Standards of Medical Care in Diabetes 2021- Diabetes management in pregnancy

Recommendations

• Lifestyle behavior change is an essential component of management of gestational diabetes mellitus and may suffice for the treatment of many women. Insulin should be added if needed to achieve glycemic targets.
• Insulin is the preferred medication for treating hyperglycemia in gestational diabetes mellitus. Metformin and glyburide should not be used as first-line agents, as both cross the placenta to the fetus.
• Metformin, when used to treat polycystic ovary syndrome and induce ovulation, should be discontinued by the end of the first trimester.

Insulin use

Recommendations

• Insulin should be used for management of type 1 diabetes in pregnancy. Insulin is the preferred agent for the management of type 2 diabetes in pregnancy.
• Either multiple daily injections or insulin pump technology can be used in pregnancy complicated by type 1 diabetes.

Preeclampsia and Aspirin

Recommendation

• Women with type 1 or type 2 diabetes should be prescribed low-dose aspirin 100–150 mg/day starting at 12 to 16 weeks of gestation to lower the risk of preeclampsia. E A dosage of 162 mg/day may be acceptable; currently in the U.S., low-dose aspirin is available in 81-mg tablets.

Pregnancy and Drug Considerations

Recommendations

• In pregnant patients with diabetes and chronic hypertension, a blood pressure target of 110–135/85 mmHg is suggested in the interest of reducing the risk for accelerated maternal hypertension and minimizing impaired fetal growth.
• 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.

Postpartum Care

Recommendations

• 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 contraceptive plan should be discussed and implemented with all women with diabetes of reproductive potential.
• Screen women with a recent history of gestational diabetes mellitus at 4–12 weeks postpartum, using the 75-g oral glucose tolerance test and clinically appropriate nonpregnancy diagnostic criteria.
• Women with a history of gestational diabetes mellitus found to have prediabetes should receive intensive lifestyle interventions and/or metformin to prevent diabetes.
• Women with a history of gestational diabetes mellitus should have lifelong screening for the development of type 2 diabetes or prediabetes every 1–3 years.
• 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.
• Postpartum care should include psychosocial assessment and support for self-care.