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Standards of Medical Care in Diabetes—2018 Diabetes Care Volume 41, Supplement 1, January 2018 S137 13. Management of Diabetes American Diabetes Association in Pregnancy: Standards of Medical Care in Diabetesd2018 Diabetes Care 2018;41(Suppl. 1):S137–S143 | https://doi.org/10.2337/dc18-S013 13. 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 as outlined below. In general, specific risks of uncontrolled diabetes in pregnancy include spontaneous abortion, 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 Family planning 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, microcephaly, .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 insulin dosage and to avoid hyper- gression, directly proportional to eleva- clude rubella, syphilis, hepatitis B virus, glycemia or hypoglycemia. 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, blood typing, prescrip- to establish a food plan and insulin-to- ies are confounded by the association be- tion of prenatal vitamins (with at least carbohydrate ratio and to determine tween elevated periconceptional A1C and 400 mg of folic acid), and smoking 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 hormone, creatinine, Early pregnancy is a time of insulin sensi- – – optimize glycemic control prior to con- and urinary albumin to creatinine ratio; tivity, lower glucose 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 insulin resistance 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 retinopathy will need close third trimester. In women with normal unplanned pregnancies 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, hyperglycemia 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 red blood cell 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 fetus and placenta 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 diabetic retinopathy. placental hormones. 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 carbohydrates to match glycemia unawareness. care.diabetesjournals.org Management of
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