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MS WordPerinatologist Corner - C.E.U/C.M.E. Modules
Preconception Counseling for Women with Diabetes and Hypertension
Sponsored by The Indian Health Service Clinical Support Center
Step 10. Preconception Counseling - Put it all together
Appropriate preconception health care improves pregnancy outcomes. When started at least one month before conception, folic acid supplements can prevent neural tube defects. Targeted genetic screening and counseling should be offered on the basis of age, ethnic background, or family history.
Before conception, women should be screened for human immunodeficiency virus and syphilis infection and begin treatment to prevent the transmission of disease to the fetus. Immunizations against hepatitis B, rubella, and varicella should be completed, if needed. Women should be counseled on ways to prevent infection with toxoplasmosis, cytomegalovirus, and parvovirus B19. Environmental toxins such as cigarette smoke, alcohol, and street drugs, and chemicals such as solvents and pesticides should be avoided. In women with diabetes, it is important to optimize disease control through intensive management before pregnancy.
Medications for hypertension, epilepsy, thromboembolism, depression, and anxiety should be reviewed and changed, if necessary, before the patient becomes pregnant. Counseling about exercise, obesity, nutritional deficiencies, and the overuse of vitamins A and D is beneficial. Physicians may also choose to discuss occupational and financial issues related to pregnancy and to screen patients for domestic violence.
Preconceptional counseling for women with pregestational diabetes mellitus has been reported to be beneficial and cost-effective and should be encouraged. Because fewer than one third of women with diabetes mellitus seek preconceptional counseling, any visit to a health care provider should be used as an opportunity to review the aspects of diabetes management during pregnancy. Preconceptional counseling should focus on the importance of euglycemic control before pregnancy, as well as the adverse obstetric and maternal outcomes that can result from poorly controlled diabetes.
A search for underlying vasculopathy is advisable and, in selected patients, may include a retinal examination by an ophthalmologist, a 24-hour urine collection for protein excretion and creatinine clearance, and electrocardiography. Because up to 40% of young women with type 1 diabetes mellitus also may have thyroid dysfunction, thyroid function studies also should be obtained. Multi-vitamins containing at least 400 µg of folic acid should be prescribed to all women contemplating pregnancy. This is particularly important in women with diabetes given their increased risk of neural tube defects. Higher doses of folic acid may be beneficial in some cases, especially in the presence of other risk factors for neural tube defects.
Yet reproductive issues in an at risk population of women with diabetes are still not included in routine management of diabetes care or other chronic illnesses in outpatient clinics. In the meantime, the Centers for Disease Control and Prevention offer excellent resources for providers and patients.
Once the patient does become pregnant, then use of standardized guidelines for care of diabetes in pregancy and hypetension in pregnancy should be consulted.
In addition, the diabetes in pregnancy modules on this site look at screening and diagnosis for glucose intolerance during pregnancy, while the management and postpartum module discusses both management and prevention issues.
Resources for hypertension in pregnancy on this site include modules on mild pre-eclampsia, severe pre-eclampsia, and gestational hypertension and chronic hypertension in pregnancy.
