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

Management of Diabetes in the Reproductive Age Group

Preconception counseling should be incorporated into routine diabetes care starting at puberty for all individuals with diabetes and reproductive potential, with a target A1C <6.5% to minimize risks of congenital anomalies and pregnancy complications. 1

Preconception Care Strategy

Glycemic Control

• Target A1C <6.5% (48 mmol/mol) before conception to minimize congenital anomalies and pregnancy complications 1
• Regular blood glucose monitoring with fasting targets <95 mg/dL (5.3 mmol/L) and 1-hour postprandial <140 mg/dL (7.8 mmol/L) 1
• Consider continuous glucose monitoring to help achieve target A1C levels 1

Medication Management

• Review and adjust medications to eliminate potentially teratogenic drugs:
  • Discontinue ACE inhibitors, angiotensin receptor blockers, and statins 1, 2
  • Insulin is the preferred treatment during pregnancy 2
  • Metformin may be continued in the preconception period for women with type 2 diabetes 2

Contraception

• Effective contraception (preferably long-acting, reversible contraception) should be used until glycemic targets are achieved 1
• Family planning discussions should be integrated into routine diabetes care 1
• The risk of unplanned pregnancy outweighs the risk of any given contraception option 1

Multidisciplinary Team Approach

• Optimal management requires a team including:
  • Endocrinologist
  • Maternal-fetal medicine specialist
  • Registered dietitian nutritionist
  • Diabetes care and education specialist 1, 2

Comprehensive Assessment Before Pregnancy

Medical Evaluation

• Renal function assessment (serum creatinine and urinary albumin-to-creatinine ratio) 2
• Retinopathy screening (comprehensive dilated eye exam) 1, 2
• Assessment for neuropathy and cardiovascular disease 2
• Thyroid function testing, particularly for women with type 1 diabetes 2

Education Components

• Risks of diabetic embryopathy with poor glycemic control 1
• Importance of achieving near-euglycemia before conception 1
• Potential pregnancy complications including:
  • Spontaneous abortion
  • Fetal anomalies
  • Preeclampsia
  • Fetal demise
  • Macrosomia
  • Neonatal hypoglycemia 1

Special Considerations

Type 1 vs. Type 2 Diabetes

• Both type 1 and type 2 diabetes carry similar risks for adverse pregnancy outcomes 1, 3
• Women with type 2 diabetes may need additional focus on weight management and insulin resistance 4
• Women with type 1 diabetes may have higher risk of hypoglycemia during pregnancy 1

Common Pitfalls and Caveats

• Unplanned pregnancies have significantly higher risk of congenital anomalies due to poor glycemic control during organogenesis (5-8 weeks gestation) 2
• Pregnancy may worsen existing retinopathy, nephropathy, or cardiovascular disease 2
• Insulin requirements change dramatically throughout pregnancy, requiring vigilant monitoring 2
• Diabetic ketoacidosis can occur at lower blood glucose levels during pregnancy 2

Long-term Considerations

• Diabetes in pregnancy increases risk of offspring developing obesity, hypertension, and type 2 diabetes later in life 1
• Postpartum period requires continued attention to glycemic control and contraception 1
• Breastfeeding should be encouraged but may increase risk of overnight hypoglycemia 1

By implementing this comprehensive management approach for diabetes in the reproductive age group, healthcare providers can significantly reduce maternal and fetal risks, improving both short and long-term outcomes for mothers and their children.