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Diabetes Care Volume 41, Supplement 1, January 2018 S137

13. Management of American Diabetes Association in : Standards of Medical Care in Diabetesd2018 Diabetes Care 2018;41(Suppl. 1):S137–S143 | https://doi.org/10.2337/dc18-S013 3 AAEETO IBTSI PREGNANCY IN DIABETES OF MANAGEMENT 13.

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 and . The rise in GDM and type 2 diabetes in parallel with 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 as outlined below. In general, specific risks of uncontrolled diabetes in pregnancy include spontaneous , fetal anomalies, preeclampsia, fetal demise, macrosomia, neonatal hy- poglycemia, 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 c Starting at puberty, preconception counseling should be incorporated into rou- tine diabetes care for all girls of childbearing potential. A c should be discussed and effective contraception should be prescribed and used until a woman is prepared and ready to become Suggested citation: American Diabetes Associa- pregnant. A tion. 13. Management of diabetes in pregnancy: c Preconception counseling should address the importance of glycemic control as Standards of Medical Care in Diabetesd2018. close to normal as is safely possible, ideally A1C ,6.5% (48 mmol/mol), to reduce Diabetes Care 2018;41(Suppl. 1):S137–S143 the risk of congenital anomalies. B © 2017 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not All women of childbearing age with diabetes should be counseled about the impor- for profit, and the work is not altered. More infor- tance of tight glycemic control prior to conception. Observational studies show an mation is available at http://www.diabetesjournals increased risk of diabetic embryopathy, especially anencephaly, , .org/content/license. S138 Management of Diabetes in Pregnancy Diabetes Care Volume 41, Supplement 1, January 2018

congenital heart disease, and caudal re- Preconception counseling visits should in- with dosage and to avoid hyper- gression, directly proportional to eleva- clude rubella, syphilis, hepatitis B virus, glycemia or . Referral to a tions in A1C during the first 10 weeks of and HIV testing, as well as Pap smear, registered dietitian is important in order pregnancy. Although observational stud- cervical cultures, typing, prescrip- to establish a food plan and insulin-to- ies are confounded by the association be- tion of prenatal vitamins (with at least ratio and to determine tween elevated periconceptional A1C and 400 mg of folic acid), and cessa- weight gain goals. other poor self-care behaviors, the quan- tion counseling if indicated. Diabetes- fi tity and consistency of data are convinc- speci c testing should include A1C, Insulin Physiology ing and support the recommendation to thyroid-stimulating , creatinine, Early pregnancy is a time of insulin sensi- – – optimize glycemic control prior to con- and urinary albumin to creatinine ratio; tivity, lower levels, and lower in- , ception, with A1C 6.5% (48 mmol/mol) review of the medication list for potentially sulin requirements in women with type 1 associated with the lowest risk of congen- teratogenic drugs, i.e., ACE inhibitors (8), diabetes. The situation rapidly reverses as ital anomalies (3,4). angiotensin receptor blockers (8), and increases exponentially There are opportunities to educate all statins (9,10); and referral for a compre- during the second and early third trimes- women and adolescents of reproductive hensive eye exam. Women with preexist- ters and levels off toward the end of the age with diabetes about the risks of ing diabetic will need close third trimester. In women with normal unplanned and improved monitoring during pregnancy to ensure pancreatic function, insulin production is maternal and fetal outcomes with preg- that retinopathy does not progress. sufficient to meet the challenge of this nancy planning (5). Effective preconcep- physiological insulin resistance and to tion counseling could avert substantial maintain normal glucose levels. However, health and associated cost burdens in GLYCEMIC TARGETS IN PREGNANCY in women with GDM or preexisting dia- offspring (6). Family planning should be betes, occurs if treatment discussed, and effective contraception Recommendations is not adjusted appropriately. should be prescribed and used until a c Fasting and postprandial self- woman is prepared and ready to become monitoring of blood glucose are recom- Glucose Monitoring pregnant. mended in both gestational diabetes Reflecting this physiology, fasting and To minimize the occurrence of compli- mellitus and preexisting diabetes in postprandial monitoring of blood glucose cations, beginning at the onset of puberty pregnancy to achieve glycemic con- is recommended to achieve metabolic con- or at diagnosis, all women with diabetes trol. Some women with preexisting trol in pregnant women with diabetes. Pre- of childbearing potential should receive diabetes should also test blood glu- prandial testing is also recommended for education about 1) the risks of malforma- cose preprandially. B women with preexisting diabetes using in- tions associated with unplanned pregnan- c Due to increased turn- sulin pumps or basal-bolus therapy, so that cies and poor metabolic control and over, A1C is slightly lower in normal premeal rapid-acting insulin dosage can be 2) the use of effective contraception at pregnancy than in normal nonpreg- adjusted. Postprandial monitoring is associ- all times when preventing a pregnancy. nant women. The A1C target in preg- ated with better glycemic control and lower Preconception counseling using develop- nancy is 6–6.5% (42–48 mmol/mol); risk of preeclampsia (11–13). There are no mentally appropriate educational tools ,6% (42 mmol/mol) may be opti- adequately powered randomized trials enables adolescent girls to make well- mal if this can be achieved without comparing different fasting and postmeal informed decisions (5). Preconception significant hypoglycemia, but the glycemic targets in diabetes in pregnancy. counseling resources tailored for adoles- targetmayberelaxedto,7% Similar to the targets recommended cents are available at no cost through the (53 mmol/mol) if necessary to pre- by the American College of Obstetri- American Diabetes Association (ADA) (7). vent hypoglycemia. B cians and Gynecologists (14), the ADA- recommended targets for women with Preconception Testing Pregnancy in women with normal glucose type 1 or type 2 diabetes (the same as metabolism is characterized by fasting for GDM; described below) are as follows: Recommendation levels of blood glucose that are lower c Women with preexisting type 1 or than in the nonpregnant state due to ○ Fasting ,95 mg/dL (5.3 mmol/L) and type 2 diabetes who are planning insulin-independent glucose uptake by either pregnancy or who have become the and and by postpran- ○ One-hour postprandial ,140 mg/dL pregnant should be counseled on dial hyperglycemia and carbohydrate in- (7.8 mmol/L) or the risk of development and/or tolerance as a result of diabetogenic ○ Two-hour postprandial ,120 mg/dL progression of . placental . In patients with pre- (6.7 mmol/L) Dilated eye examinations should oc- existing diabetes, glycemic targets are cur before pregnancy or in the first usually achieved through a combination These values represent optimal control if trimester, and then patients should of insulin administration and medical nu- they can be achieved safely. In practice, it be monitored every trimester and trition therapy. Because glycemic targets may be challenging for women with type 1 for 1-year postpartum as indicated in pregnancy are stricter than in nonpreg- diabetes to achieve these targets without by the degree of retinopathy and nant individuals, it is important that hypoglycemia, particularly women with a as recommended by the eye care women with diabetes eat consistent history of recurrent hypoglycemia or hypo- provider. B amounts of to match glycemia unawareness. care.diabetesjournals.org Management of Diabetes in Pregnancy S139

If women cannot achieve these targets plasma glucose ,95 mg/dL [5.3 mmol/L]) used, but both cross the placenta to without significant hypoglycemia, the ADA who meet glucose goals after a week of the fetus, with likely cross- suggests less stringent targets based on clin- medical nutrition therapy can safely per- ing to a greater extent than glyburide. ical experience and individualization of care. form self-monitoring of blood glucose All oral agents lack long-term safety every other day, rather than daily (26). A1C in Pregnancy data. A Observational studies show the lowest c Metformin, when used to treat Medical Nutrition Therapy rates of adverse fetal outcomes in association polycystic ovary syndrome and in- Medical nutrition therapy for GDM is an with A1C ,6–6.5% (42–48 mmol/mol) duce ovulation, need not be con- individualized nutrition plan developed early in gestation (4,15–17). Clinical trials tinued once pregnancy has been between the woman and a registered di- have not evaluated the risks and benefits confirmed. A etitian familiar with the management of of achieving these targets, and treatment GDM (27,28). The food plan should pro- goals should account for the risk of ma- GDM is characterized by increased risk of vide adequate calorie intake to promote ternal hypoglycemia in setting an individ- macrosomia and birth complications and fetal/neonatal and , ualized target of ,6% (42 mmol/mol) an increased risk of maternal type 2 diabe- achieve glycemic goals, and promote ap- to ,7% (53 mmol/mol). Due to physio- tes after pregnancy. The association of propriate . There logical increases in red blood cell turn- macrosomia and birth complications with is no definitive research that identifies a over, A1C levels fall during normal oral (OGTT) results is specific optimal calorie intake for women pregnancy (18,19). Additionally, as A1C continuous with no clear inflection points with GDM or suggests that their calorie represents an integrated measure of glu- (20). In other words, risks increase with needs are different from those of pregnant cose, it may not fully capture postprandial progressive hyperglycemia. Therefore, all women without GDM. The food plan should hyperglycemia, which drives macrosomia. women should be tested as outlined in bebasedonanutritionassessmentwith Thus, although A1C may be useful, it Section 2 “Classification and Diagnosis of guidance from the Dietary Reference Intakes should be used as a secondary measure Diabetes.” Although there is some het- (DRI). The DRI for all pregnant women of glycemic control in pregnancy, after erogeneity, many randomized controlled recommends a minimum of 175 g of carbo- self-monitoring of blood glucose. trials suggest that the risk of GDM may be hydrate, a minimum of 71 g of protein, and Inthesecondandthirdtrimesters, reduced by diet, exercise, and lifestyle 28 g of fiber. As is true for all nutrition A1C ,6% (42 mmol/mol) has the lowest counseling, particularly when interven- therapy in patients with diabetes, the risk of large-for-gestational-age infants, tions are started during the first or early amount and type of carbohydrate will im- whereas other adverse outcomes in- in the second trimester (21–23). pact glucose levels, especially postmeal crease with A1C $6.5% (48 mmol/mol). excursions. Taking all of this into account, a target of Lifestyle Management After diagnosis, treatment starts with Pharmacologic Therapy 6–6.5% (42–48 mmol/mol) is recom- medical nutrition therapy, physical activ- Women with greater initial degrees of hy- mended but ,6% (42 mmol/mol) may ity, and weight management depending perglycemia may require earlier initiation be optimal as pregnancy progresses. on pregestational weight, as outlined in of pharmacologic therapy. Treatment has These levels should be achieved without the section below on preexisting type 2 been demonstrated to improve perinatal hypoglycemia, which, in addition to the diabetes, and glucose monitoring aiming outcomes in two large randomized stud- usual adverse sequelae, may increase for the targets recommended by the Fifth ies as summarized in a U.S. Preventive the risk of low birth weight. Given the International Workshop-Conference on Services Task Force review (29). Insulin alteration in red blood cell kinetics during Gestational Diabetes Mellitus (24): is the first-line agent recommended for pregnancy and physiological changes in treatment of GDM in the U.S. While indi- glycemic parameters, A1C levels may ○ Fasting ,95 mg/dL (5.3 mmol/L) and vidual randomized controlled trials sup- need to be monitored more frequently either port the efficacy and short-term safety than usual (e.g., monthly). ○ One-hour postprandial ,140 mg/dL of metformin (30,31) and glyburide (32) MANAGEMENT OF GESTATIONAL (7.8 mmol/L) or for the treatment of GDM, both agents DIABETES MELLITUS ○ Two-hour postprandial ,120 mg/dL cross the placenta. There is not agree- (6.7 mmol/L) ment regarding the comparative advan- Recommendations tages and disadvantages of the two oral c Lifestyle change is an essential com- Depending on the population, studies sug- agents; the most recent systematic re- ponent of management of gesta- gest that 70–85% of women diagnosed view of randomized controlled trials com- tional diabetes mellitus and may with GDM under Carpenter-Coustan or paring metformin and glyburide for GDM suffice for the treatment of many National Diabetes Data Group (NDDG) cri- found no clear differences in maternal or women. Medications should be teria can control GDM with lifestyle mod- neonatal outcomes (33). A more recent added if needed to achieve glyce- ification alone; it is anticipated that this randomized controlled trial demon- mic targets. A proportion will be even higher if the lower strated that glyburide and metformin c Insulin is the preferred medication for International Association of the Diabetes are comparable oral treatments for treating hyperglycemia in gestational and Pregnancy Study Groups (IADPSG) GDM regarding glucose control and ad- diabetes mellitus as it does not cross (25) diagnostic thresholds are used. A re- verse effects. In this study, they were the placenta to a measurable extent. cent randomized controlled trial suggests combined, with data demonstrating a Metformin and glyburide may be that women with mild GDM (fasting high efficacy rate with a significantly S140 Management of Diabetes in Pregnancy Diabetes Care Volume 41, Supplement 1, January 2018

reduced need for insulin, with a possible this approach would reduce morbidity, and type 2 diabetes in pregnancy advantage for metformin over glyburide save lives, and lower health care costs (49). because it does not cross the pla- as first-line therapy (34). However, more centa, and because oral agents are definitive studies are required in this area. Type 1 Diabetes generally insufficient to overcome Long-term safety data are not available Women with type 1 diabetes have an in- the insulin resistance in type 2 dia- for any oral agent (35). creased risk of hypoglycemia in the first betesandareineffectiveintype1di- trimester and, like all women, have al- Sulfonylureas abetes. E tered counterregulatory response in Concentrations of glyburide in umbilical cord pregnancy that may decrease hypoglyce- plasma are approximately 70% of maternal The physiology of pregnancy necessitates mia awareness. Education for patients levels (36). Glyburide was associated with frequent titration of insulin to match and family members about the preven- a higher rate of changing requirements and underscores tion, recognition, and treatment of hypo- and macrosomia than insulin or metfor- the importance of daily and frequent self- glycemia is important before, during, and min in a 2015 systematic review (37). fi monitoring of blood glucose. In the rst after pregnancy to help to prevent and Metformin trimester, there is often a decrease in manage the risks of hypoglycemia. Insulin Metformin was associated with a lower risk total daily insulin requirements, and resistance drops rapidly with delivery of of neonatal hypoglycemia and less maternal women, particularly those with type 1 di- the placenta. Women become very insu- weight gain than insulin in 2015 systematic abetes, may experience increased hypo- lin sensitive immediately following deliv- reviews (37–39); however, metformin glycemia. In the second trimester, rapidly ery and may initially require much less may slightly increase the risk of prematu- increasing insulin resistance requires insulin than in the prepartum period. rity. Furthermore, nearly half of patients weekly or biweekly increases in insulin Pregnancy is a ketogenic state, and with GDM who were initially treated with dose to achieve glycemic targets. In women with type 1 diabetes, and to a lesser metformin in a randomized trial needed general, a smaller proportion of the total extent those with type 2 diabetes, are at risk insulin in order to achieve acceptable glu- daily dose should be given as basal insulin for at lower blood glu- , . cose control (30). Umbilical cord blood ( 50%) and a greater proportion ( 50%) cose levels than in the nonpregnant state. levels of metformin are higher than simul- as prandial insulin. Late in the third tri- Women with preexisting diabetes, espe- taneous maternal levels (40,41). None of mester, there is often a leveling off or cially type 1 diabetes, need ketone strips these studies or meta-analyses evaluated small decrease in insulin requirements. at home and education on diabetic ketoaci- long-term outcomes in the offspring. Pa- Due to the complexity of insulin manage- dosis prevention and detection. In addition, tients treated with oral agents should be ment in pregnancy, referral to a specialized rapid implementation of tight glycemic con- informed that they cross the placenta, center offering team-based care (with trol in the setting of retinopathy is associ- and although no adverse effects on the team members including high-risk obste- ated with worsening of retinopathy (50). fetus have been demonstrated, long-term trician, endocrinologist, or other provider studies are lacking. experienced in managing pregnancy in Type 2 Diabetes Randomized, double-blind, controlled women with preexisting diabetes, dietitian, Type2diabetesisoftenassociatedwith trials comparing metformin with other nurse, and social worker, as needed) is rec- obesity. Recommended weight gain during – therapies for ovulation induction in ommended if this resource is available. pregnancy for women is 15 25 – women with polycystic ovary syndrome None of the currently available insulin lb and for obese women is 10 20 lb (51). have not demonstrated benefitinprevent- preparations have been demonstrated to Glycemic control is often easier to achieve ing spontaneous abortion or GDM (42), cross the placenta. in women with type 2 diabetes than in and there is no evidence-based need to thosewithtype1diabetesbutcanrequire continue metformin in such patients once Preeclampsia and Aspirin much higher doses of insulin, sometimes pregnancy has been confirmed (43–45). necessitating concentrated insulin formula- Recommendation tions. As in type 1 diabetes, insulin require- Insulin c Women with type 1 or type 2 dia- ments drop dramatically after delivery. The Insulin may be required to treat hypergly- betes should be prescribed low- risk for associated hypertension and other cemia, and its use should follow the dose aspirin 60–150 mg/day (usual comorbidities may be as high or higher with guidelines below. Both multiple daily in- dose 81 mg/day) from the end of type 2 diabetes as with type 1 diabetes, sulin injections and continuous subcuta- the first trimester until the baby is even if diabetes is better controlled and of neous insulin infusion are reasonable born in order to lower the risk of shorter apparent duration, with pregnancy alternatives, and neither has been shown preeclampsia. A loss appearing to be more prevalent in the to be superior during pregnancy (46). third trimester in women with type 2 dia- Diabetes in pregnancy is associated with betes compared with the first trimester in MANAGEMENT OF PREEXISTING an increased risk of preeclampsia (47). women with type 1 diabetes (52,53). TYPE 1 DIABETES AND TYPE 2 Based upon the results of clinical trials, DIABETES IN PREGNANCY the U.S. Preventive Services Task Force PREGNANCY AND DRUG Insulin Use recommends the use of low-dose aspirin CONSIDERATIONS (81 mg/day) as a preventive medication Recommendation Recommendations after 12 weeks of gestation in women c Insulin is the preferred agent for man- c In pregnant patients with diabetes who are at high risk for preeclampsia (48). agement of both type 1 diabetes and chronic hypertension, blood Acost-benefit analysis has concluded that care.diabetesjournals.org Management of Diabetes in Pregnancy S141

Gestational Diabetes Mellitus history of GDM and , only 5–6 pressure targets of 120–160/80– Initial Testing women need to be treated with either 105 mmHg are suggested in the Because GDM may represent preexisting intervention to prevent one case of dia- interest of optimizing long-term ma- undiagnosed type 2 or even type 1 diabe- betes over 3 years (64). In these women, ternal health and minimizing impaired tes, women with GDM should be tested lifestyle intervention and metformin re- fetal growth. E for persistent diabetes or prediabetes at duced progression to diabetes by 35% c Potentially teratogenic medications 4–12 weeks postpartum with a 75-g OGTT and 40%, respectively, over 10 years com- (i.e., ACE inhibitors, angiotensin re- using nonpregnancy criteria as outlined in pared with placebo (65). If the pregnancy ceptor blockers, statins) should be Section 2 “Classification and Diagnosis of has motivated the adoption of a healthier avoided in sexually active women of Diabetes.” diet, building on these gains to support childbearing age who are not using weight loss is recommended in the post- reliable contraception. B Postpartum Follow-up partum period. The OGTT is recommended over A1C at In normal pregnancy, blood pressure is the time of the 4- to 12-week postpartum Preexisting Type 1 and Type 2 Diabetes lower than in the nonpregnant state. visit because A1C may be persistently im- Insulin sensitivity increases with delivery In a pregnancy complicated by diabetes pacted (lowered) by the increased red of the placenta and then returns to pre- and chronic hypertension, target goals blood cell turnover related to pregnancy pregnancy levels over the following for systolic blood pressure 120–160 or blood loss at delivery and because the 1–2 weeks. In women taking insulin, par- mmHg and diastolic blood pressure 80– OGTT is more sensitive at detecting glu- ticular attention should be directed to hy- 105 mmHg are reasonable (54). Lower cose intolerance, including both predia- poglycemia prevention in the setting of blood pressure levels may be associ- betes and diabetes. Reproductive-aged and erratic sleep and eat- ated with impaired fetal growth. In a women with prediabetes may develop ing schedules. 2015 study targeting diastolic blood pres- type 2 diabetes by the time of their next Contraception sure of 100 mmHg versus 85 mmHg in pregnancy and will need preconception A major barrier to effective preconception pregnant women, only 6% of whom had evaluation. Because GDM is associated care is the fact that the majority of pregnan- GDM at enrollment, there was no dif- with an increased lifetime maternal risk cies are unplanned. Planning pregnancy is ference in pregnancy loss, neonatal care, for diabetes estimated at 50–70% after critical in women with preexisting diabetes or other neonatal outcomes, although 15–25 years (60,61), women should also due to the need for preconception glycemic women in the less intensive treatment be tested every 1–3 years thereafter if the control and preventive health services. group had a higher rate of uncontrolled 4- to 12-week 75-g OGTT is normal, with Therefore, all women with diabetes of child- hypertension (55). frequency of testing depending on other bearing potential should have family plan- During pregnancy, treatment with ACE risk factors including family history, pre- ning options reviewed at regular intervals. inhibitors and angiotensin receptor block- pregnancy BMI, and need for insulin or This applies to women in the immediate ers is contraindicated because they may oral glucose-lowering medication during . Women with diabetes cause fetal renal dysplasia, oligohydram- pregnancy. Ongoing evaluation may be have the same contraception options and nios, and intrauterine growth restriction performed with any recommended glyce- recommendations as those without diabe- (8). Antihypertensive drugs known to be mic test (e.g., A1C, fasting plasma glu- tes. The risk of an unplanned pregnancy effective and safe in pregnancy include cose, or 75-g OGTT using nonpregnant outweighs the risk of any given contracep- methyldopa, labetalol, diltiazem, cloni- thresholds). dine, and prazosin. Chronic diuretic use tion option. during pregnancy is not recommended Gestational Diabetes Mellitus and Type 2 References as it has been associated with restricted Diabetes WomenwithahistoryofGDMhavea 1. Holmes VA, Young IS, Patterson CC, et al.; Di- maternal plasma volume, which may re- greatly increased risk of conversion to abetes and Pre- Intervention Trial Study duce uteroplacental perfusion (56). On Group. Optimal glycemic control, pre-eclampsia, type 2 diabetes over time and not solely the basis of available evidence, statins and in women with type 1 within the 4- to 12-week postpartum time should also be avoided in pregnancy (57). diabetes in the Diabetes and Pre-eclampsia Inter- frame (60). In the prospective Nurses’ vention Trial. Diabetes Care 2011;34:1683–1688 Health Study II, subsequent diabetes risk 2. Dabelea D, Hanson RL, Lindsay RS, et al. Intra- after a history of GDM was significantly uterine exposure to diabetes conveys risks for type 2 diabetes and obesity: a study of discordant Postpartum care should include psy- lower in women who followed healthy sibships. Diabetes 2000;49:2208–2211 chosocial assessment and support for eating patterns (62). Adjusting for BMI 3. Guerin A, Nisenbaum R, Ray JG. Use of mater- self-care. moderately, but not completely, attenua- nal GHb concentration to estimate the risk of con- ted this association. Interpregnancy or post- genital anomalies in the offspring of women with partum weight gain is associated with prepregnancy diabetes. Diabetes Care 2007;30: Lactation 1920–1925 In light of the immediate nutritional and increased risk of adverse pregnancy out- 4. Jensen DM, Korsholm L, Ovesen P, et al. Peri- immunological benefits of breastfeeding comes in subsequent pregnancies (63) and conceptional A1C and risk of serious adverse preg- for the baby, all women including those earlier progression to type 2 diabetes. nancy outcome in 933 women with type 1 diabetes. with diabetes should be supported in at- Both metformin and intensive lifestyle Diabetes Care 2009;32:1046–1048 5. Charron-Prochownik D, Sereika SM, Becker D, tempts to breastfeed. Breastfeeding may intervention prevent or delay progression et al. Long-term effects of the booster-enhanced also confer longer-term metabolic benefits to diabetes in women with prediabetes READY-Girls preconception counseling program to both mother (58) and offspring (59). and a history of GDM. Of women with a on intentions and behaviors for family planning S142 Management of Diabetes in Pregnancy Diabetes Care Volume 41, Supplement 1, January 2018

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