U Translated from English to Spanish - www.onlinedoctranslator.

com

S254 Diabetes CareVolume 46, Supplement 1, January 2023

15. Management of Diabetes in the Nuha A. ElSayed, Grazia Aleppo, Vanita R.

Aroda, Raveendhara R. Bannuru, Florence
Pregnancy: Standards of Care M. Brown, Dennis Bruemmer, Billy S. Collins,
Marisa E. Hilliard,

in diabetes—2023 Diana Isaacs, Eric L. Johnson, Scott Kahan,

Kamlesh Khunti, José León, Sarah K. Lyons,
Diabetes Care 2023;46(Suppl 1):S254–S266 | https://doi.org/10.2337/dc23-S015 Mary Lou Perry, Priya Prahalad,
Richard E. Pratley, Jane Jeffrie Seley, Robert C.
Stanton and Robert A. Gabbay, on behalf of the
American Diabetes Association
15.
MANA
GEME
NT OF
DIABE
TES
IN
PREG The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the current
NANC
Y ADA clinical practice recommendations and is intended to provide the components of diabetes
care, goals, and general guidelines for the treatment. to evaluate the quality of care. Members of
the P Committee
The ADA Professional, a multidisciplinary committee of experts, is responsible for
the Standards of Care annually or more frequently as needed. A detailed

as well
obtain
description of the standards, statements, and reports

as
to

For the ADA Evidence Rating System for Clinical Practice Recommendations and a complete list of
Professional Practice Committee members, see Introduction and Methodology. Readers who wish to
comment on the and attention you are invited
to do so at professional.diabetes.org/SOC .

DIABETES IN PREGNANCY
The prevalence of diabetes in pregnancy nted in the USA. USA In parallel with the
global obesity epidemic. Not only and type prevalence of type 1 diabetes, there is also an
2 diabetes in people of re dramatic age in pro increase
the reported rates of di gestational tes mellitus (GDM). diabetes
confers a significantly increased maternal and fetal risk largely related
with the degree of ia, but also related to chronic complications iabetes. In general,
hyperglucose and the specific risks of diabetes in the spontaneous, fetal anomalies,
comorbidities of pregnancy preeclampsia, stillbirth, neonatal, hyperbilirubinemia and difficulty
include abortion
macrosomia, syndrome
respiratory hypogl others. Additionally, diabetes in pregnancy can increase the
neonat risk of hypertension
obesity, ,
Advice

nes
Disclosure information for each author is available at
Starting at puberty and continuing in all people with diabetes and reproductive potential, https://doi.org/10.2337/dc23-SDIS.
preconception counseling should be incorporated into routine diabetes care. TO
Suggested citation: ElSayed NA, Aleppo G, Aroda VR,
15.2Family planning should be discussed and effective contraception (with consideration for long- et al., American Diabetes Association. 15. Management
acting reversible contraception) should be prescribed and used until the person's treatment of diabetes in pregnancy: Standards of care in diabetes
plan and A1C are optimized for pregnancy. TO —2023.Diabetes Care 2023; 46 (Supplement 1): S254–

15.3Preconception counseling should address the importance of achieving glucose levels as close S266

to normal as safely possible, ideally A1C <6.5% (48 mmol/mol), to reduce the risk of
congenital anomalies, preeclampsia , macrosomia, premature birth and other
complications. TO
© 2022 by the American Diabetes Association. Readers
may use this article as long as the work is properly cited,
the use is educational and nonprofit, and the work is not
altered. More information is available at https://www .
diabetesjournals.org/journals/pages/license.
diabetesjournals.org/care Management of diabetes in pregnancy Yes255

All people with diabetes and reproductive potential
should be informed about the importance of
achieving and maintaining euglycemia as close as
possible before conception and during pregnancy.
Observational studies show an increased risk of
diabetic embryopathy, especially anencephaly,
microcephaly, congenital heart disease, renal
anomalies, and caudal regression, directly
proportional to A1C elevations during the first 10
weeks of pregnancy (3). Although observational
studies are confounded by the association
between elevated periconceptional A1C and other
self-care behaviors, the quantity and consistency
of data is compelling and supports the
recommendation to optimize blood glucose before
conception, given that organogenesis occurs
primarily between 5 and 8 weeks. of gestation,
with A1C <6.5% (48 mmol/mol), which is
associated with the lowest risk of congenital
anomalies, preeclampsia, and preterm birth (3–7).
A systematic review and meta-analysis of
observational studies of preconception care for
pregnant women with pre-existing diabetes
demonstrated lower A1C and reduced risk of birth
defects, preterm birth, perinatal mortality, small-
for-gestational-age births, and hospital admission.
neonatal intensive care unit (8).
There are opportunities to educate all adults
and adolescents with diabetes and reproductive
multidisciplinary clinic that includes an
endocrinologist, a maternal-fetal medicine
specialist, a registered dietitian nutritionist, and
a health care and education specialist.
diabetes, when available. b
15.5 In addition to focused care on achieving A
glycemic goals, standard preconception
care should be augmented with an
additional focus on nutrition,
diabetes education and screening
comorbidities and diabetes. b
15.6 People with diabetes
2 pre-existing condition that is missing or
that is left must receive information about the risk
of
and/or progression of the
Diabetic retinopathy. Ideally, dilated eye exams
should be performed before pregnancy or in the
first trimester, and then pregnant women should be
monitored every trimester and for 1 year after
delivery, as indicated by the degree of
retinopathy and as indicated. recommended
by the eye health professional. b
The importance of preconception care for lications
all pregnant people is highlighted in
American College of Obstetricians and po 1 or type
Gynecologists (ACOG) Committee planning
a Opinion 762, “Prepregnancy
registered dietitian nutritionist (RDN).
Diabetes-specific counseling should include an
explanation of the risks to the mother and fetus
related to pregnancy and ways to reduce the risk,
including glycemic goal setting, lifestyle and
behavioral management, and medical nutrition
therapy (17). The most important diabetes-specific
component of preconception care is achieving
glycemic goals before conception. Furthermore,
the presence of microvascular complications is
associated with an increased risk of disease
of nicotine products progression and adverse
including marijuana. l pregnancy outcomes
screening tests (20). Diabetes-specific
transmission s testing should include A1C,
vaccines creatinine, and urinary albumin-to-
routine, u creatinine ratio. Particular attention
supleme should be paid to reviewing the list of
free utili potentially harmful medications, i.e.,
ACE inhibitors (21,22), angiotensin receptor
blockers (21), and statins (22,23). A referral for a
comprehensive eye exam is recommended.
People with pre-existing diabetic retinopathy will
need close monitoring during pregnancy to
evaluate the progression of retinopathy and
provide treatment if indicated (24).

potential about the risks of unplanned pregnancies pregnan Counseling” (16). Preconception
and about the best maternal and fetal outcomes counseling for pregnant women with pre-existing type 1 or
t woman
with pregnancy planning (8). Preconception type 2 diabetes is highly effective in reducing

counseling could avoid significant problems and the risk of congenital malformations and

associated costs in offspring should be discussed
about family planning, including the benefits of
long-term contraception, and effective
contraception should be prepared and ready for
(10–14).
ar the appearance of complications, at
puberty or at the time of
o, all adults and adolescents of childbearing
age should be educated about1) the risks of
malformations associated with unplanned pregnancies
reversible action and even mild hyperglycemia
prescribe and use and2) the use of effective
one until the person contraception at all times to
isstay em ini prevent pregnancy.
Preconception counseling using
developmentally appropriate educational
tools allows adolescent girls to make
well-informed decisions (8). Preconception
ga
ve counseling resources designed for adolescents are
available at no cost through the American Association of
Diabetes (ADA) (15).
Preconception care
recommendations
15.41 Generally, people with preexisting diabetes who
are planning a pregnancy should begin
receiving preconception care in a
reducing the risk of preterm birth and admission
to neonatal intensive care units. Preconception
counseling is also likely to reduce perinatal
mortality and small-for-gestational-age birth
weight (17). A key
The point is the need to incorporate a question about
pregnancy plans into the routine primary and gynecological
care of people with diabetes. Preconception care for people
with diabetes should include standard screening and care
recommended for anyone planning a pregnancy (16).
Prescription of prenatal vitamins with at least 400mg of folic
acid and 150mg of potassium iodide (18) is recommended
before conception. It is important to review and advise on
the use of alcohol and recreational drugs, standard
treatment includes diseases of
and thyroid diseases, careful genetic testing of all
s and prescription and over-the-counter medications, and a
review of travel history and plans with special attention to
areas known to have Zika virus. , as described by ACOG.
See Table 15.1 for additional details on the elements of
preconception care (16,19).
Counseling about the specific risks of obesity in
pregnancy and lifestyle interventions to prevent and
treat obesity are recommended, including referral to a
 Yes256 Management of diabetes in pregnancy Diabetes CareVolume 46, Supplement 1, January 2023

The preconception plan should include:

GLYCEMIC OBJECTIVES IN
w Table
Nutrition and medication plan to achieve glycemic goals before conception, including 15.1—Checklist
appropriate for preconception
monitoring care for
implementation, people with
continuous diabetes
glucose (16,19)
monitoring, and pump technology
PREGNANCY
w Preconception education should include:
Contraceptive plan to prevent pregnancy until glycemic goals are achieved
w
w Comprehensive
Management plan for general nutritional
health, gynecological evaluation
concerns, comorbidand recommendations
conditions or for:
recom - Overweight/obesity
complications, if present, or underweight
including hypertension, nephropathy, retinopathy;
mend
15.7Control of fasting and
ations and thyroid dysfunction
Rh incompatibility; meal planning
postprandial blood Correction of nutritional deficiencies in the diet.
glucose is - CAFFEINE INTAKE
recommended
gestational as ininpre-
both - safe food preparation TECHNIQUE . w
diabetesdiabetes
existing mellitus in Lifestyle recommendations for:

pregnancy to achieve - MODERATE REGULAR EXERCISE

- Avoid hyperthermia (jacuzzis)
optimal glucose levels. Adequate sleep
Glucose goals are w Comprehensive diabetes self-management education
fasting plasma glucose w Diabetes in pregnancy counseling according to current standards, including the natural history of insulin resistance in
pregnancy and postpartum; preconception glycemic goals; avoid DKA/severe hyperglycemia; avoid severe
<95 mg/dL (5.3 mmol/L)
hypoglycemia; progression of retinopathy; PCOS (if applicable); fertility in people with diabetes; diabetes
and 1-h postprandial
genetics; risks for pregnancy,
glucose <140 mg/dL including spontaneous abortions, stillbirths, malformations enitas, macrosomia, labor and
(7.8 mmol/L) or 2-h premature birth, hypertensive disorders in pregnancy, w
postprandial glucose supplementation
<120 mg /dl (6.7
- FOLIC ACID SUPPLEMENT (400METROG RUTIN) free sale.
mmol/l). L). - Proper use of medications and supplies
The evaluation and health plan should include:
15.8 Some
Due to people with
increased pre-
red blood
w General assessment of general health w
existing diabetes
cell turnover, should
A1C is
Assessment of diabetes and its comorb ilties and complications, including DKA/severe
also check
slightly lowertheir blood
during hyperglycemia; severe hypoglycemia/d awareness of hypoglycemia; barriers to lipidemia,
glucose before
pregnancy meals.
in people withb attention; comorbidities such as hyper hypertension, NAFLD, PCOS and dysfunction
and without diabetes. thyroid; Complications c macrovascular age, nephropathy, neuropathy (including
autonomic dysfunction d the intestine and bladder) and retinopathy.
Ideally, the A1C goal in obstetric/gynecological, including history of: cesarean section,
w Background Screening
pregnancy is <6% (42 malformations c congenital or fetal loss, current contraceptive methods, azo disorders,
mmol/mol) if this can be hypertensive d postpartum hemorrhage, preterm birth, previous macrosomia,
achieved without incompatibility w thrombotic events (DVT/PE)
significant hypoglycemia, Review d current conditions and their suitability during pregnancy

but the goal can be The evaluation of

w diabetes comorbidities, including a comprehensive foot examination;
lowered to <7% (53 Co
complete soulological; ECG in people 35 years and older who have risk factor signs/symptoms
mmol/mol)
pre if necessary
and blood glucose
and, if abnormal, further evaluation; lipid panel; serum
postprandial, continuous
to prevent pregnancy.
monitoring of ina; TSH; and protein-to-creatinine ratio in urine
hypoglycemia. b
glucose can help achieve the •
15.9When A1Cused in addition
target to and
in diabetes w Genetic carrier status (based on history):
control ofpregnancy. b - CYSTIC FIBROSIS
- SICKLE CELL ANEMIA
15.10When used in addition to
monitoring
of blood glucose, - Tay-Sachs disease
- thalassemia
targets traditional - Others if indicated
w Infectious disease
preprandial and
- NEISSERIA GONORRHOEAE/CHLAMYDIA TRACHOMATIS
postprandial
of u - HEPATITIS C
e
objectives,
gluco and d
- HIV
hyp e
monitoring
n in
se ogl PAP test
e yce
tie
to
mia
-
yn Syphili
redu
p or Vaccines should include: w
a s
1 et
ce continuco
5 a ous mpl Rubella w Chickenpox w
. lGlucose can be
macr
d usedicat
monitori
in
i
shoulded
addition to, butng Hepatitis B w Influenza
1 oso
a wit
i
1 b not be used
substitute
n foras a
blood h w Others if indicated
T e
h t glucose monitoring to
e
e achieve optimal pre-
s
m
and postprandial
e
glycemic goals.
t15.12Calculations my
of indicators
h Commonly used glucose
of
o
d management and A1C
s estimates should not be
used in pregnancy as
A1C
estimates.
15.13Nutritional advice must
support c
a balance of
macronutrients

DKA, diabetic ketoacidosis; DVT/PE, deep vein thrombosis/pulmonary embolism; ECG, electrocardiogram; NAFLD,
diabetesjournals.org/care Management of diabetes in pregnancy Yes257
Yes258 Management of diabetes in pregnancy
including fruits, vegetables, legumes,
whole grains and healthy fats rich in
nutrients with n-3 fatty acids including nuts,
seeds and fish in the eating pattern. my
Pregnancy in people with normal glucose metabolism is
characterized by fasting blood glucose levels that are lower
than in the non-pregnant state due to insulin-independent
glucose uptake by the fetus and placenta and by mild
postprandial hyperglycemia and carbohydrate intolerance
as a result of diabetogenic placental hormones. . In people
with pre-existing diabetes, glycemic goals are usually
achieved through a combination of insulin administration
and medical nutrition therapy. Because glycemic goals in
pregnancy are more stringent than in non-pregnant people,
it is important for pregnant people with diabetes to
consume consistent amounts of carbohydrates to equalize
insulin dosage and avoid hyperglycemia or hypoglycemia.
Referral to an RDN is important to establish a meal plan
and insulin-to-carbohydrate ratio and determine weight
gain goals. The quality of carbohydrates must be
evaluated. A subgroup analysis of the CONCEPTT
(Continuous Glucose Monitoring in Pregnant Women With
Type 1 Diabetes Trial) study showed that the diets of
people planning to become pregnant and currently
pregnant evaluated during the pre-randomization phase
were characterized by a high content of fat and low fat
content.
consumption of fruits and vegetables was inadequate for
every four participants in micronutrient ries, highlighting the
medical nutrition therapy (25). A nutrition during pregnancy
recommends a balance of macronutrients. You should
avoid a diet that severely restricts any kind of
macronutrients, specifically the ketogenic diet that lacks
carbohydrates, the Paleo diet due to EOS, and any diet
characterized by saturated fats. Nutrient-rich foods are
recommended, including beans, legumes, .
He
whole grains, and
Healthy fats with n-3 fatty acids
including nuts, seeds and fish, which ia of the
are less likely to promote excessive pertos
weight gain.
Processed foods, fatty red meat, and sweetened
foods and beverages should be limited (26).
Insulin physiology
Since early pregnancy is a time of increased insulin
sensitivity and lower glucose levels, many people with
type 1 diabetes will have lower insulin requirements
and an increased risk of hypoglycemia (27). At around
16 weeks, insulin resistance begins to increase and
total daily insulin doses increase linearly -5% per week achieve these goals, particularly
until week 36. This usually results in a doubling of the
daily insulin dose compared to the pre-pregnancy
requirement. The insulin requirement levels off
towards the end of the third trimester with aging of the
placenta. A rapid reduction in insulin requirements
may indicate the development of placental
insufficiency (28). In people with normal pancreatic
function, insulin production is sufficient to meet the
challenge of insulin resistance and maintain glucose
levels. However, in pe diabetes,
g monitoring
Reflecting this physiology, fasting physiologic
and postprandial blood glucose al
give them
monitoring is recommended to onas with
achieve
metabolic control
in pregnant
people with
diabetes.
Preprandial testing is also recommended when
using insulin pumps or basal bolus therapy so that
the dose of rapid-acting insulin can be adjusted
before meals. Postprandial monitoring is
associated with better glycemic outcomes and a
lower risk of preeclampsia (29–31). There are no
adequately powered randomized trials comparing
different fasting and postprandial glycemic targets
in diabetes during pregnancy.
Similar to the ACOG-recommended goals (the upper
limits are the same as for GDM, described below) (32), the
ADA-recommended goals for pregnant people with type 1
or type 2 diabetes are following:
Fasting glucose 70–95 mg/dL
(3.9–5.3 mmol/L) and
One-hour postprandial glucose 110–140
mg/dL (6.1–7.8 mmol/L) or
Two-hour postprandial glucose 100–120 mg/dL mmol/mol) is optimal during pregnancy if it can
(5.6–6.7 mmol/L)
Diabetes CareVolume 46, Supplement 1, January 2023
The lower limits are based on the average
normal blood glucose during pregnancy (33). The
lower limits do not apply to people with type 2
diabetes treated with nutrition alone.
Hypoglycemia in pregnancy is defined and
addressed in Recommendations 6.10–6.15
(Section 6, “ Glycemic Objectives ”). These values
represent optimal control to achieve safely. It will
be a challenge for a type 1 to i can be ractic,
can with
those diabetes
hypoglycemi you or ignorance of person
hypoglycemia,
a achieve cannot n history of
these without hypoglycemia
Significantly, the ADA suggests less sated
objectives in the clinical experience and ation of
care.
A1C in pregnancy
In studies of people without preexisting
diabetes, increasing A1C levels within the normal
range is associated with adverse outcomes (34).
In the Hyperglycemia and Adverse Pregnancy
Outcomes (HAPO) study, increasing blood
glucose levels were also associated with worse
outcomes (35). Observational studies in
preexisting diabetes and pregnancy show the
lowest rates of adverse fetal outcomes in
association with A1C <6–6.5% (42–48 mmol/mol)
in early gestation (4–6.36). Clinical trials have not
evaluated the risks and benefits of achieving these
goals, and treatment goals should take into
account the risk of maternal hypoglycemia by
setting an individualized goal of <6% (42
mmol/mol) to <7% (53 mmol/mol). Due to
physiological increases in red blood cell turnover,
A1C levels fall during normal pregnancy (37,38).
Additionally, because A1C represents an
integrated measure of glucose, it may not fully
capture postprandial hyperglycemia, which drives
macrosomia. Therefore, although A1C may be
useful, it should be used as a secondary measure
of glycemic outcomes in pregnancy, after blood
glucose monitoring.
In the second and third trimesters, A1C <6%
(42 mmol/mol) has the lowest risk of large for
gestational age babies (36,39,40), preterm
birth (41), and preeclampsia (1,42). Taking all
of this into account, a goal of <6% (42
be achieved without significant hypoglycemia.
The A1C goal in a given individual
diabetesjournals.org/care
It must be achieved without hypoglycemia,
which, in addition to the usual adverse sequelae,
can increase the risk of low birth weight (43).
Given the alteration in red blood cell kinetics
during pregnancy and the physiological changes in
glycemic parameters, A1C levels may need to be
monitored more frequently than usual (e.g. e.g.,
monthly).
Continuous Glucose Monitoring in Pregnancy
CONCEPTT 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
goals versus standard care for pregnant people with type 1
diabetes. Demonstrated the value of real-time CGM in
pregnancy complicated by type 1 diabetes by showing mild
improvement in A1C without increased hypoglycemia and
reductions in large-for-gestational-age deliveries, length of
hospital stay, and hypoglycemia. neonatal (44)
observational cohort study evaluating CGM-reported glycemic
variables found that lower mean glucose, lower standard
deviation, and higher percentage time in target range were
associated with lower risk of large-for-age births gestational and
other adverse neonatal outcomes (45). Using CGM-reported
mean glucose is superior to using estimated A1C, glucose
control indicator, and other calculations to estimate A1C, given
the changes in A1C that occur during pregnancy (46). CGM
time-in-range (TIR) can be used to assess glycemic outcomes in
people with type 1 diabetes, but does not provide actionable
data to address postprandial and fasting hypoglycemia or
hyperglycemia.
The cost of CGM in complicated type 1 pregnancies is offset by
better neonatal outcomes (47). but does not provide practical
data to address fasting and postprandial hypoglu. The cost of
MC
due to type 1 diabetes are compensated better results
maternal and neonatal (47). but does not provide actionable data
to address fasting and postprandial hypoglycemia diab
or hyperglycemia. The cost of CGM in
plicated by type 1 diabetes are offset by
bles
maternal and neonatal outcomes emia
(47). complicated
there is enough data to
give the use of CGM in people with type 2
diabetes or GDM (48,49).
The international consensus on IRR
emba
with (50) supports pregnancy goal ranges and
better
targets for IRR for people with type 1
diabetes using CGM as reported in
ambulatory glucose profiling; however, it
does not specify the type or accuracy of the device
or the need for alarms and
Management of diabetes in pregnancy Yes259
alerts A prospective observational study including 20 GDM is characterized by an increased risk of
pregnant people with type 1 diabetes simultaneously
large-for-gestational-age birth weight and
monitored with intermittent scanning CGM (isCGM)
and real-time CGM (rtCGM) for 7 days in early neonatal and pregnancy complications and an
pregnancy demonstrated a higher percentage of time
below the range in the isCGM group. Therefore, increased risk of long-term maternal type 2
asymptomatic hypoglycemia measured by isCGM
should not necessarily lead to a reduction in insulin
diabetes and abnormal glucose metabolism in
dose and/or an increase in bedtime carbohydrate offspring in infancy. These associations with
intake, unless these episodes are confirmed by blood
glucose meter measurements. blood glucose (51). maternal oral glucose tolerance test (OGTT)
CGM device selection should be based on each results are continuous without inflection points.
individual's circumstances, preferences, and needs.
Target range 63–140 mg/dL (3.5–7.8 mmol/L): In other words, long-term risks increase with
progressive maternal hyperglycemia. .
IRR, target >70%
Time below range (<63 mg/dL [3 mmol/L]), target <4% Therefore, all pregnant people should be
Time below range (<54 mg clear (35.52). L screened as described in
mmol/L]), target <1% DMG untreated Section 2, “Diabetes
Time above range mmol/L]), target <25% and style insulin reduced Classification and
behavior is an essential component of the
cellul It is likely that glucose
management of gestational diabetes mellitus and may
pres disturbance in childhood
be sufficient treatment for many people. Insulin should
be added if necessary to achieve glycemic goals. TO
. An
15.15 Insulin is the preferred medication to treat
Diagnosis.” Although there is some
hyperglycemia in gestational diabetes mellitus.
heterogeneity, many RCTs and a
Metformin and glyburide should
Cochrane review suggest that the risk of GDM
not be used as first-line agents, can be reduced by diet, exercise and lifestyle
as both cross the placenta to advice, particularly when interventions are
the fetus. A Other oral and initiated during the first trimester or early in the
injectable hypoglycemic dL [7,8 second. (54–56). There are no intervention
medications without insulin trials in children of mothers with GDM. A meta-
lack long-term safety analysis of 11 RCTs demonstrated that
PREGNANCY ELLITUS metformin treatment during pregnancy does
MANAGEMENT not reduce the risk of GDM in high-risk
data. individuals with obesity, polycystic ovary
rec syndrome, or preexisting insulin resistance
15.1 15.16 Metformin, when used (57).
to treat PCOS and induce
ovulation, should be stopped at Lifestyle and Behavior Management After
the end of the first trimester. diagnosis, treatment begins with medical nutrition
TO therapy, physical activity, and weight management,
15.17 Telehealth visits for pregnant based on pregestational weight, as described below in
women with gestational diabetes the section on pre-existing type 2 diabetes as well as
mellitus improve outcomes compared to management. of glucose with the aim of achieving the
standard in-person care. TO objectives recommended by the Fifth International
Workshop-Conference on Diabetes Mellitus
Gestational (59):
Fasting glucose <95 mg/dL (5.3 mmol/L)
and
One-hour postprandial glucose <140 mg/dl
(7.8 mmol/l) or
Yes260 Management of diabetes in pregnancy
• postprandial GLUCOSE at two hours <120
mg/dl (6.7 mmol/l)
The lower glycemic target limits defined above for
pre-existing diabetes apply to insulin-treated GDM.
Depending on the population, studies suggest that
between 70 and 85% of people diagnosed with GDM
according to the Carpenter-Coustan criteria can
control GDM with lifestyle changes alone; It is
anticipated that this proportion will be even higher if
the lower diagnostic thresholds of the International
Diabetes Association and Pregnancy Study Groups
are used (60).
Medical nutrition therapy
Medical nutrition therapy for GDM is an individualized
nutrition plan developed between the pregnant person
and an RDN familiar with the management of GDM
(61,62). The feeding plan should provide adequate
caloric intake to promote fetal/neonatal and maternal
health, achieve glycemic goals, and promote weight
gain, according to the 2009 Institute of Medicine
recommendations (63). There is no definitive research
that identifies a specific optimal caloric intake for
people with GDM or that suggests that their caloric
needs are different than those of pregnant people
without GDM. The meal plan should be based on a
nutritional assessment using a National Institute of
Medicine dietary reference intake guideline. The
recommended dietary reference intake for all pregnant
people is a minimum of 175 g of carbohydrates, a
minimum of 71 g of fiber, and 28 g of fiber (64). The
nutrition plan should emphasize monounsaturated
polyunsaturated fats while limiting saturated fats and
avoiding trans fats. As with all nutritional therapies in
people with diabetes, the amount and type of
carbohydrates will affect glucose levels. The current
recommended amount of carbohydrates is 175 g, or -
35% of a 2000 calorie diet. The release of higher
quality, denser nutrients results in control of
mealtime/fasting, less acids, better insulin action and
vascular benefits and may reduce excess childhood
adiposity. People who substitute fat for carbohydrates
may increase
unintentionally lipolysis, promote elevated levels of
free fatty acids and worsen maternal insulin resistance
(65,66). ketone in
urine on an
empty stomach
The tests may be useful in identifying those who are
severely restricting carbohydrates to control blood
glucose. Simple carbohydrates will result in higher
excursions after meals.
Physical activity
A systematic review demonstrated improvements
in glucose control and reductions in the need for
insulin initiation or insulin dose requirements with
an exercise intervention. There was heterogeneity
in the types of effective exercise (aerobic,
resistance or both) and the duration of exercise
(20-50 min/day, 2-7 days/week of moderate
intensity) (67).
Drug therapy
Treatment of GDM with lifestyle and insulin has
been shown to improve perinatal outcomes in two
large randomized trials as summarized in a review
by the US Preventive Services Task Force. USA
(68 insulin is the first line agent
recommended for treatment in
the USA. USA Although RCTs they
ind
limited effectiveness of met support the
Glyburide (71) is 69.70) and the is
recommended for the DMG, these ofagents
glucose
are not
treatment of GDM for the first treatment that are
placenta and data. known to have long-term
safety
term for offspring are cause for concern (32).
Furthermore, in separate RCTs, glyburide and
metformin failed to achieve adequate glycemic
outcomes in 23% and 25–28% of participants with
GDM, respectively 72,73).
Sulfonylureas
Sulfonylureas are known to cross the placenta
and have been associated with increased
neonatal hypoglycemia. Glybenclamide
concentrations in umbilical cord plasma are
approximately 50 to 70% of maternal levels
(72,73). In meta-analyses and systematic reviews,
glyburide was associated with a higher rate of
neonatal hypoglycemia, macrosomia, and
increased neonatal abdominal circumference than
insulin or metformin (74,75).
Glyburide was not found to be
inferior to insulin based on a composite outcome
of neonatal hypoglycemia, macrosomia, and
hyperbilirubinemia (76). I don't know
long-term safety data are available for
offspring exposed to glyburide (76).
Diabetes CareVolume 46, Supplement 1, January 2023
metformin
Metformin was associated with a lower risk of
neonatal hypoglycemia and less maternal weight
gain than insulin in systematic reviews (74,77–
79). However, metformin easily crosses the
placenta, resulting in cord blood metformin
levels.
umbilical as high or higher levels
simultaneous maternal (80,81). analysis
of the Metformin study i station Diabetes:
The Offspring Follow-U ofp (MiG TOFU) of 9-year-
7 to 9 years, the offspringold offspring exposed to
metformin for treatment GDM were heavier and
the Auckland cohort
they had a waist-height ion and a
circumfere e waist higher than insulin (82).
nce
exp This difference did not occur in the
Adelaide cohort. In two
l use of metformin in PCOS pregnancy, 4-
year follow-up of offspring demonstrated higher
BMI and greater obesity in offspring exposed to
metformin (83,84). A follow-up study at 5–10 years
showed that the offspring had higher BMI, weight-
to-height ratios, waist circumferences, and a
in
borderline increase in fat mass (84,85). A recent
meta-analysis concluded that metformin exposure
resulted in smaller neonates with postnatal growth
acceleration, resulting in higher BMI in infancy
(84).
Double-blind, randomized controlled trials
comparing metformin with other therapies for
ovulation induction in people with polycystic ovary
syndrome have not demonstrated benefits in
preventing miscarriage or GDM (86), and there is
no need-based in evidence of continuing
metformin in
this people. (87–89).
There are some people with GDM who require
medical treatment and may not be able to use insulin
safely or effectively during pregnancy due to cost,
language barriers, understanding, or cultural
influences. Oral agents may be an alternative for
these individuals after discussing the known risks and
the need for more long-term safety data in the
offspring. However, due to the potential for growth
restriction or acidosis in the event of insufficiency
placental infection, metformin should not be
used in pregnant women with hypertension or
preeclampsia or in those at risk of
intrauterine growth restriction (90,91).
 diabetesjournals.org/care Management of diabetes in pregnancy Yes261

recommendations
Insulin It may be appropriate for pregnancy because the
Insulin should
15.18 Insulin use should
be follow
used the guidelines
to control below.
type Both
1 diabetes in pregnancy.
predictiveAlow
Insulin is the
glucose preferred
threshold for agent for the management of type 2 diabetes in pregnancy. b
discontinuing
15.19 Both multiple
multiple daily daily
insulininjections
injectionsand
and insulin insulin
pump technology can
continuous is in the
be used range of premeal
in pregnancies and overnight
complicated by type 1 diabetes . C
Recommendation
subcutaneous insulin infusion are reasonable glucose target values in pregnancy and may allow for
but may require much higher doses of insulin,
15.20Pregnant women
management with and
strategies typeneither
1 or type 2 diabetes
has been should be
shown to prescribed
more low-dose
aggressive prandial aspirin
dosing. of
See100 to 150 mg/day starting
SENSOR at 12requiring
sometimes to 16 weeks of gestation
concentrated to reduce
insulin
bethe risk oftopreeclampsia.
superior the other during pregnancy (92). formulations. Insulin is the preferred treatment for
AUGMENTED PUMPS and AUTOMATED
e A dose of 162 mg/day may be acceptable e ; currently, in the USA. In the US, low-dose aspirin is available in 81 type
mg tablets.
2 diabetes in pregnancy. An RCT of
INSULIN DELIVERY SYSTEMS in Section 7, “ metformin added to insulin for the treatment of
MANAGEMENT OF TYPE 1 DIABETES Diabetes Technology,” for more information on these systems.
type 2 diabetes found less maternal weight gain
PRE-EXISTING AND TYPE 2
DIABETES and fewer cesarean deliveries. There were fewer
IN PREGNANCY macrosomic neonates, but the number of little
Insulin use ones
before gestational age 7). Like
Diabetes type 1
In type 1 diabetes, insulin requirements are
Pregnant women with type 1 diabetes are at
reduced shortly after delivery.
increased risk of hypoglycemia in the first
trimester and, like all pregnant women, have an
The associated and other
altered counterregulatory response in pregnancy
comor risk nsion of being as tall or
that may decrease awareness of hypoglycemia.
with s typetaller
2 diabetes that with
Educating people with diabetes and their families
diabetes type diabetes is better
about the prevention, recognition, and treatment of
controlled and shorter apparent
hypoglycemia is important before, during, and
Pregnancy
duration,risk
andappears
the to be more
after pregnancy.
common in the third trimester in those with type 2
diabetes, compared to the first trimester in those
help prevent and control the risks of
with type 1 diabetes (108,109).
hypoglycemia. Insulin resistance falls rapidly with
placental delivery.
The physiology of pregnancy requires frequent
titration of insulin to adapt to changing Pregnancy is a ketogenic state, and people PREECAMPSIA AND ASPIRIN
requirements and underlines the importance of with type 1 diabetes and, to a lesser extent, those Insulin use
frequent daily monitoring of blood glucose. Due to with type 2 diabetes, are at risk of diabetic
the complexity of insulin management in ketoacidosis (DKA) with lower blood glucose
pregnancy, referral to a specialized center that levels than in the non-pregnant state. Pregnant
offers team care (with team members including a people with type 1 diabetes should be given
maternal-fetal medicine specialist, an ketone strips and receive education on the
endocrinologist, or another health professional prevention and detection of DKA. The oncarries a
with experience in the management of pregnancy high risk of stillbirth.
and pre-existing diabetes, RDN, health care
Those on DKA who cannot eat often require 10%
dextrose with an insulin drip to adequately meet
diabetes and education specialist the higher carbohydrate demands of the placenta
social worker, as needed resource is and fetus in the third trimester to resolve their
available. ketosis.
No human insulin preparations have and Retinopathy is a special concern in pregnancy.
been shown to the
The necessary rapid implementation of euglycemia in
currently available the the setting of retinopathy is associated with worsening
(92–97). If The insulinsplacenta
studied in of retinopathy (106).
preferred
in RCTs (98– studies are preferred to
Diabetes in pregnancy is associated with an
1 cohort 2), the
increased risk of preeclampsia (110). The US
is case reports.
your Preventive Services Task Force. USA
In many health professionals prefer insulin during Type 2 diabetes
recommends the use of low-dose aspirin (81
pregnancy, it is not superior to multiple injections Type 2 diabetes is often associated with obesity.
mg/day) as a preventive medication at 12 weeks
103,104). None of the current systems The recommended weight gain during pregnancy
for overweight people is 15 to 25 pounds and for of gestation in people at high risk of preeclampsia

those who are obese is 10 to 20 pounds (63). There (111). However, a meta-analysis and an additional
Closed-loop insulin pump hybrids approved by the US
are no adequate data on optimal weight gain versus trial demonstrate that low-dose aspirin <100 mg is
Food and Drug Administration. USA (FDA) meets
weight maintenance in pregnant women with a BMI not effective in reducing preeclampsia. Low-dose
pregnancy goals. However, predictive low glucose
>35 kg/m 2 . aspirin >100 mg is required (112–114). A cost-
suspension technology has been shown to
benefit analysis has concluded that this approach

(PLGS) in non-pregnant people is better than Optimal glycemic goals are usually would reduce morbidity, save lives, and reduce
sensor-augmented insulin pumps (SAP) to reduce low easier to achieve during pregnancy with type 2 health care costs (115).
glucose values (105). diabetes than with type 1 diabetes
Yes262 Management of diabetes in pregnancy Diabetes CareVolume 46, Supplement 1, January 2023
diabetesjournals.org/care
Studies are needed to evaluate the long-term effects of
prenatal aspirin exposure on offspring (116).
PREGNANCY AND DRUGS
CONSIDERATIONS
recommendations
15.21 In pregnant women with diabetes and
chronic hypertension, a blood
pressure threshold of 140/90 mmHg
for initiation or titration of therapy is
associated with better pregnancy
outcomes than reserving treatment for
severe hypertension, with no
increased risk of birth weight. born
small for gestational age. A There are
limited data on the optimal lower limit,
but therapy should be reduced for
blood pressure <90/60 mmHg. A
blood pressure goal of 110 to 135/85
mmHg is suggested in order to reduce
the risk of accelerated maternal
hypertension. TO
15.22 Potentially harmful medications during
pregnancy (i.e., ACE inhibitors, angiotensin
receptor blockers, statins) should be
discontinued before conception and avoided
in sexually active persons of childbearing
potential who are not using reliable methods
of contraception. b
In normal pregnancy, blood pressure is
lower than in the non-pregnant state RCT of
Chronic Hypertension and Pregnancy
(CHAP) Consortium Trial on the Treatment of Mild
Chronic Hypertension During Pregnancy
Demonstrated Blood Pressure of 140/90 mmHg
ral for start or
reduces the
ersos of
omit fetal health.
CHAP study mitigates concerns about
small for
gestational age.
Mean ± SD blood
pressure
the titration of
measurements
the incidence of achieved in the
re
pregnant treated vs. untreated
groups were systolic 129.5 ± 10.0 vs.
132.6 ± 10.1 mmHg (difference
between groups 3.11 [95% CI] : 3.95
to 2.28]) and diastolic 79.1 ± 7.4
versus 81.5 ± 8.0 mmHg (2.33 [2.97
to 0.04]) (118). Individuals with diabetes
they had an even better composite outcome score
than those without diabetes (118).
As a result of the CHAP study, ACOG
issued a Practice Advisory recommending a
blood pressure of 140/90 mmHg as a threshold
for initiation or titration of medical therapy for
chronic hypertension in pregnancy (119)
instead of the recommended threshold
previously 160/110 mm Hg (120).
The CHAP study provides additional guidance
for the management of hypertension in pregnancy.
Data from the previously published Control of
Hypertension in Pregnancy Study (CHIPS) support
a target blood pressure goal of 110–135/85 mmHg
to reduce the risk of uncontrolled maternal
hypertension and minimize fetal growth impairment
(120–135/85 mmHg). 122). The 2015 study (121)
excluded pregnancies complicated by pre-existing
diabetes and only 6% of participants had GDM at
the time of enrollment. There was no difference in
pregnancy loss, neonatal care, or other neonatal
outcomes in the more stringent versus less
stringent hypertension control groups.
During pregnancy, ACE inhibitors and sinin
blockers are contraindicated, fetal renal
dysplasia, pulmonary lesions, and respiratory
restriction.
to ACE inhibitor in the first ion (121).
trimester does not appear to I lie with the
be associated with congenital flowers of
Angi receptors the
malformations (123).
because it can
cause growth
oligohydram rauterino (21).
U io found that after
adjus factors of confusion, exposure
t ACE inhibitors and angiotensin receptor
However,
blockers should be discontinued as early as
possible in the first trimester to avoid fetopathy in
the second and third trimesters (123).
Antihypertensive drugs known to be effective and
safe during pregnancy include methyldopa,
nifedipine, labetalol, diltiazem, clonidine, and
prazosin. Atenolol is not recommended, but other
b-blockers can be used, if necessary. Chronic use
of diuretics during pregnancy is not recommended
as it has been associated with restricted maternal
plasma volume, which may reduce uteroplacental
perfusion (124). Based on available evidence,
statins should also be avoided during pregnancy
(125).
See pregnancy and antihypertensive medications in
Section 10, “ Cardiovascular Disease and Risk
Management ,” for more information about blood pressure
control during pregnancy.
Management of diabetes in pregnancy Yes263
POST-PARTUM CARE
recommendations
15.23 Insulin resistance decreases dramatically
immediately after delivery, and insulin
requirements should be evaluated and
adjusted, as they are often about half of pre-
pregnancy requirements for the first few days
after delivery. c
15.24 A plan should be discussed and
implemented
plan antic person reprod
of gestational diabetes or with all ages
mellitus 4 and 12 in age
weeks after arto, using
you sound with a
15.25Exa
background
the
oral glucose tolerance of 75 g and
clinically appropriate non-pregnancy
diagnostic criteria. b
15.26 Overweight/obese people
with a history of gestational diabetes
mellitus who present with prediabetes
should receive intensive lifestyle interventions
and/or metformin to prevent diabetes. TO
15.27Breastfeeding is recommended to
reduce the risk of maternal type 2
diabetes and should be considered
when choosing whether to breastfeed
or formula feed. b
15.28 People with a history of gestational
diabetes mellitus should undergo
lifelong screening for the development
of type 2 diabetes or prediabetes every
1 to 3 years. b
15.29 People with a history of gestational diabetes
mellitus should seek preconception diabetes
screening and preconception care to identify
and treat hyperglycemia and prevent birth
defects. my
15.30 Postpartum care should include
psychosocial assessment and self-
care support. my
Gestational diabetes mellitus
Initial tests
Because GDM often represents previously
undiagnosed prediabetes, type 2 diabetes, young
adulthood-onset diabetes, or even the development of
type 1 diabetes, people with GDM should be
Yes264 Management of diabetes in pregnancy Diabetes CareVolume 46, Supplement 1, January 2023

tested for persistent diabetes or prediabetes between
4 and 12 weeks postpartum with a fasting OGTT of 75
g using non-pregnancy criteria as described in Section
2, “Classification and diagnosis of diabetes ,”
specifically Table 2.2 .In the absence of unequivocal
hyperglycemia, a positive screen for diabetes requires
two abnormal values. If both fasting plasma glucose
($126 mg/dL [7.0 mmol/L]) and 2-h plasma glucose
($200 mg/dL [11.1 mmol/L]) are abnormal in a single
blood glucose test detection, then the diagnosis of
diabetes is made. If only one abnormal value on the
OGTT meets the criteria for diabetes, the test should
be repeated to confirm that the abnormality persists.
Testing OGTT immediately after delivery, while still
hospitalized, has shown improved test participation but
also variably reduced sensitivity for the diagnosis of
impaired fasting glucose, impaired glucose tolerance,
and type 2 diabetes. 2 (126,127).
Postpartum follow-up
OGTT on A1C is recommended between 4 and 12
weeks postpartum because A1C may be persistently
affected (decreased) by pregnancy-related increased
red blood cell turnover, blood loss during delivery or by
the glucose profile of the previous 3 months. The
OGTT is more sensitive in detecting glucose
intolerance, including prediabetes and diabetes.
People of childbearing age with prediabetes may
develop type 2 diabetes around the time of their next
pregnancy and will need preconception evaluation.
Because GDM is associated with an increased lifetime
maternal risk of diabetes estimated at 50 to 60%,
people should also undergo 75 g every 1 to 3 years
from 4 to 12 weeks after normal. Continuous
evaluation is with any recommended glycemic test
(e.g. e.g., annual A1C, annual fasting plasma glucose,
pregnancy outcomes (131) and a higher risk of GDM,
while in people with a BMI >25 kg/ m2 , weight loss is
associated with a lower risk of developing GDM in
subsequent pregnancy (132). The development of type
2 diabetes is 18% higher per unit increase in BMI
relative to pre-pregnancy BMI at follow-up, highlighting
the importance of effective weight control after GDM
(133). Additionally, postpartum lifestyle interventions
are effective in reducing the risk of type 2 diabetes
(134
Both metformin and intensive lifestyle therapy
prevented progression to diabetes and prediabetes
and history
with any of the prevent a case of diabetes
5) . In these individuals, the
lifestyle and metformin progression to diabetes by 35%
and effectively, over 10 years in
comparison with placebo (136). If pregnancy has
motivated the adoption of healthy nutrition, it is
recommended to take advantage of these
achievements to support weight loss in the
postpartum period. (See Section 3, “Preventing
or delaying type 2 diabetes and associated
rvinced
comorbidities.”)
delay
Pre-existing type 1 and type 2 people with
diabetes
MG. Only five and a
Six people with ediabet
history of
GDM must tryInsulin sensitivity increases
interventions to dramatically with delivery of the
placenta. In one study, insulin
during 3 requirements in the immediate
postpartum period are approximately
interventio 34% lower than prepregnancy insulin
ns they requirements (137). Insulin sensitivity then
returns to pre-pregnancy levels over the next
reduced
1 to 2 weeks. For people taking insulin, special attention
should be paid to preventing hypoglycemia in the context of
breastfeeding and erratic sleeping and feeding schedules
(138).
and reduce the risk of other complications.
Therefore, all people of childbearing potential
with diabetes should review their family
planning options at regular intervals to ensure
that effective contraception is implemented and
maintained. This applies to people in the
immediate postpartum period. People with
diabetes have the same contraceptive options
and recommendations as people without
diabetes. Long-acting reversible contraception
may be ideal for people with diabetes and of
childbearing age.
References
Anticon
1. Dabelea D, Hanson RL, Lindsay RS, et
Ab
al. In utero exposure to diabetes carries
risks of type 2 diabetes and obesity: a study of
discordant sibships.
Diabetes 2000;49:2208–2211
2. Holmes VA, Young IS, Patterson CC, et
al.; Diabetes and Preeclampsia Intervention
Trials Study Group. Optimal glycemic control,
preeclampsia, and gestational hypertension in women
with type 1 diabetes in the Diabetes and Preeclampsia
Intervention Trial. Diabetes Care 2011;34:1683–1688
3. Guerin A, Nisenbaum R, Ray JG. Use of maternal GHb
concentration to estimate the risk of congenital anomalies
in the offspring of women with diabetes before pregnancy.
Diabetes Care 2007;30:1920–1925
4. Jensen DM, Korsholm L, Ovesen P, et al.
Periconception A1C and risk of serious adverse pregnancy
outcomes in 933 women with type 1 diabetes. Diabetes
Care 2009;32:1046–1048 5. Nielsen GL, Møller M,
Sørensen HT. HbA1c in early diabetic pregnancy and
pregnancy outcomes:

People with a history of GDM have a 28,129), the
much higher risk of converting to type tests whether
2 diabetes over time (129), and the OGTT of
people with GDM have a 10-fold childbirth is
higher risk of developing type 2 ede perform
diabetes compared to people without GDM (128). The
absolute risk of developing type 2 diabetes after GDM
increases linearly throughout a person's life, being
approximately
Lactation
Considering the immediate nutritional and
immunological benefits of breastfeeding for the baby,
all mothers, including those with diabetes, should be
supported in breastfeeding attempts.
Breastfeeding may also confer long-term metabolic
benefits to both the mother (139) and offspring
(140). Breastfeeding reduces the risk of developing
type 2 diabetes in mothers with previous GDM. It
may improve metabolic risk factors in offspring, but
more studies are needed (141). However,

Gestational ellitus and breastfeeding may increase the risk of overnight

Diabetes 20% at hypoglycemia and insulin dosage may need to be
10
adjusted.
years,
30% at 20 years, 40% at 30 years, 50% at 40 years
and 60% at 50 years (129). In the prospective Nurses' carrier for attention
Health Study II (NHS II), the subsequent risk of To effective conception is the fact that most
diabetes after a history of GDM was significantly lower pregnancies are not aborted. Pregnancy
in those who followed healthy eating patterns (130).
planning is essential in people with pre-existing
Adjusting for BMI attenuated this association
diabetes to achieve optimal glycemic goals
moderately, but not completely. Interpregnancy weight
necessary to prevent congenital malformations
gain is associated with a higher risk of adverse