With no less than 42 (!) recommendations, this is the longest chapter in the 2018 Diabetes Canada Clinical Practice Guidelines. That’s because there is a lot to say about management of not only diabetes predating pregnancy, but also gestational diabetes (diabetes that develops in pregnancy).
As a summary of this chapter is beyond the scope of a blog post due to its length, I have picked out some of the key pearls to share here.
1. Key Messages for women with diabetes who are pregnant or planning a pregnancy – this is a completely new section, and a must read not only for women with diabetes, but also women at risk for gestational diabetes.
2. Contraception for women with diabetes is ESSENTIAL, until both the woman and her health care providers agree that she is safe and ready for pregnancy. There are many steps to be taken that must be in place before any attempts at pregnancy. This includes having good and stable blood sugar control, ensuring no unsafe medications are on board, vitamin supplementation, and eye checks.
3. A1C target pre pregnancy should be 7% or less, and ideally 6.5% or less if it can be achieved safely (without low blood sugars).
4. A1C target during pregnancy should be 6.5%, and ideally 6.1% or less if it can be achieved safely (without low blood sugars).
5. Folic acid 1mg should be started 3 months pre pregnancy, and continued until at least 12 weeks of pregnancy (the 2013 Guidelines recommended more)
6. Women on metformin or glyburide for type 2 diabetes with good control can continue these medications until pregnant. Once pregnant, it is recommended to switch to insulin. (the previous guidelines recommended that all women with type 2 diabetes should be switched to insulin and stabilized on insulin prior to pregnancy). Metformin use during pregnancy in women with type 2 diabetes is currently under active study.
7. Recommendations for appropriate weight gain in pregnancy are based on pre pregnancy BMI.
8. Screening for gestational diabetes is recommended for all women at 24-28 weeks of pregnancy, with the preferred method being a 50g glucose challenge as the initial test. Women who are at increased risk of gestational diabetes should have blood testing for diabetes at the first pregnancy visit.
9. For women with gestational diabetes, testing for diabetes after pregnancy remains essential.
10. New recommendations for fetal surveillance and timing of delivery are provided.
I emphasize again that there are many other changes and expansions of recommendations in this chapter of the guidelines – anyone practicing in this area of diabetes care is encouraged to embrace the chapter in its entirety.