© IDF (Europe) 1999

20 Pregnancy and contraception
21 Surgery and diabetes

TYPE 2 DIABETES - 20 - PREGNANCY AND CONTRACEPTION

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20 PREGNANCY AND CONTRACEPTION

Enquire :

• as to need for contraceptive advice if pregnancy not intended
• as part of Annual Review as to pregnancy intentions

Advise :

• on barrier methods, or low-dose oral contraceptives if low arterial risk
• not to discontinue contraception until adequate metabolic control achieved
• repeatedly the need for pregnancy planning
• on the intensity of diabetic pregnancy management, and the risks to the fetus

If pregnancy is intended :

• start folic acid
• stop oral glucose-lowering drugs ( consider insulin therapy )
• stop statins
• optimize blood glucose control ( Sections 8 and 11 ) :
  • self-monitoring targets :

    pre-prandial	: 3.5-5.5 mmol/l ( 65-100 mg/dl )
    post-prandial	: 5.0-8.0 mmol/l ( 90-145 mg/dl )

• assess and normalize ( <130/80 mmHg ) blood pressure :
  • replace ACE inhibitors with methyldopa / nifedipine / labetalol
• assess retina and treat as indicated
• review education and repeat as needed
• urge to stop smoking

If venous plasma glucose >6.0 mmol/l ( >=110 mg/dl ) at any time :

• perform 75 g oral glucose tolerance test
• manage as diabetes :
• if fasting plasma glucose >=7.0 mmol/l ( >125 mg/dl )
• or 2-h plasma glucose >=7.8 mmol/l ( >=140 mg/dl )

20.3 Pregnancy care

Organize joint obstetric care in a designated centre :

• include a diabetologist, a diabetes teaching nurse, a dietician, an obstetrician,
  a midwife, and a neonatologist

Provide support for continuing good blood glucose control :

• frequent review ( every 1-2 weeks )
• appropriate educational support
• regular self-monitoring of blood glucose with reliable system
• target blood glucose as close to normal as possible, while avoiding hypoglycaemia

self-monitored blood glucose	fasting	: 3.5-5.5 mmol/l ( 65-100 mg/dl )
	post-prandial	: 5.0-7.5 mmol/l ( 90-135 mg/dl )
glycated haemoglobin close to the upper limit of normal

• food intake
• weight controlling but adequate to maintain maternal and fetal nutrition
• frequent small meals may facilitate improved blood glucose control
• insulin therapy if blood glucose control remains above targets

Examine eyes each trimester

Provide regular obstetric care :

• ultrasound examination early and repeated for dates and fetal malformation
• fetal monitoring in later stages
• frequent antenatal review

Provide a normal safe delivery :

• deliver at term unless obstetric or diabetes risk
• deliver vaginally unless obstetric or diabetes risk
• provide optimal neonatal care :
• access to specialized neonatal intensive care
• neonatologists warned of expected delivery
• good blood glucose control during / after labour
• IV infusion of glucose and insulin with frequent blood glucose measurement
• cessation of insulin therapy at delivery if started during pregnancy
  ( and no suspicion of Type 1 diabetes )

If diabetes before pregnancy provide advice for post-pregnancy blood glucose control

If diabetes diagnosed in pregnancy :

• confirm remission at post-natal follow-up
• advise patient / family doctor of need for regular arterial risk factor review
  for rest of life

Evaluate quality of care

• monitor outcomes of pregnancy of women with diabetes
• compare outcomes with other diabetes services
• review any need for improvements in pregnancy care

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TYPE 2 DIABETES - 20 - PREGNANCY AND CONTRACEPTION

TYPE 2 DIABETES - 21 - SURGERY

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21 MANAGEMENT OF DIABETES DURING SURGERY

21.1 Organization

Prepare a local care protocol

Disseminate the protocol to relevant professionals

21.2 Management

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TYPE 2 DIABETES - 21 - SURGERY

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