Mother’s Health. Before becoming pregnant, you need a thorough physical exam. Any problems that could jeopardize your health or that of your baby will be assessed. These problems include high blood pressure, heart disease, and kidney, nerve, and eye damage. If you have any of these complications, they need to be treated before you try to conceive.  Even kidney transplant recipients who are otherwise healthy have had babies. Your A1C level will be measured, as well as your thyroid function, if you have type 1 diabetes. In addition, your exam will include a review of all the medications, herbs, and supplements you are taking to make sure they are compatible with a safe pregnancy.

In rare cases, diabetes-related problems may be so serious that it’s safer to avoid pregnancy. If you have untreated high blood pressure, cardiovascular disease, kidney failure, or crippling gastrointestinal neuropathy, think carefully about this decision. Pregnancy can make these conditions worse, or they can lead to related problems, such as stroke or heart attack.

If you have any signs of heart disease, such as chest pain on exertion, an electrocardiogram may be done. Signs of nerve damage will also be checked. If the nerves that control heart rate or blood pressure have been damaged, this can affect how you   will   respond   to   the   physical   stress   of   pregnancy.

Neuropathy can also affect how well your body nourishes you and your growing baby, so tell your provider if you have had persistent problems with nausea, vomiting, or diarrhea.

Your prepregnancy exam will also include an evaluation of your kidneys. In women with high blood glucose levels and untreated kidney disease, kidney function can worsen during pregnancy.  Fortunately,  pregnancy does not appear to have long-lasting effects on kidney function.  If you have kidney problems,  you need to be prepared for a potentially more difficult pregnancy.  This can include problems with edema (swelling) and high blood pressure. If you have been treated with ACE inhibitors or ARBs for kidney disease or high blood pressure, your medication will probably be changed. Taking these drugs during pregnancy can cause kidney problems for the baby.

You will also be referred to an ophthalmologist who will examine your eyes, especially the retina - the part of your eye that senses visual images. Your pupils will be dilated so that the back of the retina can be checked for damage caused by diabetes. Untreated diabetic retinopathy may get worse during pregnancy and should be treated and stable before you become pregnant. You will continue to get your eyes examined throughout the pregnancy.

Glucose   Management.  Although   birth defects occur in 1 to 2 percent of all babies born to women without diabetes,  they occur more often among babies born to women with diabetes.  These problems include abnormalities of the central nervous system, heart, and kidneys. The risks cannot be completely eliminated for anyone. But you can lower your risk to the same level as mothers without diabetes by keeping your blood glucose levels as close to normal as possible before and during the first trimester of your pregnancy.

Why is well-controlled blood glucose important before conception?  You want your blood glucose levels to be as favorable to your developing baby as possible.
All the baby’s major organs are formed during the first 6 to 8 weeks of pregnancy,

which may be before you know you’re pregnant. In several studies, women who had an A1C of 1 percent above normal (i.e., less than 7 percent) before conception lowered their baby’s risk of birth defects to 1 to 2 percent, the same as women without diabetes. Babies of mothers who began intensive diabetes management after conceiving were more likely to have birth defects. In addition, it takes time to find a diabetes management plan that will work for you. This takes some trial and error as well as patience. It may take too long if you wait until you are pregnant.

Before you become pregnant, you probably will intensify your daily diabetes care. If you have type 1 diabetes, you will begin or fine-tune your plan by using several insulin injections each day or switching to insulin pump therapy. If you have type 2 diabetes, using oral diabetes medicines during pregnancy is not recommended because they may harm the baby. You will probably need to begin insulin therapy. Many women with type 2 diabetes who in the past have managed without medication find that they need to use insulin during pregnancy.

Your A1C level will be measured frequently. It is recommended that your A1C level be less than 1 percent above a normal A1C level (less than 7 percent) before you stop using birth control. It might also be helpful for you to record your basal body temperatures (see the box on predicting ovulation on page 343) so that you know when you can and do conceive. This will be useful to know for decision making later in pregnancy.