How should a 34-year-old woman with diabetes and a glycated hemoglobin (A1C) of 6.5% who is planning pregnancy be managed pre-conception?

Management of 34-Year-Old Woman with A1C 6.5% Planning Pregnancy

This patient should delay conception until her A1C is optimized to <6.5% (ideally <6%), use effective contraception during this optimization period, and begin intensive preconception management immediately to reduce the risk of congenital anomalies, spontaneous abortion, and other pregnancy complications. 1

Immediate Actions

Contraception Until Metabolic Optimization

• Prescribe effective contraception immediately and continue until glycemic targets are achieved 1, 2
• Consider long-acting reversible contraception for highest efficacy 2
• An A1C of 6.5% places her at the threshold where risk of congenital anomalies begins to rise significantly above baseline 1

Glycemic Target Before Conception

• Target A1C <6.5% (ideally <6%) before attempting pregnancy to minimize risk of congenital anomalies (anencephaly, microcephaly, congenital heart disease, caudal regression) 1
• Epidemiological data show that A1C values up to 1% above normal are associated with malformation rates similar to non-diabetic pregnancies, but rates continue to decrease with lower A1C levels 1
• Her current A1C of 6.5% is at the upper acceptable limit; achieving <6% would provide the lowest risk 1

Comprehensive Preconception Evaluation

Medication Review and Adjustment

• Immediately discontinue potentially teratogenic medications: ACE inhibitors, ARBs, statins 1
• Transition to insulin if not already using it, as insulin is the preferred agent with established safety data for pregnancy 2
• If currently on oral agents or GLP-1 receptor agonists, transition to insulin before conception 2

Laboratory Assessment

• Thyroid-stimulating hormone (especially important in type 1 diabetes) 1
• Serum creatinine and urine albumin-to-creatinine ratio 1
• Baseline A1C (already obtained at 6.5%) 1

Screening for Diabetic Complications

• Ophthalmology referral for baseline retinopathy screening 1
• Assess for nephropathy, hypertension, and cardiovascular disease 1
• Evaluate for autonomic and peripheral neuropathy 1

Infectious Disease and Routine Screening

• Rubella immunity, rapid plasma reagin, hepatitis B, HIV testing 1
• Pap smear and cervical cultures 1
• Blood typing 1

Nutritional Supplementation

• Prescribe prenatal vitamins with at least 400 mcg folic acid (or 4-5 mg if BMI >35) 1, 2
• Begin immediately, as neural tube closure occurs by 28 days post-conception 1

Intensive Diabetes Management Program

Self-Management Skills Required

• Implement frequent self-monitoring of blood glucose (preprandial and postprandial) 1
• Establish appropriate meal planning with registered dietitian 1
• Master insulin self-administration and dose adjustment 1
• Learn hypoglycemia recognition and treatment (patient and family members) 1
• Incorporate regular physical activity 1

Multidisciplinary Team Approach

• Refer to multidisciplinary preconception care team including endocrinology/diabetology, maternal-fetal medicine specialist, diabetes educators (nurse and dietitian), and social worker 1, 2
• This team-based approach has been shown to reduce congenital malformations from 10.9% to 1.2% and spontaneous abortions from 24% to 7% 3, 4

Counseling on Pregnancy Risks

Maternal and Fetal Risks of Suboptimal Control

• Congenital anomalies (anencephaly, microcephaly, congenital heart disease, caudal regression) increase directly with A1C elevation 1, 5
• Spontaneous abortion risk is substantially elevated with uncontrolled diabetes 1, 5
• Preeclampsia, macrosomia, intrauterine fetal demise, neonatal hypoglycemia, and neonatal hyperbilirubinemia 1, 5
• Long-term offspring risk of obesity and type 2 diabetes 1

Evidence for Preconception Care Benefits

• Women who achieve optimal glycemic control before conception have dramatically better outcomes: 1.2% vs 10.9% major malformation rate and 7% vs 24% spontaneous abortion rate compared to those who present already pregnant 3, 4
• These benefits occur despite increased hypoglycemia during intensive management (median 2.7 episodes per week), which was not associated with excess malformations 4

Timeline and Follow-Up

Before Attempting Conception

• Achieve and maintain A1C <6.5% (ideally <6%) for at least 2-3 months 1
• Complete all screening evaluations and medication adjustments 1
• Ensure patient has mastered intensive insulin management skills 1

Common Pitfall to Avoid

• Do not allow conception attempts until glycemic optimization is achieved, as 61% of diabetic women still enter pregnancy with suboptimal control despite being under medical care 6
• Women not specifically advised to achieve target A1C levels before pregnancy are significantly more likely to conceive with suboptimal control 6

Once Pregnant

• A1C target during pregnancy becomes <6% (even lower than preconception) due to altered red blood cell turnover 1
• Intensive glucose monitoring with targets: premeal/bedtime/overnight 60-99 mg/dL, peak postprandial 100-129 mg/dL 1