The food plan should be based on a nutrition assessment with guidance from the Dietary Reference Intakes (DRI). What we do next will make us Connected for Life. Special attention should be paid to the review of the medication list for potentially harmful drugs (i.e., ACE inhibitors [19,20], angiotensin receptor blockers [19], and statins [21,22]). 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. 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 (81,82). 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. 15.19 Women with type 1 or type 2 diabetes should be prescribed low-dose aspirin 100150 mg/day starting at 12 to 16 weeks of gestation to lower the risk of preeclampsia. 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. Women with GDM have a 10-fold increased risk of developing type 2 diabetes compared with women without GDM (119). The U.S. Preventive Services Task Force recommends the use of low-dose aspirin (81 mg/day) as a preventive medication at 12 weeks of gestation in women who are at high risk for preeclampsia (96). As in type 1 diabetes, insulin requirements drop dramatically after delivery. 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. Preconception counseling using developmentally appropriate educational tools enables adolescent girls to make well-informed decisions (8). The preconception care of women with diabetes should include the standard screenings and care recommended for all women planning pregnancy (17). 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. Diabetes Care. A Insulin is the preferred agent for the management of type 2 diabetes in pregnancy. A. 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). The American Diabetes Association is committed to improving the lives of all those affected by diabetes through this publication of the most widely respected guidelines for health professionals, said Dr. Robert Gabbay, Chief Scientific and Medical Officer at the American Diabetes Association. Thus, although A1C may be useful, it should be used as a secondary measure of glycemic control in pregnancy, after blood glucose monitoring. Both metformin and intensive lifestyle intervention prevent or delay progression to diabetes in women with prediabetes and a history of GDM. Recommended weight gain during pregnancy for women with overweight is 1525 lb and for women with obesity is 1020 lb (62). 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. Type 2 diabetes is often associated with obesity. The insulin requirement levels off toward the end of the third trimester with placental aging. There are no data to support the use of TIR in women with type 2 diabetes or GDM. ACOG and ADA recommend the same thresholds for both GDM and pregestational diabetes. 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. B, 15.5 In addition to focused attention on achieving glycemic targets A, standard preconception care should be augmented with extra focus on nutrition, diabetes education, and screening for diabetes comorbidities and complications. Members of the ADA Professional Practice Committee, a . E, 14.12 Commonly used estimated A1C and glucose management indicator calculations should not be used in pregnancy as estimates of A1C. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC. Given that early pregnancy is a time of enhanced insulin sensitivity and lower glucose levels, many women with type 1 diabetes will have lower insulin requirements and an increased risk for hypoglycemia (30). 14.16 Insulin should be used for management of type 1 diabetes in pregnancy. 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. 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. 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. The American Diabetes Association released its 2022 Standards of Care, which provides an annual update on practice guidelines. 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. B, 15.8 Due to increased red blood cell turnover, A1C is slightly lower in normal pregnancy than in normal nonpregnant women. 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). 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. 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. Insulin is the preferred treatment for type 2 diabetes in pregnancy. If women cannot achieve these targets without significant hypoglycemia, the ADA suggests less stringent targets based on clinical experience and individualization of care. University of North Carolina, Chapel Hill. 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. However, lactation can increase the risk of overnight hypoglycemia, and insulin dosing may need to be adjusted. 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 OGTT is more sensitive at detecting glucose intolerance, including both prediabetes and diabetes. 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. Box 7023 Merrifield, VA 22116-7023. 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). 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. Women with type 1 diabetes should be prescribed ketone strips and receive education on DKA prevention and detection. Patterns of glycemia in normal pregnancy: should the current therapeutic targets be challenged? None of the currently available human insulin preparations have been demonstrated to cross the placenta (9095). 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). The food plan should provide adequate calorie intake to promote fetal/neonatal and maternal health, achieve glycemic goals, and promote weight gain according to 2009 Institute of Medicine recommendations (62). There are no adequately powered randomized trials comparing different fasting and postmeal glycemic targets in diabetes in pregnancy. 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). For 82 years, the ADA has driven discovery and research to treat, manage, and prevent diabetes while working relentlessly for a cure. 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. 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. Appropriate use of over-the-counter medications and supplements, Evaluation of diabetes and its comorbidities and complications, including: DKA/severe hyperglycemia; severe hypoglycemia/hypoglycemia unawareness; barriers to care; comorbidities such as hyperlipidemia, hypertension, NAFLD, PCOS, and thyroid dysfunction; complications such as macrovascular disease, nephropathy, neuropathy (including autonomic bowel and bladder dysfunction), and retinopathy, Evaluation of obstetric/gynecologic history, including history of: cesarean section, congenital malformations or fetal loss, current methods of contraception, hypertensive disorders of pregnancy, postpartum hemorrhage, preterm delivery, previous macrosomia, Rh incompatibility, and thrombotic events (DVT/PE), Review of current medications and appropriateness during pregnancy, Diabetes complications and comorbidities, including: comprehensive foot exam; comprehensive ophthalmologic exam; ECG in women starting at age 35 years who have cardiac signs/symptoms or risk factors, and if abnormal, further evaluation; lipid panel; serum creatinine; TSH; and urine protein-to-creatinine ratio.

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