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 (84). 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. 2. Classification and Diagnosis of Diabetes: Standards of - PubMed Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes2021. C, 15.23 A contraceptive plan should be discussed and implemented with all women with diabetes of reproductive potential. Fasting urine ketone testing may be useful to identify women who are severely restricting carbohydrates to control blood glucose. If women cannot achieve these targets without significant hypoglycemia, the ADA suggests less stringent targets based on clinical experience and individualization of care. Insulin pumps that allow for the achievement of pregnancy fasting and postprandial glycemic targets may reduce hypoglycemia and allow for more aggressive prandial dosing to achieve targets. Here's what these new updates mean, including your options for first-line glucose-lowering therapies, when you should be screened for diabetes, the expanded use of diabetes care technology, and more. Insulin is the preferred treatment for type 2 diabetes in pregnancy. Long-acting, reversible contraception may be ideal for many women. Adjusting for BMI attenuated this association moderately, but not completely. Insulin use should follow the guidelines below. It is required that all programs that are accredited/recognized by ADCES and ADA meet these guidelines in order to bill for Medicare. 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). B, 15.25 Women with a history of gestational diabetes mellitus found to have prediabetes should receive intensive lifestyle interventions and/or metformin to prevent diabetes. 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. 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. The food plan should be based on a nutrition assessment with guidance from the Dietary Reference Intakes (DRI). An RCT of metformin added to insulin for the treatment of type 2 diabetes found less maternal weight gain and fewer cesarean births. 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. There are no intervention trials in offspring of mothers with GDM. More information is available at, This site uses cookies. 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). DKA carries a high risk of stillbirth. ACOG and ADA recommend the following target levels to reduce risk of macrosomia Fasting or preprandial blood glucose values < 95 mg/dL Postprandial blood glucose values < 140 mg/dL at 1 hour and < 120 mg/dL at 2 hours Review weekly but may alter based on degree of glucose control Diet and Exercise Nutritional assessment and plan Your donation is free, convenient, and tax-deductible. See Table 14.1 for additional details on elements of preconception care (16,18). There is no definitive research that identifies a specific optimal calorie intake for women with GDM or suggests that their calorie needs are different from those of pregnant women without GDM. 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. In studies of women without preexisting diabetes, increasing A1C levels within the normal range are associated with adverse outcomes (36). 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. 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. 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 (9). A Insulin is the preferred agent for the management of type 2 diabetes in pregnancy. The online version of the Standards of Care will continue to be annotated in real-time with necessary updates if new evidence or regulatory changes merit immediate incorporation through the living Standards of Care process. Mount Sinai Hospital, Canada. American Diabetes Association. 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). 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 (45). B. 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). For 82 years, the ADA has driven discovery and research to treat, manage, and prevent diabetes while working relentlessly for a cure. Reflecting this physiology, fasting and postprandial monitoring of blood glucose is recommended to achieve metabolic control in pregnant women with diabetes. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC. 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. 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. Gestational Diabetes | ACOG As in type 1 diabetes, insulin requirements drop dramatically after delivery. 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). Recommended weight gain during pregnancy for women with overweight is 1525 lb and for women with obesity is 1020 lb (62). 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. 15. Management of Diabetes in Pregnancy: 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. It means that, by working with your doctor, you can have a healthy pregnancy and a healthy baby. Classification and Diagnosis of Diabetes:Standards of Medical Care in Diabetes2021. B, 15.8 Due to increased red blood cell turnover, A1C is slightly lower in normal pregnancy than in normal nonpregnant women. Thus, although A1C may be useful, it should be used as a secondary measure of glycemic control in pregnancy, after blood glucose monitoring. 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. Diabetes shouldnt stop you from living a healthy life. 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. 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. Join us to develop and nurture an open dialogue between industry and AACE to advance patient care. Helping tackle commonly faced diabetes issues. 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. It can include special meal plans and regular physical activity. Hybrid closed-loop insulin pumps that allow for the achievement of pregnancy fasting and postprandial glycemic targets may reduce hypoglycemia and allow for more aggressive prandial dosing to achieve targets. 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? Partner with Us. Diabetes-specific counseling should include an explanation of the risks to mother and fetus related to pregnancy and the ways to reduce risk, including glycemic goal setting, lifestyle and behavioral management, and medical nutrition therapy. 2021 Updates to the ADA Standards of Care | diaTribe Change Diabetes Care 1 January 2022; 45 (Supplement_1): S232S243. In addition, diabetes in pregnancy may increase the risk of obesity, hypertension, and type 2 diabetes in offspring later in life (1,2). Gestational diabetes occurs when your body can't make enough insulin during your pregnancy. ADA - E Consensus. B, 15.11 Continuous glucose monitoring metrics may be used in addition to but should not be used as a substitute for self-monitoring of blood glucose to achieve optimal pre- and postprandial glycemic targets. 1-800-DIABETES Preprandial testing is also recommended when using insulin pumps or basal-bolus therapy so that premeal rapid-acting insulin dosage can be adjusted. There are no data to support the use of TIR in women with type 2 diabetes or GDM. A, 14.23 Screen women with a recent history of gestational diabetes mellitus at 412 weeks postpartum, using the 75-g oral glucose tolerance test and clinically appropriate nonpregnancy diagnostic criteria. Bethesda, MD, National Library of Medicine. Some women develop diabetes for the first time during pregnancy. American Diabetes Association Releases 2023 Standards of Care in Special attention should be paid to the review of the medication list for potentially harmful drugs (i.e., ACE inhibitors [20,21], angiotensin receptor blockers [20], and statins [22,23]). 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). 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. There were fewer macrosomic neonates, but there was a doubling of small-for-gestational-age neonates (104). 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. Gestational diabetes - Diagnosis and treatment - Mayo Clinic 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 (111). Health equity for those living with diabetes. This update presents: Today, the Standards of Care is available online and is published as a supplement to the January 2021 issue of Diabetes Care. 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. 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). In the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study, increasing levels of glycemia were also associated with worsening outcomes (37). 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. Practice Guidelines Resources | American Diabetes Association Management of diabetes in pregnancy: Standards of Medical Care in Diabetes2022. 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). 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). Today, the American Diabetes Association released the 2021 Standards of Medical Care in Diabetes. American Diabetes Association; 14. 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). Medical Optimization of Management of Type 2 Diabetes Complicating Pregnancy (MOMPOD). It can also include daily blood glucose testing and insulin injections. However, due to the potential for growth restriction or acidosis in the setting of placental insufficiency, metformin should not be used in women with hypertension or preeclampsia or at risk for intrauterine growth restriction (82,83). Health problems can occur when blood sugar is too high. 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 (49). A blood sugar level of 190 milligrams per deciliter (mg/dL), or 10.6 millimoles per liter (mmol/L), indicates gestational diabetes. 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). If women cannot achieve these targets without significant hypoglycemia, the ADA suggests less stringent targets based on clinical experience and individualization of care. Women with type 1 diabetes should be prescribed ketone strips and receive education on DKA prevention and detection. Not all hybrid closed-loop pumps are able to achieve the pregnancy targets. Diabetes Care also publishes the ADAs recommendations and statements, clinically relevant review articles, editorials and commentaries. P.O. Other Standards of Care resources, including a webcast with continuing education credit and a full slide deck, can be found on DiabetesPro. 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 referral for a comprehensive eye exam is recommended. These associations with maternal oral glucose tolerance test (OGTT) results are continuous with no clear inflection points (38,51). 14. Management of Diabetes in Pregnancy: - PubMed Gestational diabetes mellitus is a condition in which carbohydrate intolerance develops during pregnancy. Standards of Medical Care for Patients with Diabetes Mellitus Diabetes and Population Health 1. The ADA's 2022 Standards of Medical Care in Diabetes Update 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). 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. The preconception care of women with diabetes should include the standard screenings and care recommended for all women planning pregnancy (16). 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). Preconception counseling resources tailored for adolescents are available at no cost through the American Diabetes Association (ADA) (15). One study showed that care of preexisting diabetes in clinics that included diabetes and obstetric specialists improved care (27). Therefore, all women should be screened as outlined in Section 2, Classification and Diagnosis of Diabetes (https://doi.org/10.2337/dc22-S002). Long-term safety data for offspring exposed to glyburide are not available (74). 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). For 80 years the ADA has been driving discovery and research to treat, manage and prevent diabetes, while working relentlessly for a cure. Topics covered are of interest to clinically oriented physicians, researchers, epidemiologists, psychologists, diabetes care and education specialists and other health care professionals. Cystic Fibrosis-Related Diabetes Clinical Care Guidelines On the basis of available evidence, statins should also be avoided in pregnancy (118). American Diabetes Association. More than 122 million Americans have diabetes or prediabetes and are striving to manage their lives while living with the disease. In these women, lifestyle intervention and metformin reduced progression to diabetes by 35% and 40%, respectively, over 10 years compared with placebo (112). PDF Di abe te s Cl i ni c al P r ac ti c e G ui de l i ne - Capital Health 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. 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. A. National Standards for DSMES - ADCES 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. A large study found that after adjusting for confounders, first trimester ACE inhibitor exposure does not appear to be associated with congenital malformations (21). 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). Postprandial monitoring is associated with better glycemic control and lower risk of preeclampsia (3133). 14.15 Metformin, when used to treat polycystic ovary syndrome and induce ovulation, should be discontinued by the end of the first trimester. However, a meta-analysis and an additional trial demonstrate that low-dose aspirin <100 mg is not effective in reducing preeclampsia. 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). Gestational Diabetes | CDC 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. Diabetes Emergency Plan; Prescription Help; Join Us. Insulin should be added if needed to achieve glycemic targets. Some women with preexisting diabetes should also test blood glucose preprandially. 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 (29). Additionally, as A1C represents an integrated measure of glucose, it may not fully capture postprandial hyperglycemia, which drives macrosomia.
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