Each January I look forward to reading The Standards of Medical Care in Diabetes (previously Clinical Practice Recommendations) published by the American Diabetes Association. The recommendations are evidence based, reviewed by a wide variety of experts and provide the basis on which to make clinical decision to help our patients with diabetes. This year a new section was added on the Management of Diabetes in Pregnancy. The guidelines are in bold followed by suggestions on how I see they can be incorporated into the role of the diabetes educator.
Provide preconception counseling that addresses the importance of tight control in reducing the risk of congenital anomalies with an emphasis on achieving A1C < 7, if this can be achieved without hypoglycemia.
This is such a critical area and must be emphasized “pre-conceptually”. I have become much more open discussing the importance of optimal blood glucose management prior to pregnancy with my teenage patients with type 1 diabetes. All women of child bearing age can benefit from a reminder that blood glucose control does matter – big time. In addition to our patients with type 1 diabetes, it is important to have this conversation with women with prediabetes and type 2 diabetes as well. I make it a point to review the information on an ongoing basis.
Potentially teratogenic medications (ACE inhibitors, statins, etc.) should be avoided in sexually active women of childbearing age who are not using reliable contraception.
Reviewing medications with the patient and contacting the HCP if there is a conflict is part of the responsibility of the diabetes educator. This is a pertinent issue for all women with diabetes taking these medications so they understand the potential risks if they do become pregnant.
GDM should be managed first with diet and exercise, and medications should be added if needed.
There is no controversy in regards to this recommendation. However, the optimal quantity of carbohydrates per meal continues to be an ongoing discussion. Exercise is a powerful tool to help maintain normal BG in this population and can be tolerated by almost all women during pregnancy.
Women with pre-gestational diabetes should have a baseline ophthalmology exam in the first trimester and then be monitored every trimester as indicated by degree of retinopathy.
The role of the diabetes educator in this area is to ask the question, “have you had a recent ophthalmology check-up and if so when” to make sure this area of concern is addressed as early as possible and that a follow up referral is made if this has not yet been completed.
Due to alterations in red blood cell turnover that lower the normal A1C level in pregnancy, the A1C target in pregnancy is <6% if this can be achieved without significant hypoglycemia.
Continuing to review and evaluate BG patterns and A1C results during pregnancy and coaching adjustments in food intake and exercise is an integral part our practice. Insulin adjustments may also be a part of the role of the diabetes educator depending on practice agreements.
Medications widely used in pregnancy include insulin, metformin, and glyburide; most oral agents cross the placenta or lack long-term safety data.
This is a good conversation to have with women prior to conception. Reviewing medications prior to and during pregnancy will help to reduce the risks of an inappropriate medication being taken during gestation.
Helping women achieve the best care during their pregnancy includes supporting their efforts at excellent BG control. These recommendations reinforce the care we know we need to provide to all women of reproductive years who have diabetes. This is a time where women, even some of our most challenging, are receptive to recommendations and we need to be there! Listening to their concerns, providing education, monitoring BG outcomes and helping to support their goals during pregnancy is a truly rewarding part of our job!