C. The physiology of pregnancy necessitates frequent titration of insulin to match changing requirements and underscores the importance of daily and frequent self-monitoring of blood glucose. 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 75-g OGTT using nonpregnancy criteria as outlined in Section 2 Classification and Diagnosis of Diabetes (https://doi.org/10.2337/dc21-S002). Given the alteration in red blood cell kinetics during pregnancy and physiological changes in glycemic parameters, A1C levels may need to be monitored more frequently than usual (e.g., monthly). 112). In general, specific risks of diabetes in pregnancy include spontaneous abortion, fetal anomalies, preeclampsia, fetal demise, macrosomia, neonatal hypoglycemia, hyperbilirubinemia, and neonatal respiratory distress syndrome, among others. Dilated eye examinations should occur ideally before pregnancy or in the first trimester, and then patients should be monitored every trimester and for 1 year postpartum as indicated by the degree of retinopathy and as recommended by the eye care provider. The American Diabetes Association (ADA) is the nation's leading voluntary health organization fighting to bend the curve on the diabetes epidemic and help people living with diabetes thrive. 14. Management of Diabetes in Pregnancy: Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. Family planning should be discussed, including the benefits of long-acting, reversable contraception, and effective contraception should be prescribed and used until a woman is prepared and ready to become pregnant (1014). Women in DKA who are unable to eat often require 10% dextrose with an insulin drip to adequately meet the higher carbohydrate demands of the placenta and fetus in the third trimester in order to resolve their ketosis. 14. Management of Diabetes in Pregnancy: Guidelines | American Association of Clinical Endocrinology Search for other works by this author on: Intrauterine exposure to diabetes conveys risks for type 2 diabetes and obesity: a study of discordant sibships, Diabetes and Pre-eclampsia Intervention Trial Study Group, Optimal glycemic control, pre-eclampsia, and gestational hypertension in women with type 1 diabetes in the diabetes and pre-eclampsia intervention trial, Use of maternal GHb concentration to estimate the risk of congenital anomalies in the offspring of women with prepregnancy diabetes, Peri-conceptional A1C and risk of serious adverse pregnancy outcome in 933 women with type 1 diabetes, Glycaemic control during early pregnancy and fetal malformations in women with type I diabetes mellitus, Maternal glycemic control in type 1 diabetes and the risk for preterm birth: a population-based cohort study, Long-term effects of the booster-enhanced READY-Girls preconception counseling program on intentions and behaviors for family planning in teens with diabetes, Preventable health and cost burden of adverse birth outcomes associated with pregestational diabetes in the United States, Contraceptive use among women with prediabetes and diabetes in a US national sample, Description and comparison of postpartum use of effective contraception among women with and without diabetes, The intrauterine device in women with diabetes mellitus type I and II: a systematic review, Long-acting reversible contraceptionhighly efficacious, safe, and underutilized, American College of Obstetricians and Gynecologists Committee on Practice BulletinsObstetrics, ACOG Practice Bulletin No. In practice, it may be challenging for women with type 1 diabetes to achieve these targets without hypoglycemia, particularly women with a history of recurrent hypoglycemia or hypoglycemia unawareness. Furthermore, glyburide and metformin failed to provide adequate glycemic control in separate RCTs in 23% and 2528% of women with GDM, respectively (70,71). In light of the immediate nutritional and immunological benefits of breastfeeding for the baby, all women, including those with diabetes, should be supported in attempts to breastfeed. 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 (58). (Evidence A)Long-term use of Metformin may be associated with biochemical vitamin B12 . Because GDM is associated with an increased lifetime maternal risk for diabetes estimated at 5060% (107,108), women should also be tested every 13 years thereafter if the 412 weeks postpartum 75-g OGTT is normal. Most women who have gestational diabetes deliver healthy babies. Breastfeeding may also confer longer-term metabolic benefits to both mother (127) and offspring (128). Join us to develop and nurture an open dialogue between industry and AACE to advance patient care. The American Diabetes Association (ADA) Standards of Medical Care in Diabetes includes the 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. Although there is some heterogeneity, many randomized controlled trials (RCTs) suggest that the risk of GDM may be reduced by diet, exercise, and lifestyle counseling, particularly when interventions are started during the first or early in the second trimester (5254). There are no data to support the use of TIR in women with type 2 diabetes or GDM. Treatment aims to keep your blood glucose (blood sugar) levels normal. Classification and Diagnosis of Diabetes:Standards of Medical Care in Diabetes2021. More About Our Partners. 15.15 Metformin, when used to treat polycystic ovary syndrome and induce ovulation, should be discontinued by the end of the first trimester. There are no adequately powered randomized trials comparing different fasting and postmeal glycemic targets in diabetes in pregnancy. A meta-analysis of 32 RCTs evaluating the effectiveness of telehealth visits for GDM demonstrated reduction of incidences of cesarean delivery, neonatal hypoglycemia, premature rupture of membranes, macrosomia, pregnancy-induced hypertension or preeclampsia, preterm birth, neonatal asphyxia, and polyhydramnios compared with standard in-person care (57). There are no adequately powered randomized trials comparing different fasting and postmeal glycemic targets in diabetes in pregnancy. In the absence of unequivocal hyperglycemia, a positive screen for diabetes requires two abnormal values. The OGTT is more sensitive at detecting glucose intolerance, including both prediabetes and diabetes. Preconception counseling resources tailored for adolescents are available at no cost through the American Diabetes Association (ADA) (15). In women with normal pancreatic function, insulin production is sufficient to meet the challenge of this physiological insulin resistance and to maintain normal glucose levels. However, there is no consensus on the structure of multidisciplinary team care for diabetes and pregnancy, and there is a lack of evidence on the impact on outcomes of various methods of health care delivery (28). Women with a history of GDM have a greatly increased risk of conversion to type 2 diabetes over time (120). Special attention should be paid to the review of the medication list for potentially harmful drugs (i.e., ACE inhibitors [19,20], angiotensin receptor blockers [19], and statins [21,22]). Diabetes confers significantly greater maternal and fetal risk largely related to the degree of hyperglycemia but also related to chronic complications and comorbidities of diabetes. E, 14.17 Either multiple daily injections or insulin pump technology can be used in pregnancy complicated by type 1 diabetes. The American Diabetes Association is committed to improving the lives of all those affected by diabetes through this publication of the most widely respected guidelines for health professionals, said Dr. Robert Gabbay, Chief Scientific and Medical Officer at the American Diabetes Association. Gestational Diabetes | CDC Standards of Medical Care for Patients with Diabetes Mellitus Diabetes and Population Health 1. Cystic Fibrosis-Related Diabetes Clinical Care Guidelines A recent meta-analysis concluded that metformin exposure resulted in smaller neonates with acceleration of postnatal growth resulting in higher BMI in childhood (74). Although observational studies are confounded by the association between elevated periconceptional A1C and other poor self-care behavior, the quantity and consistency of data are convincing and support the recommendation to optimize glycemia prior to conception, given that organogenesis occurs primarily at 58 weeks of gestation, with an A1C <6.5% (48 mmol/mol) being associated with the lowest risk of congenital anomalies, preeclampsia, and preterm birth (37). Interpregnancy or postpartum weight gain is associated with increased risk of adverse pregnancy outcomes in subsequent pregnancies (110) and earlier progression to type 2 diabetes. 11 Once women achieve and maintain good glycemic control, the frequency of testing can be decreased. The American Diabetes Association (ADA) is the nations leading voluntary health organization fighting to bend the curve on the diabetes epidemic and help people living with diabetes thrive. Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes2022. 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). women with prior gestational diabetes. CONCEPTT (Continuous Glucose Monitoring in Pregnant Women With Type 1 Diabetes Trial) was a randomized controlled trial (RCT) of real-time 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. In one study, insulin requirements in the immediate postpartum period are roughly 34% lower than prepregnancy insulin requirements (125). E A dosage of 162 mg/day may be acceptable; currently in the U.S., low-dose aspirin is available in 81-mg tablets. A. As treatable as it is, gestational diabetes can hurt 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. Copyright 19952023. A. The most important diabetes-specific component of preconception care is the attainment of glycemic goals prior to conception. An RCT of metformin added to insulin for the treatment of type 2 diabetes found less maternal weight gain and fewer cesarean births. Suggested citation: American Diabetes Association Professional Practice Committee. B, 14.11 Continuous glucose monitoring metrics may be used as an adjunct but should not be used as a substitute for self-monitoring of blood glucose to achieve optimal pre- and postprandial glycemic targets. About the American Diabetes Association Time above range (>140 mg/dL [7.8 mmol/L]), goal <25%. In two RCTs of metformin use in pregnancy for polycystic ovary syndrome, follow-up of 4-year-old offspring demonstrated higher BMI and increased obesity in the offspring exposed to metformin (73,74). CGM time in range (TIR) can be used for assessment of glycemic control in patients with type 1 diabetes, but it does not provide actionable data to address fasting and postprandial hypoglycemia or hyperglycemia. 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. Moderate exercise is recommended by the American Diabetes Association (ADA): Preconception counseling using developmentally appropriate educational tools enables adolescent girls to make well-informed decisions (8). Ensure treatment decisions are timely, rely on evidence-basedguidelines, and are made . The American Diabetes Association (ADA) suggests the following options: 4 ounces (1/2 cup) of juice or regular soda, 8 ounces (1 cup) of skim milk, or 5 to 6 hard candies (eg, Life-Savers); glucose tablets can also be used (check package for grams per tablet as content varies). 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. The OGTT is more sensitive at detecting glucose intolerance, including both prediabetes and diabetes. Metformin was associated with a lower risk of neonatal hypoglycemia and less maternal weight gain than insulin in systematic reviews (72,7577). The insulin requirement levels off toward the end of the third trimester with placental aging. Pregnancy is a ketogenic state, and women with type 1 diabetes, and to a lesser extent those with type 2 diabetes, are at risk for diabetic ketoacidosis (DKA) at lower blood glucose levels than in the nonpregnant state. In one study, insulin requirements in the immediate postpartum period are roughly 34% lower than prepregnancy insulin requirements (113,114). The guidelines provided by the American Diabetes Association (ADA) on diagnosis and management of hyperglycemia in pregnancy are widely followed. Of women with a history of GDM and prediabetes, only 56 women need to be treated with either intervention to prevent one case of diabetes over 3 years (123). Diabetes-specific testing should include A1C, creatinine, and urinary albumin-to-creatinine ratio. However, lactation can increase the risk of overnight hypoglycemia, and insulin dosing may need to be adjusted. Not all hybrid closed-loop pumps are able to achieve the pregnancy targets. While many providers prefer insulin pumps in pregnancy, it is not clear that they are superior to multiple daily injections (91,92). During pregnancy, treatment with ACE inhibitors and angiotensin receptor blockers is contraindicated because they may cause fetal renal dysplasia, oligohydramnios, pulmonary hypoplasia, and intrauterine growth restriction (20). Glyburide was associated with a higher rate of neonatal hypoglycemia and macrosomia than insulin or metformin in a 2015 meta-analysis and systematic review (65). Observational studies show an increased risk of diabetic embryopathy, especially anencephaly, microcephaly, congenital heart disease, renal anomalies, and caudal regression, directly proportional to elevations in A1C during the first 10 weeks of pregnancy (3). ACOG and ADA recommend the following target levels to reduce risk of macrosomia Fasting or preprandial blood glucose values < 95 mg/dL Postprandial blood glucose values < 140 mg/dL at 1 hour and < 120 mg/dL at 2 hours Review weekly but may alter based on degree of glucose control Diet and Exercise Nutritional assessment and plan 3/6/18, 3/12/2019, 3/9/2021. 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. Reflecting this physiology, fasting and postprandial monitoring of blood glucose is recommended to achieve metabolic control in pregnant women with diabetes. 14.7 Fasting and postprandial self-monitoring of blood glucose are recommended in both gestational diabetes mellitus and preexisting diabetes in pregnancy to achieve optimal glucose levels. These recommendations were developed by a panel of experts who built upon prior Standards be reviewing the latest and most significant scientific research. Women in DKA who are unable to eat often require 10% dextrose with an insulin drip to adequately meet the higher carbohydrate demands of the placenta and fetus in the third trimester in order to resolve their ketosis. Guidelines The aims of the European Association for the Study of Diabetes (EASD) are to encourage and support research in the field of diabetes, the rapid diffusion of acquired knowledge and to facilitate its application. Low-dose aspirin >100 mg is required (109111). Search for other works by this author on: Intrauterine exposure to diabetes conveys risks for type 2 diabetes and obesity: a study of discordant sibships, Diabetes and Pre-eclampsia Intervention Trial Study Group, Optimal glycemic control, pre-eclampsia, and gestational hypertension in women with type 1 diabetes in the diabetes and pre-eclampsia intervention trial, Use of maternal GHb concentration to estimate the risk of congenital anomalies in the offspring of women with prepregnancy diabetes, Peri-conceptional A1C and risk of serious adverse pregnancy outcome in 933 women with type 1 diabetes, Glycaemic control during early pregnancy and fetal malformations in women with type I diabetes mellitus, Maternal glycemic control in type 1 diabetes and the risk for preterm birth: a population-based cohort study, Systematic review and meta-analysis of the effectiveness of pre-pregnancy care for women with diabetes for improving maternal and perinatal outcomes, Long-term effects of the booster-enhanced READY-Girls preconception counseling program on intentions and behaviors for family planning in teens with diabetes, Preventable health and cost burden of adverse birth outcomes associated with pregestational diabetes in the United States, Contraceptive use among women with prediabetes and diabetes in a US national sample, Description and comparison of postpartum use of effective contraception among women with and without diabetes, The intrauterine device in women with diabetes mellitus type i and ii: a systematic review, Long-acting reversible contraceptionhighly efficacious, safe, and underutilized, American College of Obstetricians and Gynecologists Committee on Practice BulletinsObstetrics, ACOG Practice Bulletin No. C, 15.23 A contraceptive plan should be discussed and implemented with all women with diabetes of reproductive potential. 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). 15.19 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. 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). Retinopathy is a special concern in pregnancy. It is required that all programs that are accredited/recognized by ADCES and ADA meet these guidelines in order to bill for Medicare. In studies of women without preexisting diabetes, increasing A1C levels within the normal range are associated with adverse outcomes (36). However, in women with diabetes, hyperglycemia occurs if treatment is not adjusted appropriately. 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). 190: Gestational diabetes mellitus. The prevalence of diabetes in pregnancy has been increasing in the U.S. in parallel with the worldwide epidemic of obesity. Standard care includes screening for sexually transmitted diseases and thyroid disease, recommended vaccinations, routine genetic screening, a careful review of all prescription and nonprescription medications and supplements used, and a review of travel history and plans with special attention to areas known to have Zika virus, as outlined by ACOG. A, 14.23 Screen women with a recent history of gestational diabetes mellitus at 412 weeks postpartum, using the 75-g oral glucose tolerance test and clinically appropriate nonpregnancy diagnostic criteria. Table 3. Patterns of glycemia in normal pregnancy: should the current therapeutic targets be challenged? If women cannot achieve these targets without significant hypoglycemia, the ADA suggests less stringent targets based on clinical experience and individualization of care. PDF Guideline for Detection 3.1.0 Screening for Gestational Diabetes and Complications of gestational diabetes. Gestational Diabetes | ACOG This Guideline was approved November 13, 2016, and updated February 12, 2018. During pregnancy, treatment with ACE inhibitors and angiotensin receptor blockers is contraindicated because they may cause fetal renal dysplasia, oligohydramnios, pulmonary hypoplasia, and intrauterine growth restriction (19). Glycemic control is often easier to achieve in women with type 2 diabetes than in those with type 1 diabetes but can require much higher doses of insulin, sometimes necessitating concentrated insulin formulations. 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 management, and medical nutrition therapy. B, 14.26 Women with a history of gestational diabetes mellitus should seek preconception screening for diabetes and preconception care to identify and treat hyperglycemia and prevent congenital malformations. Women of reproductive age with prediabetes may develop type 2 diabetes by the time of their next pregnancy and will need preconception evaluation. Therefore, all women should be screened as outlined in Section 2, Classification and Diagnosis of Diabetes (https://doi.org/10.2337/dc22-S002). Therefore, all women with diabetes of childbearing potential should have family planning options reviewed at regular intervals to make sure that effective contraception is implemented and maintained. Diabetes Care 2022;45(Suppl. The insulin requirement levels off toward the end of the third trimester with placental aging. Counseling on the specific risks of obesity in pregnancy and lifestyle interventions to prevent and treat obesity, including referral to a registered dietitian nutritionist (RD/RDN), is recommended when indicated. Preconception counseling resources tailored for adolescents are available at no cost through the American Diabetes Association (ADA) (16). While individual RCTs support limited efficacy of metformin (67,68) and glyburide (69) in reducing glucose levels for the treatment of GDM, these agents are not recommended as first-line treatment for GDM because they are known to cross the placenta and data on long-term safety for offspring is of some concern (35). In patients with preexisting diabetes, glycemic targets are usually achieved through a combination of insulin administration and medical nutrition therapy. Dilated eye examinations should occur ideally before pregnancy or in the first trimester, and then patients should be monitored every trimester and for 1 year postpartum as indicated by the degree of retinopathy and as recommended by the eye care provider. A cost-benefit analysis has concluded that this approach would reduce morbidity, save lives, and lower health care costs (100). B, 14.9 When used in addition to pre- and postprandial self-monitoring of blood glucose, continuous glucose monitoring can help to achieve A1C targets in diabetes and pregnancy. Women with type 1 diabetes have an increased risk of hypoglycemia in the first trimester and, like all women, have altered counterregulatory response in pregnancy that may decrease hypoglycemia awareness. B, 15.25 Women with a history of gestational diabetes mellitus found to have prediabetes should receive intensive lifestyle interventions and/or metformin to prevent diabetes. A Insulin is the preferred agent for the management of type 2 diabetes in pregnancy. Rockville, MD, Agency for Healthcare Research and Quality, 2014 (Evidence Syntheses, No. Gestational diabetes can be a scary diagnosis, but like other forms of diabetes, it's one that you can manage. Gestational diabetes mellitus that requires medication to achieve euglycemia is often termed class A2GDM. Insulin resistance drops rapidly with delivery of the placenta. In addition, diabetes in pregnancy may increase the risk of obesity, hypertension, and type 2 diabetes in offspring later in life (1,2). Postprandial monitoring is associated with better glycemic control and lower risk of preeclampsia (3133). The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the 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. Treatment of GDM with lifestyle and insulin has been demonstrated to improve perinatal outcomes in two large randomized studies as summarized in a U.S. Preventive Services Task Force review (66). PDF Gestational Diabetes Guideline - Kaiser Permanente Box 7023 Merrifield, VA 22116-7023. It demonstrated the value of 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 (46). Recommended weight gain during pregnancy for women with overweight is 1525 lb and for women with obesity is 1020 lb (62). Diabetes - Symptoms and causes - Mayo Clinic Metformin was associated with a lower risk of neonatal hypoglycemia and less maternal weight gain than insulin in systematic reviews (65,6769). 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). 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. About Diabetes Care More information is available at, This site uses cookies. 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). Metformin and glyburide should not be used as first-line agents, as both cross the placenta to the fetus. Treatment of GDM with lifestyle and insulin has been demonstrated to improve perinatal outcomes in two large randomized studies as summarized in a U.S. Preventive Services Task Force review (59). Women with a history of GDM have a greatly increased risk of conversion to type 2 diabetes over time (108). Insulin should be added if needed to achieve glycemic targets. Your Guide to the 2022 Changes to the ADA Standards of Care - diaTribe
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