Diabetes Care 1 January 2021; 44 (Supplement_1): S200S210. Checklist for preconception care for women with diabetes (17,19). Standard care includes screening for sexually transmitted diseases and thyroid disease, recommended vaccinations, routine genetic screening, a careful review of all prescription and nonprescription medications and supplements used, and a review of travel history and plans with special attention to areas known to have Zika virus, as outlined by ACOG. 2451 Crystal Drive, Suite 900 Arlington, VA 22202. Standards of Medical Care for Patients with Diabetes Mellitus Diabetes and Population Health 1. E, 14.20 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. 11 Once women achieve and maintain good glycemic control, the frequency of testing can be decreased. Insulin is the first-line agent recommended for treatment of GDM in the U.S. American Diabetes Association Professional Practice Committee; 15. Preconception counseling using developmentally appropriate educational tools enables adolescent girls to make well-informed decisions (8). These values represent optimal control if they can be achieved safely. There are no adequate data on optimal weight gain versus weight maintenance in women with BMI >35 kg/m2. Sulfonylureas are known to cross the placenta and have been associated with increased neonatal hypoglycemia. 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). In patients with preexisting diabetes, glycemic targets are usually achieved through a combination of insulin administration and medical nutrition therapy. Interpregnancy or postpartum weight gain is associated with increased risk of adverse pregnancy outcomes in subsequent pregnancies (110) and earlier progression to type 2 diabetes. This condition is called gestational diabetes (GD).Women with GD need special care both during and after pregnancy. Women with a history of GDM have a greatly increased risk of conversion to type 2 diabetes over time (108). Introduction: Gestational diabetes mellitus (GDM) is a major public health problem, affecting about one in every six pregnancies globally. Checklist for preconception care for women with diabetes (16,18). The OGTT is more sensitive at detecting glucose intolerance, including both prediabetes and diabetes. 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. Of women with a history of GDM and prediabetes, only 56 women need to be treated with either intervention to prevent one case of diabetes over 3 years (123). Insulin sensitivity increases dramatically with delivery of the placenta. Planning pregnancy is critical in women with preexisting diabetes due to the need for preconception glycemic control to prevent congenital malformations and reduce the risk of other complications. Diabetes has brought us together. Observational studies show an increased risk of diabetic embryopathy, especially anencephaly, microcephaly, congenital heart disease, renal anomalies, and caudal regression, directly proportional to elevations in A1C during the first 10 weeks of pregnancy (3). Antihypertensive drugs known to be effective and safe in pregnancy include methyldopa, nifedipine, labetalol, diltiazem, clonidine, and prazosin. This was not found in the Adelaide cohort. Counseling on the specific risks of obesity in pregnancy and lifestyle interventions to prevent and treat obesity, including referral to a registered dietitian nutritionist (RD/RDN), is recommended when indicated. Metformin was associated with a lower risk of neonatal hypoglycemia and less maternal weight gain than insulin in systematic reviews (65,6769). Diabetes Care 1 January 2022; 45 (Supplement_1): S232S243. Atenolol is not recommended, but other -blockers may be used, if necessary. Therefore, all women with diabetes of childbearing potential should have family planning options reviewed at regular intervals to make sure that effective contraception is implemented and maintained. However, ACE inhibitors and angiotensin receptor blockers should be stopped as soon as possible in the first trimester to avoid second and third trimester fetopathy (21). B, 15.18 Either multiple daily injections or insulin pump technology can be used in pregnancy complicated by type 1 diabetes. Although there is some heterogeneity, many RCTs and a Cochrane review suggest that the risk of GDM may be reduced by diet, exercise, and lifestyle counseling, particularly when interventions are started during the first or early in the second trimester (5355). 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 (48). However, metformin readily crosses the placenta, resulting in umbilical cord blood levels of metformin as high or higher than simultaneous maternal levels (78,79). CONCEPTT (Continuous Glucose Monitoring in Pregnant Women With Type 1 Diabetes Trial) was a randomized controlled trial (RCT) of real-time continuous glucose monitoring (CGM) in addition to standard care, including optimization of pre- and postprandial glucose targets versus standard care for pregnant women with type 1 diabetes. If the pregnancy has motivated the adoption of a healthier diet, building on these gains to support weight loss is recommended in the postpartum period. Complications in your baby can be caused by gestational diabetes, including: Low-dose aspirin >100 mg is required (109111). Of women with a history of GDM and prediabetes, only 56 women need to be treated with either intervention to prevent one case of diabetes over 3 years (111). American Diabetes Association. Glycemic target lower limits defined above for preexisting diabetes apply for GDM that is treated with insulin. . A blood sugar level below 140 mg/dL (7.8 mmol/L) is usually considered within the standard range on a glucose challenge test, although this may vary by clinic or lab. Long-term safety data for offspring exposed to glyburide are not available (74). A Other oral and noninsulin injectable glucose-lowering medications lack long-term safety data. 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. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. The American Diabetes Association released its 2022 Standards of Care, which provides an annual update on practice guidelines. A, 15.3 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. Although there is some heterogeneity, many randomized controlled trials (RCTs) suggest that the risk of GDM may be reduced by diet, exercise, and lifestyle counseling, particularly when interventions are started during the first or early in the second trimester (5254). These associations with maternal oral glucose tolerance test (OGTT) results are continuous with no clear inflection points (37,50). Medical Optimization of Management of Type 2 Diabetes Complicating Pregnancy (MOMPOD). 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. In the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study, increasing levels of glycemia were also associated with worsening outcomes (37). Glyburide was associated with a higher rate of neonatal hypoglycemia, macrosomia, and increased neonatal abdominal circumference than insulin or metformin in meta-analyses and systematic reviews (72,73). Liberalizing higher quality, nutrient-dense carbohydrates results in controlled fasting/postprandial glucose, lower free fatty acids, improved insulin action, and vascular benefits and may reduce excess infant adiposity. Other Standards of Care resources, including a webcast with continuing education credit and a full slide deck, can be found on DiabetesPro. 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). 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. 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. Guidelines are systematically developed statements to assist patients and providers in choosing appropriate health . Furthermore, glyburide and metformin failed to provide adequate glycemic control in separate RCTs in 23% and 2528% of women with GDM, respectively (63,64). . More recently, glyburide failed to be found noninferior to insulin based on a composite outcome of neonatal hypoglycemia, macrosomia, and hyperbilirubinemia (66). 26-31 Research also suggests that . A key point is the need to incorporate a question about a woman's plans for pregnancy into routine primary and gynecologic care. Diabetes shouldnt stop you from living a healthy life. Women of reproductive age with prediabetes may develop type 2 diabetes by the time of their next pregnancy and will need preconception evaluation. Helping tackle commonly faced diabetes issues. 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. Glycemic control is often easier to achieve in women with type 2 diabetes than in those with type 1 diabetes but can require much higher doses of insulin, sometimes necessitating concentrated insulin formulations. Both multiple daily insulin injections and continuous subcutaneous insulin infusion are reasonable delivery strategies, and neither has been shown to be superior to the other during pregnancy (84). 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. CGM time in range (TIR) can be used for assessment of glycemic control in patients with type 1 diabetes, but it does not provide actionable data to address fasting and postprandial hypoglycemia or hyperglycemia. B, 14.5 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. Box 7023 Merrifield, VA 22116-7023. Insulin resistance drops rapidly with delivery of the placenta. In these women, lifestyle intervention and metformin reduced progression to diabetes by 35% and 40%, respectively, over 10 years compared with placebo (112). The American Diabetes Association (ADA) recently released its 2021 Standards of Medical Care, which provides healthcare professionals, researchers, and insurers with updated guidelines on diabetes care and management. The current recommended amount of carbohydrate is 175 g, or 35% of a 2,000-calorie diet. 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. For 80 years the ADA has been driving discovery and research to treat, manage and prevent diabetes, while working relentlessly for a cure. Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes2022. 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). A major barrier to effective preconception care is the fact that the majority of pregnancies are unplanned. The pharmacologic basis for better clinical practice, Pharmacokinetics, efficacy and safety of glyburide for treatment of gestational diabetes mellitus, Glibenclamide, metformin, and insulin for the treatment of gestational diabetes: a systematic review and meta-analysis, Groupe de Recherche en Obsttrique et Gyncologie (GROG), Effect of glyburide vs subcutaneous insulin on perinatal complications among women with gestational diabetes: a randomized clinical trial, Metformin compared with glyburide for the management of gestational diabetes, Glyburide versus metformin and their combination for the treatment of gestational diabetes mellitus: a randomized controlled study, Comparative efficacy and safety of OADs in management of GDM: network meta-analysis of randomized controlled trials, Placental passage of metformin in women with polycystic ovary syndrome, Population pharmacokinetics of metformin in late pregnancy, Metformin in gestational diabetes: the offspring follow-up (MiG TOFU): body composition and metabolic outcomes at 7-9 years of age, Metformin use in PCOS pregnancies increases the risk of offspring overweight at 4 years of age: follow-up of two RCTs, Neonatal, infant, and childhood growth following metformin versus insulin treatment for gestational diabetes: a systematic review and meta-analysis, Intrauterine metformin exposure and offspring cardiometabolic risk factors (PedMet study): a 5-10 year follow-up of the PregMet randomised controlled trial. In the absence of unequivocal hyperglycemia, a positive screen for diabetes requires two abnormal values. These values represent optimal control if they can be achieved safely. In the prospective Nurses Health Study II (NHS II), subsequent diabetes risk after a history of GDM was significantly lower in women who followed healthy eating patterns (121). Insulin pumps that allow for the achievement of pregnancy fasting and postprandial glycemic targets may reduce hypoglycemia and allow for more aggressive prandial dosing to achieve targets. ACOG and ADA recommend the following target levels to reduce risk of macrosomia Fasting or preprandial blood glucose values < 95 mg/dL Postprandial blood glucose values < 140 mg/dL at 1 hour and < 120 mg/dL at 2 hours Review weekly but may alter based on degree of glucose control Diet and Exercise Nutritional assessment and plan E. Because GDM often represents previously undiagnosed prediabetes, type 2 diabetes, maturity-onset diabetes of the young, or even developing type 1 diabetes, women with GDM should be tested for persistent diabetes or prediabetes at 412 weeks postpartum with a 75-g OGTT using nonpregnancy criteria as outlined in Section 2 Classification and Diagnosis of Diabetes (https://doi.org/10.2337/dc21-S002). Join the fight with us on Facebook (American Diabetes Association), Twitter (@AmDiabetesAssn) and Instagram (@AmDiabetesAssn). Women with type 1 diabetes should be prescribed ketone strips and receive education on DKA prevention and detection. This Guideline was approved November 13, 2016, and updated February 12, 2018. Oral agents may be an alternative in these women after a discussion of the known risks and the need for more long-term safety data in offspring. 14.21 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. 15.1 Starting at puberty and continuing in all women with diabetes and reproductive potential, preconception counseling should be incorporated into routine diabetes care. In other words, short-term and long-term risks increase with progressive maternal hyperglycemia. 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. Postprandial monitoring is associated with better glycemic control and lower risk of preeclampsia (3133). The prevalence of diabetes in pregnancy has been increasing in the U.S. in parallel with the worldwide epidemic of obesity. 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.