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Diabetes Care Volume 42, Supplement 1, January 2019 S165

14. Management of in American Diabetes Association : Standards of Medical Care in Diabetesd2019 Diabetes Care 2019;42(Suppl. 1):S165–S172 | https://doi.org/10.2337/dc19-S014 4 AAEETO IBTSI PREGNANCY IN DIABETES OF MANAGEMENT 14. The American Diabetes Association (ADA) “Standards of Medical Care in Diabetes” includes ADA’s current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA’s clinical practice recommendations, please refer to the Standards of Care Introduction. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

DIABETES IN PREGNANCY The prevalence of diabetes in pregnancy has been increasing in the U.S. The majority is mellitus (GDM) with the remainder primarily preexisting and . The rise in GDM and type 2 diabetes in parallel with obesity both in the U.S. and worldwide is of particular concern. Both type 1 diabetes and type 2 diabetes in pregnancy confer significantly greater maternal and fetal risk than GDM, with some differences according to type of diabetes. In general, specific risks of uncontrolled diabetes in pregnancy include spontaneous , fetal anomalies, preeclampsia, fetal demise, macrosomia, neonatal , and neonatal hyperbilirubinemia, among others. In addition, diabetes in pregnancy may increase the risk of obesity and type 2 diabetes in offspring later in life (1,2).

PRECONCEPTION COUNSELING

Recommendations 14.1 Starting at and continuing in all women with reproductive potential, preconception counseling should be incorporated into routine diabetes care. A 14.2 should be discussed and effective contraception should be prescribed and used until a is prepared and ready to become pregnant. A 14.3 Preconception counseling should address the importance of glycemic Suggested citation: American Diabetes Associa- management as close to normal as is safely possible, ideally A1C ,6.5% tion. 14. Management of diabetes in pregnancy: (48 mmol/mol), to reduce the risk of congenital anomalies, preeclampsia, Standards of Medical Care in Diabetesd2019. macrosomia, and other complications. B Diabetes Care 2019;42(Suppl. 1):S165–S172 © 2018 by the American Diabetes Association. All women of childbearing age with diabetes should be counseled about the Readers may use this article as long as the work is properly cited, the use is educational and not importance of tight glycemic control prior to conception. Observational studies show for profit, and the work is not altered. More infor- an increased risk of diabetic embryopathy, especially anencephaly, microcephaly, mation is available at http://www.diabetesjournals congenital , and caudal regression, directly proportional to elevations in .org/content/license. S166 Management of Diabetes in Pregnancy Diabetes Care Volume 42, Supplement 1, January 2019

A1C during the first 10 weeks of preg- 14.5 Women with preexisting diabe- diabetes should also test nancy (3). Although observational stud- tes should ideally be managed preprandially. B ies are confounded by the association in a multidisciplinary clinic in- 14.7 Due to increased red blood cell between elevated periconceptional A1C cluding an endocrinologist, turnover, A1C is slightly lower in and other poor self-care behaviors, the maternal-fetal special- normal pregnancy than in nor- quantity and consistency of data are ist, dietitian, and diabetes educa- mal nonpregnant women. Ide- convincing and support the recommen- tor, when available. B ally, the A1C target in pregnancy dation to optimize glycemic control prior is ,6% (42 mmol/mol) if this can to conception, with A1C ,6.5% (48 Preconception visits should include be achieved without significant mmol/mol) associated with the lowest , syphilis, B virus, and hypoglycemia, but the target risk of congenital anomalies (3–6). HIV testing, as well as Pap test, cervical may be relaxed to ,7% (53 There are opportunities to educate all cultures, blood typing, prescription of mmol/mol) if necessary to pre- women and adolescents of reproductive prenatal vitamins (with at least 400 vent hypoglycemia. B age with diabetes about the risks of mg of folic acid), and smoking cessation unplanned and improved counseling if indicated. Diabetes-specific Pregnancy in women with normal glu- maternal and fetal outcomes with preg- testing should include A1C, - cose metabolism is characterized by fast- nancy planning (7). Effective preconcep- stimulating , creatinine, and uri- ing levels of blood glucose that are lower tion counseling could avert substantial nary albumin-to-creatinine ratio; review than in the nonpregnant state due to health and associated cost burdens in of the medication list for potentially -independent glucose uptake by offspring (8). Family planning should be teratogenic drugs, i.e., ACE inhibitors the and and by postpran- discussed, and effective contraception (10), angiotensin receptor blockers (10), dial and carbohydrate in- should be prescribed and used until a and statins (11,12); and referral for a tolerance as a result of diabetogenic woman is prepared and ready to become comprehensive eye exam. Women with placental . In patients with pregnant. preexisting will preexisting diabetes, glycemic targets To minimize the occurrence of com- need close during pregnancy are usually achieved through a combi- plications, beginning at the onset of to ensure that retinopathy does not nationof insulinadministration and med- puberty or at diagnosis, all and progress (13). Preconception counseling ical nutrition therapy. Because glycemic women with diabetes of childbearing po- should include an explanation of the risks targets in pregnancy are stricter than in tential should receive education about to and fetus related to pregnancy nonpregnant individuals, it is important 1) the risks of malformations associated and the ways to reduce risk and include that women with diabetes eat consistent with unplanned pregnancies and poor glycemic goal setting, lifestyle manage- amounts of carbohydrates to match with metabolic control and 2) the use of ef- ment, and medical nutrition therapy. insulin dosage and to avoid hyperglyce- fective contraception at all times when Several studies have shown improved mia or hypoglycemia. Referral to a reg- preventing a pregnancy. Preconcep- outcomes when istered dietitian is important in order to tion counseling using developmentally care has been delivered from precon- establish a food plan and insulin-to- appropriate educational tools enables ception through pregnancy by a multi- carbohydrate ratio and to determine adolescent girls to make well-informed disciplinary group focused on improved weight gain goals. decisions (7). Preconception counseling glycemic control (14–16). One study resources tailored for adolescents are showed that care of preexisting diabe- available at no cost through the Amer- tes in clinics that included diabetes Insulin Physiology ican Diabetes Association (ADA) (9). Early pregnancy is a time of enhanced and obstetric specialists improved care insulin sensitivity, lower glucose levels, (17). However, there is no consensus on and lower insulin requirements in Preconception Care the structure of multidisciplinary team women with type 1 diabetes. The situ- Recommendations care for diabetes and pregnancy, and ation rapidly reverses as insulin resis- 14.4 Women with preexisting type 1 there is a lack of evidence on the impact tance increases exponentially during the or type 2 diabetes who are plan- on outcomes of various methods of second and early third trimesters and ning pregnancy or who have delivery (18). levels off toward the end of the third become pregnant should be trimester. In women with normal pan- counseled on the risk of devel- creatic function, insulin production is opment and/or progression of GLYCEMIC TARGETS IN PREGNANCY sufficient to meet the challenge of this diabetic retinopathy. Dilated eye physiological and to examinations should occur ide- Recommendations maintain normal glucose levels. How- ally before pregnancy or in the 14.6 Fasting and postprandial self- ever, in women with GDM or preexisting first trimester, and then patients monitoring of blood glucose are diabetes, hyperglycemia occurs if treat- should be monitored every tri- recommended in both gesta- ment is not adjusted appropriately. mester and for 1-year postpar- tional diabetes mellitus and pre- tum as indicated by the degree of existing diabetes in pregnancy retinopathy and as recommended to achieve glycemic control. Glucose Monitoring Reflecting this physiology, fasting and by the eye care provider. B Some women with preexisting postprandial monitoring of blood glucose care.diabetesjournals.org Management of Diabetes in Pregnancy S167

is recommended to achieve metabolic maternal hypoglycemia in setting an GDM is characterized by increased risk of control in pregnant women with diabe- individualized target of ,6% (42 macrosomia and complications tes. Preprandial testing is also recom- mmol/mol) to ,7% (53 mmol/mol). Due and an increased risk of maternal type 2 mended for women with preexisting to physiological increases in red blood diabetes after pregnancy. The associa- diabetes using insulin pumps or basal- cell turnover, A1C levels fall during tion of macrosomia and birth complica- bolus therapy, so that premeal rapid- normal pregnancy (26,27). Additionally, tions with oral acting insulin dosage can be adjusted. as A1C represents an integrated mea- (OGTT) results is continuous with no clear Postprandial monitoring is associated sure of glucose, it may not fully cap- inflection points (24). In other words, with better glycemic control and lower ture postprandial hyperglycemia, which risks increase with progressive hypergly- risk of preeclampsia (19–21). There are drives macrosomia. Thus, although A1C cemia. Therefore, all women should no adequately powered randomized tri- may be useful, it should be used as a sec- be tested as outlined in Section 2 als comparing different fasting and post- ondary measure of glycemic control in “Classification and Diagnosis of Diabe- meal glycemic targets in diabetes in pregnancy, after self-monitoring of blood tes.” Although there is some heteroge- pregnancy. glucose. neity, many randomized controlled trials Similar to the targets recommended In the second and third trimesters, (RCTs) suggest that the risk of GDM may by the American College of Obstetri- A1C ,6% (42 mmol/mol) has the lowest be reduced by diet, exercise, and life- cians and Gynecologists (the same as risk of large-for-gestational-age style counseling, particularly when inter- for GDM; described below) (22), the (25,28,29), preterm delivery (30), and ventions are started during the first or ADA-recommended targets for women preeclampsia (1,31). Taking all of this early in the second trimester (33–35). with type 1 or type 2 diabetes are as into account, a target of ,6% (42 follows: mmol/mol) is optimal during pregnancy Lifestyle Management fi if it can be achieved without signi - After diagnosis, treatment starts with ○ , Fasting 95 mg/dL (5.3 mmol/L) and cant hypoglycemia. The A1C target in medical nutrition therapy, physical ac- either a given patient should be achieved tivity, and weight management depend- ○ , One-hour postprandial 140 mg/dL without hypoglycemia, which, in addi- ing on pregestational weight, as outlined (7.8 mmol/L) or tion to the usual adverse sequelae, may in the section below on preexisting type 2 ○ , Two-hour postprandial 120 mg/dL increase the risk of low (32). diabetes, and glucose monitoring aiming (6.7 mmol/L) Given the alteration in red blood cell for the targets recommended by the Fifth kinetics during pregnancy and physiolog- International Workshop-Conference on These values represent optimal control if ical changes in glycemic parameters, A1C Gestational Diabetes Mellitus (36): they can be achieved safely. In practice, levels may need to be monitored more it may be challenging for women frequently than usual (e.g., monthly). ○ Fasting ,95 mg/dL (5.3 mmol/L) and with type 1 diabetes to achieve these either targets without hypoglycemia, particu- ○ One-hour postprandial ,140 mg/dL larly women with a history of recur- MANAGEMENT OF GESTATIONAL (7.8 mmol/L) or rent hypoglycemia or hypoglycemia DIABETES MELLITUS ○ Two-hour postprandial ,120 mg/dL unawareness. (6.7 mmol/L) If women cannot achieve these tar- Recommendations 14.8 Lifestyle change is an essential gets without significant hypoglycemia, component of management of Depending on the population, studies the ADA suggests less stringent targets gestational diabetes mellitus suggest that 70–85% of women di- based on clinical experience and indi- and may suffice for the treat- agnosed with GDM under Carpenter- vidualization of care. ment of many women. Medica- Coustan or National Diabetes Data Group tions should be added if needed (NDDG) criteria can control GDM with A1C in Pregnancy to achieve glycemic targets. A lifestyle modification alone; it is antici- In studies of women without preexist- 14.9 Insulin is the preferred medica- pated that this proportion will be even ing diabetes, increasing A1C levels within tion for treating hyperglycemia higher if the lower International Associ- the normal range is associated with ad- in gestational diabetes mellitus ation of Diabetes and Pregnancy Study verse outcomes (23). In the Hyperglyce- as it does not cross the placenta Groups (IADPSG) (37) diagnostic thresh- mia and Adverse Pregnancy Outcome to a measurable extent. Metfor- olds are used. (HAPO) study, increasing levels of glyce- min and glyburide should not be mia were associated with worsening used as first-line agents, as both Medical Nutrition Therapy outcomes (24). Observational studies Medical nutrition therapy for GDM is an cross the placenta to the fetus. in preexisting diabetes and pregnancy individualized nutrition plan developed All oral agents lack long-term show the lowest rates of adverse fetal between the woman and a registered safety data. A outcomes in association with A1C ,6– dietitian familiar with the management 14.10 Metformin, when used to treat 6.5% (42–48 mmol/mol) early in gesta- of GDM (38,39). The food plan should polycystic syndrome and tion (4–6,25). Clinical trials have not provide adequate calorie intake to induce , should be dis- evaluated the risks and benefits of promote fetal/neonatal and maternal continued once pregnancy has achieving these targets, and treatment health, achieve glycemic goals, and pro- been confirmed. A goals should account for the risk of mote appropriate gestational weight S168 Management of Diabetes in Pregnancy Diabetes Care Volume 42, Supplement 1, January 2019

gain. There is no definitive research that systematic reviews (46,49,50); however, and frequent self-monitoring of blood identifies a specific optimal calorie in- metformin may slightly increase the risk glucose. Early in the first trimester, take for women with GDM or suggests of prematurity. Like glyburide, metfor- there is an increase in insulin require- that their calorie needs are different min crosses the placenta, and umbili- ments, followed by a decrease in weeks from those of pregnant women without cal levels of metformin are 9 through 16 (60). Women, particularly GDM. The food plan should be based higher than simultaneous maternal levels those with type 1 diabetes, may experi- on a nutrition assessment with guidance (51,52). In the Metformin in Gestational ence increased hypoglycemia. After from the Dietary Reference Intakes Diabetes: The Offspring Follow-Up (MiG 16 weeks, rapidly increasing insulin re- (DRI). The DRI for all pregnant women TOFU) study’sanalysesof7-to9-year-old sistance requires weekly increases in recommends a minimum of 175 g of offspring, 9-year-old offspring exposed insulin dose of about 5% per week to carbohydrate, a minimum of 71 g of to metformin for the treatment of GDM achieve glycemic targets. There is protein, and 28 g of fiber. As is true were larger (based on a number of roughly a doubling of insulin require- for all nutrition therapy in patients with measurements) than those exposed to ments by the late third trimester. In diabetes, the amount and type of car- insulin(53).In two RCTs of metformin use general, a smaller proportion of the total bohydrate will impact glucose levels, in pregnancy for polycystic ovary syn- daily dose should be given as basal in- especially postmeal excursions. drome, follow-up of 4-year-old offspring sulin (,50%) and a greater proportion demonstrated higher BMI and increased (.50%) as prandial insulin. Late in the Pharmacologic Therapy obesity in the offspring exposed to met- third trimester, there is often a leveling Treatment of GDM with lifestyle and formin (53,54). Further study of long- off or small decrease in insulin require- insulin has been demonstrated to im- term outcomes in the offspring is needed ments. Due to the complexity of insu- prove perinatal outcomes in two large (53,54). lin management in pregnancy, referral randomized studies as summarized in a Randomized, double-blind, controlled to a specialized center offering team- U.S. Preventive Services Task Force re- trials comparing metformin with other based care (with team members includ- view (40). Insulin is the first-line agent therapies for in ing maternal-fetal medicine specialist, recommended for treatment of GDM in women with polycystic ovary syndrome endocrinologist, or other provider ex- the U.S. While individual RCTs support have not demonstrated benefit in pre- perienced in managing pregnancy in limited efficacy of metformin (41,42) venting spontaneous abortion or GDM women with preexisting diabetes, di- and glyburide (43) in reducing glucose (55), and there is no evidence-based etitian, nurse, and social worker, as levels for the treatment of GDM, these need to continue metformin in such needed) is recommended if this re- agents are not recommended as first- patients once pregnancy has been con- source is available. line treatment for GDM because they firmed (56–58). None of the currently available hu- are known to cross the placenta and Insulin man insulin preparations have been data on safety for offspring is lacking Insulin use should follow the guidelines demonstrated to cross the placenta – (22).Furthermore,intwoRCTs,glyburide below. Both multiple daily insulin injec- (61 66). and metformin failed to provide ade- tions and continuous subcutaneous insu- A recent Cochrane systematic review fi quate glycemic control in 23% and 25– lin infusion are reasonable delivery was not able to recommend any speci c 28%, respectively (44,45), of women with strategies, and neither has been shown insulin regimen over another for the GDM. to be superior during pregnancy (59). treatment of diabetes in pregnancy (67). Sulfonylureas Sulfonylureas are known to cross the MANAGEMENT OF PREEXISTING Preeclampsia and Aspirin placenta and have been associated TYPE 1 DIABETES AND TYPE Recommendation with increased neonatal hypoglycemia. 2 DIABETES IN PREGNANCY 14.12 Women with type 1 or type 2 Concentrations of glyburide in umbilical Insulin Use diabetes should be prescribed cord plasma are approximately 70% of Recommendation low-dose aspirin 60–150 mg/day maternal levels (44,45). Glyburide was 14.11 Insulin is the preferred agent (usual dose 81 mg/day) from associated with a higher rate of neona- for management of both type 1 the end of the first trimester tal hypoglycemia and macrosomia than diabetes and type 2 diabetes in until the baby is born in order insulin or metformin in a 2015 meta- pregnancy because it does not to lower the risk of preeclamp- analysis and systematic review (46). cross the placenta and be- sia. A More recently, glyburide failed to be cause oral agents are generally found noninferior to insulin based on insufficient to overcome the Diabetes in pregnancy is associated a composite outcome of neonatal hypo- insulin resistance in type 2 di- with an increased risk of preeclampsia glycemia, macrosomia, and hyperbiliru- abetes and are ineffective in (68). Based upon the results of clinical binemia. Long-term safety data for type 1 diabetes. E trials, the U.S. Preventive Services Task offspring are not available (47,48). Force recommends the use of low-dose Metformin The physiology of pregnancy necessi- aspirin (81 mg/day) as a preventive med- Metformin was associated with a lower tates frequent titration of insulin to ication after 12 weeks of in risk of neonatal hypoglycemia and less match changing requirements and women who are at high risk for pre- maternal weight gain than insulin in underscores the importance of daily (69). A cost-benefit analysis care.diabetesjournals.org Management of Diabetes in Pregnancy S169

has concluded that this approach would may be as high or higher with type 2 is not recommended as it has been reduce morbidity, save lives, and lower diabetes as with type 1 diabetes, even if associated with restricted care costs (70). diabetes is better controlled and of plasma volume, which may reduce utero- shorter apparent duration, with preg- placental perfusion (77). On the basis Type 1 Diabetes nancy loss appearing to be more prev- of available evidence, statins should also Women with type 1 diabetes have an alent in the third trimester in women be avoided in pregnancy (78). increased risk of hypoglycemia in the first with type 2 diabetes compared with the Please see PREGNANCY AND ANTIHYPERTENSIVE trimester and, like all women, have al- first trimester in women with type 1 MEDICATIONS in Section 10 “Cardiovascular tered counterregulatory response in diabetes (73,74). Disease and Risk Management” for more pregnancy that may decrease hypogly- information on managing blood pressure in pregnancy. cemia awareness. Education for patients PREGNANCY AND DRUG and family members about the preven- CONSIDERATIONS tion, recognition, and treatment of hy- poglycemia is important before, during, Recommendations and after pregnancy to help to prevent 14.13 In pregnant patients with di- Postpartum care should include psy- and manage the risks of hypoglycemia. abetes and chronic hyperten- chosocial assessment and support for Insulin resistance drops rapidly with de- sion, blood pressure targets self-care. – – livery of the placenta. Women become of 120 160/80 105 mmHg are very insulin sensitive immediately follow- suggested in the interest of In light of the immediate nutritional and ing delivery and may initially require optimizing long-term mater- immunological benefits of much less insulin than in the prepartum nal health and minimizing im- for the baby, all women including those period. paired fetal growth. E with diabetes should be supported in Pregnancy is a ketogenic state, and 14.14 Potentially teratogenic medica- attempts to breastfeed. Breastfeeding women with type 1 diabetes, and to a tions (i.e., ACE inhibitors, an- may also confer longer-term metabolic lesser extent those with type 2 diabetes, giotensin receptor blockers, benefits to both mother (79) and off- are at risk for at statins) should be avoided in spring (80). lower blood glucose levels than in the sexually active women of - nonpregnant state. Women with pre- bearing age who are not using Gestational Diabetes Mellitus existing diabetes, especially type 1 di- reliable contraception. B Initial Testing abetes, need ketone strips at home and Because GDM may represent preexisting education on diabetic ketoacidosis pre- undiagnosed type 2 or even type 1 di- vention and detection. In addition, rapid In normal pregnancy, blood pressure abetes, women with GDM should be implementation of tight glycemic control is lower than in the nonpregnant state. tested for persistent diabetes or predi- in the setting of retinopathy is associated In a pregnancy complicated by diabe- abetes at 4–12 weeks postpartum with a with worsening of retinopathy (13). tes and chronic , target 75-g OGTT using nonpregnancy criteria The role of continuous glucose mon- goals for systolic blood pressure 120– as outlined in Section 2 “Classification itoring in pregnancies impacted by di- 160 mmHg and diastolic blood pressure and Diagnosis of Diabetes.” abetes is still being studied. In one RCT, 80–105 mmHg are reasonable (75). continuous glucose monitoring use in Lower blood pressure levels may be Postpartum Follow-up pregnancies complicated by type 1 di- associated with impaired fetal growth. The OGTT is recommended over A1C at abetes showed improved neonatal out- In a 2015 study targeting diastolic blood the time of the 4- to 12-week postpartum comes and a slight reduction in A1C, but pressure of 100 mmHg versus 85 mmHg visit because A1C may be persistently interestingly no difference in severe hy- in pregnant women, only 6% of whom impacted (lowered) by the increased red poglycemic events compared with con- had GDM at enrollment, there was no blood cell turnover related to pregnancy trol subjects (71). difference in pregnancy loss, neonatal or blood loss at delivery and because care, or other neonatal outcomes, al- the OGTT is more sensitive at detecting Type 2 Diabetes though women in the less intensive glucose intolerance, including both pre- Type 2 diabetes is often associated with treatment group had a higher rate of diabetes and diabetes. Reproductive- obesity. Recommended weight gain dur- uncontrolled hypertension (76). aged women with may ing pregnancy for overweight women is During pregnancy, treatment with develop type 2 diabetes by the time 15–25 lb and for obese women is 10–20 lb ACE inhibitors and angiotensin receptor of their next pregnancy and will need (72). Glycemic control is often easier to blockers is contraindicated because they preconception evaluation. Because GDM achieve in women with type 2 diabetes may cause fetal renal dysplasia, oligo- is associated with an increased life- than in those with type 1diabetes but can hydramnios, and intrauterine growth time maternal risk for diabetes estimated require much higher doses of insulin, restriction (10). Antihypertensive drugs at 50–70% after 15–25 years (81,82), sometimes necessitating concentrated known to be effective and safe in preg- women should also be tested every 1– insulin formulations. As in type 1 diabe- nancy include methyldopa, nifedipine, 3 years thereafter if the 4- to 12-week tes, insulin requirements drop dramati- labetalol, diltiazem, clonidine, and postpartum 75-g OGTT is normal, with cally after delivery. The risk for associated prazosin. Atenolol is not recommended. frequency of testing depending on other hypertension and other comorbidities Chronic diuretic use during pregnancy risk factors including family history, S170 Management of Diabetes in Pregnancy Diabetes Care Volume 42, Supplement 1, January 2019

prepregnancy BMI, and need for insulin or pregnancy is critical in women with pre- inhibitors: effects on fetal and neonatal out- oral glucose-lowering medication dur- existing diabetes due to the need for comes. Reprod Toxicol 2008;26:175–177 ing pregnancy. Ongoing evaluation may preconception glycemic control to pre- 12. Bateman BT, Hernandez-Diaz S, Fischer MA, et al. Statins and congenital malformations: co- be performed with any recommended vent congenital malformations and re- hort study. BMJ 2015;350:h1035 glycemic test (e.g., A1C, fasting plasma duce the risk of other complications. 13. Chew EY, Mills JL, Metzger BE, et al.; National glucose, or 75-g OGTT using nonpregnant Therefore, all women with diabetes of Institute of Child Health and Develop- thresholds). childbearing potential should have fam- ment Diabetes in Early Pregnancy Study. Met- ily planning options reviewed at regular abolic control and progression of retinopathy: Gestational Diabetes Mellitus and Type 2 the Diabetes in Early Pregnancy Study. Diabetes Diabetes intervals. This applies to women in the Care 1995;18:631–637 Women with a history of GDM have a immediate . Women 14. McElvy SS, Miodovnik M, Rosenn B, et al. A greatly increased risk of conversion to with diabetes have the same contracep- focused preconceptional and early pregnancy program in women with type 1 diabetes reduces type 2 diabetes over time (81). In the tion options and recommendations as those without diabetes. The risk of an and malformation rates to prospective Nurses’ Health Study II (NHS general population levels. J Matern Fetal Med II), subsequent diabetes risk after a his- unplanned pregnancy outweighs the risk 2000;9:14–20 tory of GDM was significantly lower in of any given contraception option. 15. 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