Ineffective management of blood glucose levels during preconception and pregnancy has been associated with severe maternal and fetal complications in women with pre-existing diabetes. Studies have demonstrated that preconception counseling and pre-pregnancy care can dramatically reduce these risks. However, pregnancy-related outcomes in women with diabetes continue to be less than ideal. This review highlights and discusses a variety of patient, provider, and organizational factors that can contribute to these suboptimal outcomes. Based on the findings of studies reviewed and authors’ clinical and research experiences, recommendations have been proposed focusing on various aspects of care provided, including improved accessibility to effective preconception and pregnancy-related care and better organized clinic consultations that are sensitive to women’s diabetes and pregnancy needs.
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Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
Negrato CA, Mattar R, Gomes MB. Adverse pregnancy outcomes in women with diabetes. Diabetol Metab Syndr. 2012;4:41.
Kitzmiller JL, Block JM, Brown FM, et al. Managing pre-existing diabetes for pregnancy: summary of evidence and consensus recommendations for care. Diabetes Care. 2008;31:1060–79.
• de Valk HW, Visser GH. Insulin during pregnancy, labour, and delivery. Best Pract Res Clin Obstet Gynaecol. 2011;25:65–76. This article offers a good description of the changes in insulin requirements during pregnancy and details of insulin therapy that helps women with pre-existing diabetes regulate their blood glucose levels during pregnancy.
Lambert K, Holt RI. The use of insulin analogues in pregnancy. Diabetes Obes Metab. 2013. doi:10.1111/dom.12098 [Epub ahead of print].
Lain KY, Catalano PM. Metabolic changes in pregnancy. Clin Obstet Gynecol. 2007;50:938–48.
Jovanovic L, Knopp RH, Brown Z, et al. Declining insulin requirement in the late first trimester of diabetic pregnancy. Diabetes Care. 2001;24:1130–6.
Trujillo AL. Insulin analogs and pregnancy. Diabetes Spectrum. 2007;20:94–101.
Murphy HR, Elleri D, Allen JM. Pathophysiology of postprandial hyperglycaemia in women with type 1 diabetes during pregnancy. Diabetologia. 2012;55:282–93.
American Diabetes Association. Preconception care of women with diabetes. Diabetes Care. 2004;(Suppl 1):S76–8.
Garner P. Type 1 diabetes mellitus and pregnancy. Lancet. 1995;346:157–61.
Penney GC, Mair G, Pearson DW. Outcomes of pregnancies in women with type 1 diabetes in Scotland: a nation population-based study. BJOG. 2003;110:315–8.
Boulot P, Chabbert-Buffet N, d’Ercole C, et al. French multicentric survey of outcome of pregnancy in women with pregestational diabetes. Diabetes Care. 2003;26:2990–3.
Ekbom P, Damm P, Nøgaard K, et al. Urinary albumin excretion and 24-hour blood pressure as predictors of pre-eclampsia in type I diabetes. Diabetologia. 2000;43:927–31.
Evers IM, de Valk HW, Visser GH. Risk of complications of pregnancy in women with type 1 diabetes: nationwide prospective study in The Netherlands. BMJ. 2004;17;328:915.
Jensen DM, Damm P, Moelsted-Pedersen L, et al. Outcomes in type 1 diabetic pregnancies: a nationwide, population-based study. Diabetes Care. 2004;27:2819–23.
Lapolla A, Dalfrà MG, Spezia R, et al. Outcome of pregnancy in type 1 diabetic patients treated with insulin lispro or regular insulin: an Italian experience. Acta Diabetol. 2008;45:61–6.
Macintosh MC, Fleming KM, Bailey JA, et al. A perinatal mortality and congenital anomalies in babies of women with type 1 or type 2 diabetes in England, Wales, and Northern Ireland: population based study. BMJ. 2006;22;333:177.
Vargas R, Repke JT, Ural SH. Type 1 diabetes mellitus and pregnancy. Rev Obstet Gynecol. 2010;3:92–100.
• Ringholm L, Pederson-Bjergaard U, Thorsteinsson B, et al. Hypoglycemia during pregnancy in women with Type 1 diabetes. Diabet Med. 2012;29:558–66. This article offers a very good review of the incidence, risk factors, and clinical management of hypoglycemia during pregnancy in pregnant women with type 1 diabetes.
Rosenn BM, Miodovnik M, Khoury JC, et al. Counterregulatory hormonal responses to hypoglycemia during pregnancy. Obstet Gynecol. 1996;87:568–74.
Chew EY, Mills JL, Metzger BE, et al. Metabolic control and progression of retinopathy. The Diabetes in Early Pregnancy Study. National Institute of Child Health and Human Development Diabetes in Early Pregnancy Study. Diabetes Care. 1995;18:631–7.
Brindley BG, Jovanovic L. Pregnancy in adolescents with type 1 diabetes. Growth, Genetics, & Hormones. 2004;20:49–55.
Feig D, Palda V. Type 2 diabetes in pregnancy: a growing concern. Lancet. 2002;11(359):1690–2.
Bell R, Baily K, Cresswell T, et al. Trends in prevalence and outcomes of pregnancy in women with pre-existing type I and type II diabetes. BJOG. 2008;115:445–52.
Lusignan S, Sismanidis C, Carey IM, et al. Trends in the prevalence and management of diagnosed type 2 diabetes 1994–2001 in England and Wales. BMC Fam Pract. 2005;22;6:13.
Temple RC, Murphey H. Type 2 diabetes in pregnancy - an increasing problem. Best Pract Res Clin Endocrinol Metab. 2010;24:591–603.
Murphy HR, Rayman G, Duffield K, et al. Changes in the glycemic profiles of women with type 1 and type 2 diabetes during pregnancy. Diabetes Care. 2007;30:2785–91.
•• Balsells M, García-Patterson A, Gich I, et al. Maternal and fetal outcome in women with type 2 vs type 1 diabetes mellitus: a systematic review and metaanalysis. J Clin Endocrinol Metab. 2009;94:4284–91. This article presents a useful review of the comparisons between maternal and fetal outcomes in women with type 1 and type 2 diabetes.
Murphy HR, Steel SA, Roland JM, et al. Obstetric and perinatal outcomes in pregnancies complicated by type 1 and type 2 diabetes: influences of glycaemic control, obesity and social disadvantage. Diabet Med. 2011;28:1060–7.
Lee-Parritz A. New technologies for the management of pregestational diabetes mellitus. Obstet Gynecol Surv. 2012;67:167–75.
Diabetes care and research in Europe: the Saint Vincent declaration. Diabet Med. 1990;7:360.
Colstrup M, Mathiesen ER, Damm P, et al. Pregnancy in women with type 1 diabetes: have the goals of St. Vincent's declaration been met concerning fetal and neonatal complications? J Matern Fetal Neonatal Med. 2013; [Epub ahead of print].
Kinsley B. Achieving better outcomes in pregnancies complicated by type 1 and type 2 diabetes mellitus. Clin Ther. 2007;29(Suppl D):S153–60.
Kitzmiller JL, Buchanan TA, Kjos S, et al. Pre-conception care of diabetes, congenital malformations, and spontaneous abortions. Diabetes Care. 1996;19:514–41.
Ray JG, O'Brien TE, Chan WS. Preconception care and the risk of congenital anomalies in the offspring of women with diabetes mellitus: a meta-analysis. QJM. 2001;94:435–44.
American Diabetes Association. Standards of Medical Care in Diabetes–2013. Diabetes Care. 2013;36 Suppl 1:S11–66.
Wahabi HA, Alzeidan RA, Bawazeer GA, et al. Preconception care for diabetic women for improving maternal and fetal outcomes: a systematic review and meta-analysis. BMC Pregnancy Childbirth. 2010;14;10:63.
Tripathi A, Rankin J, Aarvold J, et al. Preconception counseling in women with diabetes: a population-based study in the north of England. Diabetes Care. 2010;33:586–8.
Pearson DW, Kernaghan D, Lee R, et al. The relationship between pre-pregnancy care and early pregnancy loss, major congenital anomaly or perinatal death in type I diabetes mellitus. BJOG. 2007;114:104–7.
Bell R, Glinianaia SV, Tennant PW, et al. Peri-conception hyperglycaemia and nephropathy are associated with risk of congenital anomaly in women with pre-existing diabetes: a population-based cohort study. Diabetologia. 2012. [Epub ahead of print].
Chuang CH, Chase GA, Bensyl DM, et al. Contraceptive use by diabetic and obese women. Women’s Health Issues. 2005;15:167–73.
Finer LB, Henshaw SK. Disparities in rates of unintended pregnancy in the United Sates, 1994 and 2001. Perspect Sex Reprod Health. 2006;38:90–6.
Schwarz EB, Postlethwaite D, Hung YY, et al. Provision of contraceptive services to women with diabetes mellitus. J Gen Intern Med. 2012;27:196–201.
Kim C, Ferrara A, McEwen LN, et al. Preconception care in managed care: the translating research into action for diabetes study. Am J Obstet Gynecol. 2005;192:227–32.
Makda SI, Davies MJ, Wilmot E, et al. Prescribing in pregnancy for women with diabetes: use of potential teratogenic drugs and contraception. Diabet Med. 2013;30:457–63.
Evers IM, ter Braak EW, de Valk H, et al. Risk indicators predictive for severe hypoglycemia during the first trimester of type 1 diabetic pregnancy. Diabetes Care. 2002;25:554–9.
Rosenn BM, Miodovnik M, Holcberg G, et al. Hypoglycemia: the price of intensive insulin therapy for pregnant women with insulin-dependent diabetes mellitus. Obstet Gynecol. 1995;85:417–22.
Nielsen LR, Pedersen-Bjergaard U, Thorsteinsson B, et al. Hypoglycemia in pregnant women with type 1 diabetes: predictors and role of metabolic control. Diabetes Care. 2008;31:9–14.
Ringholm L, Pedersen-Bjergaard U, Thorsteinsson B, et al. Hypoglycemia in pregnant women with type 1 diabetes: clinical features and management. Diabetic Hypoglycemia. 2011;3:3–7.
Delamater AM, Jacobson AM, Anderson B, et al. Psychosocial therapies in diabetes: report of the Psychosocial Therapies Working Group. Diabetes Care. 2001;24:1286–92.
Stenhouse E, Letherby G. Mother/daughter relationships during pregnancy and the transition to motherhood of women with pre-existing diabetes: raising some issues. Midwifery. 2011;27:120–4.
Rasmussen B, Dunning T, Hendrieckx C, et al. Transition to motherhood in type 1 diabetes: design of the pregnancy and postnatal well-being in transition questionnaires. BMC Pregnancy Childbirth. 2013;13:54.
Neithercott T. Real-life stories of diabetes and pregnancy. Available at: http://forecast.diabetes.org/magazine/features/real-life-stories-diabetes-and-pregnancy. Accessed April 2013.
Langer N, Langer O. Pre-existing diabetics: relationship between glycemic control and emotional status in pregnancy. J Matern Fetal Med. 1998;7:257–63.
Berg M. Pregnancy and diabetes: how women handle the challenges. J Perinat Educ. 2005;14:23–32.
Berg M, Lundgren I, Lindmark G. Childbirth experience in women at high risk: is it improved by use of a birth plan? J Perinat Educ. 2003;12:1–15.
Gupton A, Heaman M, Cheung LW. Complicated and uncomplicated pregnancies: women's perception of risk. J Obstet Gynecol Neonatal Nurs. 2001;30:192–201.
Hatmaker DD, Kemp VH. Perception of threat and subjective well-being in low-risk and high-risk pregnant women. J Perinat Neonatal Nurs. 1998;12:1–10.
Berg M, Honkasalo ML. Pregnancy and diabetes: a hermeneutic phenomenological study of women's experiences. J Psychosom Obstet Gynaecol. 2000;21:39–48.
McCorry NK, Hughes C, Spence D, et al. Pregnancy planning and diabetes: a qualities exploration of women’s attitudes toward preconception care. J Midwifery Womens Health. 2012;57:396–402.
Lavender T, Platt MJ, Tsekiri E, et al. Women’s perceptions of being pregnant and having pregestational diabetes. Midwifery. 2010;26:589–95.
King R, Wellard S. Juggling type 1 diabetes and pregnancy in rural Australia. Midwifery. 2009;25:126–33.
Holing EV, Beyer CS, Brown ZA, et al. Why don't women with diabetes plan their pregnancies? Diabetes Care. 1998;21:889–95.
Berg M, Sparud-Lundin C. Experiences of professional support during pregnancy and childbirth—a qualitative study of women with type 1 diabetes. BMC Pregnancy Childbirth. 2009;3;9:27.
Murphy HR, Temple RC, Ball VE, et al. Personal experiences of women with diabetes who do not attend pre-pregnancy care. Diabet Med. 2010;27:92–100.
Charron-Prochownik D, Ferons-Hannan M, Sereika S, et al. Randomized efficacy trial of early preconception counseling for diabetic teens (READY-girls). Diabetes Care. 2008;31:1327–30.
Murphy HR, Roland JM, Skinner TC, et al. Effectiveness of a regional prepregnancy care program in women with type 1 and type 2 diabetes: benefits beyond glycemic control. Diabetes Care. 2010;33:2514–20.
ACOG technical bulletin. Preconceptional care. Number 205—May 1995. American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet. 1995;50:201–7.
Zhu H, Graham D, Teh RW, et al. Utilisation of preconception care in women with pregestational diabetes in western Australia. Aust N Z J Obstet Gynaecol. 2012;52:593–6.
Kitzmiller JL, Wallerstein R, Correa A, et al. Preconception care for women with diabetes and prevention of major congenital malformations. Birth Defects Res A Clin Mol Teratol. 2010;88:791–803.
Owens MD, Kieffer EC, Chowdhury FM. Preconception care and women with or at risk for diabetes: implications for community intervention. Matern Child Health J. 2006;10(5 Suppl):S137–41.
Janz NK, Herman WH, Becker MP, et al. Diabetes and pregnancy. Factors associated with seeking preconception care. Diabetes Care. 1995;18:157–65.
Casele HL, Laifer SA. Factors influencing preconception control of glycemia in diabetic women. Arch Intern Med. 1998;22(158):1321–4.
Korenbrot CC, Steinberg A, Bender C, et al. Preconception care: a systematic review. Matern Child Health J. 2002;6:75–88.
Bernasko J. Contemporary management of type 1 diabetes mellitus in pregnancy. Obstet Gynecol Surv. 2004;59:628–36.
Kendrick JM. Preconception care of women with diabetes. J Perinat Neonatal Nurs. 2004;18:14–25. quiz 26–7.
American Diabetes Association. Preconception care of women with diabetes. Diabetes Care. 2003;26:91S–3S.
Meltzer SJ. Prepregnancy care: a shared responsibility. Diabetes Care. 2010;33:2713–5.
Downs JS, Arslanian S, de Bruin WB, et al. Implications of type 2 diabetes on adolescent reproductive health risk: an expert model. Diabetes Educ. 2010;36:911–9.
Romano AM. A changing landscape: implications of pregnant women's internet use for childbirth educators. J Perinat Educ. 2007;16:18–24.
Sparud-Lundin C, Ranerup A, Berg M. Internet use, needs and expectations of web-based information and communication in childbearing women with type 1 diabetes. BMC Med Inform Decis Mak. 2011;7;11:49.
Ritterband L, Gonder-Frederick L, Cox D, et al. Internet interventions: In review, in use, and into the future. Professional Psychology: Research and Practice. 2003;34:527–34.
Helen R. Murphy is funded by a research fellowship supported by the National Institute for Health Research. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health. Lee Ritterband has been awarded an R21 grant by NIH/NIDDK to develop and test the feasibility of an Internet intervention to assist women with type 1 diabetes contemplating pregnancy better regulate their blood glucose levels in preparation for pregnancy. She is a part equity owner of BeHealth Solutions, LLC, a company who licenses software from UVA and makes this software and services for evidence-based clinical research and who are working to expand public access to proven eHealth interventions. This software includes a platform to build and host Internet interventions as well as 2 interventions developed by Dr. Ritterband and his team (1 for pediatric encopresis and 1 for adults with insomnia). Although none of this is explicitly discussed in this paper, within the Recommendation section, mention is made of accessing care via the Internet. Dr. Ritterband's wife, Dawn Ritterband, provides consultation to BeHealth Solutions, LLC.
Harsimran Singh has been awarded an R21 grant by NIH/NIDDK to develop and test the feasibility of an Internet intervention to assist women with type 1 diabetes contemplating pregnancy better regulate their blood glucose levels in preparation for pregnancy.
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Conflict of Interest
Harsimran Singh declares that he has no conflict of interest.
Helen R. Murphy serves on the Medtronic European Advisory Board.
Christel Hendrieckx declares that she has no conflict of interest.
Lee Ritterband declares that she has no conflict of interest.
Jane Speight serves on the Accu-Chek Advisory Board, Roche Diagnostics Australia, and also Sanofi Aventis, Roche Diagnostics Australia (both relating to diabetes management but not specifically to pregnancy issues). She has received grant support from Sanofi Aventis (relating to diabetes management but not specifically to pregnancy issues). She has also received payment for development of educational presentations including service on speakers' bureaus from Sanofi Diabetes, Abbott Diabetes Care, and Roche Diagnostics (relating to diabetes management but not specifically to pregnancy issues). She also received travel expenses provided to support her attendance at a DAWN-2 Study meeting from Novo Nordisk (relating to diabetes management but not specifically to pregnancy issues).
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This article does not contain any studies with human or animal subjects performed by any of the authors.
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Singh, H., Murphy, H.R., Hendrieckx, C. et al. The Challenges and Future Considerations Regarding Pregnancy-Related Outcomes in Women with Pre-Existing Diabetes. Curr Diab Rep 13, 869–876 (2013). https://doi.org/10.1007/s11892-013-0417-5
- Pre-existing diabetes
- Congenital malformations
- Preconception counseling
- Prepregnancy care
- Glycemic control
- High-risk pregnancy
- Fetal outcomes
- Neonatal death