Use of the CGM-reported mean glucose is superior to the use of estimated A1C, glucose management indicator, and other calculations to estimate A1C given the changes to A1C that occur in pregnancy (49). One study showed that care of preexisting diabetes in clinics that included diabetes and obstetric specialists improved care (27). As treatable as it is, gestational diabetes can hurt you and your baby. None of the currently available human insulin preparations have been demonstrated to cross the placenta (8489). 15.1 Starting at puberty and continuing in all women with diabetes and reproductive potential, preconception counseling should be incorporated into routine diabetes care. Checklist for preconception care for women with diabetes (17,19). However, ACE inhibitors and angiotensin receptor blockers should be stopped as soon as possible in the first trimester to avoid second and third trimester fetopathy (20). Due to physiological increases in red blood cell turnover, A1C levels fall during normal pregnancy (40,41). Patterns of glycemia in normal pregnancy: should the current therapeutic targets be challenged? See pregnancy and antihypertensive medications in Section 10, Cardiovascular Disease and Risk Management (https://doi.org/10.2337/dc22-S010), for more information on managing blood pressure in pregnancy. Hybrid closed-loop insulin pumps that allow for the achievement of pregnancy fasting and postprandial glycemic targets may reduce hypoglycemia and allow for more aggressive prandial dosing to achieve targets. Pregnancy is a ketogenic state, and women with type 1 diabetes, and to a lesser extent those with type 2 diabetes, are at risk for diabetic ketoacidosis (DKA) at lower blood glucose levels than in the nonpregnant state. The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Both metformin and intensive lifestyle intervention prevent or delay progression to diabetes in women with prediabetes and a history of GDM. Rockville, MD, Agency for Healthcare Research and Quality, 2014 (Evidence Syntheses, No. This difference was not found in the Adelaide cohort. However, lactation can increase the risk of overnight hypoglycemia, and insulin dosing may need to be adjusted. The American Diabetes Association (ADA) Standards of Medical Care in Diabetes includes the ADAs current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. The importance of preconception care for all women is highlighted by the American College of Obstetricians and Gynecologists (ACOG) Committee Opinion 762, Prepregnancy Counseling (17). In the Metformin in Gestational Diabetes: The Offspring Follow-Up (MiG TOFU) studys analyses of 7- to 9-year-old offspring, the 9-year-old offspring exposed to metformin for the treatment of GDM in the Auckland cohort were heavier and had a higher waist-to-height ratio and waist circumference than those exposed to insulin (80). During pregnancy, your body makes more hormones and goes through other changes, such as weight gain. A, 15.16 Telehealth visits for pregnant women with gestational diabetes mellitus improve outcomes compared with standard in-person care. As is true for all nutrition therapy in patients with diabetes, the amount and type of carbohydrate will impact glucose levels. Genetic carrier status (based on history): Nutrition and medication plan to achieve glycemic targets prior to conception, including appropriate implementation of monitoring, continuous glucose monitoring, and pump technology, Contraceptive plan to prevent pregnancy until glycemic targets are achieved, Management plan for general health, gynecologic concerns, comorbid conditions, or complications, if present, including: hypertension, nephropathy, retinopathy; Rh incompatibility; and thyroid dysfunction, Copyright American Diabetes Association. . To minimize the occurrence of complications, beginning at the onset of puberty or at diagnosis, all girls and women with diabetes of childbearing potential should receive education about 1) the risks of malformations associated with unplanned pregnancies and even mild hyperglycemia and 2) the use of effective contraception at all times when preventing a pregnancy. In the second and third trimesters, A1C <6% (42 mmol/mol) has the lowest risk of large-for-gestational-age infants (39,42,43), preterm delivery (44), and preeclampsia (1,45). Diabetes-specific counseling should include an explanation of the risks to mother and fetus related to pregnancy and the ways to reduce risk, including glycemic goal setting, lifestyle and behavioral management, and medical nutrition therapy. CGM time in range (TIR) can be used for assessment of glycemic control in patients with type 1 diabetes, but it does not provide actionable data to address fasting and postprandial hypoglycemia or hyperglycemia. Glyburide was associated with a higher rate of neonatal hypoglycemia, macrosomia, and increased neonatal abdominal circumference than insulin or metformin in meta-analyses and systematic reviews (72,73). Because GDM is associated with an increased lifetime maternal risk for diabetes estimated at 5060% (107,108), women should also be tested every 13 years thereafter if the 412 weeks postpartum 75-g OGTT is normal. Although there is some heterogeneity, many randomized controlled trials (RCTs) suggest that the risk of GDM may be reduced by diet, exercise, and lifestyle counseling, particularly when interventions are started during the first or early in the second trimester (5254). The U.S. Preventive Services Task Force recommends the use of low-dose aspirin (81 mg/day) as a preventive medication at 12 weeks of gestation in women who are at high risk for preeclampsia (108). However, predictive low glucose suspend (PLGS) technology has been shown in nonpregnant people to be better than sensor augment technology (SAP) for reducing low glucoses (103). 11 Once women achieve and maintain good glycemic control, the frequency of testing can be decreased. B, 15.5 In addition to focused attention on achieving glycemic targets A, standard preconception care should be augmented with extra focus on nutrition, diabetes education, and screening for diabetes comorbidities and complications. Type 2 diabetes is often associated with obesity. Around 16 weeks, insulin resistance begins to increase, and total daily insulin doses increase linearly 5% per week through week 36. 15.22 Insulin resistance decreases dramatically immediately postpartum, and insulin requirements need to be evaluated and adjusted as they are often roughly half the prepregnancy requirements for the initial few days postpartum. B, 15.25 Women with a history of gestational diabetes mellitus found to have prediabetes should receive intensive lifestyle interventions and/or metformin to prevent diabetes. Low-dose aspirin >100 mg is required (9799). Gestational diabetes mellitus that requires medication to achieve euglycemia is often termed class A2GDM. A major barrier to effective preconception care is the fact that the majority of pregnancies are unplanned. Of women with a history of GDM and prediabetes, only 56 women need to be treated with either intervention to prevent one case of diabetes over 3 years (123). Glucose targets are fasting plasma glucose <95 mg/dL (5.3 mmol/L) and either 1-h postprandial glucose <140 mg/dL (7.8 mmol/L) or 2-h postprandial glucose <120 mg/dL (6.7 mmol/L). The OGTT is more sensitive at detecting glucose intolerance, including both prediabetes and diabetes. Arlington, VA 22202, For donations by mail: . Diabetes in pregnancy is associated with an increased risk of preeclampsia (107). Queensland clinical guidelines . A key point is the need to incorporate a question about a womans plans for pregnancy into routine primary and gynecologic care. Counseling on the specific risks of obesity in pregnancy and lifestyle interventions to prevent and treat obesity, including referral to a registered dietitian nutritionist (RD/RDN), is recommended when indicated. Pregnancy is a ketogenic state, and women with type 1 diabetes, and to a lesser extent those with type 2 diabetes, are at risk for diabetic ketoacidosis (DKA) at lower blood glucose levels than in the nonpregnant state. The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. In the Metformin in Gestational Diabetes: The Offspring Follow-Up (MiG TOFU) study's analyses of 7- to 9-year-old offspring, the 9-year-old offspring exposed to metformin in the Auckland cohort for the treatment of GDM were heavier and had a higher waist-to-height ratio and waist circumference than those exposed to insulin (72). In one study, insulin requirements in the immediate postpartum period are roughly 34% lower than prepregnancy insulin requirements (125). Review and counseling on the use of nicotine products, alcohol, and recreational drugs, including marijuana, is important. Women with type 1 diabetes have an increased risk of hypoglycemia in the first trimester and, like all women, have altered counterregulatory response in pregnancy that may decrease hypoglycemia awareness. A, 14.2 Family planning should be discussed, and effective contraception (with consideration of long-acting, reversible contraception) should be prescribed and used until a woman's treatment regimen and A1C are optimized for pregnancy. Helping tackle commonly faced diabetes issues. A meta-analysis of 32 RCTs evaluating the effectiveness of telehealth visits for GDM demonstrated reduction of incidences of cesarean delivery, neonatal hypoglycemia, premature rupture of membranes, macrosomia, pregnancy-induced hypertension or preeclampsia, preterm birth, neonatal asphyxia, and polyhydramnios compared with standard in-person care (57). 15.14 Insulin is the preferred medication for treating hyperglycemia in gestational diabetes mellitus. There are no adequately powered randomized trials comparing different fasting and postmeal glycemic targets in diabetes in pregnancy. search. Join Us. Observational studies show an increased risk of diabetic embryopathy, especially anencephaly, microcephaly, congenital heart disease, renal anomalies, and caudal regression, directly proportional to elevations in A1C during the first 10 weeks of pregnancy (3). See Table 15.1 for additional details on elements of preconception care (17,19). ACOG and ADA recommend the following target levels to reduce risk of macrosomia Fasting or preprandial blood glucose values < 95 mg/dL Postprandial blood glucose values < 140 mg/dL at 1 hour and < 120 mg/dL at 2 hours Review weekly but may alter based on degree of glucose control Diet and Exercise Nutritional assessment and plan In normal pregnancy, blood pressure is lower than in the nonpregnant state. There are no data to support the use of TIR in women with type 2 diabetes or GDM. Reflecting this physiology, fasting and postprandial monitoring of blood glucose is recommended to achieve metabolic control in pregnant women with diabetes. Women with GDM have a 10-fold increased risk of developing type 2 diabetes compared with women without GDM (107). 3/6/18, 3/12/2019, 3/9/2021. The American Diabetes Association is committed to improving the lives of all those affected by diabetes through this publication of the most widely respected guidelines for health professionals, said Dr. Robert Gabbay, Chief Scientific and Medical Officer at the American Diabetes Association. The food plan should be based on a nutrition assessment with guidance from the Dietary Reference Intakes (DRI). The 2023 Standards of Care in Diabetes includes all of ADA's current clinical practice recommendations and is intended to provide clinicians, patients, researchers, payers, and others with the components of diabetes care, general treatment goals, and tools to evaluate the quality of care. Moderate exercise is recommended by the American Diabetes Association (ADA): Education for patients and family members about the prevention, recognition, and treatment of hypoglycemia is important before, during, and after pregnancy to help to prevent and manage the risks of hypoglycemia. Diabetes-specific counseling should include an explanation of the risks to mother and fetus related to pregnancy and the ways to reduce risk including glycemic goal setting, lifestyle management, and medical nutrition therapy. Long-term safety data for offspring exposed to glyburide are not available (66). A blood sugar level below 140 mg/dL (7.8 mmol/L) is usually considered within the standard range on a glucose challenge test, although this may vary by clinic or lab. Chronic diuretic use during pregnancy is not recommended as it has been associated with restricted maternal plasma volume, which may reduce uteroplacental perfusion (105). doi: . Comprehensive nutrition assessment and recommendations for: Correction of dietary nutritional deficiencies, Comprehensive diabetes self-management education. Taking all of this into account, a target of <6% (42 mmol/mol) is optimal during pregnancy if it can be achieved without significant hypoglycemia. It doesn't mean that you had diabetes before you conceived or that you will have diabetes after you give birth. B, 14.8 Due to increased red blood cell turnover, A1C is slightly lower in normal pregnancy than in normal nonpregnant women. The Diabetes in Early Pregnancy Study, A focused preconceptional and early pregnancy program in women with type 1 diabetes reduces perinatal mortality and malformation rates to general population levels, Effectiveness of a regional prepregnancy care program in women with type 1 and type 2 diabetes: benefits beyond glycemic control, Cost-benefit analysis of preconception care for women with established diabetes mellitus, ATLANTIC DIP: closing the loop: a change in clinical practice can improve outcomes for women with pregestational diabetes, Implementation of guidelines for multidisciplinary team management of pregnancy in women with pre-existing diabetes or cardiac conditions: results from a UK national survey, Insulin requirements throughout pregnancy in women with type 1 diabetes mellitus: three changes of direction, The association of falling insulin requirements with maternal biomarkers and placental dysfunction: a prospective study of women with preexisting diabetes in pregnancy, Preprandial versus postprandial blood glucose monitoring in type 1 diabetic pregnancy: a randomized controlled clinical trial, Postprandial versus preprandial blood glucose monitoring in women with gestational diabetes mellitus requiring insulin therapy, National Institute of Child Health and Human DevelopmentDiabetes in Early Pregnancy Study, Maternal postprandial glucose levels and infant birth weight: the Diabetes in Early Pregnancy Study, Committee on Practice BulletinsObstetrics, ACOG Practice Bulletin No.

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