The international consensus on time in range (49) endorses pregnancy target ranges and goals for TIR for patients with type 1 diabetes using CGM as reported on the ambulatory glucose profile. National Standards for DSMES - ADCES Two designated representatives of the American College of Cardiology (ACC) reviewed and provided feedback on the "Cardiovascular Disease and Risk Management" section, and this section received endorsement from ACC. 201: Pregestational diabetes mellitus, Diabetes and Reproductive Health for Girls, American College of Obstetricians and Gynecologists Committee on Gynecologic Practice, American Society for Reproductive Medicine, ACOG Committee Opinion No. Reflecting this physiology, fasting and postprandial monitoring of blood glucose is recommended to achieve metabolic control in pregnant women with diabetes. Preprandial testing is also recommended when using insulin pumps or basal-bolus therapy so that premeal rapid-acting insulin dosage can be adjusted. E. Diabetes in pregnancy is associated with an increased risk of preeclampsia (95). After diagnosis, treatment starts with medical nutrition therapy, physical activity, and weight management, depending on pregestational weight, as outlined in the section below on preexisting type 2 diabetes, as well as glucose monitoring aiming for the targets recommended by the Fifth International Workshop-Conference on Gestational Diabetes Mellitus (58): Fasting glucose <95 mg/dL (5.3 mmol/L) and either, One-hour postprandial glucose <140 mg/dL (7.8 mmol/L) or, Two-hour postprandial glucose <120 mg/dL (6.7 mmol/L). Comprehensive nutrition assessment and recommendations for: Correction of dietary nutritional deficiencies, Comprehensive diabetes self-management education. In the Metformin in Gestational Diabetes: The Offspring Follow-Up (MiG TOFU) studys analyses of 7- to 9-year-old offspring, the 9-year-old offspring exposed to metformin for the treatment of GDM in the Auckland cohort were heavier and had a higher waist-to-height ratio and waist circumference than those exposed to insulin (80). Gestational Diabetes | ACOG Prescription of prenatal vitamins (with at least 400 g of folic acid and 150 g of potassium iodide [17]) is recommended prior to conception. Appropriate use of over-the-counter medications and supplements, Evaluation of diabetes and its comorbidities and complications, including: DKA/severe hyperglycemia; severe hypoglycemia/hypoglycemia unawareness; barriers to care; comorbidities such as hyperlipidemia, hypertension, NAFLD, PCOS, and thyroid dysfunction; complications such as macrovascular disease, nephropathy, neuropathy (including autonomic bowel and bladder dysfunction), and retinopathy, Evaluation of obstetric/gynecologic history, including history of: cesarean section, congenital malformations or fetal loss, current methods of contraception, hypertensive disorders of pregnancy, postpartum hemorrhage, preterm delivery, previous macrosomia, Rh incompatibility, and thrombotic events (DVT/PE), Review of current medications and appropriateness during pregnancy, Diabetes complications and comorbidities, including: comprehensive foot exam; comprehensive ophthalmologic exam; ECG in women starting at age 35 years who have cardiac signs/symptoms or risk factors, and if abnormal, further evaluation; lipid panel; serum creatinine; TSH; and urine protein-to-creatinine ratio. 203: Chronic hypertension in pregnancy, Less-tight versus tight control of hypertension in pregnancy, Treatment of hypertension in pregnant women, Risks of statin use during pregnancy: a systematic review, Progression to type 2 diabetes in women with a known history of gestational diabetes: systematic review and meta-analysis, Incidence rate of type 2 diabetes mellitus after gestational diabetes mellitus: a systematic review and meta-analysis of 170,139 women, Healthful dietary patterns and type 2 diabetes mellitus risk among women with a history of gestational diabetes mellitus, Interpregnancy weight change and risk of adverse pregnancy outcomes: a population-based study, Diabetes Prevention Program Research Group, Prevention of diabetes in women with a history of gestational diabetes: effects of metformin and lifestyle interventions, The effect of lifestyle intervention and metformin on preventing or delaying diabetes among women with and without gestational diabetes: the Diabetes Prevention Program outcomes study 10-year follow-up, Peripartum management of glycemia in women with type 1 diabetes, Breastfeeding and the basal insulin requirement in type 1 diabetic women, Duration of lactation and incidence of type 2 diabetes, Does breastfeeding influence the risk of developing diabetes mellitus in children? Diabetes has brought us together. However, predictive low glucose suspend (PLGS) technology has been shown in nonpregnant people to be better than sensor augment technology (SAP) for reducing low glucoses (103). Accessed 21 June 2020. 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. Health problems can occur when blood sugar is too high. https://doi.org/10.2337/dc21-S014. Accessed 17 October 2021. ADA Releases 2021 Standards of Medical Care in Diabetes Centered on Evolving Evidence, Technology, and Individualized Care, Problem Solving to Improve Diabetes Management, Make a Difference with Positive Self-Talk. A systematic review and meta-analysis of observational studies of preconception care for women with preexisting diabetes demonstrated lower A1C and reduced risk of birth defects, preterm delivery, perinatal mortality, small-for-gestational-age births, and neonatal intensive care unit admission (8). There are no adequately powered randomized trials comparing different fasting and postmeal glycemic targets in diabetes in pregnancy. In normal pregnancy, blood pressure is lower than in the nonpregnant state. A, 14.3 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. 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 fasting 75-g OGTT using nonpregnancy criteria as outlined in Section 2, Classification and Diagnosis of Diabetes (https://doi.org/10.2337/dc22-S002), specifically Table 2.2. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADAs clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Join the fight with us on Facebook (American Diabetes Association), Twitter (@AmDiabetesAssn) and Instagram (@AmDiabetesAssn). The diet should emphasize monounsaturated and polyunsaturated fats while limiting saturated fats and avoiding trans fats. Diabetes-specific counseling should include an explanation of the risks to mother and fetus related to pregnancy and the ways to reduce risk, including glycemic goal setting, lifestyle and behavioral management, and medical nutrition therapy. 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). As is true for all nutrition therapy in patients with diabetes, the amount and type of carbohydrate will impact glucose levels. It demonstrated the value of real-time CGM in pregnancy complicated by type 1 diabetes by showing a mild improvement in A1C without an increase in hypoglycemia and reductions in large-for-gestational-age births, length of stay, and neonatal hypoglycemia (47). ADA Releases 2021 Standards of Medical Care in Diabetes Centered on 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. Preconception counseling using developmentally appropriate educational tools enables adolescent girls to make well-informed decisions (8). There was heterogeneity in the types of effective exercise (aerobic, resistance, or both) and duration of exercise (2050 min/day, 27 days/week of moderate intensity) (65). It can also include daily blood glucose testing and insulin injections. In other words, short-term and long-term risks increase with progressive maternal hyperglycemia. 14.18 Women with type 1 or type 2 diabetes should be prescribed low-dose aspirin 100150 mg/day starting at 12 to 16 weeks of gestation to lower the risk of preeclampsia. Taking all of this into account, a target of <6% (42 mmol/mol) is optimal during pregnancy if it can be achieved without significant hypoglycemia. The U.S. Preventive Services Task Force recommends the use of low-dose aspirin (81 mg/day) as a preventive medication at 12 weeks of gestation in women who are at high risk for preeclampsia (96). More About Our Partners. 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, PREGNANCY AND ANTIHYPERTENSIVE MEDICATIONS, https://clinicaltrials.gov/ct2/show/NCT01353391, https://clinicaltrials.gov/ct2/show/NCT02932475, https://www.ncbi.nlm.nih.gov/books/NBK196392/, https://www.diabetesjournals.org/content/license. Education for patients and family members about the prevention, recognition, and treatment of hypoglycemia is important before, during, and after pregnancy to help to prevent and manage the risks of hypoglycemia. 2. Classification and Diagnosis of Diabetes: Standards of - PubMed 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. 15. E A dosage of 162 mg/day may be acceptable E; currently, in the U.S., low-dose aspirin is available in 81-mg tablets. 15.15 Metformin, when used to treat polycystic ovary syndrome and induce ovulation, should be discontinued by the end of the first trimester. Diabetes Care 2022;45(Suppl. Observational studies in preexisting diabetes and pregnancy show the lowest rates of adverse fetal outcomes in association with A1C <66.5% (4248 mmol/mol) early in gestation (46,39). Long-acting, reversible contraception may be ideal for many women. Complications in your baby can be caused by gestational diabetes, including: 201: Pregestational Diabetes Mellitus, Diabetes and Reproductive Health for Girls, ACOG Committee Opinion No. Referral to an RD/RDN is important in order to establish a food plan and insulin-to-carbohydrate ratio and to determine weight gain goals. (Evidence A)Long-term use of Metformin may be associated with biochemical vitamin B12 . The 2015 study (104) excluded pregnancies complicated by preexisting diabetes and only 6% had GDM at enrollment. A review of current evidence, 2020 by the American Diabetes Association, Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. The DRI for all pregnant women recommends a minimum of 175 g of carbohydrate, a minimum of 71 g of protein, and 28 g of fiber. Referral to an RD/RDN is important in order to establish a food plan and insulin-to-carbohydrate ratio and to determine weight gain goals. Rockville, MD, Agency for Healthcare Research and Quality, 2014 (Evidence Syntheses, No. B, 15.8 Due to increased red blood cell turnover, A1C is slightly lower in normal pregnancy than in normal nonpregnant women. 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. In the absence of unequivocal hyperglycemia, a positive screen for diabetes requires two abnormal values. American Diabetes Association Releases 2023 Standards of Care in These values represent optimal control if they can be achieved safely. However, a meta-analysis and an additional trial demonstrate that low-dose aspirin <100 mg is not effective in reducing preeclampsia. This Guideline was approved November 13, 2016, and updated February 12, 2018. Moderate exercise is recommended by the American Diabetes Association (ADA): DKA, diabetic ketoacidosis; DVT/PE, deep vein thrombosis/pulmonary embolism; ECG, electrocardiogram; NAFLD, nonalcoholic fatty liver disease; PCOS, polycystic ovary syndrome; TSH, thyroid-stimulating hormone. As is true for all nutrition therapy in patients with diabetes, the amount and type of carbohydrate will impact glucose levels. A Other oral and noninsulin injectable glucose-lowering medications lack long-term safety data. A rapid reduction in insulin requirements can indicate the development of placental insufficiency (31). These associations with maternal oral glucose tolerance test (OGTT) results are continuous with no clear inflection points (38,51). Absolute risk increases linearly through a womans lifetime, being approximately 20% at 10 years, 30% at 20 years, 40% at 30 years, 50% at 40 years, and 60% at 50 years (108). Metformin and glyburide should not be used as first-line agents, as both cross the placenta to the fetus. In the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study, increasing levels of glycemia were also associated with worsening outcomes (38). A recent meta-analysis concluded that metformin exposure resulted in smaller neonates with acceleration of postnatal growth resulting in higher BMI in childhood (74). Insulin should be added if needed to achieve glycemic targets. 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. However, untreated or uncontrolled blood sugar levels can cause problems for you and your baby. If women cannot achieve these targets without significant hypoglycemia, the ADA suggests less stringent targets based on clinical experience and individualization of care. Your Guide to the 2022 Changes to the ADA Standards of Care - diaTribe Diabetes mellitus (also called "diabetes") is a condition in which too much glucose (sugar) stays in the blood instead of being used for energy. Women with diabetes have the same contraception options and recommendations as those without diabetes. A. University of North Carolina, Chapel Hill. Atenolol is not recommended, but other -blockers may be used, if necessary. American Diabetes Association; 14. 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). Mount Sinai Hospital, Canada. If women cannot achieve these targets without significant hypoglycemia, the ADA suggests less stringent targets based on clinical experience and individualization of care. Treatment aims to keep your blood glucose (blood sugar) levels normal. 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. Effective preconception counseling could avert substantial health and associated cost burdens in offspring (9). 15.17 Insulin should be used for management of type 1 diabetes in pregnancy. E, 14.6 Women 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. E, 15.21 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. Simple carbohydrates will result in higher postmeal excursions. Diabetes Emergency Plan; Prescription Help; Join Us. The food plan should provide adequate calorie intake to promote fetal/neonatal and maternal health, achieve glycemic goals, and promote weight gain according to 2009 Institute of Medicine recommendations (62). Similar to the targets recommended by ACOG (upper limits are the same as for gestational diabetes mellitus [GDM], described below) (34), the ADA-recommended targets for women with type 1 or type 2 diabetes are as follows: Fasting glucose 7095 mg/dL (3.95.3 mmol/L) and either, One-hour postprandial glucose 110140 mg/dL (6.17.8 mmol/L) or, Two-hour postprandial glucose 100120 mg/dL (5.66.7 mmol/L). These values represent optimal control if they can be achieved safely. Additionally, as A1C represents an integrated measure of glucose, it may not fully capture postprandial hyperglycemia, which drives macrosomia. The preconception care of women with diabetes should include the standard screenings and care recommended for all women planning pregnancy (16). CONCEPTT (Continuous Glucose Monitoring in Pregnant Women With Type 1 Diabetes Trial) was a randomized controlled trial of 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.
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