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14. Management of Diabetes in Pregnancy: Standards of Medical Diabetes Care Volume 42, Supplement 1, January 2019 S165 14. Management of Diabetes in American Diabetes Association Pregnancy: Standards of Medical Care in Diabetesd2019 Diabetes Care 2019;42(Suppl. 1):S165–S172 | https://doi.org/10.2337/dc19-S014 14. MANAGEMENT OF DIABETES IN PREGNANCY 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 gestational diabetes mellitus (GDM) with the remainder primarily preexisting type 1 diabetes and type 2 diabetes. 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 abortion, fetal anomalies, preeclampsia, fetal demise, macrosomia, neonatal hypoglycemia, 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 puberty and continuing in all women with reproductive potential, preconception counseling should be incorporated into routine diabetes care. A 14.2 Family planning should be discussed and effective contraception should be prescribed and used until a woman 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 heart disease, 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 blood nancy (3). Although observational stud- tes should ideally be managed glucose 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 medicine 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 rubella, syphilis, hepatitis 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 pregnancies and improved counseling if indicated. Diabetes-specific Pregnancy in women with normal glu- maternal and fetal outcomes with preg- testing should include A1C, thyroid- cose metabolism is characterized by fast- nancy planning (7). Effective preconcep- stimulating hormone, 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 insulin-independent glucose uptake by offspring (8). Family planning should be teratogenic drugs, i.e., ACE inhibitors the fetus and placenta and by postpran- discussed, and effective contraception (10), angiotensin receptor blockers (10), dial hyperglycemia 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 hormones. In patients with pregnant. preexisting diabetic retinopathy will preexisting diabetes, glycemic targets To minimize the occurrence of com- need close monitoring 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 girls 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 mother 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- diabetes and pregnancy 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 health care 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 insulin resistance 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
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