Preconception health care reduces maternal, neonatal risk in diabetes

Issue: September 2016

SAN DIEGO — Comprehensive preconception health care that begins before a woman is even considering pregnancy offers the best chance to minimize both the maternal and neonatal risks associated with diabetes, according to a speaker here.

“Risks associated with diabetes and pregnancy are most effectively managed prior to conceiving,” Erin Raney, PharmD, BC-ADM, professor of pharmacy practice at Midwestern University College of Pharmacy-Glendale, Arizona, told Endocrine Today before a presentation at the American Association of Diabetes Educators annual meeting. “Thus, preconception care is important for all women and men of childbearing age, regardless of their immediate plans for pregnancy.”

Erin Raney

Women with diabetes have a greater risk for adverse pregnancy outcomes for both the mother and the neonate, Raney said. These risks include spontaneous abortion, preeclampsia and preterm labor, as well as fetal anomalies, macrosomia and neonatal hypoglycemia.

“These risks are reduced when pregnancy is planned at the point where glycemic control is maximized, and lifestyle and medication approaches are solidified prior to conceiving,” Raney said.

In a recent study examining the opportunities for preconception care in diabetes, researchers found that proper preconception counseling for women with diabetes could prevent more than 8,000 preterm births, almost 4,000 birth defects and almost 2,000 perinatal deaths each year, Raney said.

“So we have an immense opportunity,” Raney said. “No matter what setting we are all in and what discipline we represent, we interact with patients and family and friends who can all benefit from these concepts.”

According to recent CDC data, among all women of childbearing age, only 20% reported any preconception counseling in the year prior to pregnancy; about 30% reported the use of folic acid within 1 month prior to pregnancy; about 25% reported using tobacco within 3 months prior to pregnancy; 54.2% reported using alcohol within 3 months prior to pregnancy.

Additionally, about 45% of pregnancies in the United States are unintended, Raney said. In the diabetes population, numbers were improved; about 50% of women with diabetes prior to pregnancy reported receiving preconception counseling, Raney said.

“We have a lot of unintended pregnancies where we need to look at capturing that counseling opportunity in all settings,” Raney said. “All women of childbearing age deserve preconception consultation.”

A key question

Health care providers interacting with women of childbearing age need to ask one key question, Raney said: “Would you like to become pregnant in the next year?”

From there, a preconception plan should be based on whether a woman would like to become pregnant within the next year, is ambivalent about pregnancy within the next year, or does not desire to become pregnant within the next year, Raney said. Any plan should be based on the woman’s individual risk factors, including medical conditions, environmental exposures and tobacco or alcohol use, among other factors, and may include nutrition or supplementation recommendations, such as folic acid, vitamin D or calcium.

The ADA also recommends several preconception assessments for women with diabetes, including glucose control (HbA1c less than 6.5% prior to pregnancy is recommended), a renal function assessment (urinary albumin-to-creatinine ratio/serum creatinine), comprehensive eye exam, assessment of thyroid function, an HIV test and an up-to-date PAP test.

Medication safety

A preconception consultation should include a review of any medications a patient is taking for their risks associated with pregnancy, and, if possible, safer alternatives should be identified, Raney said. If high-risk medications are being used, Raney said, effective contraception should be recommended.

“It is very surprising to me how often the patient will say to me, ‘I don’t think my doctor would put me on anything that is unsafe,’” Raney said. “I try to empower patients to know that, when you are of childbearing age and you are receiving an acute or chronic medication, it is not likely that your pregnancy plans are considered, unless there is a specific initiative. The trust on the part of the patient, I’ve found, is quite surprising to me.”

If pregnancy is desired, Raney said, health care providers should plan a transition period for medications and optimize other factors associated with disease control.

There are limited clinical trial data on medication safety in pregnancy, and pregnancy risk categories, until recently, were oversimplified, Raney said.

“Additional research is needed regarding medication safety in pregnancy,” Raney told Endocrine Today. “We also need to broaden our awareness of best practices for the delivery of preconception care across all clinical settings in an efficient and effective manner.”– by Regina Schaffer

Reference: Raney E. S12. A Healthy Beginning: Diabetes and Preconception Health. Presented at: AADE 2016; Aug. 12-15, 2016; San Diego.

Disclosure: Raney reports no relevant financial disclosures.