations to Reduce Maternal and Fetal Risks of Preexisting Diabetes What Are the Risks of Diabetes in Pregnancy

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Women with diabetes and their families need a clear understanding of the risks of diabetes in pregnancy, as the women themselves must play the key role in preventing many of these complications. Diabetes education, both general and specific to pregnancy, is essential, as is a clear, straightforward discussion of risks and strategies to prevent complications.

Table 2 provides a checklist for some of the specific components of preconception counseling and care. Structuring preconception counseling is complex, both due to the complexity of the disease and due to the emotional impact that this information can have. Various complications are entangled with other complications [i.e., nephropathy with preeclampsia, and prematurity, diabetic ketoacidosis (DKA) with intrauterine fetal demise (IUFD), making counseling even more difficult].

Recommendation. All women with diabetes who are planning a pregnancy should be advised of the risks of diabetes and pregnancy and ways to minimize those risks.

Fertility: Will We Have Trouble Getting Pregnant?

Few data exist regarding the fertility of women with DM1. A Swedish population-based study examined the Standardized Fertility Ratio (ratio of observed to expected number of live births) as a proxy for fertility in which one would equal that of the general population (29). The ratio was 0.77 (95% CI 0.60-0.98) in women with DM1 and macrovascular and microvascular complications such as retinopa-thy, nephropathy, and neuropathy. This suggests some decrease in fertility, though more data is needed on the relative impact of DM1, hyperglycemia and diabetes complications on fertility.

Fertility in women with DM2 is an even more complex issue. Obesity and polycystic ovarian syndrome (PCOS), both known to effect fertility, often occur with DM2. One review found that

Table 2

Checklist for Preconception Counseling and Care

Initial visit

Establish near euglycemia as preconception goal

Initiate insulin and discontinue oral hypoglycemic agents (except possibly metformin).

Diabetes education for insulin dosing to improve glycemic control Develop plan for contraception until euglycemia is achieved Counsel on the natural history of insulin resistance in pregnancy

Counsel on risks to pregnancy including spontaneous abortion, congenital malformations, macrosomia, neonatal hypoglycemia, IUFD, etc. Counsel on management of significant hyperglycemia. (For patients with DM1, review DKA prevention with special consideration for pregnancy's impact on risk for DKA and DKA's potential impact on pregnancy). Counsel on hypoglycemia safety, including driving safety and the use of glucagon Genetic counseling for diabetes Counsel on the risk of retinopathy Initiate preconception ophthalmologic evaluation Obtain lipid profile, if not previously performed Medical nutrition therapy (MNT)

Consider need for cardiac evaluation in high-risk patients

Counsel on smoking cessation strategies and set this as a preconception goal, if applicable Obtain a baseline measure of urine albumin excretion Counsel on the risks of preeclampsia and preterm delivery Counsel on the risk of progressive renal disease Counsel on maternal fertility, and if applicable, PCOS Obtain baseline TSH, if no previous one available Subsequent hyperglycemic visits Evaluation of and counseling on insulin dosing to improve glycemic control MNT for improving glycemic control Reinforcement of smoking cessation if applicable Initial euglycemic visit

Once glycemic goal is achieved, discontinue contraception and reevaluate medication list with special attention to lipid-lowering and antihypertensive medications Begin prenatal vitamin

Refer to reproductive endocrinology, if needed women with a BMI greater than 30 kg/m2 have a much higher risk of infertility and a higher risk of miscarriage (30). A more detailed discussion of fertility in these settings is provided in Chap. 10.

Recommendation. Some women with preexisting diabetes may have trouble conceiving, but most will not. Clinicians should maintain a high index of suspicion for PCOS, and if clinical criteria are met, further investigation for PCOS and possibly, congenital adrenal hyperplasia may be warranted. If infertility is documented or there are other clinical concerns, referral to a reproductive endocrinologist may be indicated.

Maternal Hypoglycemia: Will Low Blood Sugars Hurt My Baby?

Hypoglycemia can be a serious problem, endangering maternal safety, especially during the first trimester of pregnancy. Careful attention should be paid to patient education, including the correct treatment of mild hypoglycemia, family education on the use of glucagon, and a thorough discussion of safe driving practices. To investigate the effect of hypoglycemia during organogenesis, an analysis of major congenital anomalies in offspring from a prepregnancy clinic was performed. One of the 12 women who had abnormal babies experienced hypoglycemia during organogenesis; 45 other women with severe hypoglycemia had normal babies. In fact, women who attended the prepregnancy clinic, as opposed to those who did not, had lower first trimester HbA1c and significantly lower rates of congenital malformations (31). This was consistent with earlier findings showing no increased rate of malformations in women with hypoglycemia (22).

Recommendations. Careful education on hypoglycemia treatment and safety precautions are important for maternal safety. However, hypoglycemia does not appear to increase the risk of congenital malformations.

Diabetic Ketoacidosis and Intrauterine Fetal Demise (IUFD): How High Is Dangerous?

In contrast to the fetus' relative tolerance of hypoglycemia, the fetus does not tolerate severe hyperglycemia or DKA well. To make matters worse, pregnant women are more likely to go into DKA at lower levels of hyperglycemia than women who are not pregnant (32). As a result, the diagnosis of DKA may be delayed. Fetal mortality may occur in 9-35% of cases in which DKA occurs in the mother (33, 34).

IUFD is more common in pregnancies complicated by diabetes. Not all cases are found to have a clear cause. Peripheral vascular disease and placental factors are thought to play a role in some cases. Extreme hyperglycemia may play a role also, as Priscilla White's original article showed a now well-recognized association between DKA and IUFD (11).

Recommendation. All women with DM1 should be counseled on appropriate measures to prevent, recognize, and treat DKA.

Hypertension/Nephropathy/Preeclampsia and Prematurity

The relationship between hypertension, diabetic nephropathy and preeclampsia is complex, the increased rate of preterm birth seen in women with diabetes is influenced by multiple factors including the higher rate of preeclampsia.

Hypertension: How Does Hypertension Effect a Pregnancy? Are My Blood Pressure Medications Safe in Pregnancy? Hypertension is a risk factor for preeclampsia, which is discussed in more detail in the section "Preeclampsia: What is the danger of preeclampsia?" and in Chaps. 16 and 19. The main focus of PCC, one study found that hypertension is selecting appropriate medications. Antihypertensive medications considered unsafe in pregnancy include ACE inhibitors (35) and ARBs (36). These should be discontinued prior to conception, and if necessary, replaced with antihypertensives commonly used in pregnancy. Calcium channel blockers (nifedipine), certain beta blockers (metoprolol or labetalol), and methyl dopa are commonly used.

Recommendations. The antihypertensive medication regimen should be reviewed and modified prior to conception to include only those antihypertensives considered safe in pregnancy.

Nephropathy: Does Pregnancy Increase My Risk of Kidney Disease? Does My Kidney Disease Affect My Pregnancy? For most women with diabetes, pregnancy does not increase the risk for renal disease. Even though the urine albumin excretion rate naturally increases in pregnancy, it usually returns to baseline after pregnancy, even in patients with diabetes (37). The EURODIAB trial showed that pregnancy was not a factor in the development of microalbuminuria (38), and the DCCT found no important long-term effects of pregnancy on the development of renal disease or nephropathy (39). A 2002 study found that in women with microalbuminuria and normal baseline renal function, pregnancy had no prolonged impact on renal function (40). Studies in women with other forms of mild renal impairment have shown similar results (41).

However, some women with diabetes will have progression of renal disease during pregnancy. Gordon et al. found that women with an initial creatinine clearance less than 90 ml/min or proteinuria greater than 1 g/day had a significantly increased risk for progression of renal disease during pregnancy (42). In women with moderate renal impairment (serum creatinine 1.4-1.9 mg/dl), 40% demonstrated a decline in renal function during pregnancy (41). In women with severe renal impairment (serum creatinine greater than 2.0 mg/dl) 13 out of 20 had a decline in renal function, which persisted and resulted in end-stage renal failure in 7 out of 13 (41).

Severity of nephropathy is a risk factor for preeclampsia and increased perinatal mortality. For women with serum creatinine greater than 2.0 mg/dl the risk of preterm delivery is greater then 90%; the risk of preeclampsia is 60%, and the risk of perinatal death is 10% (43).

Recommendations. A serum creatinine and an assessment of urinary protein excretion to assess risk are needed in all women with preexisting diabetes. In women with renal disease, a clear discussion of the maternal and fetal risks related to renal disease, preeclampsia and pre term delivery is important.

Preeclampsia: What Is the Danger of Preeclampsia? Preeclampsia is the onset of hypertension and proteinuria during pregnancy after the 20th week of gestation. It can lead to maternal acute renal failure, cerebrovascular and cardiovascular events, and death (44). It occurs in 5-7% of the general population during pregnancy, and significant risk factors for the development of preeclampsia include nulliparity [RR 2.91 (95% CI 1.28-6.61)], preexisting diabetes [RR 3.56 (95% CI 2.54-4.99)], and previous preeclampsia in pregnancy [RR 7.91 (95% CI 5.85-8.83)]. Additional risk factors include advanced maternal age (greater than 40 years old), BMI greater than 35 kg/m2, and hypertension (45).

Multiple studies have recognized the increased risk of developing preeclampsia in pregnancies specifically complicated by diabetes (7, 46). A nationwide Dutch study prospectively compared pregnant women with type 1 diabetes with the nondiabetic pregnant population and found a 12-fold increase in the risk of developing preeclampsia (95% CI 9-16.1) (46). In Denmark 18.1% of women with DM1 developed preeclampsia compared with 2.6% of the background population (7).

The level of glycemic control has also been shown to be an independent risk factor for the development of preeclampsia. One study found that for each 1% increment in first trimester HbA1c, the risk for development of preeclampsia rose by a factor of 1.6; each 1% decrement in baseline HbA1c lowered the risk by 0.6-fold (47).

In studies that compared pregnancies affected by DM1 to those with DM2, no significant difference was found in rates of preeclampsia and pregnancy-induced hypertension between the populations (4, 48). While the occurrence of hypertension in pregnancy appears similar in women with type 1 and type 2 diabetes, women with type 2 diabetes more often had chronic prepregnancy hypertension. Prepregnancy microalbuminuria and diabetic nephropathy are significant risk factors for preeclampsia (49). One metaanalysis demonstrated that women with macroalbuminuria have a 41% incidence of preec-lampsia (50).

Recommendations. All women with preexisting DM should be counseled on the risk and the signs and symptoms of preeclampsia. Careful monitoring in the third trimester for the development of preeclampsia is warranted.

Prematurity/Preterm Delivery: Will I Deliver Full Term? A year 2000 prospective multicenter observational study compared the rates of preterm delivery between patients with preexisting diabetes and healthy controls. The total rate (38%) of preterm delivery [both indicated (21.9%) and spontaneous (16.1%)] among healthy singleton pregnancies in women with preexisting DM was found to be elevated compared with that among pregnancies in women with normal controls (overall rate 13.9%; indicated 3.4% and spontaneous 10.5%) (51).

A year 2004 study looking consecutively at 168 deliveries in patients with DM1 found that factors associated with spontaneous preterm delivery (which occurred in 9% of women with DM1) included age less than 25 years old, polyhydramnios, and elevated HbA1c at delivery time. Factors associated with indicated preterm delivery (which occurred in 15%) were nulliparity, chronic hypertension, worsened nephropathy or retinopathy, elevated HbA1c at delivery, and preeclampsia when compared with those associated with diabetic women who had full-term pregnancies (52).

In a large observational study, pregnant hypertensive women with DM1 more often had preterm delivery and cesarean deliveries, and their babies went to the special care unit with higher frequency than hypertensive women with DM2 (53).

Recommendations. Women need to be counseled as to the risks of preterm delivery and should consider delivering at a hospital with a neonatal intensive care unit.

Retinopathy: Why Do I Have to Have an Eye Exam?

Accelerated retinopathy leading to visual loss during pregnancy or the peripartum period can occur (54). Several studies, including the Diabetes in Early Pregnancy Study (DIEP) (55), the DCCT (39), and the EURODIAB trial (38), have investigated the relationship between preexisting diabetes and the development or progression of diabetic retinopathy.

The DCCT showed an overall twofold increased risk for worsened diabetic retinopathy during pregnancy compared with nonpregnant women. Generally the effect was transient but it was sustained during the first postpartum year. Three out of 183 women who had no retinopathy or minimal nonproliferative baseline retinopathy progressed to severe retinopathy during the study. Although this study is one of the "gold standard" studies of DM1, the overall number of pregnancies was low, and HbA1c values generally were low at baseline, likely decreasing the magnitude of effect seen (39).

The presence and severity of baseline diabetic retinopathy has been shown to be an important risk factor for progression (55-57). In one observational study, progression was defined as "development of retinopathy de novo or upgrading of retinopathy from the first trimester to later trimesters or post-partum or development or progression of new vessels requiring laser photocoagulation in one or both eyes" (56). This study noted that 9.1% of patients with no baseline retinopathy progressed during pregnancy and 58.3% of those with PDR progressed (56). These findings were remarkably similar to those of the DIEP, which reported that 10.3% of patients with no baseline retinopathy, 18.8% of those with mild nonproliferative retinopathy, and 54.8% of those with moderate to severe nonproliferative retinopathy progressed (55).

Other risk factors for the development or progression of retinopathy include level of glycemic control (38, 39, 55), the duration of diabetes (57), rapidly improving glucose control in the first trimester (55), and smoking (57). It appeared that performing laser photocoagulation on women with proliferative disease before pregnancy helped to abate progression (56, 58).

Recommendations. All women with preexisting diabetes should have a dilated retinal exam to assess retinopathy prior to conception. If active proliferative diabetic retinopathy is present, some practitioners recommend delaying conception until retinopathy has become quiescent.

Hyperlipidemia: When Should I Stop My Cholesterol Medication?

During preconception, standard monitoring and management of lipid disorders should be maintained until discontinuation of birth control methods. Once a woman is trying to conceive, HMG Co reductase inhibitors, fibric acid derivatives and most other lipid lowering agents should be discontinued. Medical Nutrition Therapy remains the mainstay of lipid management during pregnancy.

Pregnancy is known to increase triglyceride levels markedly in the second and third trimesters (59). One dangerous complication of hyperlipidemia in pregnancy occurs in severe familial hypertriglyceri-demia, where pancreatitis has been known to complicate pregnancies with devastating results. Therefore, it is important that during preconception women are screened for lipid disorders and that women with severe hypertriglyceridemia have sequential measurements of triglycerides during pregnancy (60).

Recommendations. All lipid-lowering medications should be discontinued at the time that contraception is discontinued.

Macrovascular Disease: Should I Have a Stress Test Before Becoming Pregnant?

There are relatively few cases of myocardial infarction during pregnancy. However, diabetes is clearly a risk factor for this rare event. In Roth's review of all cases reported prior to 1996, 5% of the cases of MI in pregnancy were in patients with preexisting diabetes. Risk factors for acute myocardial infarction in pregnancy or peripartum are similar to those in the general population: family history, familial hyperlipo-proteinemia, low concentration of high-density lipoprotein, high concentration of low-density lipoprotein, diabetes, smoking, and previous use of oral contraceptives. Most events occurred in the third trimester or in the postpartum period. Interestingly less than half were associated with atherosclerotic disease (61).

Smoking is an important risk factor not only for macrovascular disease but also for intrauterine growth retardation. Smoking cessation should be urged for all women in the preconception period.

Recommendations. Exercise echocardiograms may be considered for women with diabetes over the age of 35. Duration of diabetes, presence of diabetes complications, and other CAD risk factors should be included in this decision. Provide all women who smoke with counseling on smoking cessation prior to conception.

IUGR: Why Do I Have to Worry About Small Babies Too?

In a manner similar to preterm birth, there are many factors that affect the rate of IUGR. Smoking and vascular disease are thought to be two of the predominant factors. Pregnancies in women with nephropathy more frequently result in intrauterine growth restriction (49).

Recommendations. Women with preexisting diabetes should be aware of their risk for IUGR and the risk factors for it. Again smoking cessation is advised.

Thyroid Disease: Does My Thyroid Disease Affect My Pregnancy?

Thyroid disease is a common problem for women with both DM1 and DM2. All women with diabetes should be screened with a TSH for thyroid abnormalities in the preconception period. Women with hypothyroidism on stable replacement hormone doses should be advised to increase their thyroid hormone dose by 30% once pregnancy is confirmed (62). It is beyond the scope of this chapter to discuss the management of hyper or hypothyroidism in detail.

Recommendations. All women with diabetes should be screened with a TSH for thyroid dysfunction in the preconception period.

Congenital Malformations: What Congenital Malformations Are Associated with Diabetes?

Because perinatal mortality is closely related to the congenital anomaly rate, an analysis of types of anomalies is vital to understanding adverse pregnancy outcomes in diabetes. In 1971, Kucera identified rates of anomalies observed in infants of mothers with diabetes (63). These included caudal regression, situs inversus, arthrogryposis, spinal anomalies, ureter duplex, hydronephrosis, pseudohermaphroditism, gross skeletal anomalies and anencephaly.

Since then numerous articles have been published, reporting congenital malformations, including cardiac (atrio- and ventriculoseptal defects, great artery abnormalities, Tetralogy of Fallot), genitourinary (hypospadias, ureter duplex, hydronephrosis), musculoskeletal (hemivertebra), central nervous system (neural tube defects, caudal regression, anencephaly), upper respiratory tract (cleft palate), and gastroschisis (13, 46). In a separate study, more than a third of all anomalies reported were cardiac in origin (14). Neural tube defects were generally found to be the second most common defect. One hypothesis of "diabetic embryopathy" suggests that the anomalies may be due to mesodermal and neural crest defects (64).

Multiple studies have investigated the link between diabetes control and congenital malformations (12-16) and further established that preconception interventions aimed at reducing the HbAlc at conception can reduce the rate of congenital malformations (17-23).

Recommendations. Glycemic control should be a goal prior to discontinuation of contraception.

Spontaneous Abortion: Am I At Risk for Miscarriage?

Spontaneous abortion occurs at a higher rate in pregnancies complicated by diabetes. A Danish study of women with type 1 diabetes showed a 17.5% miscarriage rate compared with 10-12% in the general population, with a longer duration of disease and older age as risk factors (65). Other studies found similar rates of early pregnancy loss (EPL) ranging from 13.5 to 16.5% (25, 66). The rate of EPL is related to the level of glycated serum protein levels (67) and HbA1c (68, 69).

Recommendations. Women should be counseled on the higher rate or EPL and its relationship to glycemic control.

Macrosomia: What Is Wrong with Having a Big Baby?

Macrosomia is defined as a birth weight at the 90th percentile. It is a factor in many cases of shoulder dystocia, which occurs when the infant's shoulders fail to pass through the pubic bones spontaneously and can result in birth injury. Macrosomia is also a risk factor for both cesarean delivery (see section "Cesarean Delivery: Will I Have to Have a Cesarean Delivery?") and a risk factor for "metabolic imprinting" (see Chap. 20).

There are several risk factors for macrosomia other than maternal glycemia including maternal obesity, previous maternal delivery of a macrosomic infant and family history. However, the main modifiable risk factor for macrosomia is maternal glycemia. While HbA1c at conception is a risk factor for macrosomia, macrosomia is associated most closely with postprandial glucose values between 29 and 32 weeks of pregnancy (70).

Metabolic imprinting refers to metabolic changes in the neonate caused by exposure to metabolic factors that increase the neonate's risk component for metabolic syndrome later in life. This is discussed in more detail in Chap. 20.

Cesarean Delivery: Will I Have to Have a Cesarean Delivery?

The rate of cesarean delivery is much higher in women with diabetes than in women without diabetes. In fact, findings indicate a relative risk 1.78-4.5 times higher for women with DM1 than in the general population (7, 46, 71). Women with DM1 have a greater risk for cesarean delivery than women with DM2 (4, 48) these findings. The increased rate in cesarean delivery is due in part to the higher rate of macrosomia, but other factors also play a role.

Recommendations. Women with diabetes should be aware of their increased risk for cesarean delivery.

Neonatal Hypoglycemia: Will My Baby Need a NICU?

Neonatal hypoglycemia is defined as neonatal blood glucose <40 mg/dl; this can result in further adverse events, such as neonatal seizures.. One study found that 7.8% of infants born to mothers with preexisting diabetes experienced neonatal hypoglycemia (72).

Recommendations. Women with diabetes should be aware of this potential complication.

Genetic Risk: Will My Baby Have Diabetes?

Offspring of parents with DM1 have an increased risk of developing diabetes later in life. Children have a 3.5% and 7.6% cumulative risk of developing diabetes if their mothers or fathers have type 1 diabetes, respectively (73). The Framingham study evaluated the prevalence of DM2 in offspring and found that maternal DM2 diagnosed earlier than 50 years of age conferred an odds ratio of 9.7 (95% CI 4.3-22) and paternal DM2 diagnosed earlier than 50 years of age conferred an odds ratio of 5.3 (95% CI 2.1-13.6) when compared with offspring without parental diabetes (74).

Recommendations. Women with diabetes should be aware of their offsprings risk for diabetes.

Perinatal Mortality and Morbidity: What Is the Chance My Baby Will Die?

The perinatal mortality rate for infants of mothers with preexisting diabetes remains several times that of the general population, yet there have been marked improvements in the last 60 years. Priscilla White's case series found an 18% fetal fatality rate (11). Between the 1940s and 1988, the perinatal mortality rate due to complications from DM1 in pregnancy fell from 250-300/1,000 live births down to 30-50/1,000 live births in the US; while this represents a marked improvement in the care of women with preexisting diabetes, the background perinatal mortality rate in cases not complicated by diabetes fell from 60/1,000 live births down to 15/1,000 live births (75). Another study found a decline in perinatal mortality between 1940 and 1990 in pregnancies of women with DM1 from greater than 30% to 4% approaching (76).

Despite these dramatic gains, increased perinatal mortality remains a significant problem. A Danish study found that DM2 is associated with higher perinatal mortality [RR 4 (95% CI 1.0-15.5)] than DM1 and the general population [RR 8.9 (95% CI 3.4-23)], and the frequency of perinatal mortality along with major congenital anomalies is actually increasing since the 1980s and early 1990s, possibly due to older maternal age, more complicated diabetes and higher body weight (4). Another study found a perinatal mortality rate for infants of mothers with DM2 of 39.1/1,000 live births, which was higher than either that for gestational diabetes (16.2/1,000) or the general population (12.5/1,000) (8).

Perhaps one reason that there may be an increased risk for mothers with DM2 is that obesity itself is a significant risk factor for stillbirth or neonatal death, doubling the risk compared with nonobese mothers (77). A body mass index less than 20 kg/m2 is also significantly associated with late fetal death (78). Although data looking at patients with preexisting DM are lacking, surgical interventions aimed at controlling prepregnancy obesity have been analyzed. Patients with prior gestational diabetes who have had gastric banding procedures before pregnancy do not incur increased risk of adverse perinatal outcomes compared with the general population, and there does not seem to be increased risk of postsurgical complications (79, 80).

While the causes of IUFD in women are not always identifiable, it is believed that uncontrolled hyperglycemia may account for half of stillbirth occurrences while congenital malformations and infection may cause a significant portion as well (81). While the frequency of pregnancy loss has been found to be similar within different types of preexisting DM, death in DM1 pregnancies is most often due to congenital anomalies and prematurity, and death in DM2 pregnancies is most often due to IUFD significantly later in pregnancy (5) (see Fig. 3).

A Scottish study showed a more than threefold higher risk of stillbirth and perinatal mortality in pregnancies of mothers with diabetes than in the background population (6). A Danish national study

Fig. 3. Rates and causes of pregnancy loss in type 1 and type 2 diabetics (including newly recognized diabetes). The scale indicates percentage of the total number of fetuses. (Reprinted with permission from (5).)

Typel Type 2

■ Stillbirth

□ Prematurity & Congenital anomaly

■ Stillbirth

□ Prematurity & Congenital anomaly

Typel Type 2

prospectively compared pregnancies in women with type 1 diabetes with the nondiabetic pregnant population from 1993 to 1999. The perinatal mortality rate was much higher in pregnancies complicated by DM1 [RR 4.1 (95% CI 2.9-5.6)]; babies were delivered earlier and had higher rates of cesarean delivery and macrosomia (7).

Perinatal morbidity for infants of mothers with diabetes includes not just macrosomia and neonatal hypoglycemia, but also rarer complications including hypocalcemia and hypomagnesemia, polycythemia, iron deficiency, respiratory distress, hyperbilirubinemia, cardiomyopathy and perinatal asphyxia (82).

A universal question among women with diabetes who are planning pregnancies is "What should I eat?" Nutrition counseling is an integral part of any diabetes PCC program as it is necessary to ensure both glycemic control and nutritional adequacy before, during and after pregnancy. Individual recommendations will vary depending on insulin-dosing plan and patient characteristics and preferences. This requires a team approach with the dietitian working in concert with the endocrinologist, obstetrician, nurse and other health care providers. The patient must have a firm understanding of carbohydrates and their relation to blood glucose measurement and insulin dosing. In addition, it is recommended that folic acid supplementation be started prior to conception. This topic is reviewed in detail and recommendations are outlined in Chap. 14: Nutrition in Pregnancy.

PCC has been successful in improving pregnancy outcomes for women with preexisting diabetes. PCC should involve a multidisciplinary approach with participation by endocrinologists, primary care physicians, obstetricians familiar with high-risk care, diabetes educators and an actively engaged patient. The ADA states that preconception and early pregnancy care need to include (1) education about the interaction of diabetes with pregnancy, (2) education in diabetes self-management skills, (3) physician-directed care and laboratory diagnosis and (4) engaging mental health professionals to reduce stress and improve adherence (60).

Preconception glycemic goals should target fasting glucose levels between 66 and 99 mg/dl and peak postprandial goals between 100 and 129 mg/dl. The goal HbAlc prior to pregnancy is "as close to normal as possible without significant hypoglycemia" (60). Basal/bolus insulin regimens are recommended. Given the increase in insulin resistance that occurs progressively during the later half of pregnancy, almost every women with preexisting diabetes will require insulin therapy during a

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