It has been known for some years that good diabetic control at the time of conception improves the chances of having a healthy baby. Entering the pregnancy with good control increases the chances of a healthy baby because important organs of the foetus develop during the early part of pregnancy – the brain, the spine, the heart, the kidneys and the gastrointestinal system. Malformations associated with diabetes are spina bifida, where the spine does not completely close and heart defects. As these malformations are formed during early pregnancy, getting into better control later in the pregnancy does not change what has already developed. However, it is important to remember that just because a woman is not in good control does not mean that she is bound to have a baby that is affected.
For these reasons, a planned pregnancy with good blood glucose control at the time of conception is the ideal situation although it is estimated that as many as two thirds of pregnancies are unplanned. A planned pregnancy also means that folic acid supplements, which reduce the risk of spina bifida and other defects, can also be taken prior to conception. Many diabetes clinics now offer ‘pre-conception counselling’ for couples intending to have a baby to try to ensure that the mother’s blood glucose control is good at conception and from the outset of the pregnancy.
Checking the safety of insulin and other drugs
It is worth checking at this stage the safety of the insulin you are using and any other drugs. None of the analogues have been tested in pregnant women or those planning pregnancy so any risks to the foetus and/or mother are unknown. Commonly prescribed for people with diabetes are ACE-inhibitors for the treatment of blood pressure and/or to slow down the progression of kidney disease and also statins to reduce cholesterol levels. Both these classes of drugs are potentially toxic for the foetus.
But do women attend pre-conception counselling?
Researchers in Hull [ref1] who carried out a study looking into the use of Humalog during pregnancy were struck by the large number of women in this study who did not have pre-conception counselling despite the fact that this was freely available to them – only 40% took it up.
So they carried out a questionnaire study in 69 women between the ages of 16 and 45 to survey their attitudes and knowledge of maternal diabetes and pregnancy. 18 of the women already had children and the rest didn’t. The results were surprising but according to the researchers are similar to other studies:
- In both women with and without children, a high proportion of women [85%] knew that their diabetes could affect the health of the baby and that good control was important at the time of the conception.
- Of the 18 with children only 44%, less than half, had attended pre-conception counselling before their last pregnancy.
- Only 52% of those without children and 28% of those with children reported the intention to do so before a future pregnancy.
So although the knowledge about the need for pre-conception counselling was there, this knowledge is not acted upon. What is more, the women that had already had one pregnancy were even less likely to seek counselling before a future pregnancy! The researchers point out that teaching and knowledge do not necessarily change behaviour and they suggest that a novel approach is needed if pregnancy outcomes are to be improved and that this should continue throughout the reproductive years.
Just a comment…
It is a shame that the questionnaire did not ask why women don’t attend pre-conception counselling. It is well recognised that pregnant women with diabetes go to great lengths to maintain very tight blood sugars to safeguard the health of the baby and indeed, their own health, so it is surprising that so few women attend. Perhaps the term ‘Pre-conception counselling’ is not one that appeals to people contemplating having a baby, especially young people! The word counselling alone can be off-putting for some people. Straight forward ‘Family Planning’ may be more appealing but a little imagination would produce a better name.
Ref 1 Diab Med 2002, Vol 19:605