Pre-Pregnancy Care for Woman with Type 2 Diabetes Mellitus

Article contributed by Ms Yong Lai Mee

The prevalence of Type 2 Diabetes Mellitus (T2DM) among women in childbearing age is increasing. Pre-existing T2DM in pregnancy increased the risk of maternal and neonatal complications such as macrosomia big baby), miscarriage, stillbirth, eclampsia (high blood pressure and its complications), and preterm labour. The American College of Obstetricians and Gynaecologists and the American Diabetes Association emphasized the importance of achieving optimum diabetes control for promoting the well-being of maternal and reduced prenatal fetus and baby adverse outcomes. Below are some tips to achieve optimum pre pregnancy diabetes care.

Blood Glucose Control

  • Keep pre pregnancy HbA1C < 6.5% to avoid complications during pregnancy.
  • Fetal mortality rate increased 4 folds in those with HbA1C >6.6%.
  • Poorly controlled pre pregnancy diabetes increases congenital heart diseases by 3 folds, neural tube defects increase by 4 folds and spontaneous miscarriages in 30-60% of all pregnancies.
  • Plan 4-6 months before pregnancy to ensure diabetes control is within target range.

Blood Glucose Monitoring

  • Aim for Fasting Blood Glucose < 6mmol/mol and 2 hours after meal <8mmol/L.
  • Check blood glucose daily, frequency 4 to 7 times daily include Fasting Blood Glucose and 2 Hour Post Meal and Bedtime.
  • Learn how to self check and monitor blood glucose.
  • Active involvement of care and self-care yield better diabetes control.

Healthy Dietary Plan

Consume an appropriate amount of carbohydrate to suit lifestyle, maintain blood glucose control and ideal body weight. The total amount of carbohydrate (CHO) intake can be monitored using grams, exchange list, household, or hand measures. Below is a table of practice guide recommended by American Diabetes Association. (Every exchange consists of 15g Carbohydrate). You can get more information from these links HERE and HERE

  • Plan for protein 15-20% total energy of the day such as lean meat, fish, chicken without skin or soy protein.
  • Limit total fat (25%-35% energy intake), saturated fats (<7% energy intake) and minimize trans-fat (<1% energy intake). Limit intake of saturated fat, such as red meat and processed meat consumption.
  • Have high fiber diet (20-30 gm fibre/day) by choosing plant-based foods such as vegetables, fruits, legumes and whole grain cereals.
  • Avoid consumption of sugar-sweetened beverage, replace it with plain water.
  • Follow the Malaysian Healthy Plate Model may help increase consumption of vegetables and fruits limit total fat (25%-35% energy intake), please see the diagram below.
  • Consult a dietician to develop an individualised dietary plan.

Physical Activities

  • Increased physical activity to improve diabetes control, weight maintenance, and reduce the risk of cardio-vascular disease.
  • Choose activities that likely to maintain e.g brisk walking.
  • Exercise at least 3 times/week, preferably most days of the week and with no more than 48-72 hours without physical activity.
  • The duration of exercise should be at least 150 minutes/week of moderate-intensity or at least 75 minutes/week of vigorous aerobic physical activity and at least 2 sessions per week of resistance exercise.
List of Moderate and Vigorous Activities
List of Moderate and Vigorous Activities

Obesity

  • Obesity increased the risk of T2DM development in children bearing age women.
  • The recommended ideal BMI is 18 to 23kg/m2 and waist circumference <80cm for women.
  • A Weight loss of >7% -10% of body weight within 6 months has been proven to be effective in reducing HbA1C. This can be achieved by :
  1. Reduce calorie intake of 500-1000kcal/day from baseline. Eg aim for an intake of 1200 to 1500 kcal/day.
  2. Increase exercise to ≥60 minutes per day/approximately 450 minutes per week.
  3. A combination of reduced-calorie diet, physical activity and behavior modification can provide greater initial weight loss.
  4. Use Meal Replacement Plans as part of the structured meal plan. The meal replacement product is usually a milk drink formulated with controlled quantities of calories and nutrients intended to substitute solid food meal. Check with the doctor for the meal replacement product.

Medication

1.Diabetic Medications

  • Oral diabetic medications are commonly prescribed for women with T2DM before pregnancy.
  • Metformin has minimal effect on the fetus but may increase the risk of prematurity and associated with larger offspring.
  • Sulphonylurea is associated with increased risk for baby developing low blood sugar level after delivery.
  • There was inadequate data to evaluate the safe use of Sodium-glucose Linked Transporter 2 (SGLT2) Inhibitors, Dipeptidyl Peptidase-4 (DPP4) Inhibitors and Glucagon-like Peptide-1 (GLP1 – injection) receptor agonists.
  • Due to the teratogenic (causing abnormalities to baby) effect of many oral diabetic medications, doctors preferred to switch diabetes treatment to insulin therapy prior to pregnancy.

2. Vitamins

Folic acid is important for pregnancy to prevent miscarriage and neural tube defects such as spinal bifida. Therefore, women should start taking it at least 3 months prior to pregnancy.

3.High Blood Pressure and Cholesterol Medications

  • High blood pressure medication such as ACE inhibitors, Angiotensin II receptor blockers (ARBs) and cholesterol medications like statins will be discontinued due to the teratogenicity effect.
  • Therefore, it is important to discuss with your doctor prior to embarking on pregnancy so that the high blood pressure medication can be switch to those that are proven safe in pregnancy.
  • It is important to monitor home blood pressure daily and document the readings.

4.Insulin therapy

  • Insulin is safe in pregnancy and not associated with fetal abnormalities.
  • Before pregnancy, an intensive insulin therapy is likely to be initiated in the form of a multiple-dose injection treatment to achieve good blood glucose target.
  • It is important to attend diabetes education session to learn the proper technique of insulin injection and understand how insulin work.

Eye Check

The risk of retinopathy progress may double during pregnancy.
Consult an Ophthalmologist for eye assessment. If eye problem is present, appropriate treatment will be provided.

Smoking and Alcohol

  • Women who smoke during pregnancy increased the risk of fetal death by 91%.
  • Alcohol consumption during the 1st-trimester increases the risk of abortion by 4 folds and precipitate preterm labor.
  • Quit smoking and alcohol prior to conception.

Vaccination

Vaccination is important to prevent communicable diseases. Vaccination is done according to the national clinical guideline recommendation. Click HERE for more info.

Preconception Counseling

  • Pre pregnancy diabetes counseling empowered individual with the knowledge of diabetes self-care. This session should be done at least 4-6 months before pregnancy allowing time for a medication review and lifestyle modification to achieve optimal glycaemic control.
  • See an Endocrinologist, a Diabetes Educator, and Dietician for the pre-pregnancy counseling.

Conclusion

Optimum pre-pregnancy Care in T2DM reduces the risk of complications during pregnancy. Pre-pregnancy care should be planned with a multidiscipline healthcare team at least 4-6 months prior to conception.

 

Article contributed by:

Ms Yong Lai Mee

President, Malaysian Diabetes Educators Society
Manager Diabetes Care Services/ Diabetes Educator
Subang Jaya Medical Centre

References and further reading:

  1. American Diabetes Association (ADA). (2020) Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes 2020. Diabetes Care. 43(Suppl. 1): S183-S192.
  2. American Diabetes Association (ADA). (2019) Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes 2019. Diabetes Care. 42(Suppl.1): S65-S172.
  3. Bashir, M., Dabbous, Z., Baagar, K. et. al. (2019) European Journal of Obstetrics & Gynaecology and Reproductive. 233:53-57.
  4. Bhuvaneswar, C.G., Chang, G., Epstein, L. A. and Stern, T. A. (2007) Alcohol use during pregnancy: Prevalence and Impact. Primary Care Companion Journal of Clinical Psychiatry. 9,6:457-470.
  5. Blum, A. K. (2016) Insulin use in pregnancy: An update. Spectrum. 29,2:92-97.
  6. Etomi, O. & Banerjee, A. (2018) The management of pre-existing (type 1 and type 2) diabetes mellitus in pregnancy. Medicine and Other Specialties. 46,12:731-737
  7. Klein, J., Boyle, J.A., Kirkham, R., et al. (2017) Preconception care for women with type 2 diabetes mellitus: A mixed-methods study of provider knowledge and practice. Diabetes Research and Clinical Practice. 129:105-115.
  8. Ministry of Health (2020). Clinical Practice Guidelines: Management of type 2 Diabetes Mellitus.
    Ministry of Health (MOH). (2017) Clinical Practice Guidelines: Management of Diabetes in Pregnancy.
  9. Miodovnik, M., Lavin, J.P., Knowles, H.C., et al. (1984) Spontaneous abortions among insulin-independent diabetic women. American Journal of Obstetrics and Gynaecologists. 150:372-375.
  10. National Institute for Health and Care Excellence (NICE). (2015) Diabetes in Pregnancy: management from preconception to the postnatal period. NICE Guideline NG3, recommendation 1.1.11.
  11. Nagandla, K., Somsubhra, D. and Sachchithananthan, K. (2013) Oral hypolgyceamia agents in pregnancy: Update. Journal of Obstetrician Gynaecology Indian. March-April, 63,2:82-87.
    National Institute for Health and Care Excellence (NICE) (2015) Diabetes in pregnancy: management from preconception to the postnatal period.
  12. Shearer, D. and White, A. (2018) Preconception Management of Diabetes. BC Medical Journal. 6,5: 253-257.
  13. Roman, M. (2011) Preconception care for women with preexisting type 2 diabetes. Clinical Diabetes. 29,1:10-16.
  14. Shearer, D., White, A., Thompson, D. and Pawlowska, M. (2018) Preconception Management in Diabetes. British Columbia Medical Journal. 60,5:253-257.
  15. Temple, R.C., Aldridge, A.J. and Murphy, H.R. (2006) Pre-pregnancy care and pregnancy outcomes in women with Type 1 Diabetes. Diabetes Care. 29,8:1744-1749.
  16. Tennant, P.W.G., Glinianaia, S.V., Bilous, R.W. et. al. (2013) Pre-existing diabetes, maternal Glycated haemoglobin, and risks of fetal and infant death: a population-based study. Diabetologia. 57: 285-294. https://doi.org/10.1007/s00125-013-3108-5.
  17. Unger, J. (2007) Diabetes Management in Primary Care. Lippincott William & Wilkins. New York.

To print a pdf copy, click HERE.

Uterine Prolapse (pelvic organ prolapse)

This refers to the descend of the uterus into the lower half of the vagina and beyond. In its most severe form, the whole uterus may be outside the vagina. Besides the uterus, other pelvic organ may descend as well such as bladder (cystocoele), rectum (rectocoele) and the small intestines (enterocoele).

Symptoms and signs

  • A lump is seen or felt at the opening of the vagina. It may be seen protruding outside of the vagina.
  • Vague discomfort or pressure in the pelvic region.
  • Backache that worsens with lifting.
  • Urination problems such as frequent and painful urination, difficulty in urination. occasional stress incontinence (urine leakage when laughing, sneezing or coughing), inability to control urination (uncontrollable urine leakage).
  • Difficulty in defecation.
  • Pain during or difficulty with sexual intercourse.
  • Abnormal per vaginal bleeding, usually arising from the exposed vagina wall and cervix.

Read moreUterine Prolapse (pelvic organ prolapse)

Vasectomy – Male contraception

The aim of a vasectomy is to prevent sperm from reaching the semen by disconnecting the sperm duct. The resulting ejaculate is therefore sperm-free, eliminating the risk of pregnancy. Sort of like a cheap shark fin soup without the shark fins (sperms).

Vasectomy is the contraception of choice for 6%–8% of married couples worldwide. Vasectomy is a minor procedure that provides effective and permanent contraception. In fact, it is far more effective than many other methods of contraception, including female sterilization.

Prior to a vasectomy, it is important and both husband and wife be present together to be counseled by a specialist on the implications of the procedure. It is important that the completeness of family is ascertained and that both husband and wife had discussed beforehand and agreed that it is the husband who should undergo a vasectomy to attain permanent contraception.

Read moreVasectomy – Male contraception

Lower Urinary Tract Infection (Lower UTI, cystitis)

Infection of the lower urinary tract occurs when the inner lining of the bladder becomes infected and the urine is full of bacteria. In pregnancy, 5 – 10% of women have bacteria in their bladder and some will have no symptoms at all.

How common?

Up to 40 – 50% of women will have at least one attack in their lifetime and 25% will have recurrences.

Causes

  • Bacteria can reach the bladder from the genital and anal area, or through the bloodstream.
  • Injury to the urethra or the bladder.
  • Prolonged use of a urinary catheter to empty the bladder, such as during childbirth or surgery.

Risk factors

  • Sexual activity.
  • Infection in other parts of the genitourinary system.
  • Pregnancy.
  • Poor hygiene.
  • Menopause.
  • Diabetes mellitus.
  • Underlying abnormalities of the urinary tract, such as tumours, calculi (stones), and strictures.
  • Incomplete bladder emptying.
  • During or after major surgery

Read moreLower Urinary Tract Infection (Lower UTI, cystitis)

How Pregnancy Affects the Feet

For every pregnancy journey, a mother or mother-to-be naturally experiences feelings of excitement and apprehension. In this 40-week period, a woman’s body goes through so many phases of change. Visible changes of increasing waistline and digits on the weighing scale are often coupled with swelling in the ankles and the presence of stretch marks. Internal observations will show pregnancy’s effects on metabolism, respiration, bone density, and the digestive system, to name a few.

As the body accommodates a nurturing and developing fetus, stark changes in the anatomy and physiology of a woman will occur. Throughout the course of these 9 months, such changes actually have an impact on every organ system in the body.

In this article, we will cover how pregnancy affects the feet. Swelling is a common occurrence during this phase. Also known as oedema, swelling can occur in different parts of the body though it largely occurs in the ankle region. Puffiness in the face or the hands is occasionally present. Dark spider veins, also known as varicose veins, often cause aesthetic concerns in women. Pregnancy is presumed to be a major contributing factor in its increased prevalence. Aside from its undesirable sight, this can also lead to cramps, heaviness, aching or numbness in the feet and calves.

Read moreHow Pregnancy Affects the Feet

Contraception – Male condom

The main purpose of contraception (or birth control) is to prevent an unplanned pregnancy. You should know and understand the different types of methods available to you, the risks and benefits of each, and any possible side effects, so that both you and your partner can able to make an informed choice. Contraception can be broadly divided into:

  1. Temporary or permanent methods – permanent birth control is accomplished through sterilization (tying or removal of the fallopian tubes) or hysterectomy (removal of womb / uterus). The rest of the methods are classified as temporary or reversible.
  2. Short term or long-term methods – short term methods are condoms and oral pills. Long term methods are injectables, intrauterine device and hormonal implants.

The condom is a sheath that looks like a small, elongated balloon and is usually made of thin latex rubber, polyurethane or natural membranes. The man wears this sheath over the erect penis during intercourse. The sheath will prevent the sperm from being deposited in the vagina following ejaculation. The condom may also be effective in preventing spread of some sexually transmitted infections (STIs) such as human immunodeficiency virus (HIV), chlamydia, gonorrhoea, genital warts etc. It is the only form of temporary birth control available for men.

Advantages

  • Generally effective for contraceptive use (88-98%), provided it is use in a proper and consistent way.
  • It is readily available, inexpensive, and easy to use. Women can buy and carry condoms.
  • No medical consultation is required to start using it. It can be purchase easily and widely available.
  • It provides good protection against some STIs.
  • There are no systemic side effects from condom use.
  • Since the condom prevent the deposition of semen in the vagina, the woman will have less leaking (discharge) following intercourse.

Disadvantages

  • There is a need for the condom to be available and the extra time and effort required to put in on prior to intercourse. This may decrease the spontaneity of sex for some couples.
  • It may lessen the women or male’s sensation since the penis does not touch the vaginal walls directly.
  • It may irritate the woman’s vagina due to the friction from the condom. The lubricant may or may not help in relieving it.
  • Some women or men can be allergic to the material used to manufacture the condom.
  • The condom may break or leak, resulting in unplanned pregnancy

General instructions for use

  • There are many brands of condoms and you should try to find the best fit for you. You should check the expiry date before using it. Be careful when opening the condom packet. You should not use teeth, sharp fingernails, scissors, or other sharp instruments to open it as these may damage the condom. Push the condom to one side and gently tear along the corner or edge. It should be easy to open the pack.
  • Once you remove the condom from the pack, check for defects such as holes, tears or if it feels unusual (stickiness), do not use it. Open another pack and repeat the steps above. You should not unroll the condom to check it because this could damage it and make it difficult to put it on.
    Use a new condom for every act of intercourse. Put the condom on after the penis is erect and before any contact is made between the penis and any part of the partner’s body.
  • If using a spermicide, put some inside the condom tip.
  • The teat end should be pointing up and you should always pinch the tip enough to leave a small space for semen to collect when you start rolling the rim of the condom over the penis until the base. The pinching will make sure to eliminate any air in the tip to help keep the condom from breaking.
  • If you are using water-based lubricant, you may put more on the outside of the condom.
  • After ejaculation and before the penis gets soft, hold the rim of the condom, and carefully withdraw the penis.
  • To remove the condom, gently pull it off the penis and make sure the semen does not spill out.
  • Dispose it in a proper way. Because condoms may cause problems in sewers, do not flush it down the toilet.
  • If the condom breaks, there is a chance you can become pregnant. You should consider taking emergency contraception or see your doctor immediately for advice. You should also get tested for STIs if you are not sure of your partner’s infective status.

To print a pdf copy, click HERE

 

Colposcopy

This is a microscopic examination of the cervix, vagina, or vulva. It is used to diagnose potential abnormalities of these areas, which sometimes cannot be seen with the naked eyes. The colposcope can magnify the tissue by up to 30 times, thus making it clearer and much more accurate in terms of surface evaluation. Therefore, the biopsy of the abnormal areas performed with a colposcopic examination is more accurate than those done without the use of a colposcope.

Why do I need a colposcopy evaluation?

  • It is usually recommended if you have an abnormal Pap smear (Thin Prep) test or when pre-cancerous lesion is suspected in the vagina or labia area.

Read moreColposcopy

First visit to the gynaecologist – what you should know

Health screening as a person ages is especially important. It should be your top priority even if you are healthy. In women, this will include a visit to the gynaecologist’s clinic and will help in identifying if the woman has increased risks for developing a disease or already has the disease or condition that was not previously known about. Early identification of risks factors can help in counselling and instituting remedial or preventive measures to reduce that risk. This may in fact help to prevent the disease from occurring. Likewise, early detection of disease and starting treatment as soon as possible will results in a better outcome and lower the risks of complications. For example, many women with ovarian cancer do not have symptoms until it is too late. However, prompt diagnosis at an early stage of ovarian cancer will give excellent outcome with surgery alone and may not even need chemotherapy at all.
Many women feel nervous or even afraid to see the gynaecologist, especially if it is their first visit. Seeing a gynaecologist is just like seeing any other doctor in other specialities such as your dentist or general practitioner. They are there to help you and you should take this as an opportunity to seek their help in taking care of your health.

Read moreFirst visit to the gynaecologist – what you should know