What are the recommendations for diabetes management in a female planning to get pregnant?

From the Guidelines

Women planning pregnancy with diabetes should aim for optimal glycemic control before conception, with a target HbA1c below 6.5% (48 mmol/mol) if possible without significant hypoglycemia, as recommended by the most recent guidelines 1.

Key Recommendations

• Pre-pregnancy care should include achieving optimal glycemic control, with insulin as the preferred medication during pregnancy planning, as oral agents like metformin and sulfonylureas have limited safety data, though metformin is increasingly considered acceptable 1.
• Women on medications like SGLT-2 inhibitors (empagliflozin, dapagliflozin), GLP-1 receptor agonists (liraglutide, semaglutide), or thiazolidinediones should transition to insulin before conception 1.
• Folic acid supplementation (5mg daily) should begin at least 3 months before conception to reduce neural tube defect risk 1.
• Blood glucose targets should be fasting 70-95 mg/dL (3.9-5.3 mmol/L) and 1-hour postprandial below 140 mg/dL (7.8 mmol/L) 1.

Importance of Preconception Counseling

• Women should also receive preconception counseling about diabetes complications screening, including retinopathy assessment, as pregnancy can worsen existing retinopathy 1.
• Thyroid function should be evaluated, as thyroid disorders are common in women with type 1 diabetes 1.
• Tight glycemic control before and during pregnancy significantly reduces risks of congenital malformations, miscarriage, preeclampsia, and macrosomia, making preconception planning essential for women with diabetes 1.

Insulin Use in Pregnancy

• Insulin should be used to manage type 1 diabetes in pregnancy, and is the preferred agent for the management of type 2 diabetes in pregnancy 1.
• Either multiple daily injections or insulin pump technology can be used in pregnancy complicated by type 1 diabetes 1.

From the Research

Diabetes Management for Females Planning to Get Pregnant

To manage diabetes effectively in females planning to get pregnant, several key recommendations can be considered based on existing research:

• Achieving and maintaining good metabolic control before conception is crucial to reduce congenital malformations and other neonatal complications 2.
• Measuring HbA1c is the gold standard for monitoring metabolic control in diabetes, and aiming for HbA1c levels resembling normal values as closely as possible can help prevent episodes of hypoglycemia 2.
• Pregnancy planning is beneficial for glycemic control and pregnancy outcomes in type 1 diabetic women, with planned pregnancies resulting in significantly fewer congenital anomalies and reduced risk of adverse pregnancy outcomes 3.
• Improved glycemic control from preconception to early pregnancy and midpregnancy periods can reduce the risk of adverse perinatal and maternal outcomes, with a net decline in HbA1c associated with a lower risk of congenital anomalies, preterm birth, and severe maternal morbidity or death 4.

Key Considerations for Healthcare Providers

Healthcare providers play a critical role in supporting females with diabetes who are planning to get pregnant:

• Integrating reproductive health into diabetes care plans for all women with diabetes aged 15-50 years can help improve pregnancy outcomes 5.
• Developing innovative approaches to improve uptake of pre-pregnancy care in women with Type 2 diabetes in primary care settings is essential 5.
• Utilizing technologies such as insulin pumps, continuous glucose monitoring, and automated insulin delivery can be beneficial in the pre-pregnancy and antenatal care of women with Type 1 diabetes 5.
• Providing personalized postnatal care, targeting women with previous pregnancy loss, congenital anomaly, and perinatal mortality, can help improve health outcomes 5.

Recommendations for Women with Diabetes

Women with diabetes who are planning to get pregnant should:

• Seek preconception counseling and advice from their healthcare providers to optimize their glycemic control and reduce the risk of adverse pregnancy outcomes 6, 3.
• Aim to achieve good metabolic control before conception, with a focus on maintaining normal HbA1c levels 2.
• Consider the use of technologies such as insulin pumps and continuous glucose monitoring to improve glycemic control 5.
• Be aware of the importance of pregnancy planning and the potential benefits of improved glycemic control on pregnancy outcomes 3, 4.