Diabetes Contraceptive and Pre-pregnancy Planning (DCAPP) for T1DM and T2DM

Pre-pregnancy Planning for Type 1 and Type 2 Diabetes

This pathway is for pre-pregnancy planning for women with existing diabetes. For management of diabetes in pregnancy, see Diabetes and Pregnancy pathway.

Red Flags

  • Unplanned pregnancy
  • Poor glycaemic control during pregnancy

Background

About pre-pregnancy planning for Type 1 and Type 2 diabetes

About pre-pregnancy planning for Type 1 and Type 2 diabetes

  • A significant proportion of pregnancies among women with type 1 and type 2 diabetes are unplanned.
  • Pre-pregnancy planning involves ascertaining whether a woman of reproductive age (< 50 years), with type 1 diabetes, type 2 diabetes, or other form of permanent diabetes, is sexually active, has suitable contraception in place, or is planning to become pregnant. All women:
    • not planning to fall pregnant should have the risks of unplanned pregnancy discussed and suitable contraception in place (including abstinence).
    • planning pregnancy (including those happy to become pregnant ‘should it happen’) should receive pre-pregnancy care.
  • The risk of adverse pregnancy outcomes (e.g. miscarriage, major congenital malformations and perinatal mortality) is proportional to the level of glycaemic control before pregnancy, reflected by the pre-conception HbA1c.
  • Preconception counselling and planning have been demonstrated to reduce the risk of adverse pregnancy outcomes by 50% to 75%.

Assessment

  1. For all sexually active women of reproductive age (< 50 years) with diabetes:
    • Ensure patients have a thorough knowledge of contraception options including emergency and long-acting contraception.
    • Advise that long-acting contraception (e.g., Mirena, Implanon, vasectomy, tubal ligation) is preferred over depot medroxyprogesterone acetate (DMPA) injection to prevent unplanned pregnancy.
    • Advise of the need for pre-pregnancy planning before they intend to become pregnant.
  2. Prior to pregnancy, discuss:
    • the importance of glycaemic control in pregnancy.
    • medicationsafety in pregnancy.

Medications not recommended in pregnancy

  • Oral hypoglycaemics other than metformin
  • Glargine insulin (Lantus)
  • Medications for blood pressure other than methyldopa and beta blockers (labetalol and oxprenolol)
  • Medications for cholesterol and hypertriglyceridaemia
  1. Arrange pre-pregnancy blood and urine screening, and suggest Pap smear if due.

Pre-pregnancy blood and urine screening

  • Rubella
  • Syphilis serology
  • Hepatitis B and C, and HIV
  • Blood type
  • TSH
  • HbA1c
  • FBC, iron studies
  • Creatinine and urine albumin:creatinine ratio

Management

Practice point

Women with pre-existing diabetes are considered high-risk and should be managed in a multidisciplinary diabetes in pregnancy clinic. Patients should be booked in urgently if already pregnant.

  1. Discuss continuing contraception to prevent pregnancy until the patient has optimal glycaemic control.
  2. Start folate supplementation.

Folate supplementation

  • Recommended dose in diabetes is 5 mg daily. Note that this is higher than the dose that is routinely recommended to pregnant women without any other risk factors.
  • Start at least 3 months before conception.
  1. Optimise glycaemic control for at least 3 months before conception.
    • Ideally HbA1c < 53 mmol/mol (7%) without causing hypoglycaemia.
    • Where severe hypoglycaemia is a risk, a higher HbA1c target may be required.
  2. Review medications for suitability in pregnancy:
    • Conception while taking potentially teratogenic drugs such as glucose, blood pressure, or lipid management is associated with adverse outcomes.
    • Oral hypoglycaemic agents are not recommended.
    • Metformin– specialist supervision needed.

Metformin

  • Remains controversial in pregnancy as it does cross the placenta.
  • Data suggest it is not teratogenic.
  • There are no significant long‑term data of infants to date.
  • Can be considered if insulin is not an option, or in addition to insulin if high doses are required.
  • The Australasian Diabetes in Pregnancy Society(ADIPS) does not currently recommend the use of metformin in pregnancy except under certain circumstances.
  • Do not stop metformin if a woman is already pregnant, as this may expose the embryo to sudden worsening of glycaemia.
  • Some women with type 2 diabetes may need to be commenced on insulin therapy.
  • Substitute anti-hypertensive medications such as ACEI and ARB with methyldopa or labetalol.
  • Stop statins and fibrates.
  1. Review dietary management.

Dietary review

  • Optimal dietary management, particularly carbohydrate and weight management, is essential to maintain good glycaemic control before and during pregnancy.
  • Suggest dietitianreview and advice.
  1. Screenfor diabetes complications.

Screening

  • Screen all women for complications before conception, including eyes, kidneys, and feet.
  • Consider a dental review.
  • If complications are present, a diabetes referralis recommended.
  1. Review management of hypoglycaemia, as this is more common in early pregnancy. The risk of life threatening severe hypoglycaemia is increased in the first trimester and requires careful insulin titration.
  2. Recommend involvement with a diabetes in pregnancy service (multidisciplinary team). Otherwise, recommend review with an endocrinologist, diabetes educator, and dietitian with special interest and experience in diabetes in pregnancy management. Ensure specialists are linked to the likely obstetric service should pregnancy occur.
  3. See preconception consultationfor general pregnancy planning management.

Request

Information

For health professionals

Australian Diabetes in Pregnancy Society (ADIPS):

For patients

Health Resource Directory.org.au factsheet available with content specific for south western Sydney.