American Diabetes Association Professional Practice Committee; 15. Bethesda, MD, National Library of Medicine. Insulin sensitivity then returns to prepregnancy levels over the following 12 weeks. Lower limits do not apply to diet-controlled type 2 diabetes. 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). Women with GDM have a 10-fold increased risk of developing type 2 diabetes compared with women without GDM (119). 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. Updates to the Standards of Care are established and revised by the ADA's Professional Practice Committee (PPC). Women with type 1 diabetes should be prescribed ketone strips and receive education on DKA prevention and detection. This usually results in a doubling of daily insulin dose compared with the prepregnancy requirement. A, 14.2 Family planning should be discussed, and effective contraception (with consideration of long-acting, reversible contraception) should be prescribed and used until a woman's treatment regimen and A1C are optimized for pregnancy. 762: Prepregnancy Counseling, 2017 guidelines of the American Thyroid Association for the diagnosis and management of thyroid disease during pregnancy and the postpartum, Preconception health: changing the paradigm on well-woman health, Pregnancy outcome following exposure to angiotensin-converting enzyme inhibitors or angiotensin receptor antagonists: a systematic review, Angiotensin-converting enzyme inhibitors and the risk of congenital malformations, Prenatal exposure to HMG-CoA reductase inhibitors: effects on fetal and neonatal outcomes, Statins and congenital malformations: cohort study, National Institute of Child Health and Human Development Diabetes in Early Pregnancy Study, Metabolic control and progression of retinopathy. Observational studies show an increased risk of diabetic embryopathy, especially anencephaly, microcephaly, congenital heart disease, renal anomalies, and caudal regression, directly proportional to elevations in A1C during the first 10 weeks of pregnancy (3). However, a meta-analysis and an additional trial demonstrate that low-dose aspirin <100 mg is not effective in reducing preeclampsia. The insulin requirement levels off toward the end of the third trimester with placental aging. Selection of CGM device should be individualized based on patient circumstances. 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. 15.14 Insulin is the preferred medication for treating hyperglycemia in gestational diabetes mellitus. Ongoing evaluation may be performed with any recommended glycemic test (e.g., annual A1C, annual fasting plasma glucose, or triennial 75-g OGTT using nonpregnant thresholds). If women cannot achieve these targets without significant hypoglycemia, the ADA suggests less stringent targets based on clinical experience and individualization of care. Low-dose aspirin >100 mg is required (109111). Depending on the population, studies suggest that 7085% of women diagnosed with GDM under Carpenter-Coustan 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 (55) diagnostic thresholds are used. B. Simple carbohydrates will result in higher postmeal excursions. Evolving evidence for diabetes treatment for people also managing chronic kidney disease and heart failure; The use of technology for diabetes management and individualized care as well as recommendations for continuous glucose monitoring (CGM) for people with diabetes based on therapy; Important information on addressing social determinants of health in diabetes; Barriers to and critical times for diabetes self-management education and support (DSMES); Vaccine-specific updates, including those related to COVID-19. 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. 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). B. 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. Postprandial monitoring is associated with better glycemic control and lower risk of preeclampsia (3133). Antihypertensive drugs known to be effective and safe in pregnancy include methyldopa, nifedipine, labetalol, diltiazem, clonidine, and prazosin. 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. In women taking insulin, particular attention should be directed to hypoglycemia prevention in the setting of breastfeeding and erratic sleep and eating schedules (126). Diabetes-specific testing should include A1C, creatinine, and urinary albumin-to-creatinine ratio. In the absence of unequivocal hyperglycemia, a positive screen for diabetes requires two abnormal values. Chronic diuretic use during pregnancy is not recommended as it has been associated with restricted maternal plasma volume, which may reduce uteroplacental perfusion (117). The OGTT is more sensitive at detecting glucose intolerance, including both prediabetes and diabetes. Women with diabetes have the same contraception options and recommendations as those without diabetes. 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). B. A. Retinopathy is a special concern in pregnancy. 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. Gestational Diabetes Screening and Treatment Guideline . The necessary rapid implementation of euglycemia in the setting of retinopathy is associated with worsening of retinopathy (23). Women with preexisting diabetic retinopathy will need close monitoring during pregnancy to assess for progression of retinopathy and provide treatment if indicated (24). 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. Offspring with exposure to untreated GDM have reduced insulin sensitivity and -cell compensation and are more likely to have impaired glucose tolerance in childhood (52). Reflecting this physiology, fasting and postprandial monitoring of blood glucose is recommended to achieve metabolic control in pregnant women with diabetes. 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). Gestational Diabetes | ADA Every day more than 4,000 people are newly diagnosed with diabetes in America. Read the Standards. The American Diabetes Association (ADA) is the nation's leading voluntary health organization fighting to bend the curve on the diabetes epidemic and help people living with diabetes thrive. 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. Suggested citation: American Diabetes Association. Members of the ADA P The 2015 study (104) excluded pregnancies complicated by preexisting diabetes and only 6% had GDM at enrollment. There are no adequate data on optimal weight gain versus weight maintenance in women with BMI >35 kg/m2. 190: Gestational diabetes mellitus. More recently, glyburide failed to be found noninferior to insulin based on a composite outcome of neonatal hypoglycemia, macrosomia, and hyperbilirubinemia (66). doi: . A systematic review and meta-analysis of observational studies of preconception care for women with preexisting diabetes demonstrated lower A1C and reduced risk of birth defects, preterm delivery, perinatal mortality, small-for-gestational-age births, and neonatal intensive care unit admission (8). Helping tackle commonly faced diabetes issues. In the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study, increasing levels of glycemia were also associated with worsening outcomes (38). 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. American Diabetes Association "Standards of Medical Care-2020 for 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 (66). This needs to be individualized for the patient, so discuss the amount needed with your diabetes team. Interpregnancy or postpartum weight gain is associated with increased risk of adverse pregnancy outcomes in subsequent pregnancies (122) and earlier progression to type 2 diabetes. Diabetes Symptoms, Causes, & Treatment | ADA 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. 15.17 Insulin should be used for management of type 1 diabetes in pregnancy. 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. 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. The OGTT is recommended over A1C at 412 weeks postpartum because A1C may be persistently impacted (lowered) by the increased red blood cell turnover related to pregnancy, by blood loss at delivery, or by the preceding 3-month glucose profile. Hypoglycemia (Low Blood Glucose) | ADA - American Diabetes Association 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. On the basis of available evidence, statins should also be avoided in pregnancy (106). . Low-dose aspirin >100 mg is required (9799). See PREGNANCY AND ANTIHYPERTENSIVE MEDICATIONS in Section 10 Cardiovascular Disease and Risk Management (https://doi.org/10.2337/dc21-S010) for more information on managing blood pressure in pregnancy. Liberalizing higher quality, nutrient-dense carbohydrates results in controlled fasting/postprandial glucose, lower free fatty acids, improved insulin action, and vascular benefits and may reduce excess infant adiposity. Insulin sensitivity then returns to prepregnancy levels over the following 12 weeks. Preprandial testing is also recommended when using insulin pumps or basal-bolus therapy so that premeal rapid-acting insulin dosage can be adjusted. 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. Two designated representatives of the American College of Cardiology (ACC) reviewed and provided feedback on the "Cardiovascular Disease and Risk Management" section, and this section received endorsement from ACC. Guidelines | American Association of Clinical Endocrinology Women of reproductive age with prediabetes may develop type 2 diabetes by the time of their next pregnancy and will need preconception evaluation. Dilated eye examinations should occur ideally before pregnancy or in the first trimester, and then patients should be monitored every trimester and for 1 year postpartum as indicated by the degree of retinopathy and as recommended by the eye care provider. 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. Suggested citation: American Diabetes Association Professional Practice Committee. Oral agents may be an alternative in these women after a discussion of the known risks and the need for more long-term safety data in offspring. 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. 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). None of the currently available human insulin preparations have been demonstrated to cross the placenta (9095). Oral agents may be an alternative in these women after a discussion of the known risks and the need for more long-term safety data in offspring. PDF Guideline for Detection 3.1.0 Screening for Gestational Diabetes and The preconception care of women with diabetes should include the standard screenings and care recommended for all women planning pregnancy (16). https://doi.org/10.2337/dc21-S014. DKA carries a high risk of stillbirth. Glycemic target lower limits defined above for preexisting diabetes apply for GDM that is treated with insulin. Atenolol is not recommended, but other -blockers may be used, if necessary. Diabetes Care, a monthly journal of the American Diabetes Association (ADA), is the highest-ranked, peer-reviewed journal in the field of diabetes treatment and prevention. It demonstrated the value of real-time 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 (47). These associations with maternal oral glucose tolerance test (OGTT) results are continuous with no clear inflection points (37,50). Topics covered are of interest to clinically oriented physicians, researchers, epidemiologists, psychologists, diabetes care and education specialists and other health care professionals. Dilated eye examinations should occur ideally before pregnancy or in the first trimester, and then patients should be monitored every trimester and for 1 year postpartum as indicated by the degree of retinopathy and as recommended by the eye care provider.
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