Preconception Counseling and Type 2 Diabetes

Editor's note: This is the first article in our newly revamped “Evidence-Based Clinical Decision Making” department. For more information about our new format and its rationale, please see the editorial on p. 69 of this issue.

Background and Clinical Problem: Preconception Counseling

Diabetes has been associated with pregnancy-related complications.^1,2 Rates of spontaneous abortion and perinatal mortality and the incidence of congenital anomalies in offspring of women with diabetes remain significantly higher than that of the background population. It is well accepted that achieving a level of glycemic control comparable to the nondiabetic population can decrease the incidence of adverse pregnancy outcomes. The American Diabetes Association (ADA)¹ and the American College of Obstetricians and Gynecologists² both recommend preconception counseling (PC) for all women with diabetes who have child-bearing potential.

The ADA¹ recommends that PC include the risks of congenital malformations associated with poor metabolic control and the use of effective contraception unless the woman is in good metabolic control. The goal for glycemic management is to obtain the lowest possible hemoglobin A_1c (A1C) level without undue risk of hypoglycemia, preferably an A1C that is < 1% above the normal range. It is also recommended that providers identify and treat complications of diabetes, such as nephropathy, retinopathy, hypertension, coronary artery disease, and neuropathy, before conception.³

The majority of women with diabetes, however, do not obtain PC and continue to have unplanned pregnancies. The majority of studies (Table 1)^4,5,7–19 report that up to 62% of women with type 1 diabetes received PC, whereas < 36% of women with type 2 diabetes received PC. In studies by Gunton et al.,^4,5the rate of women with type 1 diabetes having received PC improved significantly over time (from 18.9 to 62.5%), but a …