Management of pregnancy in women with type 1 diabetes

Type 1 diabetes is increasingly common, thus affecting more women of childbearing potential. Inadequate glycemic control complicates pregnancy and can result in significant morbidity and mortality. Fetal consequences include congenital malformations, recurrent miscarriages, growth anomalies and stillbirth. Maternal consequences include worsening of diabetes vascular complications, pre-eclampsia, eclampsia and increased likelihood of caesarian section. Hence, pregnancies should be carefully planned in advance and managed by a multi-disciplinary team of experienced diabetologists, diabetes educators, and maternal-fetal medicine specialists. Educating the patient is the cornerstone of care. Preventing unplanned pregnancies, particularly in the context of uncontrolled diabetes, excellent glycemic control in the months leading to discontinuation of birth control, recognition and stabilization of associated co-morbidities and diabetic complications are some of the measures shown to improve pregnancy outcome in diabetes. During pregnancy, glycemic targets are typically set lower than the non-pregnant state (i.e., fasting blood glucose <90 mg/dL [5.0 mmol/L] and peak, 1 h post-prandial <120 mg/dL [6.7 mmol/L]) with a target glycated hemoglobin close to or possibly lower than 6%. Several insulin analogues are now approved for use in pregnancy, facilitating insulin administration, while many patients elect insulin pump therapy (with or without the addition of continuous glucose monitor sensing). Stringent glucose control is maintained through labor, and insulin requirements decrease to pre-pregnancy levels after delivery. Women who choose to pursue breastfeeding should be encouraged to do so, and supported by minimizing mother/baby separation and providing access to a lactation specialist.