The link between diabetes and reproductive health starts from the prevalence of diabetes in reproductive-age women. We know that 3% to 7% of women of reproductive age who could become pregnant have diabetes. So this is not an uncommon condition in this age group or in pregnancy.

Less than one-third of women with diabetes seek pre-pregnancy counseling. Approximately 50% of pregnancies in the United States are unintended or unplanned. So having an understanding of diabetes and how it can affect pregnancy and optimize and control of diabetes prior to pregnancy and in general in life is important. But the last thing that I would say about these important linkages has to do with equity and health disparities. Diabetes, especially type 2, has higher rates in women of color, including Black women, Native American women, and Latina women.

Some of the main consequences and risks associated with diabetes and pregnancy include:

• a risk of developing high blood pressure during pregnancy—that’s a spectrum of conditions including gestational hypertension, and pre-eclampsia, and eclampsia. 
• blood sugar control is much more challenging in pregnancy because of the hormonal changes that occur, requiring very frequent surveillance by the patient at home or when they come in for care for visits.
• the risk of worsening conditions that are associated with diabetes, including retinopathy, renal disease, and things along those lines, and we monitor those very closely.
• risk of early pregnancy loss and risk of stillbirth. These risks are significantly amplified when blood sugar control was poor in the pre-pregnancy timeframe and during pregnancy. 
• birth defects or fetal anomalies in a variety of organ systems, including cardiac anomalies and complex cardiac anomalies, and central nervous system anomalies including spina bifida.
• And then finally, there's a risk of delivery complications, especially fetal macrosomia, which is a baby that weighs a significant amount and can have some birth challenges during a vaginal delivery that can be risky and complicated.

We are still in the middle of an incredibly devastating global pandemic with COVID-19, and I think providers should have conversations with patients about COVID-19 vaccination. We know that people with pre-existing conditions are at highest risk for having severe COVID-19 infection, and we also know that women who become pregnant, who develop COVID-19, are at incredible risk for having complications.

A number of these things are only captured and diagnosed by frequent outpatient monitoring. This is why we really focus on having these conversations with patients about pre-pregnancy hemoglobin A1C levels. What are the best levels that can help reduce these risks?

Any woman with diabetes seeking pregnancy should be referred to a maternal fetal medicine specialist for a preconception consultation. At a visit like this, the maternal fetal medicine physician will have a conversation about what blood sugar control looks like in pregnancy, and also have a conversation about invoking the type of resources that they utilize to guide patients through this journey of diabetes management and pregnancy, not the least of which are nutritional counselors and registered dietitians who have this experience. There will also be a discussion about what prenatal care and monitoring looks like specific to the woman who has diabetes, and how we mitigate some of the risks that can be present or higher in women who have diabetes in pregnancy. It should also include an incredibly comprehensive inventory of the medications that patients take.

Postpartum is an incredibly important time frame for women who have diabetes. There has been over time some debate about contraception and what are safe contraceptives for women who are postpartum. I want to emphasize that the overwhelming majority of hormonal contraceptives are incredibly safe for women who have diabetes, and we should be supporting women to utilize the most effective contraceptives that they wish to use. 

Another consideration in the postpartum timeframe for women who have diabetes is supporting them and their desires to breastfeed. There are a lot of outstanding lactation consultants who support women in their breastfeeding goals, and they are a wonderful resource for women who might be struggling or just need general support.

This is an area of significant optimism. There are a number of investigators nationally who are highly dedicated to understanding

• pre-pregnancy diabetes, gestational diabetes, how we can understand them better, how we can manage better
• the perspective of equity and disparities, trying to understand these conditions and the effect of diabetes in pregnancy for underserved women
• the utilization of text and telehealth and understanding how we best utilize those technologies

So, lots of investigators doing work that is federally sponsored and making incredible contributions to the field of diabetes and understanding how we can improve the lives of women and make their pregnancies as safe as possible.