Insulin sensitivity then returns to prepregnancy levels over the following 12 weeks. Members of the ADA Professional Practice Committee, a . 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. Referral to an RD/RDN is important in order to establish a food plan and insulin-to-carbohydrate ratio and to determine weight gain goals. Women with a history of GDM have a greatly increased risk of conversion to type 2 diabetes over time (120). In women taking insulin, particular attention should be directed to hypoglycemia prevention in the setting of breastfeeding and erratic sleep and eating schedules (115). Members of the ADA P Diabetes in pregnancy is associated with an increased risk of preeclampsia (107). Low-dose aspirin >100 mg is required (109111). Classification and Diagnosis of Diabetes:Standards of Medical Care in Diabetes2021. In the second and third trimesters, A1C <6% (42 mmol/mol) has the lowest risk of large-for-gestational-age infants (39,42,43), preterm delivery (44), and preeclampsia (1,45). Women of reproductive age with prediabetes may develop type 2 diabetes by the time of their next pregnancy and will need preconception evaluation. Those with elevated blood pressure measurements should have their measurements repeated on a . Women with preexisting diabetic retinopathy will need close monitoring during pregnancy to assess for progression of retinopathy and provide treatment if indicated (24). Diabetes - Symptoms and causes - Mayo Clinic 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). Blood pressure should be measured at routine diabetes visits per ADA guidelines. Effective preconception counseling could avert substantial health and associated cost burdens in offspring (10). Box 7023 Merrifield, VA 22116-7023. Hypoglycemia (Low Blood Glucose) | ADA - American Diabetes Association Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. Metformin and glyburide should not be used as first-line agents, as both cross the placenta to the fetus. Suggested citation: American Diabetes Association Professional Practice Committee. 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). 190: Gestational Diabetes Mellitus. A referral for a comprehensive eye exam is recommended. What we do next will make us Connected for Life. 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). 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). 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. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADAs clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). In other words, short-term and long-term risks increase with progressive maternal hyperglycemia. If these targets cannot be met and the majority of fasting and/or postprandial values are elevated, then pharmacotherapy is recommended. The insulin requirement levels off toward the end of the third trimester with placental aging. C, 14.22 A contraceptive plan should be discussed and implemented with all women with diabetes of reproductive potential. The necessary rapid implementation of euglycemia in the setting of retinopathy is associated with worsening of retinopathy (23). 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 (46,39). 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). 15.1 Starting at puberty and continuing in all women with diabetes and reproductive potential, preconception counseling should be incorporated into routine diabetes care. There are no adequate data on optimal weight gain versus weight maintenance in women with BMI >35 kg/m2. 14.18 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. Preconception counseling resources tailored for adolescents are available at no cost through the American Diabetes Association (ADA) (15). 1):S232S243, American Diabetes Association Professional Practice Committee. 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 (88,89). 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. All rights reserved. Diabetes has brought us together. Gestational diabetes mellitus (GDM) is a serious and frequent pregnancy complication that can lead to short and long-term risks for both mother and fetus. An Update of Medical Nutrition Therapy in Gestational Diabetes Mellitus 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). One study showed that care of preexisting diabetes in clinics that included diabetes and obstetric specialists improved care (28). American Diabetes Association; 14. Gestational Diabetes | ADA However, metformin readily crosses the placenta, resulting in umbilical cord blood levels of metformin as high or higher than simultaneous maternal levels (78,79). 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). While many providers prefer insulin pumps in pregnancy, it is not clear that they are superior to multiple daily injections (91,92). 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. 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. Women of reproductive age with prediabetes may develop type 2 diabetes by the time of their next pregnancy and will need preconception evaluation. B, 14.8 Due to increased red blood cell turnover, A1C is slightly lower in normal pregnancy than in normal nonpregnant women. Gestational Diabetes | ACOG 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. 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. 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. During pregnancy, your body makes more hormones and goes through other changes, such as weight gain. Diabetes Care. Review and counseling on the use of nicotine products, alcohol, and recreational drugs, including marijuana, is important. 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. The American Diabetes Association released its 2022 Standards of Care, which provides an annual update on practice guidelines. Type 2 diabetes is often associated with obesity. B. Additionally, as A1C represents an integrated measure of glucose, it may not fully capture postprandial hyperglycemia, which drives macrosomia. 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. 201: Pregestational Diabetes Mellitus, Diabetes and Reproductive Health for Girls, ACOG Committee Opinion No. American Diabetes Association. Therefore, all women should be tested as outlined in Section 2 Classification and Diagnosis of Diabetes (https://doi.org/10.2337/dc21-S002). (Evidence A)Long-term use of Metformin may be associated with biochemical vitamin B12 . Women with preexisting diabetic retinopathy will need close monitoring during pregnancy to assess for progression of retinopathy and provide treatment if indicated (23). One study showed that care of preexisting diabetes in clinics that included diabetes and obstetric specialists improved care (27). This usually results in a doubling of daily insulin dose compared with the prepregnancy requirement. Review and counseling on the use of nicotine products, alcohol, and recreational drugs, including marijuana, is important. 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). Reflecting this physiology, fasting and postprandial monitoring of blood glucose is recommended to achieve metabolic control in pregnant women with diabetes. 14.16 Insulin should be used for management of type 1 diabetes in pregnancy. Furthermore, glyburide and metformin failed to provide adequate glycemic control in separate RCTs in 23% and 2528% of women with GDM, respectively (63,64).