Ch36 Pregnanدرحاب Cy

Canadian Diabetes Association
Clinical Practice Guidelines

Pregnancy
Chapter 36
David Thompson, Howard Berger,
Denice Feig, Robert Gagnon, Tina Kader,
Erin Keely, Sharon Kozak, Edmond Ryan,
Mathew Sermer, Christina Vinokuroff
In collaboration with
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Copyright 2013 Canadian Diabetes Association
Diabetes in Pregnancy: 2 Categories

Pregestational diabetes
Pregnancy in
pre-existing diabetes
Type 1 diabetes
Type 2 diabetes

Gestational diabetes
Diabetes diagnosed in
pregnancy
Diabetes in Pregnancy: Consider Phases

1. Preconception counseling
1. Screening
2. Glycemic control during

pregnancy

pregnancy
3. Management in labour
4. Postpartum considerations 4. Postpartum considerations


1. Screening

pregnancy

pregnancy

Dysglycemia in Pregnancy can Result in

Adverse Pregnancy Outcome
Elevated glucose levels can have adverse effects

on the fetus
1st trimester fetal malformations
2nd and 3rd trimester: risk of macrosomia and
metabolic complications

Risk of Fetal Anomaly Relative to

Periconceptional A1C
Glycemic control pre-conception = essential
Guerin A et al. Diabetes Care 2007;30:1-6.

Need a Preconception Checklist for

Women with Pre-existing Diabetes
2013
1. Attain a preconception A1C of 7.0% (if safe)
2. Assess for and manage any complications
3. Switch to insulin if on oral agents
4. Folic Acid 5 mg/d: 3 months pre-conception to 12

weeks post-conception
5. Discontinue potential embryopathic meds:
Ace-inhibitors/ARB (prior to or upon detection of pregnancy)

Statin therapy

Table 1: Comparison of ARB pharmacokinetics
Drug
Losartan
Trade Name
Cozaar
EXP 3174
Biological
half-life
[h]
Protein binding
[%]
Bioavailability
[%]
Renal/hepatic
clearance [%]
Daily dosage
[mg]
Food effect
6-9 h
98.7%
33%
10%/90%
Minimal
50100 mg
69 h
99.8%
50%/50%
Candesarta
n
Atacand
9h
>99%
15%
60%/40%
No
432 mg
Valsartan
Diovan
6h
95%
25%
30%/70%
No
80320 mg
Irbesartan
Avapro
1115 h
9095%
70%
1%/99%
No
150300 mg
Telmisartan
Micardis
24 h
>99%
4258%
1%/99%
No
4080 mg
Eprosartan
Teveten
5h
98%
13%
30%/70%
No
400800 mg
Olmesartan
Benicar/Olmetec
1416 h
>99%
29%
40%/60%
No
1040 mg
Azilsartan
Edarbi
11 h
>99%
60%
55%/42%
No
4080 mg

ACE inhibitors can be divided into three groups based on their molecular structure:
Sulfhydryl-containing agents[edit]
Captopril (trade name Capoten), the first ACE inhibitor
Zofenopril
Dicarboxylate-containing agents[edit]
This is the largest group, including:
Enalapril (Vasotec/Renitec)
Ramipril (Altace/Prilace/Ramace/Ramiwin/Triatec/Tritace)
Quinapril (Accupril)
Perindopril (Coversyl/Aceon/Perindo)
Lisinopril (Listril/Lopril/Novatec/Prinivil/Zestril)
Benazepril (Lotensin)
Imidapril (Tanatril)
Trandolapril (Mavik/Odrik/Gopten)
Cilazapril (Inhibace)
Phosphonate-containing agents[edit]
Fosinopril (Fositen/Monopril) is the only member of this group
Naturally occurring[edit]
Casokinins and lactokinins, breakdown products of casein and whey, occur naturally after ingestion of milk products, especially
cultured milk. Their role in blood pressure control is uncertain.[24]
The lactotripeptides Val-Pro-Pro and Ile-Pro-Pro produced by the probiotic Lactobacillus helveticus or derived from casein have
been shown to have ACE-inhibiting and antihypertensive functions

Preconception Counseling for

Pregestational Diabetes
Advise reproductive age women with diabetes about

reliable birth control
NOTE: Metformin in PCOS may improve fertility need to

warn about possible pregnancy
Metformin safe for ovulation induction in PCOS
Achieving a healthy weight is essential obesity

associated with adverse pregnancy outcomes

Metformin is safe in pregnancy and women with

gestational diabetes treated with metformin have less
weight gain during pregnancy than those treated with
insulin. Babies born to women treated with metformin
have been found to develop less visceral fat, making
them less prone to insulin resistance in later life.

Screen for Complications:

Pre-pregnancy and Intrapartum
Screening for:
1. Retinopathy: Need ophthalmological evaluation
2. Nephropathy: Assess creatinine + urine
microalbumin / creatinine ratio (ACR)
Women with microalbuminuria or overt nephropathy are at

risk for hypertension and preeclampsia

Recommendations 1-2: Preconception Care

1. All women of reproductive age with type 1 or type 2
diabetes should receive advice on reliable birth control,
the importance of glycemic control prior to pregnancy,
impact of BMI on pregnancy outcomes, need for folic
acid and the need to stop potentially embyropathic
drugs prior to pregnancy [Grade D, Level 4].
2. Women with type 2 diabetes and irregular
menses/PCOS who are started on metformin or a
2013
should be advised that fertility may improve and be
warned about possible pregnancy [Grade D, Consensus].

Recommendation 3: Preconception Care

3. Before attempting to become pregnant, women
with type 1 or type 2 diabetes should:
a) Receive preconception counseling that
includes optimal diabetes management and
nutrition, preferably in consultation with an
interdisciplinary pregnancy team to optimize
maternal and neonatal outcomes [Grade C, Level 3]


(continued)
b) Strive to attain a preconception A1C of 7.0% (or
A1C as close to normal as can safely be achieved)
to decrease the risk of:
Spontaneous abortion [Grade C, Level 3]
Congenital anomalies [Grade C, Level 3]
Pre-eclampsia [Grade C, Level 3]
Progression of retinopathy in pregnancy [Grade A, level

1 for type 1 diabetes (23); Grade D, Consensus for type 2 diabetes]


(continued)
c)
Supplement their diet with multivitamins containing

5 mg of folic acid at least 3 months preconception and continuing until at least 12 weeks
post-conception [Grade D, Level 4]. Supplementation
should continue with a multivitamin containing 0.41.0 mg of folic acid from 12 weeks
postconception through to 6 weeks postpartum
or as long as breastfeeding continues [Grade D,
Consensus].


(continued)
d)
Discontinue medications that are potentially

embryopathic, including any from the following
classes:
ACE inhibitors and ARBs prior to conception

or upon detection of pregnancy [Grade C, Level 3]
Statins [Grade D, Level 4]
2013


4. Women with type 2 diabetes who are planning a
pregnancy should switch from non-insulin
antihyperglycemic agents to insulin for glycemic
control [Grade D, Consensus].
Women with pregestational diabetes who also
have PCOS may continue metformin for
ovulation induction [Grade D, Consensus].

Recommendations 5 and 6: Preconception

and Complications
5. Women should undergo an ophthalmological
evaluation by an eye care specialist [Grade A, Level 1, for
type 1; Grade D, Level 4 for type 2].
6. Women should be screened for chronic kidney

disease prior to pregnancy [Grade D level 4 for type 1 diabetes
Grade D, consensus for type 2 diabetes]. Women with
microalbuminuria or overt nephropathy are at
increased risk for the development of HTN and
preeclampsia [Grade A level 1]; and should be followed
closely for these conditions [Grade D, Consensus]

1. Screening

pregnancy

pregnancy

Need Optimal Glycemic Control in

Pregnancy for Pre-existing Diabetes
Individualized insulin therapy with close monitoring
Bolus insulin: May use aspart or lispro instead of regular

insulin
Basal insulin: May use detemir or glargine as alternative to
NPH
Encourage patients to SMBG pre- and postprandially

Target glucose values
Fasting PG <5.3 mmol/L
1h postprandial PG <7.8 mmol/L


1. Screening

pregnancy

pregnancy

Glucose Management During Labour and

Delivery
2013
Maternal blood glucose levels should be kept

between 4.0 -7.0 mmol/L neonatal
hypoglycemia
Women should receive adequate glucose during

labour in order to meet the high energy requirements
IV Dextrose + IV insulin protocols may be helpful

Postpartum care for pre-existing diabetes

1. Adjust insulin at risk of hypoglycemia
2. Encourage women to breastfeed
3. Metformin and glyburide may be used during breastfeeding no long term data but appears safe
4. Screen for postpartum thyroiditis in T1DM
check TSH at 6-8 weeks postpartum

Recommendation 7: Management in
Pregnancy for Pregestational Diabetes
7. Pregnant women with type 1 or type 2 diabetes
should:
a) Receive an individualized insulin regimen and
glycemic targets typically using intensive insulin
therapy [Grade A, Level 1B for type 1; Grade A, Level 1 for type 2]
b) Strive for target glucose values [Grade D consensus]:
Fasting PG below 5.3 mmol/L
1h postprandial below 7.8 mmol/L
2h postprandial below 6.7 mmol/L

Recommendation 7: Management in Pregnancy

for Pre-gestational Diabetes (continued)
c) Be prepared to raise these targets if need be
because of the increased risk of severe
2013
hypoglycemia during pregnancy [Grade D, Consensus]
d) Perform SMBG, both pre- and postprandially
to achieve glycemic targets and improve
pregnancy outcomes [Grade C, Level 3]

Recommendations 8-9: Management in

Pregnancy for Pre-gestational Diabetes
8. Women with pregestational diabetes may use
2013 aspart or lispro in pregnancy instead of regular
insulin to improve glycemic control and reduce
hypoglycemia [Grade C level 2 for aspart , Grade C, Level 3 for lispro].
9. Detemir [Grade C, Level 2] or glargine [Grade C, Level 3 ] may
be used in women with pregestational diabetes as
2013
an alternative to NPH.

Recommendation 10 and 11: Intrapartum

Glucose Management
10. Women should be closely monitored during labour
and delivery and maternal blood glucose levels
2013
should be kept between 4.0 and 7.0 mmol/L in
order to minimize the risk of neonatal hypoglycemia
[Grade D, Consensus]
11. Women should receive adequate glucose during

2013

Recommendations 12 and 13: Postpartum

Glucose Management
12. Women with pregestational diabetes should be
carefully monitored postpartum as they have a
2013
high risk of hypoglycemia [Grade D, Consensus].
13. Metformin and glyburide may be used during
breast-feeding [Grade C, Level 3 for metformin; Grade D, Level 4 for
2013
glyburide].

Recommendation 14 and 15: Postpartum

Glucose Management
14. Women with type 1 diabetes in pregnancy should
be screened for postpartum thyroiditis with a TSH
test at 6-8 weeks postpartum [Grade D, Consensus].
15. All women should be encouraged to breast-feed,
since this may reduce offspring obesity, especially in
the setting of maternal obesity [Grade C level 3-]


1. Screening & diagnosis

pregnancy

pregnancy

Gestational Diabetes (GDM) Diagnosis
Universal screening for GDM @ 24-28 weeks

Gestational Age (GA)
Screen earlier if risk factors for GDM:
Previous GDM
BMI 30 kg/m2
Prediabetes
Polycystic ovarian syndrome
High risk population

(Aboriginal, Hispanic, South
Asian, Asian, African)
Current fetal macrosomia or

polyhydramnios
Age 35 years
History of macrosomic infant
Corticosteroid use
Acanthosis nigricans

Why Diagnose and Treat GDM?
Macrosomia
Shoulder dystocia and
nerve injury
Neonatal hypoglycemia
Preterm delivery
Hyperbilirubinemia

Caesarian section
Offspring obesity (?)
Offspring diabetes (?)
HAPO: Incidence of Adverse Outcomes

Increases Along Continuum

Copyright
Canadian Diabetes
Metzger
BE,et2013
al. Hyperglycemia
andAssociation
Adverse Pregnancy Outcomes. NEJM 2008;358(19):1991-2002.
Benefits of Treatment of GDM

Benefits of Treatment of GDM

Copyright
Diabetes Association
Horvath
K et
al.2013
BMJCanadian
2010;340:c1935
Diagnosis of GDM
Are there clear threshold glucose levels

above which the risk of adverse neonatal
or maternal outcomes increases?

IADPSG
Diabetes Care 2010;22:676-682

HAPO: Incidence of Adverse Outcomes

Increases Along Continuum No Threshold
Metzger
BE,et2013
al. HAPO.
NEJM
2008;358(19):1991-2002.
Copyright
Canadian
Diabetes
Association
Are there clear threshold glucose levels

above which the risk of adverse neonatal
or maternal outcomes increases?
NO

IADPSG Consensus Threshold Values for

Diagnosis of GDM (1 Value is Diagnostic)
Glucose measure
with a 75 g OGTT
Glucose threshold
(mmol/L)
Proportion of HAPO
cohort above
threshold (%)
5.1
8.3
1-h plasma glucose
10.0
14.0
2-h plasma glucose
8.5
16.1
Fasting plasma
glucose (FPG)
Based on odds ratio (OR) of 1.75 for primary outcome

OGTT = Oral Glucose Tolerance Test
HAPO = Hyperglycemia and Adverse Pregnancy Outcomes study
IADPSG. Diabetes Care 2010;22:676-682
Odds Ratio (OR) of 1.75 vs. 2.0 for Primary

Outcome in HAPO
OR 1.75
OR 2.0
5.1
5.3
1-h plasma glucose
10.0
10.6
2-h plasma glucose
8.5
9.0
% of cohort that met

1 threshold above
16.1%
8.8%
Threshold glucose
levels (mmol/L) after
a 75g OGTT
Fasting plasma
glucose
OGTT = Oral Glucose Tolerance Test

HAPO = Hyperglycemia and Adverse Pregnancy Outcomes study
IADPSG. Diabetes Care 2010;22:676-682
HAPO: Incidence of Adverse Outcomes for

Glucose Categories (OR 1.75 or 2.0 )
Metzger
BE,et2013
al. HAPO.
NEJM
2008;358(19):1991-2002.
Copyright
Canadian
Diabetes
Association
Remains a Controversial Topic

Considerations for the CDA Adopting the

IADPSG Thresholds
How can we select an odds ratio threshold in the

absence of a true threshold in the data?
What is the impact on the patient and workload of

increasing the prevalence of GDM?
Do we have sufficient evidence with respect to

treatment benefit at the various thresholds to make
an informed decision?
In the absence of clear benefit, should the diagnostic

criteria be changed from 2008?

2013 CDA Diagnostic Criteria for GDM

PREFERRED APPROACH (2 steps)
1. 50 gram glucose challenge test
2. 75 gram oral glucose tolerance test
Using thresholds of OR 2.0
ALTERNATIVE APPROACH (1 step)
1. 75 gram oral glucose tolerance test
Using thresholds of OR 1.75

2013
2013 GDM Diagnosis: Two Approaches

2013
2013 GDM Diagnosis: Preferred Approach

2013

2013

2013

2013

2013

2013
2013 GDM diagnosis: Alternative Approach

2013
2013 GDM diagnosis: Alternative Approach

2013
Recommendations 16-17: Diagnosis of GDM

16. All pregnant women should be screened for GDM
at 24-28 weeks of gestation [Grade C, Level 3].
17. If there is a high risk of GDM based on multiple
clinical factors, screening should be offered at any
stage in the pregnancy [Grade D, Consensus]. If the initial
screening is performed before 24 weeks of
gestation and is negative, rescreen between 24-28
weeks of gestation. (see next slide)

Recommendation 17: Risk Factors for GDM

(continued)
Age 35 years
Polycystic ovarian
syndrome
Previous GDM
Prediabetes
Acanthosis nigricans
High risk population
Corticosteroid use
Aboriginal, Hispanic, South

Asian, Asian, African
BMI 30 kg/m2

History of macrosomic
infant
Current fetal macrosomia
or polyhydramnios
Recommendation 18: Diagnosis of GDM

18. The preferred approach for the screening and
diagnosis of GDM is the following [Grade D, Consensus]:
a) Screening for GDM should be conducted using the 50 g
glucose challenge test (GCT) administered in the nonfasting state with plasma glucose measured one hour later
2013
[Grade D, Level 4]. A plasma glucose value 7.8 mmol/L at
one hour will be considered a positive screen and will be
an indication to proceed to the 75 gram OGTT [Grade C, Level
2]. A plasma glucose value >11.1 mmol/L can be
considered to be diagnostic of gestational diabetes and
does not require a 75 gram OGTT for confirmation [Grade C,
Level 3].

(continued)
b) If the GCT screen is positive, a 75 gram OGTT
should be performed as the diagnostic test for
GDM using the following criteria: >1 of the
following values:
2013
Fasting >5.3 mmol/L,
1h >10.6 mmol/L,
2h >9.0 mmol/L
[Grade B, Level 1]


19. An alternative approach that may be used to screen
and diagnose GDM is the one-step approach [Grade D,
Consensus]:
a) A 75 gram OGTT should be performed (with no

prior screening 50g GCT) as the diagnostic test for
2013
GDM using the following criteria [Grade D, Consensus]:
1 of the following values:
Fasting > 5.1 mmol/L,
1h > 10.0 mmol/L,
2h > 8.5 mmol/L
[Grade B, Level 1 (4)]


1. Screening & diagnosis

pregnancy

pregnancy

GDM: Glycemic Management During Pregnancy
Perform SMBG, both fasting and postprandially

Glycemic Targets during pregnancy:
Target glucose values
Fasting PG <5.3 mmol/L
Receive nutrition counseling
Moderate carbohydrate restriction: 3 meals + 3 snacks

Targets not met within 2 weeks start insulin
Avoid hypocaloric diet weight loss + ketosis

IOM Guidelines for Gestational Weight Gain

Pre-Pregnancy BMI
Recommended range
of total weight gain
(Kg)
Recommended range
of total weight gain
(lb)
BMI <18.5
12.5 18.0
28 40
BMI 18.5 - 24.9
11.5 16.0
25 35
BMI 25.0 - 29.9
7.0 11.5
15 23
BMI > or = 30
5.0 9.0
11 20
Recommended rate of weight gain and total weight gain for singleton
Pregnancies according to pre-pregnancy BMI
Institute of Medicine. Weight gain during pregnancy: reexamining the guidelines. Consensus
Report. May 2009. The National Academies Press. Washington, DC.
What About Insulin Analogues and Oral

Agents Among Patients with GDM?
May use rapid-acting analog insulin for postprandial

glucose control no difference in perinatal outcomes
May use glyburide or metformin for women who

are non-adherent to or who refuse insulin
Likely safe BUT it is OFF-Label no long-term data, need

discussion with patient

2013
GDM: Glycemic Management During Labour

and Delivery
Keep maternal blood glucose l between 4.0 and 7.0

mmol/L reduce risk of neonatal hypoglycemia
Women should receive adequate glucose during


Postpartum GDM Management Checklist

1. Encourage Breastfeeding
2. 75g OGTT between 6 weeks - 6 months
postpartum to detect prediabetes or diabetes
3. Discuss increased long-term risk of diabetes
Importance of returning to pre-pregnancy weight

Recommendation 20: Management During

Pregnancy (GDM)
20. Women with GDM should:
a. Strive for target glucose values:
Fasting PG below 5.3 mmol/L [Grade B, Level 2]
1h postprandial below 7.8 mmol/L [Grade B, Level 2]
2h postprandial below 6.7 mmol/L [Grade B, Level 2]
b. Perform SMBG, both fasting and postprandially to

achieve glycemic targets and improve pregnancy
outcomes [Grade B, Level 2]
c.
Avoid ketosis during pregnancy [Grade C, Level 3]


Pregnancy (GDM)
21. Receive nutrition counseling from a registered
dietitian during pregnancy [Grade C, Level 3] and
postpartum [Grade D, Consensus]. Recommendations for
weight gain during pregnancy should be based on
pregravid BMI [Grade D, Consensus].

Recommendation 22 and 24: Management

During Pregnancy (GDM)
22. If women with GDM do not achieve glycemic targets
within 2 weeks from nutritional therapy alone,
insulin therapy should be initiated [Grade D, Consensus].
23. Insulin therapy in the form of multiple injections
should be used [Grade A, Level 1].
24. Rapid-acting bolus analog insulin may be used
over regular insulin for postprandial glucose control
2013
although perinatal outcomes are similar [Grade B, Level 2].

Pregnancy (GDM)
25. For women who are non-adherent to or who refuse
insulin, glyburide [Grade B, Level 2] or metformin [Grade B,
Level 2] may be used as alternative agents for
glycemic control. Use of oral agents in pregnancy is
off-label and this should be discussed with the
patient [Grade D, Consensus].

Recommendation 26: Intrapartum

Management (GDM)
26. Women should be closely monitored during labour
and delivery and maternal blood glucose levels
2013
should be kept between 4.0 and 7.0 mmol/L in
order to minimize the risk of neonatal hypoglycemia.
27. Women should receive adequate glucose during

2013
[Grade D, Consensus].

Recommendation 28: Postpartum (GDM)

28. Women with GDM should be encouraged to
breastfeed immediately after delivery in order to
2013 avoid neonatal hypoglycemia [Grade D, Level 4] and to
continue for at least three months postpartum in
order to prevent childhood obesity [Grade C, Level 3] and
reduce risk of maternal hyperglycemia [Grade C, Level 3].
29. Women should be screened with a 75g OGTT
between 6 weeks and 6 months postpartum to
detect prediabetes and diabetes [Grade D, Consensus].
CDA Clinical Practice Guidelines

http://guidelines.diabetes.ca for professionals
1-800-BANTING (226-8464)
http://diabetes.ca for patients


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Canadian Diabetes Association

Clinical Practice Guidelines

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Diabetes in Pregnancy: 2 Categories

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Diabetes in Pregnancy: Consider Phases

2. Glycemic control during

2. Glycemic control during

4. Postpartum considerations 4. Postpartum considerations

Diabetes in Pregnancy: Consider Phases

2. Glycemic control during

2. Glycemic control during

4. Postpartum considerations 4. Postpartum considerations

Dysglycemia in Pregnancy can Result in

Elevated glucose levels can have adverse effects

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Risk of Fetal Anomaly Relative to

Guerin A et al. Diabetes Care 2007;30:1-6.

Need a Preconception Checklist for

1. Attain a preconception A1C of 7.0% (if safe)

2. Assess for and manage any complications

3. Switch to insulin if on oral agents

4. Folic Acid 5 mg/d: 3 months pre-conception to 12

5. Discontinue potential embryopathic meds:

Ace-inhibitors/ARB (prior to or upon detection of pregnancy)

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Table 1: Comparison of ARB pharmacokinetics

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Preconception Counseling for

Advise reproductive age women with diabetes about

NOTE: Metformin in PCOS may improve fertility need to

Metformin safe for ovulation induction in PCOS

Achieving a healthy weight is essential obesity

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Metformin is safe in pregnancy and women with

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Screen for Complications:

Women with microalbuminuria or overt nephropathy are at

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Recommendations 1-2: Preconception Care

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Recommendation 3: Preconception Care

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Recommendation 3: Preconception Care

Spontaneous abortion [Grade C, Level 3]

Congenital anomalies [Grade C, Level 3]

Pre-eclampsia [Grade C, Level 3]

Progression of retinopathy in pregnancy [Grade A, level

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Recommendation 3: Preconception Care

Supplement their diet with multivitamins containing

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Recommendation 3: Preconception Care

Discontinue medications that are potentially

ACE inhibitors and ARBs prior to conception

Statins [Grade D, Level 4]

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Recommendation 4: Preconception Care

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca

Recommendations 5 and 6: Preconception

6. Women should be screened for chronic kidney

Diabetes in Pregnancy: Consider Phases

2. Glycemic control during