Diabetes mellitus is a disease which affects endocrine system and it is considered to beone of the most serious health problems to modern global health. Glycemic control is one of themost important aspects of preconception care; however other aspects such as folic acid supplementation, smoking cessation, screening and treatment of diabetes complications and discontinuing teratogenic medication, are as important for improving maternal and fetal outcomes. Effective preconception care is associated with improved pregnancy outcomes for women with diabetes. A multidisciplinary team work is essential for preconception care. Outcome becomes fruitful with patient awareness and managing diabetes before pregnancy in an organised manner.

Diabetes is a disease that affects millions of people and their families. The WHO estimates that more than 180 million people worldwide have diabetes. This number is likely to become 300 million by 2030 [1].

Diabetes has become a major health burden affecting primarily young adults and women in their reproductive age [2,3]. Type 1 diabetes is rising alarmingly worldwide, at a rate of 3% per year. Some 70,000 children aged 14 and under, develop Type 1 diabetes annually. Type 2 diabetes is also increasing in number among children and adolescents as obesity rates in this population continue to soar, in both developed and developing nations [4].

Given its’ prevalence and heavy healthcare and quality-of-life burden [6], there is a great need for better treatment options. Despite improved access and quality of antenatal care, women and their foetuses with pre gestational diabetes are associated with increased risks of adverse pregnancy outcomes [7-11].

The first population-based epidemiological study on fertility rates over time among women with Type 1 diabetes was conducted in Sweden during 1965 to 2004 [12]. The lowest standardized fertility ratios were observed among women who had their first hospitalization for diabetes in the earliest years. The presence of diabetic microvascular or cardiovascular complications was associated with particularly low fertility, essentially regardless of year of first hospitalization.

Menstrual abnormalities Shortening of reproductive period (late menarche and premature menopause) Poor glycemic control and presence of diabetes complications Hyperandrogenism and polycystic ovary syndrome Autoimmunity (Hashimoto's thyroiditis and antiovarian autoantibodies) Sexual dysfunction

With changing dietary and lifestyle patterns, the prevalence of obesity is increasing, thus raising the incidence of Type 2 diabetes during the reproductive years. Going in this direction, the disease can be linked to polycystic ovarian syndrome, the most common hormonal disorder among women of reproductive age, and a leading cause of infertility. Legro et al. showed that PCOS women are at significantly increased risk for impaired glucose tolerance and Type 2 diabetes mellitus at all weights and at a young age [13]. A study by A mini et al. showed that PCOS is highly prevalent in Type 2 diabetic patients [14].

Again, obesity is common in both PCOS and Type 2 diabetic women. Studies show that obese women seeking pregnancy experience longer times to conception, unrelated to age and to cyclic regularity, which is suggestive of alterations in ovarian function during the periconceptual period [15,16].

Preconception care is defined as a care that aim to identify and modify risks during pregnancy and improves pregnancy outcome through prevention and management. It is very alarming that 50% of all pregnancies are unplanned [17]. Improved preconception care is a mandatory component for women with diabetes.

Diabetes affects women in many ways, and one of them is the focus of the present discussion – the association between diabetes mellitus and planning conception.Women with diabetes should be informed about the benefits of preconception glycaemic control at each contact with healthcare professionals, from adolescence onwards [18]. Many of the complications of diabetes mellitus during pregnancy can be prevented by optimizing maternal health in the preconception period [19].

Periconceptional period is one of the most vital periods in a woman’s life especially if she is suffering from any major illness like diabetes. Preconception care for women with diabetes is an effective means to reduce the incidence of adverse pregnancy outcomes [20-23]. Diabetic mothers are vulnerable to early pregnancy losses

together with an increased incidence of congenital malformations in infants. Therefore, optimal medical care and pre conceptional counselling becomes a must in such patients [24]. This is best accomplished through a multidisciplinary team approach including a diabetologist, obstetrician, a dietitian, and other specialists as and when necessary.

Education in self management skills have a special role in diabetes. This model of care is important for patients to achieve the level of sustained glycemic control necessary to prevent congenital malformations. All diabetic women of child-bearing potential should be counselled about the risks of unplanned pregnancy and their use of appropriate contraception should be assured until metabolic control is achieved and conception is attempted. The first few weeks of pregnancy, when a woman may not be aware of her ongoing pregnancy, are particularly important because diabetic embryopathy induced by hyperglycaemia develop during this time [25,26]. Diabetic embryopathy includes the following congenital malformations in the fetus and are strongly related to the degree of hyperglycaemia in the periconceptional period:

In women with advanced complications of diabetes, weighing the risk of a pregnancy to their health versus the desire for child bearing is particularly important.

Women with diabetes should be empowered to take control of their own disease process. Therefore, its very important that the goals and specific roles of each member of the team should be clear [31]. Women with type 2 diabetes may be less likely to prepare for pregnancy and achieve good glycemic control compared with those with type 1 diabetes [32,33]. While the risk of pregnancy complications may be similar for women with type 1 and type 2 diabetes, women with type 1 diabetes are more likely to have pre gestational micro vascular complications and are at higher risk of developing severe hypo- and hyperglycaemia and diabetic ketoacidosis.

The above constitutes an integrated model of care, demanding coordination of the roles of the different team members. Motivation for intensive self-management is dependent on the team’s approach to imparting knowledge and skills to women with diabetes. Comprehensive and ongoing patient education is critical for shared decision-making about management goals and medication changes and for helping patients meet the considerable demands of self-care. Support system, includes family and work environment. Psychosocial status including adherence issues, social support network, and stress factors related to both diabetes and pregnancy should be discussed.

Based on the above information gathered, these professionals will review the patient’s current management plan and develop a comprehensive treatment plan.

The NICE guideline states that an HbA1C > 10% is a contraindication to pregnancy. In contrast ADIPS suggests that impaired renal function as measured by a serum creatinine> 0.2 mmol/L should be a contraindication to pregnancy.

Diet is one of the most important behavioural aspects of diabetes treatment. Understanding how different food intakes affect glycemia and developing a food plan of meals and snacks helps women reduce glucose fluctuations and manage fluctuations that occur.

The desired outcome of the preconception phase of careis to lower HbA1C test values to a level associated with optimal development during organogenesis. In order to achieve this goal, diet and nutrition has a great role. Nutrition history includes weight changes, history of eating disorders, gastrointestinal problems, and lifestyle considerations. Diet recall or food diaries may be of benefit in identifying specific problems within the meal plan.

Calculation of caloric needs based on height, weight, age, and activity level with development of a meal plan, including distribution of calories, carbohydrate, fat, and protein to achieve optimal nutrition while maintaining appropriate weight and acceptable glycemic control is the need of the hour.

Medical Nutrition Therapy for Diabetes should consider the following key aspects:

Consistency in day-to-day carbohydrate intake at meals and snacks

Weight management and increased physical activity

Caloric intake (balanced with caloric expenditure)

Nutritional content (balance of selected protein, carbohydrates, and fats)

Timing of meals and snacks

Adjusting insulin (in case of Type 1 diabetics) for variations in blood glucose, food, or activity

Meal-insulin timing

Rallis in his study [51]concluded that a high-fat, low-carbohydrate, ketogenic diet may prove to be a more effective dietary intervention in the treatment of type 2 diabetes mellitus [52,53], whereas the present nutritional guidelines appear biased towards the promotion of carbohydrate-rich diets as mentioned above. The concept behind a ketogenic diet uses the idea that dietary macronutrient content modification promotes a shift from a carbohydrate to a lipid dominant metabolism. In order to achieve a ketogenic state, carbohydrate

intake must be restricted to about 10% of total dietary intake. Protein and fat should make up ~20% and ~70% of the diet, respectively [54]. Under these conditions, the body begins to upregulate lipolytic enzymes and bypass the dependence on glucose for energy [55].

Hallberg et al did assess compliance of the ketogenic diet among diabetic patients using objective serum ketone monitoring and demonstrated that 87% of their participants were able to maintain a ketogenic diet for at least a year [56]. Dietary fats appear to play a role in mood stability [57], and endogenously produced ketone bodies (by-product of a ketogenic diet) naturally suppress appetite [58] both of which may assistin improving patient satisfaction and compliance with this nutritional methodology. A recent meta-analysis by Sainsbury et al however found that while carbohydrate-restricted dietsproduced greater reductions in HBA1C at 3 and 6 months, there was no statistically significant difference at 12 or 24 months [59].

High risk of diabetic complications and potential risks for pregnancy-related complications [60] require a detailed physical examination initiating with a blood pressure measurement (including orthostatic changes) before conception with special emphasis on the following [10]:

The counselling sessions are important primarily for patient education, motivation, and instruction in more effective management strategies. At each visit, it is extremely important to make sure that the patient has understood what is being discussed and instructed. Evaluation of self monitoring of blood glucose; observation of technique used by the patient and to correlate test with the laboratory; testing log of the patient should be reviewed for appropriate timing of testing, frequency of testing, and values. Make sure that the patient has understood the insulin algorithms, identify the problem areas and reinstruct.

Evaluation of frequency, duration and timing of hypoglycaemic and hyperglycaemic episodes with an attempt to identify its’ cause, are reviewed. Monthly HbA1C measurements prior to pregnancy are needed. Review the exercise plans, including timing, duration, and intensity as it relates to her tolerance of the activity.

Review with the nutritionist/dietician is extremely important. Root cause of many of the associated complications can be identified tracking the food records of each day (with timings), the blood glucose values before and after those particular meals and the amount of insulin injected. Review weight changes and determine the appropriateness of the prescribed meal plan and adjust as necessary.

Unfortunately, unplanned pregnancies occur in about twothirds ofwomen with diabetes, precluding adequate preconception care and leading to apersistent excess of malformations in their infants [62]. There are no contraceptive methods that are specifically contraindicated in women with diabetes.

Compliance is the sole issue seen in many patients. Again, counselling has a key role in overcoming the patient’s resistance. Stress issues should be discussed in detail. Explore ways and give suggestions on how to cope with it.Reinforce the importance of the overall treatment plan with the patient.

In the end, the importance of carefully planning a pregnancy and the need for effective contraceptionand avoiding pregnancy until a good glycemic control is achieved, should again be elaborated. The contraceptive methods with proven high degrees of effectiveness are to be preferred. Together with this, there is a need to review the current medications and their safety in pregnancy.