14. Metformin and glyburide should not be used as first-line agents, as both cross the placenta to the fetus. B, 15.8 Due to increased red blood cell turnover, A1C is slightly lower in normal pregnancy than in normal nonpregnant women. Women with type 1 diabetes should be prescribed ketone strips and receive education on DKA prevention and detection. A major barrier to effective preconception care is the fact that the majority of pregnancies are unplanned. Mount Sinai Hospital, Canada. Depending on the population, studies suggest that 7085% of women diagnosed with GDM under Carpenter-Coustan criteria can control GDM with lifestyle modification alone; it is anticipated that this proportion will be even higher if the lower International Association of the Diabetes and Pregnancy Study Groups (59) diagnostic thresholds are used. A review of current evidence, 2021 by the American Diabetes Association, Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. In other words, short-term and long-term risks increase with progressive maternal hyperglycemia. Insulin sensitivity increases dramatically with delivery of the placenta. There are some women with GDM requiring medical therapy who, due to cost, language barriers, comprehension, or cultural influences, may not be able to use insulin safely or effectively in pregnancy. As is true for all nutrition therapy in patients with diabetes, the amount and type of carbohydrate will impact glucose levels. Medical nutrition therapy for GDM is an individualized nutrition plan developed between the woman and an RD/RDN familiar with the management of GDM (60,61). Gestational Diabetes | ACOG PDF ACOG PRACTICE BULLETIN - SCL Health 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). Join the fight with us on Facebook (American Diabetes Association), Twitter (@AmDiabetesAssn) and Instagram (@AmDiabetesAssn). During pregnancy, treatment with ACE inhibitors and angiotensin receptor blockers is contraindicated because they may cause fetal renal dysplasia, oligohydramnios, pulmonary hypoplasia, and intrauterine growth restriction (20). Reflecting this physiology, fasting and postprandial monitoring of blood glucose is recommended to achieve metabolic control in pregnant women with diabetes. The pharmacologic basis for better clinical practice, Pharmacokinetics, efficacy and safety of glyburide for treatment of gestational diabetes mellitus, Glibenclamide, metformin, and insulin for the treatment of gestational diabetes: a systematic review and meta-analysis, Groupe de Recherche en Obsttrique et Gyncologie (GROG), Effect of glyburide vs subcutaneous insulin on perinatal complications among women with gestational diabetes: a randomized clinical trial, Metformin compared with glyburide for the management of gestational diabetes, Glyburide versus metformin and their combination for the treatment of gestational diabetes mellitus: a randomized controlled study, Comparative efficacy and safety of OADs in management of GDM: network meta-analysis of randomized controlled trials, Placental passage of metformin in women with polycystic ovary syndrome, Population pharmacokinetics of metformin in late pregnancy, Metformin in gestational diabetes: the offspring follow-up (MiG TOFU): body composition and metabolic outcomes at 7-9 years of age, Metformin use in PCOS pregnancies increases the risk of offspring overweight at 4 years of age: follow-up of two RCTs, Neonatal, infant, and childhood growth following metformin versus insulin treatment for gestational diabetes: a systematic review and meta-analysis, Intrauterine metformin exposure and offspring cardiometabolic risk factors (PedMet study): a 5-10 year follow-up of the PregMet randomised controlled trial. Diabetes Care 1 January 2021; 44 (Supplement_1): S200S210. Women of reproductive age with prediabetes may develop type 2 diabetes by the time of their next pregnancy and will need preconception evaluation. 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. B, 15.9 When used in addition to pre- and postprandial blood glucose monitoring, continuous glucose monitoring can help to achieve A1C targets in diabetes and pregnancy. The OGTT is more sensitive at detecting glucose intolerance, including both prediabetes and diabetes. During pregnancy, your body makes more hormones and goes through other changes, such as weight gain. 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. E A dosage of 162 mg/day may be acceptable E; currently, in the U.S., low-dose aspirin is available in 81-mg tablets. Read the Standards. The international consensus on time in range (50) endorses pregnancy target ranges and goals for TIR for patients with type 1 diabetes using CGM as reported on the ambulatory glucose profile; however, it does not specify the type or accuracy of the device or need for alarms and alerts. Available from, Aspirin for the prevention of preterm and term preeclampsia: systematic review and metaanalysis, Aspirin versus placebo in pregnancies at high risk for preterm preeclampsia, Low-dose aspirin for the prevention of preterm delivery in nulliparous women with a singleton pregnancy (ASPIRIN): a randomised, double-blind, placebo-controlled trial, A Cost-benefit analysis of low-dose aspirin prophylaxis for the prevention of preeclampsia in the United States, Aspirin for the prevention of preeclampsia and potential consequences for fetal brain development, International Society for the Study of Hypertension in Pregnancy (ISSHP), Hypertensive disorders of pregnancy: ISSHP classification, diagnosis, and management recommendations for international practice, ACOG Practice Bulletin No. B, 14.9 When used in addition to pre- and postprandial self-monitoring of blood glucose, continuous glucose monitoring can help to achieve A1C targets in diabetes and pregnancy. A meta-analysis of 11 RCTs demonstrated that metformin treatment in pregnancy does not reduce the risk of GDM in high-risk women with obesity, polycystic ovary syndrome, or preexisting insulin resistance (56). Family planning should be discussed, including the benefits of long-acting, reversable contraception, and effective contraception should be prescribed and used until a woman is prepared and ready to become pregnant (1014). 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. Insulin resistance drops rapidly with delivery of the placenta. Due to physiological increases in red blood cell turnover, A1C levels fall during normal pregnancy (39,40). 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. 15. Management of Diabetes in Pregnancy: 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). The diet should emphasize monounsaturated and polyunsaturated fats while limiting saturated fats and avoiding trans fats. 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. During pregnancy, treatment with ACE inhibitors and angiotensin receptor blockers is contraindicated because they may cause fetal renal dysplasia, oligohydramnios, pulmonary hypoplasia, and intrauterine growth restriction (19). Medical nutrition therapy for GDM is an individualized nutrition plan developed between the woman and an RD/RDN familiar with the management of GDM (56,57). Insulin should be added if needed to achieve glycemic targets. 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. Mothers who substitute fat for carbohydrate may unintentionally enhance lipolysis, promote elevated free fatty acids, and worsen maternal insulin resistance (63,64). Gestational Diabetes - Symptoms, Treatments | ADA 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. A key point is the need to incorporate a question about a womans plans for pregnancy into routine primary and gynecologic care. However, untreated or uncontrolled blood sugar levels can cause problems for you and your baby. Rockville, MD, Agency for Healthcare Research and Quality, 2014 (Evidence Syntheses, No. In addition, diabetes in pregnancy may increase the risk of obesity, hypertension, and type 2 diabetes in offspring later in life (1,2). 203: Chronic Hypertension in Pregnancy, Less-tight versus tight control of hypertension in pregnancy, Treatment of hypertension in pregnant women, Risks of statin use during pregnancy: a systematic review, Progression to type 2 diabetes in women with a known history of gestational diabetes: systematic review and meta-analysis, Incidence rate of type 2 diabetes mellitus after gestational diabetes mellitus: a systematic review and meta-analysis of 170,139 women, Healthful dietary patterns and type 2 diabetes mellitus risk among women with a history of gestational diabetes mellitus, Interpregnancy weight change and risk of adverse pregnancy outcomes: a population-based study, Diabetes Prevention Program Research Group, Prevention of diabetes in women with a history of gestational diabetes: effects of metformin and lifestyle interventions, The effect of lifestyle intervention and metformin on preventing or delaying diabetes among women with and without gestational diabetes: the Diabetes Prevention Program outcomes study 10-year follow-up, Peripartum management of glycemia in women with type 1 diabetes, Changes in postpartum insulin requirements for patients with well-controlled type 1 diabetes, Breastfeeding and the basal insulin requirement in type 1 diabetic women, Duration of lactation and incidence of type 2 diabetes, Does breastfeeding influence the risk of developing diabetes mellitus in children? 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. There are some women with GDM requiring medical therapy who, due to cost, language barriers, comprehension, or cultural influences, may not be able to use insulin safely or effectively in pregnancy. Recommended weight gain during pregnancy for women with overweight is 1525 lb and for women with obesity is 1020 lb (62). In light of the immediate nutritional and immunological benefits of breastfeeding for the baby, all women, including those with diabetes, should be supported in attempts to breastfeed. Members of the ADA Professional Practice Committee, a . Gestational Diabetes | ADA A cost-benefit analysis has concluded that this approach would reduce morbidity, save lives, and lower health care costs (112). It can include special meal plans and regular physical activity. American Diabetes Association Releases 2023 Standards of Care in 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). Due to physiological increases in red blood cell turnover, A1C levels fall during normal pregnancy (40,41). Women with a history of GDM have a greatly increased risk of conversion to type 2 diabetes over time (120). Diabetes shouldnt stop you from living a healthy life. There are no adequate data on optimal weight gain versus weight maintenance in women with BMI >35 kg/m2. E A dosage of 162 mg/day may be acceptable; currently in the U.S., low-dose aspirin is available in 81-mg tablets. 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? Not all hybrid closed-loop pumps are able to achieve the pregnancy targets. Hypoglycemia in pregnancy is as defined and treated in Recommendations 6.96.14 (Section 6 Glycemic Targets, https://doi.org/10.2337/dc21-S006). 15.7 Fasting and postprandial self-monitoring of blood glucose are recommended in both gestational diabetes mellitus and preexisting diabetes in pregnancy to achieve optimal glucose levels. A rapid reduction in insulin requirements can indicate the development of placental insufficiency (31). Review and counseling on the use of nicotine products, alcohol, and recreational drugs, including marijuana, is important. search. PDF Di abe te s Cl i ni c al P r ac ti c e G ui de l i ne - Capital Health A Other oral and noninsulin injectable glucose-lowering medications lack long-term safety data. None of the currently available human insulin preparations have been demonstrated to cross the placenta (9095). This needs to be individualized for the patient, so discuss the amount needed with your diabetes team. Insulin should be added if needed to achieve glycemic targets. DKA carries a high risk of stillbirth. B. More than 122 million Americans have diabetes or prediabetes and are striving to manage their lives while living with the disease. 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, 14.8 Due to increased red blood cell turnover, A1C is slightly lower in normal pregnancy than in normal nonpregnant women. It doesn't mean that you had diabetes before you conceived or that you will have diabetes after you give birth. Effective preconception counseling could avert substantial health and associated cost burdens in offspring (10). 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). Long-acting, reversable contraception may be ideal for many women. Diabetes-specific testing should include A1C, creatinine, and urinary albumin-to-creatinine ratio. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADAs clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Antihypertensive drugs known to be effective and safe in pregnancy include methyldopa, nifedipine, labetalol, diltiazem, clonidine, and prazosin. Absolute risk increases linearly through a womans lifetime, being approximately 20% at 10 years, 30% at 20 years, 40% at 30 years, 50% at 40 years, and 60% at 50 years (108). 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). 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. Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes2022. Gestational diabetes that is adequately controlled with-out medication is often termed diet-controlled GDM or class A1GDM. These associations with maternal oral glucose tolerance test (OGTT) results are continuous with no clear inflection points (38,51). Low-dose aspirin >100 mg is required (109111). 2451 Crystal Drive, Suite 900 Arlington, VA 22202. A Insulin is the preferred agent for the management of type 2 diabetes in pregnancy. 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. In patients with preexisting diabetes, glycemic targets are usually achieved through a combination of insulin administration and medical nutrition therapy. In practice, it may be challenging for women with type 1 diabetes to achieve these targets without hypoglycemia, particularly women with a history of recurrent hypoglycemia or hypoglycemia unawareness. A systematic review demonstrated improvements in glucose control and reductions in need to start insulin or insulin dose requirements with an exercise intervention. B. 15.17 Insulin should be used for management of type 1 diabetes in pregnancy. Low-dose aspirin >100 mg is required (9799). A follow-up study at 510 years showed that the offspring had higher BMI, weight-to-height ratios, waist circumferences, and a borderline increase in fat mass (82,83). 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). E. Because GDM often represents previously undiagnosed prediabetes, type 2 diabetes, maturity-onset diabetes of the young, or even developing type 1 diabetes, women with GDM should be tested for persistent diabetes or prediabetes at 412 weeks postpartum with a 75-g OGTT using nonpregnancy criteria as outlined in Section 2 Classification and Diagnosis of Diabetes (https://doi.org/10.2337/dc21-S002). E, 14.17 Either multiple daily injections or insulin pump technology can be used in pregnancy complicated by type 1 diabetes. B. (Evidence Syntheses, No. To learn more or to get involved, visit us at diabetes.org or call 1-800-DIABETES (1-800-342-2383). Preconception counseling resources tailored for adolescents are available at no cost through the American Diabetes Association (ADA) (16). 26-31 Research also suggests that . Guidelines are systematically developed statements to assist patients and providers in choosing appropriate health . E, 15.12 Commonly used estimated A1C and glucose management indicator calculations should not be used in pregnancy as estimates of A1C. A major barrier to effective preconception care is the fact that the majority of pregnancies are unplanned. Preprandial testing is also recommended when using insulin pumps or basal-bolus therapy so that premeal rapid-acting insulin dosage can be adjusted. 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. In addition, diabetes in pregnancy may increase the risk of obesity, hypertension, and type 2 diabetes in offspring later in life (1,2). A. GDM is characterized by increased risk of large-for-gestational-age birth weight and neonatal and pregnancy complications and an increased risk of long-term maternal type 2 diabetes and offspring abnormal glucose metabolism in childhood. In one study, insulin requirements in the immediate postpartum period are roughly 34% lower than prepregnancy insulin requirements (113,114).
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