Introduction
Preconception
Table 1 | Preconception checklist |
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Achieve optimal glycemic control | HbA1C < 7 % and as close to 6 % as possible without hypoglycemia -Patients should be on basal-bolus regimen with MDI or continuous subcutaneous insulin infusion -Target glucose: fasting 80–110 mg/dl, 1 h postmeal 100–155 mg/dl |
Medication assessment | Safety for pregnancy should be assessed -If patient on glargine, switch to detemir -Discontinue statins -Consider stopping ACE-I and ARB in most cases |
Medical nutrition counseling | Optimize accuracy of carbohydrate counting for glucose control -Focus on consistent timing and quality of healthy meals |
Blood pressure control | Goal <140/90, use an agent acceptable in pregnancy |
Dilated retinal exam | Evaluation of retinal status -Treatment and stabilization of proliferative diabetic retinopathy (PDR) before conception |
Nephropathy assessment | Check blood pressure (BP) measurements, serum creatinine, and urine microalbumin |
Thyroid assessment | Obtain preconception TSH -Goal preconception TSH < 2.5 in patients with known hypothyroidism |
Pregnancy
Table 2 | Pregnancy checklist |
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Achieve optimal glycemic control | HbA1C < 6 %, or as low as possible without hypoglycemia |
Medication assessment | Safety for pregnancy should be assessed -If patient on glargine, switch to detemir -Discontinue statins (ideally preconception) -Stop ACE-Is and ARBs (ideally preconception) -Aspirin 81 mg daily from 12–36 weeks (to help reduce risk of preeclampsia) |
Medical nutrition counseling | Optimize accuracy of carbohydrate counting for glucose control -Focus on consistent timing and quality of healthy meals |
Blood pressure control for chronic hypertension | Target blood pressure systolic blood pressure 110–129 mmHg and diastolic blood pressure 65–79 mmHg -Use an agent acceptable in pregnancy |
Dilated retinal exam | Approximately every trimester or more often if active retinal changes -Laser therapy is treatment of choice for PDR |
Nephropathy assessment | Preeclampsia may be difficult to distinguish from worsening diabetic nephropathy and hypertension |
Thyroid assessment | Goal TSH first trimester <2.5, 2nd, and 3rd trimester <3 -Increase LT4 dose by 30 % at conception and up to 50 % during pregnancy, usually during first 20 weeks -If patient euthyroid at conception and TPO antibodies positive, monitor TSH every 4–6 weeks during pregnancy In patients with previous history of Graves’ disease, target total T4 is 1.5 times upper range of normal to avoid fetal hypothyroidism. -Propylthiouracil is treatment of choice in first trimester, methimazole is treatment of choice in second and third trimester -Monitor thyroid receptor antibodies if maternal thyroid treated with RAI or surgery to assess for possible fetal exposure |