What is the recommended management for individuals with diabetes in the reproductive age group?

Management of Diabetes in the Reproductive Age Group

For individuals with diabetes in the reproductive age group, preconception counseling should be incorporated into routine diabetes care starting at puberty, with emphasis on achieving glycemic control (A1C <6.5%) and using effective contraception until ready for pregnancy. 1

Preconception Care

Glycemic Control

• Target A1C <6.5% (48 mmol/mol) before conception to minimize risk of:
  • Congenital anomalies
  • Preeclampsia
  • Macrosomia
  • Other pregnancy complications 2
• Glucose targets:
  • Fasting: <95 mg/dL (5.3 mmol/L)
  • 1-hour postprandial: <140 mg/dL (7.8 mmol/L)
  • 2-hour postprandial: <120 mg/dL (6.7 mmol/L) 1

Medication Review

• Discontinue potentially teratogenic medications:
  • ACE inhibitors
  • Angiotensin receptor blockers
  • Statins 2, 1
• Insulin is the preferred agent for diabetes management in pregnancy 1

Comprehensive Assessment

• Baseline evaluations should include:
  • Dilated eye examination
  • Renal function tests (creatinine, urinary albumin-to-creatinine ratio)
  • Thyroid function tests
  • Screening for other diabetes complications 2, 1
• Additional testing:
  • Rubella immunity
  • Syphilis, hepatitis B, HIV screening
  • Pap smear 1
• Prescribe folic acid supplementation (at least 400 mg daily) 1

Family Planning

• Discuss effective contraception with all women with diabetes of reproductive potential 2
• Consider long-acting, reversible contraception until treatment regimen and A1C are optimized for pregnancy 2
• Educate about risks of unplanned pregnancies with poor glycemic control 1

Multidisciplinary Management

• Women planning pregnancy should ideally be managed by a team including:
  • Endocrinologist
  • Maternal-fetal medicine specialist
  • Registered dietitian nutritionist
  • Diabetes educator 2, 1
• Regular follow-up to monitor glycemic control and adjust treatment as needed

Special Considerations

Retinopathy Management

• Dilated eye examinations should occur:
  • Before pregnancy or in first trimester
  • Every trimester during pregnancy
  • For 1 year postpartum 2, 1
• Rapid implementation of euglycemia may worsen retinopathy 2

Preeclampsia Prevention

• Women with type 1 or type 2 diabetes should be prescribed low-dose aspirin (81 mg/day) by the end of the first trimester to lower preeclampsia risk 2

Type-Specific Management

Type 1 Diabetes

• Educate about hypoglycemia awareness and management
• Provide ketone strips and education on diabetic ketoacidosis prevention 2
• Insulin requirements may fluctuate during pregnancy:
  • May decrease by 9-18% between weeks 7-15
  • May double in third trimester compared to pre-pregnancy needs 1

Type 2 Diabetes

• Often associated with obesity; recommend appropriate weight gain during pregnancy:
  • Overweight women: 15-25 lb
  • Obese women: 10-20 lb 2
• May require higher insulin doses than type 1 diabetes 2

Common Pitfalls to Avoid

• Relying solely on A1C for monitoring instead of using both pre- and postprandial glucose values 1
• Not adjusting insulin doses frequently enough to match changing requirements throughout pregnancy 1
• Delaying preconception care until actively trying to conceive
• Failing to screen for and manage diabetes complications before pregnancy

By implementing comprehensive preconception care and maintaining optimal glycemic control, individuals with diabetes in the reproductive age group can significantly reduce the risk of adverse maternal and fetal outcomes.