There was no difference in pregnancy loss, neonatal care, or other neonatal outcomes between the groups with tighter versus less tight control of hypertension (104). On the basis of available evidence, statins should also be avoided in pregnancy (106). American Diabetes Association. 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. All women of childbearing age with diabetes should be informed about the importance of achieving and maintaining as near euglycemia as safely possible prior to conception and throughout pregnancy. Ideally, the A1C target in pregnancy is <6% (42 mmol/mol) if this can be achieved without significant hypoglycemia, but the target may be relaxed to <7% (53 mmol/mol) if necessary to prevent hypoglycemia. Therefore, all women with diabetes of childbearing potential should have family planning options reviewed at regular intervals to make sure that effective contraception is implemented and maintained. B, 14.26 Women with a history of gestational diabetes mellitus should seek preconception screening for diabetes and preconception care to identify and treat hyperglycemia and prevent congenital malformations. The most important diabetes-specific component of preconception care is the attainment of glycemic goals prior to conception. Insulin sensitivity increases dramatically with delivery of the placenta. Updates to the Standards of Care are established and revised by the ADA's Professional Practice Committee (PPC). Important Updates This year, the ADA revised nearly all the sections in the Standards of Care, including recommendations for diabetes screening diagnosis, prevention, evaluation, and management of comorbidities patient education technology and glycemic assessment weight management care for special populations, such as children and older people It can include special meal plans and regular physical activity. Sulfonylureas are known to cross the placenta and have been associated with increased neonatal hypoglycemia. Gestational diabetes that is adequately controlled with-out medication is often termed diet-controlled GDM or class A1GDM. However, metformin readily crosses the placenta, resulting in umbilical cord blood levels of metformin as high or higher than simultaneous maternal levels (78,79). The prevalence of diabetes in pregnancy has been increasing in the U.S. in parallel with the worldwide epidemic of obesity. Prognosis - Most patients with gestational diabetes mellitus . About Diabetes Care Given that early pregnancy is a time of enhanced insulin sensitivity and lower glucose levels, many women with type 1 diabetes will have lower insulin requirements and increased risk for hypoglycemia (29). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC. The committee is a multidisciplinary team of 16 leading U.S. experts in the field of diabetes care and includes physicians, diabetes care and education specialists, registered dietitians, and others with experience in adult and pediatric endocrinology, epidemiology, public health, cardiovascular risk management, microvascular complications, preconception and pregnancy care, weight management and diabetes prevention, and use of technology in diabetes management. 190: Gestational Diabetes Mellitus. 14.15 Metformin, when used to treat polycystic ovary syndrome and induce ovulation, should be discontinued by the end of the first trimester. However, in women with diabetes, hyperglycemia occurs if treatment is not adjusted appropriately. A large study found that after adjusting for confounders, first trimester ACE inhibitor exposure does not appear to be associated with congenital malformations (21). The A1C target in a given patient should be achieved without hypoglycemia, which, in addition to the usual adverse sequelae, may increase the risk of low birth weight (46). More studies are needed to assess the long-term effects of prenatal aspirin exposure on offspring (101). 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). An observational cohort study that evaluated the glycemic variables reported using CGM found that lower mean glucose, lower standard deviation, and a higher percentage of time in target range were associated with lower risk of large-for-gestational-age births and other adverse neonatal outcomes (48). Although observational studies are confounded by the association between elevated periconceptional A1C and other poor self-care behavior, the quantity and consistency of data are convincing and support the recommendation to optimize glycemia prior to conception, given that organogenesis occurs primarily at 58 weeks of gestation, with an A1C <6.5% (48 mmol/mol) being associated with the lowest risk of congenital anomalies, preeclampsia, and preterm birth (37). A Other oral and noninsulin injectable glucose-lowering medications lack long-term safety data. There was heterogeneity in the types of effective exercise (aerobic, resistance, or both) and duration of exercise (2050 min/day, 27 days/week of moderate intensity) (65). In women taking insulin, particular attention should be directed to hypoglycemia prevention in the setting of breastfeeding and erratic sleep and eating schedules (126). B. Lower limits do not apply to diet-controlled type 2 diabetes. Long-term safety data for offspring exposed to glyburide are not available (66). By continuing to use our website, you are agreeing to, Justice, Equity, Diversity, and Inclusion, Institutional Subscriptions and Site Licenses, Management of Gestational Diabetes Mellitus, Management of Preexisting Type 1 Diabetes and Type 2 Diabetes in Pregnancy, https://www.ncbi.nlm.nih.gov/books/NBK196392/, https://diabetesjournals.org/journals/pages/license. C. The physiology of pregnancy necessitates frequent titration of insulin to match changing requirements and underscores the importance of daily and frequent blood glucose monitoring. 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). For 80 years the ADA has been driving discovery and research to treat, manage and prevent diabetes, while working relentlessly for a cure. Metformin is being studied in two ongoing trials in type 2 diabetes (Metformin in Women with Type 2 Diabetes in Pregnancy Trial [MiTY] [76] and Medical Optimization of Management of Type 2 Diabetes Complicating Pregnancy [MOMPOD] [77]), but long-term offspring data will not be available for some time. By continuing to use our website, you are agreeing to, Justice, Equity, Diversity, and Inclusion, Institutional Subscriptions and Site Licenses, Management of Gestational Diabetes Mellitus, Management of Preexisting Type 1 Diabetes and Type 2 Diabetes in Pregnancy, PREGNANCY AND ANTIHYPERTENSIVE MEDICATIONS, https://clinicaltrials.gov/ct2/show/NCT01353391, https://clinicaltrials.gov/ct2/show/NCT02932475, https://www.ncbi.nlm.nih.gov/books/NBK196392/, https://www.diabetesjournals.org/content/license. Women in DKA who are unable to eat often require 10% dextrose with an insulin drip to adequately meet the higher carbohydrate demands of the placenta and fetus in the third trimester in order to resolve their ketosis. E, 15.6 Women with preexisting type 1 or type 2 diabetes who are planning pregnancy or who have become pregnant should be counseled on the risk of development and/or progression of diabetic retinopathy. Glycemic target lower limits defined above for preexisting diabetes apply for GDM that is treated with insulin. In the prospective Nurses' Health Study II (NHS II), subsequent diabetes risk after a history of GDM was significantly lower in women who followed healthy eating patterns (109). Insulin sensitivity then returns to prepregnancy levels over the following 12 weeks. Diabetes confers significantly greater maternal and fetal risk largely related to the degree of hyperglycemia but also related to chronic complications and comorbidities of diabetes. If the pregnancy has motivated the adoption of a healthier diet, building on these gains to support weight loss is recommended in the postpartum period. Glycemic control is often easier to achieve in women with type 2 diabetes than in those with type 1 diabetes but can require much higher doses of insulin, sometimes necessitating concentrated insulin formulations. Chronic diuretic use during pregnancy is not recommended as it has been associated with restricted maternal plasma volume, which may reduce uteroplacental perfusion (117). In these women, lifestyle intervention and metformin reduced progression to diabetes by 35% and 40%, respectively, over 10 years compared with placebo (124). American Diabetes Association. Because glycemic targets in pregnancy are stricter than in nonpregnant individuals, it is important that women with diabetes eat consistent amounts of carbohydrates to match with insulin dosage and to avoid hyperglycemia or hypoglycemia. Long-term safety data for offspring exposed to glyburide are not available (74). Due to physiological increases in red blood cell turnover, A1C levels fall during normal pregnancy (40,41). Members of the ADA Professional Practice Committee, a . (Evidence A)Long-term use of Metformin may be associated with biochemical vitamin B12 . These associations with maternal oral glucose tolerance test (OGTT) results are continuous with no clear inflection points (37,50). Diabetes confers significantly greater maternal and fetal risk largely related to the degree of hyperglycemia but also related to chronic complications and comorbidities of diabetes. Given the alteration in red blood cell kinetics during pregnancy and physiological changes in glycemic parameters, A1C levels may need to be monitored more frequently than usual (e.g., monthly). After diagnosis, treatment starts with medical nutrition therapy, physical activity, and weight management, depending on pregestational weight, as outlined in the section below on preexisting type 2 diabetes, as well as glucose monitoring aiming for the targets recommended by the Fifth International Workshop-Conference on Gestational Diabetes Mellitus (58): Fasting glucose <95 mg/dL (5.3 mmol/L) and either, One-hour postprandial glucose <140 mg/dL (7.8 mmol/L) or, Two-hour postprandial glucose <120 mg/dL (6.7 mmol/L). However, metformin readily crosses the placenta, resulting in umbilical cord blood levels of metformin as high or higher than simultaneous maternal levels (70,71). Clinical trials have not evaluated the risks and benefits of achieving these targets, and treatment goals should account for the risk of maternal hypoglycemia in setting an individualized target of <6% (42 mmol/mol) to <7% (53 mmol/mol). Metformin in Women With Type 2 Diabetes in Pregnancy Trial (MiTy). However, lactation can increase the risk of overnight hypoglycemia, and insulin dosing may need to be adjusted. Because GDM is associated with an increased lifetime maternal risk for diabetes estimated at 5060% (119,120), women should also be tested every 13 years thereafter if the 412 weeks postpartum 75-g OGTT is normal. Insulin should be added if needed to achieve glycemic targets. All rights reserved. A Other oral and noninsulin injectable glucose-lowering medications lack long-term safety data. It demonstrated the value of CGM in pregnancy complicated by type 1 diabetes by showing a mild improvement in A1C without an increase in hypoglycemia and reductions in large-for-gestational-age births, length of stay, and neonatal hypoglycemia (46). Appropriate use of over-the-counter medications and supplements, Evaluation of diabetes and its comorbidities and complications, including: DKA/severe hyperglycemia; severe hypoglycemia/hypoglycemia unawareness; barriers to care; comorbidities such as hyperlipidemia, hypertension, NAFLD, PCOS, and thyroid dysfunction; complications such as macrovascular disease, nephropathy, neuropathy (including autonomic bowel and bladder dysfunction), and retinopathy, Evaluation of obstetric/gynecologic history, including history of: cesarean section, congenital malformations or fetal loss, current methods of contraception, hypertensive disorders of pregnancy, postpartum hemorrhage, preterm delivery, previous macrosomia, Rh incompatibility, and thrombotic events (DVT/PE), Review of current medications and appropriateness during pregnancy, Diabetes complications and comorbidities, including: comprehensive foot exam; comprehensive ophthalmologic exam; ECG in women starting at age 35 years who have cardiac signs/symptoms or risk factors and, if abnormal, further evaluation; lipid panel; serum creatinine; TSH; and urine protein-to-creatinine ratio. In addition, diabetes in pregnancy may increase the risk of obesity, hypertension, and type 2 diabetes in offspring later in life (1,2). 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. In normal pregnancy, blood pressure is lower than in the nonpregnant state. 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. 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. women with prior gestational diabetes. There were fewer macrosomic neonates, but there was a doubling of small-for-gestational-age neonates (104). Hypoglycemia in pregnancy is as defined and treated in Recommendations 6.96.14 (Section 6, Glycemic Targets, https://doi.org/10.2337/dc22-S006). Review and counseling on the use of nicotine products, alcohol, and recreational drugs, including marijuana, is important. 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). CONCEPTT (Continuous Glucose Monitoring in Pregnant Women With Type 1 Diabetes Trial) was a randomized controlled trial (RCT) of real-time continuous glucose monitoring (CGM) in addition to standard care, including optimization of pre- and postprandial glucose targets versus standard care for pregnant women with type 1 diabetes. However, in women with diabetes, hyperglycemia occurs if treatment is not adjusted appropriately. Similar to the targets recommended by ACOG (upper limits are the same as for gestational diabetes mellitus [GDM], described below) ( 34 ), the ADA-recommended targets for women with type 1 or type 2 diabetes are as follows: Fasting glucose 70-95 mg/dL (3.9-5.3 mmol/L) and either One-hour postprandial glucose 110-140 mg/dL (6.1-7.8 mmol/L) or A systematic review demonstrated improvements in glucose control and reductions in need to start insulin or insulin dose requirements with an exercise intervention. E, 14.27 Postpartum care should include psychosocial assessment and support for self-care. Gestational Diabetes Screening and Treatment Guideline . Search for other works by this author on: Intrauterine exposure to diabetes conveys risks for type 2 diabetes and obesity: a study of discordant sibships, Diabetes and Pre-eclampsia Intervention Trial Study Group, Optimal glycemic control, pre-eclampsia, and gestational hypertension in women with type 1 diabetes in the diabetes and pre-eclampsia intervention trial, Use of maternal GHb concentration to estimate the risk of congenital anomalies in the offspring of women with prepregnancy diabetes, Peri-conceptional A1C and risk of serious adverse pregnancy outcome in 933 women with type 1 diabetes, Glycaemic control during early pregnancy and fetal malformations in women with type I diabetes mellitus, Maternal glycemic control in type 1 diabetes and the risk for preterm birth: a population-based cohort study, Long-term effects of the booster-enhanced READY-Girls preconception counseling program on intentions and behaviors for family planning in teens with diabetes, Preventable health and cost burden of adverse birth outcomes associated with pregestational diabetes in the United States, Contraceptive use among women with prediabetes and diabetes in a US national sample, Description and comparison of postpartum use of effective contraception among women with and without diabetes, The intrauterine device in women with diabetes mellitus type I and II: a systematic review, Long-acting reversible contraceptionhighly efficacious, safe, and underutilized, American College of Obstetricians and Gynecologists Committee on Practice BulletinsObstetrics, ACOG Practice Bulletin No. Bethesda, MD, National Library of Medicine, Metformin versus placebo from first trimester to delivery in polycystic ovary syndrome: a randomized, controlled multicenter study, Cooperative Multicenter Reproductive Medicine Network, Clomiphene, metformin, or both for infertility in the polycystic ovary syndrome, Prospective parallel randomized, double-blind, double-dummy controlled clinical trial comparing clomiphene citrate and metformin as the first-line treatment for ovulation induction in nonobese anovulatory women with polycystic ovary syndrome, Metformin administration versus laparoscopic ovarian diathermy in clomiphene citrate-resistant women with polycystic ovary syndrome: a prospective parallel randomized double-blind placebo-controlled trial, A cautionary response to SMFM statement: pharmacological treatment of gestational diabetes, Metformin for gestational diabetes mellitus: progeny, perspective, and a personalized approach, Continuous subcutaneous insulin infusion versus multiple daily injections of insulin for pregnant women with diabetes, Insulin glargine safety in pregnancy: a transplacental transfer study, Transfer of insulin lispro across the human placenta, Transfer of insulin lispro across the human placenta: in vitro perfusion studies, Evaluation of insulin antibodies and placental transfer of insulin aspart in pregnant women with type 1 diabetes mellitus, Insulin detemir does not cross the human placenta, Different insulin types and regimens for pregnant women with pre-existing diabetes, Continuous subcutaneous insulin infusion versus intensive conventional insulin therapy in type I and type II diabetic pregnancy, Fetal growth in women managed with insulin pump therapy compared to conventional insulin, Poor pregnancy outcome in women with type 2 diabetes, Differing causes of pregnancy loss in type 1 and type 2 diabetes, Risk factors for pre-eclampsia at antenatal booking: systematic review of controlled studies, Low-Dose Aspirin for the Prevention of Morbidity and Mortality From Preeclampsia: A Systematic Evidence Review for the U.S. Preventive Services Task Force. Additionally, as A1C represents an integrated measure of glucose, it may not fully capture postprandial hyperglycemia, which drives macrosomia. The food plan should be based on a nutrition assessment with guidance from the Dietary Reference Intakes (DRI). Box 7023 Merrifield, VA 22116-7023. Insulin resistance drops rapidly with delivery of the placenta. 1):S232S243, American Diabetes Association Professional Practice Committee. Metformin was associated with a lower risk of neonatal hypoglycemia and less maternal weight gain than insulin in systematic reviews (65,6769). 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. Hypoglycemia in pregnancy is as defined and treated in Recommendations 6.96.14 (Section 6 Glycemic Targets, https://doi.org/10.2337/dc21-S006). In two RCTs of metformin use in pregnancy for polycystic ovary syndrome, follow-up of 4-year-old offspring demonstrated higher BMI and increased obesity in the offspring exposed to metformin (81,82). Atenolol is not recommended, but other -blockers may be used, if necessary. Low-dose aspirin >100 mg is required (9799). The American Diabetes Association (ADA) is the nations leading voluntary health organization fighting to bend the curve on the diabetes epidemic and help people living with diabetes thrive. For donations by mail: P.O.
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