Standards of Medical Care in Diabetes 2021- Diabetes management in pregnancy
Management of Gestational Diabetes Mellitus
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.
"14. Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes—2021," is published in the journal Diabetes Care.
DOI: https://care.diabetesjournals.org/content/44/Supplement_1/S200
USA: The American Diabetes Association (ADA) has released "Standards of Medical Care in Diabetes" which includes the ADA's current clinical practice recommendations. It is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care.
The recommendations, published in the journal Diabetes Care, focuses on management of diabetes in pregnancy.
The prevalence of diabetes in pregnancy has been increasing in the U.S. in parallel with the worldwide epidemic of obesity. Not only is the prevalence of type 1 diabetes and type 2 diabetes increasing in women of reproductive age, but there is also a dramatic increase in the reported rates of gestational diabetes mellitus. Diabetes confers significantly greater maternal and fetal risk largely related to the degree of hyperglycemia but also related to chronic complications and comorbidities of diabetes.
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. In addition, diabetes in pregnancy may increase the risk of obesity, hypertension, and type 2 diabetes in offspring later in life.
Preconception Counseling
Recommendations
- Starting at puberty and continuing in all women with diabetes and reproductive potential, preconception counseling should be incorporated into routine diabetes care.
- 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.
- 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.
Preconception Care
Recommendations
- 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.
- In addition to focused attention on achieving glycemic targets, standard preconception care should be augmented with extra focus on nutrition, diabetes education, and screening for diabetes comorbidities and complications.
- omen 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. Dilated eye examinations should occur ideally before pregnancy or in the first trimester, and then patients should be monitored every trimester and for 1 year postpartum as indicated by the degree of retinopathy and as recommended by the eye care provider.
Glycemic Targets in Pregnancy
Recommendations
- 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. Glucose targets are fasting plasma glucose <95 mg/dL (5.3 mmol/L) and either 1-h postprandial glucose <140 mg/dL (7.8 mmol/L) or 2-h postprandial glucose <120 mg/dL (6.7 mmol/L). Some women with preexisting diabetes should also test blood glucose preprandially.
- Due to increased red blood cell turnover, A1C is slightly lower in normal pregnancy than in normal nonpregnant women. Ideally, the A1C target in pregnancy is <6% (42 mmol/mol) if this can be achieved without significant hypoglycemia, but the target may be relaxed to <7% (53 mmol/mol) if necessary to prevent hypoglycemia.
- When used in addition to pre- and postprandial self-monitoring of blood glucose, continuous glucose monitoring can help to achieve A1C targets in diabetes and pregnancy.
- When used in addition to self-monitoring of blood glucose targeting traditional pre- and postprandial targets, continuous glucose monitoring can reduce macrosomia and neonatal hypoglycemia in pregnancy complicated by type 1 diabetes.
- Continuous glucose monitoring metrics may be used as an adjunct but should not be used as a substitute for self-monitoring of blood glucose to achieve optimal pre- and postprandial glycemic targets.
- Commonly used estimated A1C and glucose management indicator calculations should not be used in pregnancy as estimates of A1C.
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