Due to the complexity of insulin management in pregnancy, referral to a specialized center offering team-based care (with team members including maternal-fetal medicine specialist, endocrinologist or other provider experienced in managing pregnancy in women with preexisting diabetes, dietitian, nurse, and social worker, as needed) is recommended if this resource is available. A, 14.3 Preconception counseling should address the importance of achieving glucose levels as close to normal as is safely possible, ideally A1C <6.5% (48 mmol/mol), to reduce the risk of congenital anomalies, preeclampsia, macrosomia, preterm birth, and other complications. 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 The online version of the Standards of Care will continue to be annotated in real-time with necessary updates if new evidence or regulatory changes merit immediate incorporation through the living Standards of Care process. 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. Thus, although A1C may be useful, it should be used as a secondary measure of glycemic control in pregnancy, after blood glucose monitoring. Randomized, double-blind, controlled trials comparing metformin with other therapies for ovulation induction in women with polycystic ovary syndrome have not demonstrated benefit in preventing spontaneous abortion or GDM (78), and there is no evidence-based need to continue metformin in such patients (7981). Women with type 1 diabetes should be prescribed ketone strips and receive education on DKA prevention and detection. Metformin was associated with a lower risk of neonatal hypoglycemia and less maternal weight gain than insulin in systematic reviews (65,6769). Some women develop diabetes for the first time during pregnancy. Associations of mid-pregnancy HbA1c with gestational diabetes and risk of adverse pregnancy outcomes in high-risk Taiwanese women, Hyperglycemia and adverse pregnancy outcomes, Glycemic targets in the second and third trimester of pregnancy for women with type 1 diabetes, Reference intervals for hemoglobin A1c in pregnant women: data from an Italian multicenter study, Fetal growth is increased by maternal type 1 diabetes and HLA DR4-related gene interactions, Risk of macrosomia remains glucose-dependent in a cohort of women with pregestational type 1 diabetes and good glycemic control, Impact of type 2 diabetes, obesity and glycaemic control on pregnancy outcomes, Glycaemic control throughout pregnancy and risk of pre-eclampsia in women with type I diabetes, Relationship of fetal macrosomia to maternal postprandial glucose control during pregnancy, Continuous glucose monitoring in pregnant women with type 1 diabetes (CONCEPTT): a multicentre international randomised controlled trial, Continuous glucose monitoring in pregnant women with type 1 diabetes: an observational cohort study of 186 pregnancies, Clinical targets for continuous glucose monitoring data interpretation: recommendations from the international consensus on time in range, HAPO Follow-up Study Cooperative Research Group, HAPO Follow-Up Study Cooperative Research Group, Hyperglycemia and Adverse Pregnancy Outcome Follow-up Study (HAPO FUS): maternal glycemia and childhood glucose metabolism, Hyperglycemia and Adverse Pregnancy Outcome Follow-up Study (HAPO FUS): maternal gestational diabetes mellitus and childhood glucose metabolism, Gestational diabetes mellitus can be prevented by lifestyle intervention: the Finnish Gestational Diabetes Prevention Study (RADIEL): a randomized controlled trial, A randomized clinical trial of exercise during pregnancy to prevent gestational diabetes mellitus and improve pregnancy outcome in overweight and obese pregnant women, Summary and recommendations of the Fifth International Workshop-Conference on Gestational Diabetes Mellitus, The impact of adoption of the International Association of Diabetes In Pregnancy Study Group criteria for the screening and diagnosis of gestational diabetes, Different types of dietary advice for women with gestational diabetes mellitus, Dietary intervention in patients with gestational diabetes mellitus: a systematic review and meta-analysis of randomized clinical trials on maternal and newborn outcomes, Institute of Medicine and National Research Council, Weight Gain During Pregnancy: Reexamining the Guidelines, Benefits and harms of treating gestational diabetes mellitus: a systematic review and meta-analysis for the U.S. Preventive Services Task Force and the National Institutes of Health Office of Medical Applications of Research, Metformin versus insulin for the treatment of gestational diabetes, Metformin vs insulin in the management of gestational diabetes: a meta-analysis, A comparison of glyburide and insulin in women with gestational diabetes mellitus, Obstetric-Fetal Pharmacology Research Unit Network, Are we optimizing gestational diabetes treatment with glyburide? Depression symptoms are common in people with type 1 and type 2 diabetes. However, lactation can increase the risk of overnight hypoglycemia, and insulin dosing may need to be adjusted. 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. While individual RCTs support limited efficacy of metformin (60,61) and glyburide (62) in reducing glucose levels for the treatment of GDM, these agents are not recommended as first-line treatment for GDM because they are known to cross the placenta and data on long-term safety for offspring is of some concern (34). Insulin should be added if needed to achieve glycemic targets. Metformin and glyburide should not be used as first-line agents, as both cross the placenta to the fetus. The Standards of Medical Care in Diabetes2021 provides the latest in comprehensive, evidence-based recommendations for the diagnosis and treatment of children and adults with type 1, type 2, or gestational diabetes; strategies for the prevention or delay of type 2 diabetes; and therapeutic approaches that can reduce complications, mitigate (Evidence A)Long-term use of Metformin may be associated with biochemical vitamin B12 . B, 15.18 Either multiple daily injections or insulin pump technology can be used in pregnancy complicated by type 1 diabetes. Hypoglycemia in pregnancy is as defined and treated in Recommendations 6.96.14 (Section 6 Glycemic Targets, https://doi.org/10.2337/dc21-S006). The diet should emphasize monounsaturated and polyunsaturated fats while limiting saturated fats and avoiding trans fats. Women with a history of GDM have a greatly increased risk of conversion to type 2 diabetes over time (120). To learn more or to get involved, visit us at diabetes.org or call 1-800-DIABETES (1-800-342-2383). C, 15.23 A contraceptive plan should be discussed and implemented with all women with diabetes of reproductive potential. 14.16 Insulin should be used for management of type 1 diabetes in pregnancy. None of the currently available human insulin preparations have been demonstrated to cross the placenta (9095). However, there is no consensus on the structure of multidisciplinary team care for diabetes and pregnancy, and there is a lack of evidence on the impact on outcomes of various methods of health care delivery (28). In addition, diabetes in pregnancy may increase the risk of obesity, hypertension, and type 2 diabetes in offspring later in life (1,2). Guidelines | American Association of Clinical Endocrinology Planning pregnancy is critical in women with preexisting diabetes due to the need for preconception glycemic control to prevent congenital malformations and reduce the risk of other complications. E A dosage of 162 mg/day may be acceptable; currently in the U.S., low-dose aspirin is available in 81-mg tablets. Management of diabetes in pregnancy: Standards of Medical Care in Diabetes2022. Antihypertensive drugs known to be effective and safe in pregnancy include methyldopa, nifedipine, labetalol, diltiazem, clonidine, and prazosin. Long-term safety data for offspring exposed to glyburide are not available (74). 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 (111). 14.14 Insulin is the preferred medication for treating hyperglycemia in gestational diabetes mellitus. However, untreated or uncontrolled blood sugar levels can cause problems for you and your baby. Women with preexisting diabetic retinopathy will need close monitoring during pregnancy to assess for progression of retinopathy and provide treatment if indicated (23). In patients with preexisting diabetes, glycemic targets are usually achieved through a combination of insulin administration and medical nutrition therapy. Diabetes Care 2022;45(Suppl. A. Referral to an RD/RDN is important in order to establish a food plan and insulin-to-carbohydrate ratio and to determine weight gain goals. Both multiple daily insulin injections and continuous subcutaneous insulin infusion are reasonable delivery strategies, and neither has been shown to be superior to the other during pregnancy (84). 2021; 44 (Supplement 1):S15-S33. Associations of mid-pregnancy HbA1c with gestational diabetes and risk of adverse pregnancy outcomes in high-risk Taiwanese women, Hyperglycemia and adverse pregnancy outcomes, Glycemic targets in the second and third trimester of pregnancy for women with type 1 diabetes, Reference intervals for hemoglobin A1c in pregnant women: data from an Italian multicenter study, Fetal growth is increased by maternal type 1 diabetes and HLA DR4-related gene interactions, Risk of macrosomia remains glucose-dependent in a cohort of women with pregestational type 1 diabetes and good glycemic control, Impact of type 2 diabetes, obesity and glycaemic control on pregnancy outcomes, Glycaemic control throughout pregnancy and risk of pre-eclampsia in women with type I diabetes, Relationship of fetal macrosomia to maternal postprandial glucose control during pregnancy, Continuous glucose monitoring in pregnant women with type 1 diabetes (CONCEPTT): a multicentre international randomised controlled trial, Continuous glucose monitoring in pregnant women with type 1 diabetes: an observational cohort study of 186 pregnancies, Clinical targets for continuous glucose monitoring data interpretation: recommendations from the international consensus on time in range, HAPO Follow-up Study Cooperative Research Group, HAPO Follow-Up Study Cooperative Research Group, Hyperglycemia and Adverse Pregnancy Outcome Follow-up Study (HAPO FUS): maternal glycemia and childhood glucose metabolism, Hyperglycemia and Adverse Pregnancy Outcome Follow-up Study (HAPO FUS): maternal gestational diabetes mellitus and childhood glucose metabolism, Gestational diabetes mellitus can be prevented by lifestyle intervention: the Finnish Gestational Diabetes Prevention Study (RADIEL): a randomized controlled trial, A randomized clinical trial of exercise during pregnancy to prevent gestational diabetes mellitus and improve pregnancy outcome in overweight and obese pregnant women, Interventions to prevent women from developing gestational diabetes mellitus: an overview of Cochrane Reviews, Metformin in pregnancy to avert gestational diabetes in women at high risk: meta-analysis of randomized controlled trials, Effectiveness of telemedicine for pregnant women with gestational diabetes mellitus: an updated meta-analysis of 32 randomized controlled trials with trial sequential analysis, Summary and recommendations of the Fifth International Workshop-Conference on Gestational Diabetes Mellitus, The impact of adoption of the International Association of Diabetes in Pregnancy Study Group criteria for the screening and diagnosis of gestational diabetes, Different types of dietary advice for women with gestational diabetes mellitus, Dietary intervention in patients with gestational diabetes mellitus: a systematic review and meta-analysis of randomized clinical trials on maternal and newborn outcomes, Institute of Medicine and National Research Council, Weight Gain During Pregnancy: Reexamining the Guidelines, Nutrition therapy within and beyond gestational diabetes, A higher-complex carbohydrate diet in gestational diabetes mellitus achieves glucose targets and lowers postprandial lipids: a randomized crossover study, Physical activity programs during pregnancy are effective for the control of gestational diabetes mellitus, Benefits and harms of treating gestational diabetes mellitus: a systematic review and meta-analysis for the U.S. Preventive Services Task Force and the National Institutes of Health Office of Medical Applications of Research, Metformin versus insulin for the treatment of gestational diabetes, Metformin vs insulin in the management of gestational diabetes: a meta-analysis, A comparison of glyburide and insulin in women with gestational diabetes mellitus, Obstetric-Fetal Pharmacology Research Unit Network, Are we optimizing gestational diabetes treatment with glyburide?
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