2.2.0.0 Pre­con­cep­tion Care

Pre­con­cep­tion vis­its should in­clude rubel­la, syphilis, hep­ati­tis B virus, and HIV test­ing, as well as Pap test, cer­vi­cal cul­tures, blood typ­ing, pre­scrip­tion of pre­na­tal vi­ta­mins (with at least 400 mg of folic acid), and smok­ing ces­sa­tion coun­sel­ing if in­di­cat­ed. Di­a­betes-‍specific test­ing should in­clude A1C, thy­roid-stim­u­lat­ing hor­mone, cre­a­ti­nine, and uri­nary albumin-to-cre­a­ti­nine ratio; re­view of the med­i­ca­tion list for po­ten­tially ter­ato­genic drugs, i.e., ACE in­hibitors (10), an­giotensin re­cep­tor block­ers (10), and statins (11,12); and re­fer­ral for a com­pre­hen­sive eye exam. Women with pre­ex­ist­ing di­a­bet­ic retinopa­thy will need close mon­i­tor­ing dur­ing preg­nan­cy to en­sure that retinopa­thy does not progress (13). Pre­con­cep­tion coun­sel­ing should in­clude an ex­pla­na­tion of the risks to moth­er and fetus re­lat­ed to preg­nan­cy and the ways to re­duce risk and in­clude glycemic goal set­ting, lifestyle man­age­ment, and med­i­cal nu­tri­tion ther­apy.

Sev­er­al stud­ies have shown im­proved di­a­betes and preg­nan­cy out­comes when care has been de­liv­ered from pre­con­cep­tion through preg­nan­cy by a mul­ti­dis­ci­plinary group fo­cused on im­proved glycemic con­trol (14-16). One study showed that care of pre­ex­ist­ing di­a­betes in clin­ics that in­cluded di­a­betes and ob­stet­ric spe­cial­ists im­proved care (17). How­ev­er, there is no con­sen­sus on the struc­ture of mul­ti­dis­ci­plinary team care for di­a­betes and preg­nan­cy, and there is a lack of ev­i­dence on the im­pact on out­comes of var­i­ous meth­ods of health care de­liv­ery (18).