1. Improve the chances of successful pregnancy

2. Prescreen women of childbearing age for any health risk before attempting pregnancy.

3. Minimize risk factors.

4. Treat or stabilize medical condition prior to conception.

5. Discuss concerns (medical, social or emotional) with patients/ spouses.

6. Make a plan for actions to be taken prior to, and during, pregnancy.

A clinician should view each visit of a sexually active woman of reproductive age as an opportunity for counseling and encouraging preventive care.

Windows of opportunity for counseling are:

• Visit for birth control

• Visit for negative pregnancy test

• Post -natal visit.

• Visit for gynaecological consultation, e.g. pruritis vulvae

• As a component of routine primary medical care, to all women of child bearing age

• Visit while accompanying spouse with chronic medical disease, e.g. diabetes

• Multi disciplinary, patient-centred care

• Educate about the need for good control of diabetes.

• Effective family planning; educate about fertile period

• Manage complications, esp. retinopathy and hypertension

• Detect and manage thyroid dysfunction.

• Review concomitant drug therapy and discontinue:

• • ACE (I)

  • ARBs-

  • Diuretics

  • Beta-blockers

  • Statins

  • Non insulin diabetes drugs

• Educate about breast feeding, long term treatment

• Complete history, physical exam & evaluation (Table 1)

Figure 1

Table 1: Laboratory and special exam components of the initial and subsequent evaluation of pregnant women with preexisting type 1 or type 2 diabetes (in addition to usual prenatal lab tests)(1)

*May be delayed or omitted if performed before pregnancy. LVH, left ventricular hypertrophy; QTc, Q-T interval controlled for heart rate;

Monitoring

• Target HbA1c as close to normal, without significant hypoglycemia

• Check HbA1c at initial visit, monthly until target < 6.0 is achieved, then quarterly.

• SMBG – begin, maintain & intensify regular self monitoring of blood glucose (SMBG) as much as possible.

• • Finger stick SMBG is best

  • 1 hour post prandial blood glucose (PPG) is best

• Urine ketones should be checked when indicated (Table 2)

Figure 2

Table 2

• Intensive regime is preferred.

• Regular insulin or aspart or lispro + NPH are preferred. NPH provides the basal component to control fasting glycemia, while rapid acting acting insulin controls post prandial peaks. Rapid acting analogues such as aspart and lispro have the advantage of better post prandial control flexibility of timing of injection (before or after meals), and less hypoglycemia.

• One may use premixed or NPH insulin if blood glucose levels are not very high.

• Abdomen and thighs are preferred sites.

• Insulin doses increase during pregnancy

• Stop OHAs in preconception period

• Shift to insulin; titrate dose before conception.

• Metformin and glibenclamide can be continued until insulin is started after diagnosing pregnancy.

• By dietician as well as other team members.

• Base energy intake according to

• • BMI

  • Physical activity

  • Fetal growth

  • Desire to prevent excess maternal gain

• 3+3 meal pattern should be advised, with 3 major meals and snacks per day. A late night snack is essential to prevent nocturnal hypoglycemia.

• Folic acid 400-600μg/day should be supplemented.

• Supplementary vitamin/mineral/trace element intake from food sources; but prenatal exogenous supplement should be considered if food intake is inadequate. Folate supplementation may mask signs of vitamin B12 deficiency.

• Vegetarian pregnant women may need vitamin D, Vitamin B12 supplements

• Diabetic women are encouraged to eat at least 2 meals of oily ocean fish/week, but should avoid eating fish high in methyl mercury (sword fish, king mackerel, shark, and tilefish)

• Daily exercise regime is necessary.

• Benefits of exercise include well being, less weight gain, less adiposity, better glycemic control, and better tolerance of labour.

• Upper limb exercises are safe, while exercise with abdominal strain should be avoided.

• Three-10 minute sessions, preferably after meals, daily should be encouraged. to all patients on an exercise prescription.

• Teach warning signs of hypoglycemia, imminent labour to all patients on an exercise prescription.

• Detect, and manage

• • Anxiety

  • depression

  • Eating disorders

• Utilization of non-pharmacological therapy

• • -Cognitive Behavioural therapy

  • -Relaxation therapy

• Tricyclic antidepressants are recommended for panic disorders in pregnancy.

• Aim for systolic blood pressure < 130 mm Hg and diastolic blood pressure < 80 mm Hg.

• Two or more agents at maximal doses will often be needed for optimal control

• Safe drugs are methyldopa, calcium channel blockers and labetalol. Clonidine and prazocin may also be used.

• Lifestyle therapy should be encouraged.

• Target LDL cholesterol < 100 mg % in women without overt cardiovascular disease (CVD) and <70 mg % in those with CVD.

• Statin and fenofibrate therapy should be discontinued

• Bile acid binding resins are approved for use in pregnancy.

• For diabetic pregnant women with triglyceride >1000 mg % treatment is indicated to reduce risk of pancreatitis. Add fish oil capsules to low fat diet to attain n-3 fatty intakes of 3-9 g / day

• Optimize glucose and blood pressure control

• Discontinue ARBs, ACE (1).

• Optimize glucose and blood pressure control

• Lower hyperglycemia slowly to near – normal over 6-month period in patient with proliferative or severe non-proliferative retinopathy before attempting pregnancy.

• Laser photocoagulation can be carried out if indicated, in preconception and in pregnancy

• Advise elective LSCS to women with proliferative diabetic retinopathy.

• Metoclopramide and erythromycin are safe for use in pregnancy, for gastro paresis

• Local Capsaicin and oral clonidine can be used for painful neuropathy

• Amitriptyline and nortriptyline can be used after the first trimester

• “Endocrine disruptors” reduce sperm quality and temporal trends reveal that male fertility, and sperm counts, are declining

• Exogenous supplements may be given e.g. coenzyme Q, lycopene, zinc l-carnitine

• Ensure sexual function is normal

• Preempt performance anxiety.