A higher dose of folic acid may be considered in women with obesity, although there is no clinical evidence that this higher dose reduces congenital anomalies.
Measurement of red blood cell (RBC) folate may also be useful to guide adjustment of folic acid dosage in women with obesity or women who have had bariatric surgery.
The following factors are associated with women with pre-existing diabetes being less likely to receive preconception care: overweight; younger age; smoking history; lower socioeconomic status; lower health literacy and/or poor relationship with their health-care provider , and a greater decrease in A1C between the first and third trimester of pregnancy (32).
Closer retinal surveillance is recommended for women with more severe pre-existing retinopathy, those with poor glycemic control or women with greater reductions in A1C during pregnancy .
Potential side effects include hypertension, proteinuria, defective embryogenesis and fetal loss .
It is not known if these medications cross the placenta or if they are secreted in breastmilk.
A multifaceted preconception program that included patient information specialized clinics, electronic health records, online resources and local guidelines, increased folic acid use by 26%, improved glycemic control and decreased the risk of congenital malformations from 5% to 1.8% (9).
This involves educating women about the importance of optimal glycemic control prior to pregnancy, discontinuing potentially harmful medications and achieving a health body weight.
There are no intervention trials to support folic acid doses greater than 1 mg for women with diabetes.
Obesity, which is more common in women with type 2 diabetes, is associated with lower serum folate levels for the same intake, lower intake of folate rich foods and increased risk of neural tube defects independent of glycemic control .
Type 1 diabetes is more often associated with preeclampsia whereas type 2 diabetes is more often associated with chronic hypertension.
In the general population, the risk of preeclampsia is highest in nulliparous women and lower in multiparous women.
The term “pre-existing diabetes in pregnancy” refers to diabetes diagnosed before pregnancy.