33 and given appropriate advice about contraception at each diabetes review . This also applies to any woman in this age group who has a new diagnosis of diabetes ; if planning pregnancy , they should be advised to continue with contraception until a specialist consultation can be arranged to provide preconception advice .
A woman considering pregnancy must be supported to aim for target glucose control before conceiving , to reduce the risks of complications . This may include a care plan for weight loss , as well as steps to improve HbA1c levels .
Primary care clinicians also have an essential role in identifying women at high risk of type 2 diabetes , and this includes those who had gestational diabetes in a previous pregnancy . These patients should undergo annual HbA1c checks and be considered for referral to the NHS Diabetes Prevention Programme ( NDPP ) or NHS Digital Weight Management Programme . 5 , 6 For women at high risk who are planning pregnancy , HbA1c screening can be done every six months instead of yearly . This should help prevent these women from going on to develop diabetes , but will also ensure they are referred promptly for specialist support if they do .
Preconception blood glucose levels NICE guidelines recommend that women with an HbA1c above 86 mmol / mol should be strongly advised against pregnancy until their level is lowered , due to the risk of major foetal anomalies . 4
Women with type 1 diabetes planning pregnancy should be advised to aim for their usual recommended pre-breakfast fasting blood glucose target of 5-7 mmol / l and a glucose level of 4-7 mmol / l before meals at other times of the day .
Women with either type 1 or 2 diabetes who are planning a pregnancy should aim to keep their HbA1c below 48 mmol / mol ( 6.5 %). Where there are concerns about achieving this without problematic hypoglycaemia , advice should be sought from the secondary care diabetes team .
Diabetes reviews in women planning pregnancy The frequency of routine diabetes reviews before conception will depend on the woman ’ s needs . If HbAc1 is within the individual ’ s target range , review can be every four to six months ; if not , it will need to be more frequent , depending on the amount of support needed . Refer patients struggling to achieve targets to the local specialist diabetes team .
Diabetes reviews will usually check blood HbA1c levels , lipid levels , and liver and renal function ( urinary or blood albumin / creatinine ratio ). However , a woman planning pregnancy should undergo additional blood tests , such as full blood count , ferritin , folate and thyroid function , to help identify potential complications early .
Encourage home blood pressure monitoring , especially in women with a history of hypertension , in whom the target should be < 130 / 85mmHg . 7
It is important to emphasise that diet and lifestyle choices , including sleep hygiene and adequate hydration , are central to achieving optimal glycaemic and blood pressure control and to weight management . Referral to a dietitian or education programme can support self-management in this respect .
Medications and supplements Women with diabetes are at increased risk of having a baby with a neural tube defect such as spina bifida , and are advised to take a high-dose folic acid supplement to
References 1 NHS Digital . The National Pregnancy in Diabetes Audit . bit . ly / 3BM0H7y 2 Macintosh M et al . Perinatal mortality and congenital anomalies in babies of women with type 1 or type 2 diabetes in England , Wales , and Northern Ireland : population based study . BMJ 2006 ; 333:177 3 Lascar N et al . Type 2 diabetes in adolescents and young adults . Lancet Diabetes Endocrinol 2018 ; 6:69-80 4 NICE . Diabetes in pregnancy : management from preconception to the postnatal period . 2015 . nice . org . uk / ng3 5 NHS England . NHS Diabetes Prevention Programme . bit . ly / 35hH0Zb 6 NHS England . The NHS Digital Weight Management Programme . bit . ly / 3pfqnEz 7 NICE . Hypertension in pregnancy : Diagnosis and management . 2019 . nice . org . uk / ng133 8 NHS England . Vitamins , supplements and nutrition in pregnancy . bit . ly / 3M1GUpu 9 Bellamy L et al . Type 2 diabetes mellitus after gestational diabetes : a systematic review and meta-analysis . Lancet 2009 ; 373:1773-9
ONLINE Scan the QR code to read the full article with references and complete the module . Alternatively , visit nursinginpracticelearning . co . uk reduce this risk . Clinicians should ensure that preconception and prenatal advice includes prescribing folic acid 5mg daily . 4 Vitamin D should also be recommended as part of NHS recommendations for nutrition in pregnancy . 8
Medications that should be stopped , or changed to a safer alternative before conception ( under the direction of the specialist team ) include :
• Statins ( three to six months before conception ).
• Antihypertensives ( one month before ); ensure a switch to one that is safe in pregnancy .
• Diabetes medications , including sulfonylureas , GLP-1RAs , SGLT-2 inhibitors , DPP-4 inhibitors , pioglitazone and acarbose . 4 These must be switched to insulin using a multiple daily injection regimen . This does not include metformin .
Women taking any of these who have an unexpected pregnancy and wish to proceed with it must be referred urgently to the joint antenatal clinic and local consultant diabetologist to manage changes to their medications .
Women who become pregnant unplanned while using metformin can continue this medication , however . 4 If a woman without diabetes is on metformin for polycystic ovary syndrome ( PCOS ), then she can safely continue it ; women with PCOS are often insulin resistant and at increased risk of gestational diabetes .
Diabetes management during pregnancy Once pregnancy is confirmed in a woman with pre-existing diabetes , primary care nurses should refer the woman urgently to the joint diabetes and obstetrics antenatal clinic for an early viability scan and assessment of diabetes and its management .
Under the antenatal clinic , the woman will be reviewed by the diabetes or obstetrics team every two to four weeks , unless there is a need for her to be seen more frequently .
Primary care should not need to be involved with diabetes management during the patient ’ s pregnancy . If there are any concerns , then the secondary care diabetes team should always be at hand to provide support throughout the pregnancy .
Postpartum input from the primary care team During pregnancy , insulin requirements increase as placental hormones cause insulin resistance . After the birth , insulin requirements drop immediately . Women with pre-existing type 1 diabetes will be advised about insulin medication by the secondary care diabetes team . However , women with type 2 diabetes will often be discharged back to primary care . Those who are not breastfeeding can be restarted on oral medications and stop insulin . Those with type 2 diabetes who choose to breastfeed may need to continue metformin or insulin . If continuing input from secondary care is needed , then patients can be referred back as clinically appropriate .
Women with pre-existing diabetes should undergo early review with their diabetes team and be offered contraceptive advice . While gestational diabetes usually reverts to normal glucose tolerance postpartum , the majority of women with gestational diabetes develop type 2 diabetes over the subsequent 20 years . 9 All women with gestational diabetes should therefore be offered postnatal assessment for diabetes ; consider referral to the NDPP if required . 5
Reena Patel is a practice nurse in Leicester and Dr Sarah N Ali is a consultant diabetologist in London