Best Practices in Preconception Care in Pregestational Diabetes
Special considerations are needed when treating women of reproductive age with pregestational diabetes.
Optimized preconception care is key to creating positive short- and long-term health outcomes in patients with pregestational diabetes. Research presented at the American Association for Nurse Practitioners (AANP) 2017 National Conference, held from June 20 to 25 in Philadelphia, Pennsylvania, examined best practices in evidence-based preconception and prenatal clinical care for this patient population.
Jacqueline LaManna, ANP-BC, PhD, from the University of Central Florida in Orlando, focused on the 3 phases of care associated with pregnancy (preconception, periconception, and interconception), as well as the consequences associated with poorly managed diabetes during these 3 phases.
"Risk of major fetal anomaly is directly associated with the degree of glycemic control during [the] periconception period in women with pregestational diabetes," noted Dr LaManna. Conditions include congenital heart defects, spina bifida, anencephaly, and renal abnormalities.
In women with diabetes, reproductive planning should include an examination of potential contraindications to pregnancy, such as cardiovascular disease, proliferative retinopathy, advanced kidney disease, or severe gastroenteropathy. Contraception options should be considered, with special attention paid to contraception-associated weight gain in women with type 2 or gestational diabetes. Clinicians should aim to evaluate and treat infertility early in the reproductive planning process.
During the pre- and periconception periods, a HbA1c target of <6.5% should be established to limit hypoglycemia; glucose monitoring should increase in frequency, and undiagnosed women with diabetes risks should be regularly evaluated.
Patients with diabetes may also benefit from the creation of a high-risk pregnancy team, as well as regular examination for retinopathy, nephropathy, thyroid diseases, and hypertension. Self-management education and counseling with a clinical dietician may also be useful.
Finally, clinicians should review and modify as necessary patients' medication regimens, including antihyperglycemic medications (insulin or oral agents, including insulin aspart, insulin glargine, or metformin), antihypertensive medications (angiotensin-converting enzyme or angiotensin receptor blocker inhibitors before confirmation of pregnancy), and statins.
Regardless of diabetes status, all women should receive preconception care including reproductive life planning, nutrition evaluation, immunization status, genetic screening, and chronic medical condition evaluation and stabilization.
LaManna J. What to do before one becomes two: preconception care in women with diabetes. Presented at: American Association of Nurse Practitioners (AANP) 2017 National Conference; June 20-25, 2017; Philadelphia, PA.