As in type 1 diabetes, insulin requirements drop dramatically after delivery. . ADA - E Consensus. In general, specific risks of diabetes in pregnancy include spontaneous abortion, fetal anomalies, preeclampsia, fetal demise, macrosomia, neonatal hypoglycemia, hyperbilirubinemia, and neonatal respiratory distress syndrome, among others. 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). In patients with preexisting diabetes, glycemic targets are usually achieved through a combination of insulin administration and medical nutrition therapy. As part of the American Diabetes Association Precision Medicine in Diabetes Initiative (PMDI) - a partnership with the European Association for the Study of Diabetes (EASD) - this systematic review is part of a comprehensive evidence evaluation in support of the 2nd International Consensus Report on Precision Diabetes Medicine. 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). These associations with maternal oral glucose tolerance test (OGTT) results are continuous with no clear inflection points (37,50). A major barrier to effective preconception care is the fact that the majority of pregnancies are unplanned. . 2021; 44 (Supplement 1):S15-S33. It can include special meal plans and regular physical activity. Comprehensive nutrition assessment and recommendations for: Correction of dietary nutritional deficiencies, Comprehensive diabetes self-management education. 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). 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 (74,75). These associations with maternal oral glucose tolerance test (OGTT) results are continuous with no clear inflection points (38,51). A cost-benefit analysis has concluded that this approach would reduce morbidity, save lives, and lower health care costs (112). While individual RCTs support limited efficacy of metformin (67,68) and glyburide (69) in reducing glucose levels for the treatment of GDM, these agents are not recommended as first-line treatment for GDM because they are known to cross the placenta and data on long-term safety for offspring is of some concern (35). In the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study, increasing levels of glycemia were also associated with worsening outcomes (37). Thus, although A1C may be useful, it should be used as a secondary measure of glycemic control in pregnancy, after self-monitoring of blood glucose. 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. However, a meta-analysis and an additional trial demonstrate that low-dose aspirin <100 mg is not effective in reducing preeclampsia. 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. 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. 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. 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. 15.20 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. A blood sugar level of 190 milligrams per deciliter (mg/dL), or 10.6 millimoles per liter (mmol/L), indicates gestational diabetes. Metformin and glyburide should not be used as first-line agents, as both cross the placenta to the fetus. A Insulin is the preferred agent for the management of type 2 diabetes in pregnancy. Women of reproductive age with prediabetes may develop type 2 diabetes by the time of their next pregnancy and will need preconception evaluation. 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. 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? Patterns of glycemia in normal pregnancy: should the current therapeutic targets be challenged? 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 fasting 75-g OGTT using nonpregnancy criteria as outlined in Section 2, Classification and Diagnosis of Diabetes (https://doi.org/10.2337/dc22-S002), specifically Table 2.2. 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). Health problems can occur when blood sugar is too high. While many providers prefer insulin pumps in pregnancy, it is not clear that they are superior to multiple daily injections (101,102). 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. These recommendations were developed by a panel of experts who built upon prior Standards be reviewing the latest and most significant scientific research. doi: . A, 15.3 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. Insulin is the preferred treatment for type 2 diabetes in pregnancy. E, 14.17 Either multiple daily injections or insulin pump technology can be used in pregnancy complicated by type 1 diabetes. 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 (47). 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). Dedicated to increasing knowledge, stimulating research and promoting better health care for people with diabetes, the journal publishes original articles on human studies in clinical care, education and nutrition; epidemiology, health services and psychosocial research; emerging treatments and technologies; and pathophysiology and complications. In women taking insulin, particular attention should be directed to hypoglycemia prevention in the setting of breastfeeding and erratic sleep and eating schedules (126). women with prior gestational diabetes. 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. For 82 years, the ADA has driven discovery and research to treat, manage, and prevent diabetes while working relentlessly for a cure. There was heterogeneity in the types of effective exercise (aerobic, resistance, or both) and duration of exercise (2050 min/day, 27 days/week of moderate intensity) (65). The OGTT is more sensitive at detecting glucose intolerance, including both prediabetes and diabetes. Some women develop diabetes for the first time during pregnancy. Classification and Diagnosis of Diabetes:Standards of Medical Care in Diabetes2021. This was not found in the Adelaide cohort. 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. 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. B, 15.27 Women with a history of gestational diabetes mellitus should seek preconception screening for diabetes and preconception care to identify and treat hyperglycemia and prevent congenital malformations. Those with elevated blood pressure measurements should have their measurements repeated on a . The most important diabetes-specific component of preconception care is the attainment of glycemic goals prior to conception. This difference was not found in the Adelaide cohort. 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 (54): 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). 112). 112). 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). Sulfonylureas are known to cross the placenta and have been associated with increased neonatal hypoglycemia. Not all hybrid closed-loop pumps are able to achieve the pregnancy targets. Preconception counseling resources tailored for adolescents are available at no cost through the American Diabetes Association (ADA) (15). Blood pressure should be measured at routine diabetes visits per ADA guidelines. 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). In studies of women without preexisting diabetes, increasing A1C levels within the normal range are associated with adverse outcomes (36). Long-term safety data for offspring exposed to glyburide are not available (66). There were fewer macrosomic neonates, but there was a doubling of small-for-gestational-age neonates (104). Preprandial testing is also recommended when using insulin pumps or basal-bolus therapy so that premeal rapid-acting insulin dosage can be adjusted. About the American Diabetes Association Concentrations of glyburide in umbilical cord plasma are approximately 5070% of maternal levels (63,64). Guidelines The aims of the European Association for the Study of Diabetes (EASD) are to encourage and support research in the field of diabetes, the rapid diffusion of acquired knowledge and to facilitate its application. X. Join the fight with us on Facebook (American Diabetes Association), Twitter (@AmDiabetesAssn) and Instagram (@AmDiabetesAssn). CONCEPTT (Continuous Glucose Monitoring in Pregnant Women With Type 1 Diabetes Trial) was a randomized controlled trial of 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. 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. Because GDM is associated with an increased lifetime maternal risk for diabetes estimated at 5060% (107,108), women should also be tested every 13 years thereafter if the 412 weeks postpartum 75-g OGTT is normal. Breastfeeding may also confer longer-term metabolic benefits to both mother (127) and offspring (128). 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. Chronic diuretic use during pregnancy is not recommended as it has been associated with restricted maternal plasma volume, which may reduce uteroplacental perfusion (105). American Diabetes Association. In general, specific risks of diabetes in pregnancy include spontaneous abortion, fetal anomalies, preeclampsia, fetal demise, macrosomia, neonatal hypoglycemia, hyperbilirubinemia, and neonatal respiratory distress syndrome, among others. Glucagon & Other Emergency Glucose Products, Reproductive Health for Teen Girls with Diabetes, Policy Action to Lower the Cost of Diabetes Care, Continuous Glucose Monitors (CGMs)Everything You Need to Know, https://www.facebook.com/AmericanDiabetesAssociation?loc=superfooter, https://twitter.com/AmDiabetesAssn?loc=superfooter, https://www.instagram.com/AmDiabetesAssn/?loc=superfooter, https://www.youtube.com/user/AmericanDiabetesAssn. 15. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC. In one study, insulin requirements in the immediate postpartum period are roughly 34% lower than prepregnancy insulin requirements (113,114). Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes2022. However, lactation can increase the risk of overnight hypoglycemia, and insulin dosing may need to be adjusted. Some women with preexisting diabetes should also test blood glucose preprandially. However, there is insufficient data regarding the benefits of aspirin in women with preexisting diabetes (98). Prescription of prenatal vitamins (with at least 400 g of folic acid and 150 g of potassium iodide [18]) is recommended prior to conception. A rapid reduction in insulin requirements can indicate the development of placental insufficiency (30). More studies are needed to assess the long-term effects of prenatal aspirin exposure on offspring (113). 14.15 Metformin, when used to treat polycystic ovary syndrome and induce ovulation, should be discontinued by the end of the first trimester. September 2021 . Today, the American Diabetes Association released the 2021 Standards of Medical Care in Diabetes. In other words, short-term and long-term risks increase with progressive maternal hyperglycemia. A recent Cochrane systematic review was not able to recommend any specific insulin regimen over another for the treatment of diabetes in pregnancy (90). The guidelines provided by the American Diabetes Association (ADA) on diagnosis and management of hyperglycemia in pregnancy are widely followed. Diabetes shouldnt stop you from living a healthy life. American Diabetes Association. Updated every five years, the National Standards for Diabetes Self-Management Education and Support (DSMES) provide guidelines for operating a DSMES program. Not all hybrid closed-loop pumps are able to achieve the pregnancy targets. 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. The necessary rapid implementation of euglycemia in the setting of retinopathy is associated with worsening of retinopathy (23). Guidelines are systematically developed statements to assist patients and providers in choosing appropriate health . Copyright 19952023. 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. E, 15.12 Commonly used estimated A1C and glucose management indicator calculations should not be used in pregnancy as estimates of A1C.
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