Preconception Care for Women With Diabetes: A Review of Current Guidelines
Preconception Care for Women With Diabetes: A Review of Current Guidelines
A key finding of this review is that all the guidelines selected for comparison are of high quality and highly recommended for use in practice. Secondly, the guidelines share consistency regarding counselling about the risk of congenital malformation related to uncontrolled blood sugar preconceptionally and the use of effective contraception until good blood sugar control is achieved. Despite general agreement in all categories of recommendations, there is a lack of specific practice based recommendations in certain areas. These include which type of contraception is most suitable and how long before conception folate supplementation should be started. While medication review and advice to stop ACE inhibitors is consistently given by all the guidelines, alternative antihypertensives that are safe in pregnancy are only suggested by ADIPS, however, there is considerable evidence supporting the use of methyldopa, oxprenolol, clonidine, labetalol, prazosin and nifedipine in pregnancy.
Key differences observed in the recommendations are target levels of HbA1C to be achieved prior to pregnancy. Aiming the HbA1C level at < 1% above the upper limit of normal (generally < 7%) is recommended in preparation for pregnancy. However, there is evidence of better outcomes if the HbA1C is maintained within the normal range or lower during early pregnancy. In view of this, NICE has chosen the lower value at HbA1C as < 6.1% as a target.
Blood glucose self monitoring is recommended by all the guidelines; however the target levels are again different. When considering the two suggested targets, it may be more helpful to women to use the more specific one (pre-meal at between 4.4–6.1 mmol/l and 2 hour after meal < 8.6 mmol/l).
Deterioration of diabetic complications is another concern in pregnancy among diabetic women. As recommended by all guidelines, evaluating and treating diabetic complications are important actions to undertake before conception. However, not all guidelines outline all the possible complications that need to be evaluated. This may lead to inconsistency in practice amongst physicians.
The other obvious differences in the recommendations are in the use of oral hypoglycaemic agents. Though the safety of currently available oral antidiabetic agents (metformin and glyburide) during pregnancy looks promising, the complete safety and efficacy profile during the full term of pregnancy has not yet been established As such it is recommended to be used as an alternative by ADA 2009, ADIPs and NICE in situations such as refusal of the patient to use insulin or insulin resistance, when the likely benefits from improved glycaemic control outweigh the potential for harm.
Counselling is a major component of preconception care. The feasibility of routine incorporation into all practice visits need to be considered. Diabetic women are more likely to be engaged with health system and therefore there are more opportunities for delivery of preventive care. On top of specific counselling for diabetic women with pregnancy, general preconception care for women should not be forgotten and should include depression screening, genetic and family history risk assessment, immunisation, smoking cessation advice, advice regarding reducing alcohol intake, weight management and exercise.
A strength of this review is that all guidelines reviewed in this series are of high quality and highly recommended to be used as practice guidelines according to a respected and validated assessment tool- the AGREE instrument. The limitation of this review is the omission of non-English language guidelines.
Discussion
A key finding of this review is that all the guidelines selected for comparison are of high quality and highly recommended for use in practice. Secondly, the guidelines share consistency regarding counselling about the risk of congenital malformation related to uncontrolled blood sugar preconceptionally and the use of effective contraception until good blood sugar control is achieved. Despite general agreement in all categories of recommendations, there is a lack of specific practice based recommendations in certain areas. These include which type of contraception is most suitable and how long before conception folate supplementation should be started. While medication review and advice to stop ACE inhibitors is consistently given by all the guidelines, alternative antihypertensives that are safe in pregnancy are only suggested by ADIPS, however, there is considerable evidence supporting the use of methyldopa, oxprenolol, clonidine, labetalol, prazosin and nifedipine in pregnancy.
Key differences observed in the recommendations are target levels of HbA1C to be achieved prior to pregnancy. Aiming the HbA1C level at < 1% above the upper limit of normal (generally < 7%) is recommended in preparation for pregnancy. However, there is evidence of better outcomes if the HbA1C is maintained within the normal range or lower during early pregnancy. In view of this, NICE has chosen the lower value at HbA1C as < 6.1% as a target.
Blood glucose self monitoring is recommended by all the guidelines; however the target levels are again different. When considering the two suggested targets, it may be more helpful to women to use the more specific one (pre-meal at between 4.4–6.1 mmol/l and 2 hour after meal < 8.6 mmol/l).
Deterioration of diabetic complications is another concern in pregnancy among diabetic women. As recommended by all guidelines, evaluating and treating diabetic complications are important actions to undertake before conception. However, not all guidelines outline all the possible complications that need to be evaluated. This may lead to inconsistency in practice amongst physicians.
The other obvious differences in the recommendations are in the use of oral hypoglycaemic agents. Though the safety of currently available oral antidiabetic agents (metformin and glyburide) during pregnancy looks promising, the complete safety and efficacy profile during the full term of pregnancy has not yet been established As such it is recommended to be used as an alternative by ADA 2009, ADIPs and NICE in situations such as refusal of the patient to use insulin or insulin resistance, when the likely benefits from improved glycaemic control outweigh the potential for harm.
Counselling is a major component of preconception care. The feasibility of routine incorporation into all practice visits need to be considered. Diabetic women are more likely to be engaged with health system and therefore there are more opportunities for delivery of preventive care. On top of specific counselling for diabetic women with pregnancy, general preconception care for women should not be forgotten and should include depression screening, genetic and family history risk assessment, immunisation, smoking cessation advice, advice regarding reducing alcohol intake, weight management and exercise.
A strength of this review is that all guidelines reviewed in this series are of high quality and highly recommended to be used as practice guidelines according to a respected and validated assessment tool- the AGREE instrument. The limitation of this review is the omission of non-English language guidelines.
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