A Other oral and noninsulin injectable glucose-lowering medications lack long-term safety data. In women with normal pancreatic function, insulin production is sufficient to meet the challenge of this physiological insulin resistance and to maintain normal glucose levels. Join Us. 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. Suggested citation: American Diabetes Association. 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. The American . Mothers who substitute fat for carbohydrate may unintentionally enhance lipolysis, promote elevated free fatty acids, and worsen maternal insulin resistance (63,64). Both metformin and intensive lifestyle intervention prevent or delay progression to diabetes in women with prediabetes and a history of GDM. 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. 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). 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 (84), and there is no evidence-based need to continue metformin in such patients (8587). 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. Insulin is the first-line agent recommended for treatment of GDM in the U.S. During pregnancy, your body makes more hormones and goes through other changes, such as weight gain. 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. 14.13 Lifestyle behavior change is an essential component of management of gestational diabetes mellitus and may suffice for the treatment of many women. 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. 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. In these women, lifestyle intervention and metformin reduced progression to diabetes by 35% and 40%, respectively, over 10 years compared with placebo (112). Gestational diabetes screening is recommended at both 12-16 weeks and 24-48 weeks gestation with a 2h 75g-OGTT and 0, 1, and 2h glucose measures. Women with type 1 diabetes should be prescribed ketone strips and receive education on DKA prevention and detection. There are no intervention trials in offspring of mothers with GDM. These associations with maternal oral glucose tolerance test (OGTT) results are continuous with no clear inflection points (38,51). It may be suited for pregnancy because the predict low glucose threshold for suspending insulin is in the range of premeal and overnight glucoses targets in pregnancy and may allow for more aggressive prandial dosing. American Diabetes Association Professional Practice Committee; 15. There are opportunities to educate all women and adolescents of reproductive age with diabetes about the risks of unplanned pregnancies and about improved maternal and fetal outcomes with pregnancy planning (8). 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. 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. 14.21 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. Counseling on diabetes in pregnancy per current standards, including: natural history of insulin resistance in pregnancy and postpartum; preconception glycemic targets; avoidance of DKA/severe hyperglycemia; avoidance of severe hypoglycemia; progression of retinopathy; PCOS (if applicable); fertility in patients with diabetes; genetics of diabetes; risks to pregnancy including miscarriage, still birth, congenital malformations, macrosomia, preterm labor and delivery, hypertensive disorders in pregnancy, etc. About the American Diabetes Association Concentrations of glyburide in umbilical cord plasma are approximately 5070% of maternal levels (70,71). Some women with preexisting diabetes should also test blood glucose preprandially. In addition, diabetes in pregnancy may increase the risk of obesity, hypertension, and type 2 diabetes in offspring later in life (1,2). In the absence of unequivocal hyperglycemia, a positive screen for diabetes requires two abnormal values. doi: . It can include special meal plans and regular physical activity. Preprandial testing is also recommended when using insulin pumps or basal-bolus therapy so that premeal rapid-acting insulin dosage can be adjusted. In women with normal pancreatic function, insulin production is sufficient to meet the challenge of this physiological insulin resistance and to maintain normal glucose levels. 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). E, 15.28 Postpartum care should include psychosocial assessment and support for self-care. American Diabetes Association. 14.7 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. 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 (73,74). 1):S232S243, American Diabetes Association Professional Practice Committee. American Diabetes Association. A, 15.26 Women with a history of gestational diabetes mellitus should have lifelong screening for the development of type 2 diabetes or prediabetes every 13 years. 15.4 Women with preexisting diabetes who are planning a pregnancy should ideally be managed beginning in preconception in a multidisciplinary clinic including an endocrinologist, maternal-fetal medicine specialist, registered dietitian nutritionist, and diabetes care and education specialist, when available. As is true for all nutrition therapy in patients with diabetes, the amount and type of carbohydrate will impact glucose levels. Standards of Medical Care for Patients with Diabetes Mellitus Diabetes and Population Health 1. 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). If women cannot achieve these targets without significant hypoglycemia, the ADA suggests less stringent targets based on clinical experience and individualization of care. 14.16 Insulin should be used for management of type 1 diabetes in pregnancy. Gestational Diabetes Screening and Treatment Guideline . Around 16 weeks, insulin resistance begins to increase, and total daily insulin doses increase linearly 5% per week through week 36. Not all hybrid closed-loop pumps are able to achieve the pregnancy targets. Reflecting this physiology, fasting and postprandial monitoring of blood glucose is recommended to achieve metabolic control in pregnant women with diabetes. B, 14.11 Continuous glucose monitoring metrics may be used as an adjunct but should not be used as a substitute for self-monitoring of blood glucose to achieve optimal pre- and postprandial glycemic targets. Chronic diuretic use during pregnancy is not recommended as it has been associated with restricted maternal plasma volume, which may reduce uteroplacental perfusion (105). Prescription of prenatal vitamins (with at least 400 g of folic acid and 150 g of potassium iodide [17]) is recommended prior to conception. 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, 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? Furthermore, glyburide and metformin failed to provide adequate glycemic control in separate RCTs in 23% and 2528% of women with GDM, respectively (70,71). 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. For 80 years the ADA has been driving discovery and research to treat, manage and prevent diabetes, while working relentlessly for a cure. 14.14 Insulin is the preferred medication for treating hyperglycemia in gestational diabetes mellitus. Those with elevated blood pressure measurements should have their measurements repeated on a . Observational studies in preexisting diabetes and pregnancy show the lowest rates of adverse fetal outcomes in association with A1C <66.5% (4248 mmol/mol) early in gestation (46,38). E, 14.27 Postpartum care should include psychosocial assessment and support for self-care. In studies of women without preexisting diabetes, increasing A1C levels within the normal range are associated with adverse outcomes (36). 14.4 Women with preexisting diabetes who are planning a pregnancy should ideally be managed beginning in preconception in a multidisciplinary clinic including an endocrinologist, maternal-fetal medicine specialist, registered dietitian nutritionist, and diabetes care and education specialist, when available. Accessed 21 June 2020. Management of diabetes in pregnancy: Standards of Medical Care in Diabetes2022. 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 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). Insulin sensitivity then returns to prepregnancy levels over the following 12 weeks. 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. American Diabetes Association; 14. 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. 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). Health equity for those living with diabetes. Although there is some heterogeneity, many RCTs and a Cochrane review 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 (5355). To learn more or to get involved, visit us at diabetes.org or call 1-800-DIABETES (1-800-342-2383). 14.15 Metformin, when used to treat polycystic ovary syndrome and induce ovulation, should be discontinued by the end of the first trimester. 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. The guidelines provided by the American Diabetes Association (ADA) on diagnosis and management of hyperglycemia in pregnancy are widely followed. None of the currently available human insulin preparations have been demonstrated to cross the placenta (8489). 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). This condition is called gestational diabetes (GD).Women with GD need special care both during and after pregnancy. 112). 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). Several studies have shown improved diabetes and pregnancy outcomes when care has been delivered from preconception through pregnancy by a multidisciplinary group focused on improved glycemic control (2528).
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