Diabetes - Medical Practice Guidelines
Preconception Counseling
Prepregnancy counseling
is critical for all women of childbearing potential. The physician is responsible
for providing/referring for prepregnancy counseling. The counseling session
must include information on the risk of congenital malformations to the child
and ways to prevent them.
For women diagnosed with diabetes, and who are contemplating pregnancy and prior
to conception, a complete history and physical assessment is imperative. The
initial evaluation with the physician will probably last an hour, with subsequent
visits lasting 20 minutes and occurring monthly during the average four months
of preconception planning.
A complete history and evaluation should include, but is not limited to:
- discuss menstrual/pregnancy history, contraceptive use,
- establish
data base for perinatal risk,
- acute and
chronic complications,
- vascular status,
- glycemic control
via hemoglobin A1c levels,
- optimize glycemic
control, if Type 2 diabetic on oral agent, switch to insulin,
- if necessary,
provide instruction regarding self-monitoring of blood glucose (SMBG),
- a nutritional
assessment completed which includes an evaluation for nutritional adequacy,
make adjustments as needed,
- assess exercise
program,
- determine
immune status against rubella,
- assessment
of support system and any psycho-social factors,
- determine
if patient smokes, has excessive alcohol use, or substance use and if yes,
- explain possible
dangers to both her and to the unborn child, and
- folic acid supplement.
A physical examination
should be completed and include:
- blood pressure measurement, including orthostatic changes,
- dilated retinal
examination by an ophthalmologist or optometrist experienced in the management
of diabetic retinopathy. Patients may require a referral to an ophthalmologist
for further screening or for treatment based on findings of current exam,
and for a follow-up exam at the end of the first trimester of pregnancy,
- cardiovascular
examination,
- neurologic
assessment,
- lower extremity
examination, and
- pelvic examination
including pap smear.
Laboratory evaluations
should include:
- hemoglobin A1c levels,
- assessment
of renal function – serum creatinine and urinary excretion of total protein
and/or albumin,
- thyroid function
tests,
- lipid profile
for Type 2 diabetics and obese women,
- ECG for those
women diagnosed with diabetes for 10 years or more or who have other coronary
artery disease risk factors, and
- other tests
as indicated by the physical exam or history.
Discussions should
be held with the patient and her partner concerning:
- management goals during pregnancy - normal glycemia,
- the role of
self-monitoring of blood glucose (SMBG) and hemoglobin A1c levels,
- possible maternal
and fetal risk complications, and
- cost implications
of prenatal care and prevention of complications.
Follow-up visits
with other health team members are critical.
The frequency of follow-up visits and the composition of team members to be
seen will be dependent on the individual needs of the patient. Follow-up visits
will usually last between 15 to 45 minutes, again depending on the problems
identified.
Self-management techniques should be reviewed and modified as necessary. These
sessions are used primarily for patient education, motivation, and instruction
in more effective management strategies and techniques.
Women who have diabetes often have questions regarding the health effects on
herself and possible consequences to her fetus. Physicians and other members
of the health care team should be prepared to answer the following questions:
- Will the pregnancy affect my life expectancy?
- What effect
will my diabetes have on the baby and will my child develop diabetes?
- What effect
will the pregnancy have on diabetic nephropathy, retinopathy? and
- Are birth
control pills safe for me to use?
As soon as possible
(within two weeks) after a confirmation of pregnancy, a woman should be seen
by the health care team. Emphasis needs to be placed on proper meal planning,
to include:
- increased calcium,
- folic acid
and iron,
- other vitamin
intake,
- modifications
to meals to address nausea and vomiting,
- gestational
weight gain goals,
- risk assessment
and prevention of fasting hypoglycemia,
- insulin adjustment
algorithms to achieve target glucose control,
- quality control
in SMBG, and
- any psycho-social concerns.
