The guideline comes in response to a rising global prevalence of PDM, particularly T2DM, which significantly heightens the risk of complications such as preeclampsia, cesarean delivery, preterm birth, macrosomia, and congenital anomalies. The evidence underscores the need for pregnancy-specific diabetes management to mitigate these outcomes.
The multidisciplinary panel behind the guideline adopted a systematic, evidence-based approach, incorporating the GRADE methodology to evaluate the strength of clinical recommendations and consider patient values, feasibility, cost, and health equity. Their findings produced ten key recommendations:
- Assess pregnancy intention regularly: Healthcare providers are advised to ask about pregnancy plans during all reproductive health, diabetes, and primary care visits, including emergency care when appropriate.
- Promote contraception when pregnancy is not desired: For individuals not planning to conceive, contraception should be discussed as a key element of preconception care.
- Discontinue GLP-1 receptor agonists before conception: In individuals with T2DM, these medications should be stopped before pregnancy due to insufficient safety data.
- Avoid routine addition of metformin during pregnancy: For pregnant individuals with T2DM already on insulin, adding metformin is not recommended, given concerns over potential negative effects on fetal growth and body composition.
- Flexible dietary recommendations: Either a carbohydrate-restricted diet (<175g/day) or a standard diet (>175g/day) is acceptable, as current evidence is insufficient to strongly favor one over the other.
- Use either CGM or SMBG for glucose monitoring: In pregnant individuals with T2DM, both Continuous Glucose Monitoring (CGM) and Self-Monitoring of Blood Glucose (SMBG) are considered acceptable options.
- Stick with established glucose targets: For individuals using CGM, maintaining standard pregnancy glucose targets (e.g., fasting <95 mg/dL) is recommended over a single 24-hour average target.
- Favor hybrid closed-loop (HCL) insulin pumps in T1DM: Pregnant individuals with T1DM may benefit from using HCL systems, which adjust insulin delivery automatically based on CGM data, offering improved glucose control.
- Opt for early delivery based on risk: Rather than waiting for spontaneous labor, clinicians should assess the need for early delivery based on maternal and fetal risk factors.
- Ensure postpartum endocrine care: Following delivery or pregnancy loss, patients should receive dedicated diabetes management alongside routine obstetric care.
The authors emphasize that although these recommendations are based on low to very low certainty evidence, they reflect best practices in the absence of high-quality data. The guideline highlights the urgent need for more randomized controlled trials (RCTs) to refine glycemic targets, optimize medication use, and evaluate emerging technologies in the context of pregnancy.
Importantly, the guideline also calls for greater investment in preconception care (PCC). Despite strong evidence that PCC improves outcomes—such as reducing first-trimester HbA1c and congenital malformations—few patients currently receive it. The authors stress that implementing structured PCC strategies is crucial for improving health outcomes for both mothers and their babies.
In the evolving landscape of diabetes care, this guideline serves as a roadmap for clinicians to navigate the complexities of managing diabetes in pregnancy while adapting to rapid technological advancements.
Reference:
Wyckoff, J. A., Lapolla, A., D, B., Barbour, L. A., Brown, F. M., Catalano, P. M., Corcoy, R., Di Renzo, G. C., Drobycki, N., Murad, M. H., Tabák, A. G., Weatherup, E., & Zera, C. Preexisting Diabetes and Pregnancy: An Endocrine Society and European Society of Endocrinology Joint Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism. https://doi.org/10.1210/clinem/dgaf288
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