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Preconception counseling encourages women with diabetes to plan for healthy baby
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For women wishing to start a family, various health factors may be considered before conception. Women might adopt a healthy diet, begin taking prenatal vitamins or discontinue habits such as smoking or drinking alcohol. These healthy behaviors not only increase the odds of conception, but also can reduce risks for poor pregnancy outcomes.
For women with pre-existing diabetes, the importance of careful planning aimed at healthy pregnancy outcomes is even greater. Both type 1 and type 2 diabetes are linked to increased risks for miscarriage, fetal anomalies, preeclampsia, preterm delivery and fetal death, among others.
The risks for fetal anomalies are in direct proportion to HbA1c during the first 10 weeks of pregnancy, according to Jamie Jadid, NP, CDE, who works with patients at the High Risk Pregnancy Center in Las Vegas. Although maintaining HbA1c between 6% to 6.5% is critical during early pregnancy, the ideal time to get blood glucose under control and begin minimizing risks is before conception, Jadid told Endocrine Today.
“The most important thing we can do for people with diabetes who are planning a pregnancy is to educate them about the risks of uncontrolled diabetes with pregnancy,” she said.
Preconception counseling can play an important role in encouraging women to improve their health and limit dangers to their babies.
Counseling begins in puberty
Women with diabetes should be made aware of their pregnancy risks well before they consider having children.
“It is important that women with diabetes use effective contraception until they are ready to conceive,” Jadid said.
The early gestation period is particularly crucial to the healthy development of a fetus. For this reason, unplanned pregnancies may confer additional risk.
“A lot of women don’t even know they’re pregnant when they’re only 6 or 8 weeks,” Jadid said. “If they’re following up with their endocrinologist trying to get their blood sugars under control, they’re behind the ball.”
Often, by the time a woman sees an obstetrician, she is likely even farther along in her pregnancy, and the fetus has been exposed to harmful glucose levels during important development stages between 6 and 12 weeks, Jadid said.
The American Diabetes Association recommends that women receive preconception counseling beginning in puberty and yearly thereafter. Women with type 2 diabetes are more likely to have poorer pregnancy outcomes than those with type 1 diabetes. Jadid said this may be because the women with type 1 diabetes have likely already had a long history of preconception counseling
“Often, people with type 1 diabetes are diagnosed when they’re younger, so they’ve had their pediatricians warning them not to get pregnant unless their sugars are controlled,” she said. “These women have been aware of the risks since puberty.”
Obstacles for providers
Because preconception counseling is clearly beneficial, it might be assumed that it is routinely implemented. However, various obstacles may prevent clinicians from initiating this valuable practice.
Angela Magdaleno, DO, an internal medicine specialist at Lehigh Valley Health Network in Allentown, Pennsylvania, and colleagues found gaps in the provision of preconception counseling. Their study, presented at the Endocrine Society Annual Meeting in March, sought to determine how many women received preconception counseling from physicians in family medicine, internal medicine or OB-GYN within their health network. The researchers also sent a survey to these providers to identify barriers to preconception counseling.
Study participants included women aged 18 to 35 years with type 1 or type 2 diabetes who had a nonacute office visit with either a family medicine, internal medicine or OB-GYN provider between June 2014 and June 2016.
The researchers found that of 577 patient charts evaluated, 109 of the patients (18.9%) received preconception counseling during an office visit within the study interval. A statistically significant association was seen between specialty and the use of preconception counseling. Obstetrics visits had the highest percentage of women who received preconception counseling (36.1%) vs. family medicine (7.1%) and internal medicine (9.8%).
Of the 524 electronic surveys sent to providers, 97 were completed and returned (18.5%). The responses indicated that providers would like more time during an appointment to discuss preconception counseling and that unplanned pregnancies are a barrier to effective counseling. They further indicated that providers would prefer that the patient introduce the topic of preconception counseling.
“We found this surprising, since we thought providers should take the lead in opening these discussions,” Magdaleno told Endocrine Today.
The study concluded that Lehigh Valley Health Network was not meeting ADA’s guideline for preconception counseling.
“The fact that Lehigh Valley Health Network is not meeting this recommended standard of care increases the risk for gynecologic, obstetric and fetal health complications for women with diabetes and their children,” Magdaleno said. “In regard to other health systems, an article published in Diabetes Care in 1995 stated that approximately one-third of women with diabetes mellitus received preconception counseling. Therefore, the low rate of preconception counseling is likely an issue at other, similar health systems as well.”
Magdaleno said the correlation between obstetrics providers and a higher rate of preconception counseling is likely multifactorial but pertains to provider and patient comfort with the topic.
“Obstetrics providers receive more training and education on providing preconception counseling and are exposed to more pregnancies complicated by diabetes,” Magdaleno said. “Obstetrics providers interact with more women trying to conceive, which is an ideal opportunity to initiate preconception counseling. Patients also likely consider pregnancy an area of expertise for obstetrics providers, and therefore, patients may feel more comfortable initiating discussions with that provider.”
One of the study’s most disconcerting findings, Magdaleno said, was a discrepancy between physician perceptions about preconception counseling and reality.
“According to the survey, providers believe they are initiating preconception counseling more often than they actually do,” she said. “Due to the nature of a retrospective chart review, it is unknown if counseling is being performed more frequently than documented. However, it is concerning that providers are discussing preconception counseling at a much lower rate than they perceive.”
Details of the discussion
According to Jadid, the specific points covered in preconception counseling may vary, but the single consistent piece of advice is to ensure that a pregnancy is planned.
“At the end of the day, my message is the same: Educate women about the risks, and emphasize the importance of contraception until they’re ready,” she said.
Jadid said women with type 2 diabetes should also be aware that weight loss motivated by a desire to control blood glucose may make them more fertile, which can lead to an unplanned pregnancy.
When a patient says she is planning a pregnancy and asks for advice, Jadid said, her recommendations would depend on the patient’s goals, the type of diabetes, and the current level of diabetes control.
“If we’re talking about people with type 1 diabetes, they’re already going to be on insulin, so we can just increase their insulin doses,” she said. “We then have to look at other things that are affected by diabetes, like the kidneys, heart disease, thyroid disease, because these can also affect pregnancy. If they need those medications adjusted, we make sure their kidneys can handle a pregnancy.”
For patients with type 2 diabetes, who may not take insulin, it is necessary to switch their regimen to insulin in anticipation of pregnancy. Jadid said she also takes into consideration the potential comorbidities that may be seen in patients with type 2 diabetes.
“Somebody with type 2 is more likely to be overweight, and they might be more likely to have heart disease or high cholesterol, maybe high blood pressure,” she said. “So, we would switch their medicines over to medicine that is safe to use in pregnancy.”
Obesity confers an independent risk for adverse pregnancy outcomes, and women with obesity should also carefully avoid unplanned pregnancy, Jadid said.
“There are risks similar to a woman who has diabetes, but just based on obesity by itself,” she said.
ADA recommends that women take prenatal vitamins with at least 400 µg folic acid before conception. In terms of dietary changes, Jadid recommends an increase in protein to about 80 g daily. A daily 300- to 500-calorie increase is also recommended.
“Most of that is protein and a few extra carb servings to given them a bit of extra nutrition to nourish the baby while still controlling blood sugars,” Jadid said.
The amount of time before conception that a woman should begin making these changes depends upon their glycemic control.
“Some people have it controlled well and need just a few tweaks to get it down,” Jadid said. “Other people, it might take 4 or 5 months to get ready. At least a couple of months ahead of time is a good idea.” – by Jennifer Byrne
Reference:
Manglitz A, et al. SAT-724. Presented at: The Endocrine Society Annual Meeting; March 17-20, 2018; Chicago.
For more information:
Jamie Jadid, NP, CDE, can be reached at 2011 Pinto Lane, Suite 200, Las Vegas, NV 89106-4004; email: jjadid@hrpregnancy.com.
Angela Magdaleno, DO, can be reached at 1627 Chew St., Floor 1, Allentown, PA 18102; email: angela.magdaleno@lvhn.org.
Disclosures: Jadid and Magdaleno report no relevant financial disclosures.