During pregnancy, your body makes more hormones and goes through other changes, such as weight gain. 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. 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. 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A Insulin is the preferred agent for the management of type 2 diabetes in pregnancy. A cost-benefit analysis has concluded that this approach would reduce morbidity, save lives, and lower health care costs (112). X. B, 15.10 When used in addition to blood glucose monitoring targeting traditional pre- and postprandial targets, real-time continuous glucose monitoring can reduce macrosomia and neonatal hypoglycemia in pregnancy complicated by type 1 diabetes. 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). Due to physiological increases in red blood cell turnover, A1C levels fall during normal pregnancy (40,41). Target range 63140 mg/dL (3.57.8 mmol/L): TIR, goal >70%, Time below range (<63 mg/dL [3.5 mmol/L]), goal <4%, Time below range (<54 mg/dL [3.0 mmol/L]), goal <1%, Time above range (>140 mg/dL [7.8 mmol/L]), goal <25%, 15.13 Lifestyle behavior change is an essential component of management of gestational diabetes mellitus and may suffice for the treatment of many women. 26-31 Research also suggests that . 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. 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. E, 15.21 Potentially harmful medications in pregnancy (i.e., ACE inhibitors, angiotensin receptor blockers, statins) should be stopped at conception and avoided in sexually active women of childbearing age who are not using reliable contraception. Glyburide was associated with a higher rate of neonatal hypoglycemia and macrosomia than insulin or metformin in a 2015 meta-analysis and systematic review (65). 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). Merrifield, VA 22116-7023. Breastfeeding may also confer longer-term metabolic benefits to both mother (127) and offspring (128). 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. As in type 1 diabetes, insulin requirements drop dramatically after delivery. Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes2022. A complete list of members of the American Diabetes Association Professional Practice Committee can be found at https://doi.org/10.2337/dc22-SPPC. American Diabetes Association. A, 15.2 Family planning should be discussed, and effective contraception (with consideration of long-acting, reversible contraception) should be prescribed and used until a womans treatment regimen and A1C are optimized for pregnancy. Today, the American Diabetes Association released the 2021 Standards of Medical Care in Diabetes. 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. 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). Young children usually need less than 15 grams of carbs to fix a low blood glucose level: Infants may need 6 grams, toddlers may need 8 grams, and small children may need 10 grams. In women taking insulin, particular attention should be directed to hypoglycemia prevention in the setting of breastfeeding and erratic sleep and eating schedules (115). The 2015 study (104) excluded pregnancies complicated by preexisting diabetes and only 6% had GDM at enrollment. See Table 14.1 for additional details on elements of preconception care (16,18). The risk of an unplanned pregnancy outweighs the risk of any given contraception option. Preconception counseling resources tailored for adolescents are available at no cost through the American Diabetes Association (ADA) (15). It means that, by working with your doctor, you can have a healthy pregnancy and a healthy baby. 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. 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 (48). A review of current evidence, 2020 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. 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. If these targets cannot be met and the majority of fasting and/or postprandial values are elevated, then pharmacotherapy is recommended. Similar to the targets recommended by ACOG (upper limits are the same as for GDM, described below) (35), the ADA-recommended targets for women with type 1 or type 2 diabetes are as follows: Fasting glucose 7095 mg/dL (3.95.3 mmol/L) and either, One-hour postprandial glucose 110140 mg/dL (6.17.8 mmol/L) or, Two-hour postprandial glucose 100120 mg/dL (5.66.7 mmol/L). Insulins studied in RCTs are preferred (9699) over those studied in cohort studies (100), which are preferred over those studied in case reports only. The international consensus on time in range (49) endorses pregnancy target ranges and goals for TIR for patients with type 1 diabetes using CGM as reported on the ambulatory glucose profile. An RCT of metformin added to insulin for the treatment of type 2 diabetes found less maternal weight gain and fewer cesarean births. Comprehensive nutrition assessment and recommendations for: Correction of dietary nutritional deficiencies, Comprehensive diabetes self-management education. Atenolol is not recommended, but other -blockers may be used, if necessary. In patients with preexisting diabetes, glycemic targets are usually achieved through a combination of insulin administration and medical nutrition therapy. There are no data to support the use of TIR in women with type 2 diabetes or GDM. Rockville, MD, Agency for Healthcare Research and Quality, 2014 (Evidence Syntheses, No. 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 As a world leader in diabetes care, the ADA is proud to set the standards!, said Boris Draznin, MD, PhD, Chair of the Professional Practice Committee. However, metformin readily crosses the placenta, resulting in umbilical cord blood levels of metformin as high or higher than simultaneous maternal levels (70,71). Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. 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). This usually results in a doubling of daily insulin dose compared with the prepregnancy requirement. Arlington, VA 22202, For donations by mail: DKA, diabetic ketoacidosis; DVT/PE, deep vein thrombosis/pulmonary embolism; ECG, electrocardiogram; NAFLD, nonalcoholic fatty liver disease; PCOS, polycystic ovary syndrome; TSH, thyroid-stimulating hormone. A large study found that after adjusting for confounders, first trimester ACE inhibitor exposure does not appear to be associated with congenital malformations (20). E, 14.6 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. 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 (120). All rights reserved. The preconception care of women with diabetes should include the standard screenings and care recommended for all women planning pregnancy (17). . 14.1 Starting at puberty and continuing in all women with diabetes and reproductive potential, preconception counseling should be incorporated into routine diabetes care. 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. 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). 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. 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. Blood pressure should be measured at routine diabetes visits per ADA guidelines. 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 (21). B. Diabetes has brought us together. 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. In other words, short-term and long-term risks increase with progressive maternal hyperglycemia. C. The physiology of pregnancy necessitates frequent titration of insulin to match changing requirements and underscores the importance of daily and frequent self-monitoring of blood glucose. Therefore, all women should be tested as outlined in Section 2 Classification and Diagnosis of Diabetes (https://doi.org/10.2337/dc21-S002). If both the fasting plasma glucose (126 mg/dL [7.0 mmol/L]) and 2-h plasma glucose (200 mg/dL [11.1 mmol/L]) are abnormal in a single screening test, then the diagnosis of diabetes is made. Preconception counseling resources tailored for adolescents are available at no cost through the American Diabetes Association (ADA) (16). On the basis of available evidence, statins should also be avoided in pregnancy (118). 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. 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). Low-dose aspirin >100 mg is required (109111). https://doi.org/10.2337/dc22-S015. Glycemic target lower limits defined above for preexisting diabetes apply for GDM that is treated with insulin. There are no data to support the use of TIR in women with type 2 diabetes or GDM. We help people with diabetes thrive by fighting for their rights and developing programs, advocacy and education designed to improve their quality of life. 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 (90). 2451 Crystal Drive, Suite 900 Arlington, VA 22202. Adjusting for BMI attenuated this association moderately, but not completely. 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). 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. A blood sugar level of 190 milligrams per deciliter (mg/dL), or 10.6 millimoles per liter (mmol/L), indicates gestational diabetes. Women of reproductive age with prediabetes may develop type 2 diabetes by the time of their next pregnancy and will need preconception evaluation. Metformin was associated with a lower risk of neonatal hypoglycemia and less maternal weight gain than insulin in systematic reviews (65,6769). More recently, glyburide failed to be found noninferior to insulin based on a composite outcome of neonatal hypoglycemia, macrosomia, and hyperbilirubinemia (66). 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. (Evidence A)Long-term use of Metformin may be associated with biochemical vitamin B12 . The American Diabetes Association (ADA) recently released its 2021 Standards of Medical Care, which provides healthcare professionals, researchers, and insurers with updated guidelines on diabetes care and management. 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). 190: Gestational diabetes mellitus. Long-term safety data for offspring exposed to glyburide are not available (74). However, lactation can increase the risk of overnight hypoglycemia, and insulin dosing may need to be adjusted. Prognosis - Most patients with gestational diabetes mellitus . The 2021 Standards of Care is now live online in Diabetes Care. Family planning should be discussed, including the benefits of long-acting, reversible contraception, and effective contraception should be prescribed and used until a woman is prepared and ready to become pregnant (1115). As is true for all nutrition therapy in patients with diabetes, the amount and type of carbohydrate will impact glucose levels. E, 14.12 Commonly used estimated A1C and glucose management indicator calculations should not be used in pregnancy as estimates of A1C. The risk for associated hypertension and other comorbidities may be as high or higher with type 2 diabetes as with type 1 diabetes, even if diabetes is better controlled and of shorter apparent duration, with pregnancy loss appearing to be more prevalent in the third trimester in women with type 2 diabetes, compared with the first trimester in women with type 1 diabetes (105,106). There are no intervention trials in offspring of mothers with GDM. C, 14.22 A contraceptive plan should be discussed and implemented with all women with diabetes of reproductive potential. Not only is the prevalence of type 1 diabetes and type 2 diabetes increasing in women of reproductive age, but there is also a dramatic increase in the reported rates of gestational diabetes mellitus. See Table 15.1 for additional details on elements of preconception care (17,19). 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). However, a meta-analysis and an additional trial demonstrate that low-dose aspirin <100 mg is not effective in reducing preeclampsia. 14.19 In pregnant patients with diabetes and chronic hypertension, a blood pressure target of 110135/85 mmHg is suggested in the interest of reducing the risk for accelerated maternal hypertension A and minimizing impaired fetal growth. Health problems can occur when blood sugar is too high. DKA, diabetic ketoacidosis; DVT/PE, deep vein thrombosis/pulmonary embolism; ECG, electrocardiogram; NAFLD, nonalcoholic fatty liver disease; PCOS, polycystic ovary syndrome; TSH, thyroid-stimulating hormone. In patients with preexisting diabetes, glycemic targets are usually achieved through a combination of insulin administration and medical nutrition therapy. Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes2021. Treatment of GDM with lifestyle and insulin has been demonstrated to improve perinatal outcomes in two large randomized studies as summarized in a U.S. Preventive Services Task Force review (59). Selection of CGM device should be individualized based on patient circumstances. (Evidence Syntheses, No. Interpregnancy or postpartum weight gain is associated with increased risk of adverse pregnancy outcomes in subsequent pregnancies (110) and earlier progression to type 2 diabetes. E, 15.28 Postpartum care should include psychosocial assessment and support for self-care. ADA - E Consensus. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC. A Insulin is the preferred agent for the management of type 2 diabetes in pregnancy. Sulfonylureas are known to cross the placenta and have been associated with increased neonatal hypoglycemia. In one study, insulin requirements in the immediate postpartum period are roughly 34% lower than prepregnancy insulin requirements (113,114). 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. 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