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In France, 0.2% of women who gave birth in 2021 had type 1 diabetes, and 0.3% had type 2 diabetes. Regarding preconception care, it is recommended that women with any type of diabetes achieve an HbA1c level of less than 6.5%. For women using continuous glucose monitoring (CGM), the recommended target range is 0.70-1.80g/L (3.9-10mmol/L), and it is recommended to achieve this range at least 70% of the time. The preconception assessment includes: 1) an HbA1c measurement, 2) an assessment of microangiopathic impact, 3) an assessment of macroangiopathic complications, 4) screening for associated cardiovascular risk factors, and 5) a TSH measurement in women with type 1 diabetes (T1D), as well as screening for obstructive sleep apnea syndrome during questioning in cases of type 2 diabetes (T2D) and obesity in women with T1D. To improve preconception glycemic control, implementation of a CGM system is recommended for all women with T1D. Implementation of automated insulin delivery (AID) in anticipation of pregnancy should also be discussed as part of a shared medical decision. For type 2 diabetes, treatment with metformin and/or insulin therapy is recommended if necessary. Other antidiabetic treatments should be discontinued before conception. The following is recommended: 1) Discontinuing statin and potentially teratogenic antihypertensive treatments, replacing them with treatments compatible with pregnancy; 2) systematically providing smoking cessation advice to women who smoke, offering support from a healthcare professional trained in tobacco addiction; and 3) starting folic acid supplementation at 0.4mg per day before conception. Finally, women of childbearing age should be regularly advised of the importance of planning their pregnancies during follow-up visits. They should also be provided with dietary care to improve glycemic control, and, in some cases, encouraged to lose weight prior to pregnancy. Women should be encouraged to engage in physical activity to improve glycemic control. Regarding care during pregnancy, the following metabolic targets are recommended: Fasting blood glucose should be less than 0.95g/dL (less than 5.3mmol/L), and postprandial blood glucose should be less than 1.20g/dL (less than 6.7mmol/L) two hours after eating. Time spent in the target range (0.63-1.40g/dL [3.5-7.8mmol/L]) should be greater than 70% for type 1 diabetes (T1D) and greater than 90% for type 2 diabetes (T2D). The HbA1c level should be less than 6% during pregnancy, and hypoglycemia should be limited as much as possible. An CGM is recommended for T1D during pregnancy. For women with T2D, an CGM is recommended or they should maintain multiple daily capillary self-monitoring of blood glucose as part of individualized management. For women with type 1 diabetes, treatment with an insulin pump infusion device (IUD) is recommended during pregnancy. For type 2 diabetes, insulin therapy is recommended. The addition or continuation of metformin should be discussed on a case-by-case basis, depending on the diabetes phenotype and glycemic control. Regular monitoring by a diabetes specialist and monthly monitoring by an obstetrician-gynecologist, in collaboration with a maternity ward, are recommended from the first trimester. Depending on the patient's history, treatment, pregnancy progress, and glycemic control, monitoring may be intensified in the third trimester. Regarding ultrasound monitoring, an ultrasound should be performed between 36 and 37 weeks of gestation to assess fetal growth, guide the mode of delivery, and determine gestational age at birth. Regarding fetal heart rate monitoring, there is insufficient data to recommend its use in predicting fetal death. Similarly, there is insufficient data to recommend routine aspirin prescriptions during pregnancy to prevent maternal or perinatal morbidity. Prenatal treatment with corticosteroids is recommended according to the same indications as for non-diabetic women. This treatment involves close monitoring of maternal blood glucose control during hospitalization and an increase in the usual dose of insulin during the days following corticosteroid administration. Regarding acute diabetes complications, women who do not perceive their hypoglycemia should be identified to adapt monitoring and alert women with type 1 diabetes mellitus (T1DM) to the increased risk of hypoglycemia during the first trimester of pregnancy. Regarding diabetic ketoacidosis, capillary ketonemia should be measured when clinical signs of ketoacidosis are present (e.g., nausea, vomiting, and abdominal pain) and systematically when blood glucose levels are greater than or equal to 2g/dL (11mmol/L). Women should be screened for diabetic retinopathy (DR) through quarterly ophthalmological monitoring during pregnancy, which may increase to monthly monitoring if risk factors are present. An initial assessment of kidney function is recommended for screening for diabetic nephropathy before pregnancy or during the first trimester. If diabetic nephropathy is diagnosed, then monthly monitoring is recommended. In cases of high blood pressure, the target blood pressure should be below 140/90mmHg. In the context of pre-existing diabetes, a cesarean section is recommended for delivery if fetal weight is suspected to be greater than 4,500g to reduce the risk of brachial plexus palsy and other associated neonatal injuries. Due to the risk of fetal mortality, delivery should be considered between 37 and 38+6 weeks of gestation. The gestational age at birth depends on the presence of comorbidities, blood glucose levels, and estimated fetal weight (macrosomia or intrauterine growth restriction). The obstetrician-gynecologist, anesthesiologist, and pediatrician should be present in the maternity ward during delivery. Recommended blood glucose targets during labor and delivery are 0.8g/L to 1.4g/L (4.4mmol/L to 7.8mmol/L). Monitoring can be performed using capillary blood glucose measurements or continuous glucose monitoring (CGM). Rapid-acting insulin is the preferred treatment for managing labor. According to an advance protocol agreed upon with the diabetes specialist, insulin can be administered via an insulin pump, IUD, continuous intravenous infusion, or multiple injections. In the event of glycemic imbalance, continuous intravenous insulin therapy should be used as rescue therapy. For postpartum management of T1D, a reduction in insulin doses is recommended in the immediate postpartum period. For women with T2D, oral or injectable antidiabetic drugs should be reintroduced. If the woman is breastfeeding, metformin is the only acceptable oral antidiabetic drug. Women should be informed during pregnancy about the benefits of breastfeeding, and breastfeeding should be actively supported if desired. Breastfeeding should be encouraged in the delivery room. If the woman wishes to use contraception in the immediate postpartum period, it is recommended that she be prescribed either long-acting reversible contraception (such as a copper or hormonal intrauterine device or a subcutaneous implant) or a microgestin-only pill. An initial consultation with a diabetes specialist should take place within six months after birth. Regarding neonatal care, active measures should be taken to prevent hypoglycemia, including: 1) thermoregulation (e.g., early skin-to-skin contact and rapid drying of the newborn after birth), 2) feeding within one hour of birth, and 3) encouraging breastfeeding if desired. Blood glucose monitoring should begin before the infant's second feeding and no later than 4hours after birth, or earlier if the infant exhibits symptoms such as tremors, hypothermia, or irritability. Monitoring should continue before each feeding every three hours for at least 24hours. Each team caring for these newborns should have a protocol for preventing, monitoring, and treating hypoglycemia. The child's medical record should indicate that the pregnancy occurred in the context of preexisting diabetes and specify the type of diabetes.
Published in: Gynécologie Obstétrique Fertilité & Sénologie
Volume 54, Issue 3, pp. 132-164