Similar to the targets recommended by ACOG (upper limits are the same as for gestational diabetes mellitus [GDM], described below) ( 34 ), the ADA-recommended targets for women with type 1 or type 2 diabetes are as follows: Fasting glucose 70-95 mg/dL (3.9-5.3 mmol/L) and either One-hour postprandial glucose 110-140 mg/dL (6.1-7.8 mmol/L) or The committee is a multidisciplinary team of 16 leading U.S. experts in the field of diabetes care and includes physicians, diabetes care and education specialists, registered dietitians, and others with experience in adult and pediatric endocrinology, epidemiology, public health, cardiovascular risk management, microvascular complications, preconception and pregnancy care, weight management and diabetes prevention, and use of technology in diabetes management. doi: . . Because glycemic targets in pregnancy are stricter than in nonpregnant individuals, it is important that women with diabetes eat consistent amounts of carbohydrates to match with insulin dosage and to avoid hyperglycemia or hypoglycemia. However, lactation can increase the risk of overnight hypoglycemia, and insulin dosing may need to be adjusted. A referral for a comprehensive eye exam is recommended. A blood sugar level below 140 mg/dL (7.8 mmol/L) is usually considered within the standard range on a glucose challenge test, although this may vary by clinic or lab. All women of childbearing age with diabetes should be informed about the importance of achieving and maintaining as near euglycemia as safely possible prior to conception and throughout pregnancy. The 2015 study (104) excluded pregnancies complicated by preexisting diabetes and only 6% had GDM at enrollment. This Guideline was approved November 13, 2016, and updated February 12, 2018. In one study, insulin requirements in the immediate postpartum period are roughly 34% lower than prepregnancy insulin requirements (113,114). Given that early pregnancy is a time of enhanced insulin sensitivity and lower glucose levels, many women with type 1 diabetes will have lower insulin requirements and an increased risk for hypoglycemia (30). More information is available at, This site uses cookies. Some women with preexisting diabetes should also test blood glucose preprandially. There are some women with GDM requiring medical therapy who, due to cost, language barriers, comprehension, or cultural influences, may not be able to use insulin safely or effectively in pregnancy. Retinopathy is a special concern in pregnancy. To minimize the occurrence of complications, beginning at the onset of puberty or at diagnosis, all girls and women with diabetes of childbearing potential should receive education about 1) the risks of malformations associated with unplanned pregnancies and even mild hyperglycemia and 2) the use of effective contraception at all times when preventing a pregnancy. 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. E, 14.20 Potentially harmful medications in pregnancy (i.e., ACE inhibitors, angiotensin receptor blockers, statins) should be stopped at conception and avoided in sexually active women of childbearing age who are not using reliable contraception. E, 15.12 Commonly used estimated A1C and glucose management indicator calculations should not be used in pregnancy as estimates of A1C. Planning pregnancy is critical in women with preexisting diabetes due to the need for preconception glycemic control to prevent congenital malformations and reduce the risk of other complications. Similar to the targets recommended by ACOG (upper limits are the same as for gestational diabetes mellitus [GDM], described below) (34), the ADA-recommended targets for women with type 1 or type 2 diabetes are as follows: Fasting glucose 7095 mg/dL (3.95.3 mmol/L) and either, One-hour postprandial glucose 110140 mg/dL (6.17.8 mmol/L) or, Two-hour postprandial glucose 100120 mg/dL (5.66.7 mmol/L). The Diabetes in Early Pregnancy Study, A focused preconceptional and early pregnancy program in women with type 1 diabetes reduces perinatal mortality and malformation rates to general population levels, Effectiveness of a regional prepregnancy care program in women with type 1 and type 2 diabetes: benefits beyond glycemic control, Cost-benefit analysis of preconception care for women with established diabetes mellitus, ATLANTIC DIP: closing the loop: a change in clinical practice can improve outcomes for women with pregestational diabetes, Implementation of guidelines for multidisciplinary team management of pregnancy in women with pre-existing diabetes or cardiac conditions: results from a UK national survey, Insulin requirements throughout pregnancy in women with type 1 diabetes mellitus: three changes of direction, The association of falling insulin requirements with maternal biomarkers and placental dysfunction: a prospective study of women with preexisting diabetes in pregnancy, Preprandial versus postprandial blood glucose monitoring in type 1 diabetic pregnancy: a randomized controlled clinical trial, Postprandial versus preprandial blood glucose monitoring in women with gestational diabetes mellitus requiring insulin therapy, National Institute of Child Health and Human DevelopmentDiabetes in Early Pregnancy Study, Maternal postprandial glucose levels and infant birth weight: the Diabetes in Early Pregnancy Study, Committee on Practice BulletinsObstetrics, ACOG Practice Bulletin No. Adjusting for BMI attenuated this association moderately, but not completely. Preconception counseling using developmentally appropriate educational tools enables adolescent girls to make well-informed decisions (8). For donations by mail: P.O. Prognosis - Most patients with gestational diabetes mellitus . Every day more than 4,000 people are newly diagnosed with diabetes in America. For 82 years, the ADA has driven discovery and research to treat, manage, and prevent diabetes while working relentlessly for a cure. Box 7023 Merrifield, VA 22116-7023. However, due to the potential for growth restriction or acidosis in the setting of placental insufficiency, metformin should not be used in women with hypertension or preeclampsia or at risk for intrauterine growth restriction (82,83). As in type 1 diabetes, insulin requirements drop dramatically after delivery. In patients with preexisting diabetes, glycemic targets are usually achieved through a combination of insulin administration and medical nutrition therapy. 14.19 In pregnant patients with diabetes and chronic hypertension, a blood pressure target of 110135/85 mmHg is suggested in the interest of reducing the risk for accelerated maternal hypertension A and minimizing impaired fetal growth. There is no definitive research that identifies a specific optimal calorie intake for women with GDM or suggests that their calorie needs are different from those of pregnant women without GDM. Gestational diabetes occurs when your body can't make enough insulin during your pregnancy. 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 Management of diabetes in pregnancy: Standards of Medical Care in Diabetes2022. We help people with diabetes thrive by fighting for their rights and developing programs, advocacy and education designed to improve their quality of life. Preconception counseling resources tailored for adolescents are available at no cost through the American Diabetes Association (ADA) (15). Use of the CGM-reported mean glucose is superior to the use of estimated A1C, glucose management indicator, and other calculations to estimate A1C given the changes to A1C that occur in pregnancy (49). P.O. C. Pregnancy in women with normal glucose metabolism is characterized by fasting levels of blood glucose that are lower than in the nonpregnant state, due to insulin-independent glucose uptake by the fetus and placenta, and by mild postprandial hyperglycemia and carbohydrate intolerance as a result of diabetogenic placental hormones. 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). B. In addition, diabetes in pregnancy may increase the risk of obesity, hypertension, and type 2 diabetes in offspring later in life (1,2). Thus, although A1C may be useful, it should be used as a secondary measure of glycemic control in pregnancy, after blood glucose monitoring. Simple carbohydrates will result in higher postmeal excursions. Depending on the population, studies suggest that 7085% of women diagnosed with GDM under Carpenter-Coustan criteria can control GDM with lifestyle modification alone; it is anticipated that this proportion will be even higher if the lower International Association of the Diabetes and Pregnancy Study Groups (59) diagnostic thresholds are used. Based upon the latest scientific diabetes research and clinical trials, the Standards of Care includes new and updated recommendations and guidelines to care for people with diabetes. Health equity for those living with diabetes. Join Us. Metformin was associated with a lower risk of neonatal hypoglycemia and less maternal weight gain than insulin in systematic reviews (72,7577). Moderate exercise is recommended by the American Diabetes Association (ADA): A key point is the need to incorporate a question about a woman's plans for pregnancy into routine primary and gynecologic care. 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. 762: Prepregnancy counseling, 2017 guidelines of the American Thyroid Association for the diagnosis and management of thyroid disease during pregnancy and the postpartum, Preconception health: changing the paradigm on well-woman health, Pregnancy outcome following exposure to angiotensin-converting enzyme inhibitors or angiotensin receptor antagonists: a systematic review, Angiotensin-converting enzyme inhibitors and the risk of congenital malformations, Prenatal exposure to HMG-CoA reductase inhibitors: effects on fetal and neonatal outcomes, Statins and congenital malformations: cohort study, National Institute of Child Health and Human Development Diabetes in Early Pregnancy Study, Metabolic control and progression of retinopathy. There are no adequate data on optimal weight gain versus weight maintenance in women with BMI >35 kg/m2. A. GDM is characterized by increased risk of large-for-gestational-age birth weight and neonatal and pregnancy complications and an increased risk of long-term maternal type 2 diabetes and offspring abnormal glucose metabolism in childhood. On the basis of available evidence, statins should also be avoided in pregnancy (106). In the second and third trimesters, A1C <6% (42 mmol/mol) has the lowest risk of large-for-gestational-age infants (38,41,42), preterm delivery (43), and preeclampsia (1,44). In patients with preexisting diabetes, glycemic targets are usually achieved through a combination of insulin administration and medical nutrition therapy. 4. This usually results in a doubling of daily insulin dose compared with the prepregnancy requirement. Glucose targets are fasting plasma glucose <95 mg/dL (5.3 mmol/L) and either 1-h postprandial glucose <140 mg/dL (7.8 mmol/L) or 2-h postprandial glucose <120 mg/dL (6.7 mmol/L). A recent meta-analysis concluded that metformin exposure resulted in smaller neonates with an acceleration of postnatal growth, resulting in higher BMI in childhood (82). Arlington, VA 22202, For donations by mail: Insulin use should follow the guidelines below. Diabetes Care. 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. Although there is some heterogeneity, many RCTs and a Cochrane review 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 (5355). Most women who have gestational diabetes deliver healthy babies. Medical nutrition therapy for GDM is an individualized nutrition plan developed between the woman and an RD/RDN familiar with the management of GDM (56,57). Women with a history of GDM have a greatly increased risk of conversion to type 2 diabetes over time (108). 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. There was no difference in pregnancy loss, neonatal care, or other neonatal outcomes between the groups with tighter versus less tight control of hypertension (116). Other Standards of Care resources, including a webcast with continuing education credit and a full slide deck, can be found on DiabetesPro. Insulin should be added if needed to achieve glycemic targets. Breastfeeding may also confer longer-term metabolic benefits to both mother (116) and offspring (117). Suggested citation: American Diabetes Association Professional Practice Committee. 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. E. Diabetes in pregnancy is associated with an increased risk of preeclampsia (95). 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. Hybrid closed-loop insulin pumps that allow for the achievement of pregnancy fasting and postprandial glycemic targets may reduce hypoglycemia and allow for more aggressive prandial dosing to achieve targets. Partner with Us. Simple carbohydrates will result in higher postmeal excursions. There are no adequate data on optimal weight gain versus weight maintenance in women with BMI >35 kg/m2. Prescription of prenatal vitamins (with at least 400 g of folic acid and 150 g of potassium iodide [18]) is recommended prior to conception. Periodontal disease is commonly seen in people with diabetes, 22-24 and is considered a complication of diabetes. 112). A, 15.24 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. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC. Effective preconception counseling could avert substantial health and associated cost burdens in offspring (9). As a world leader in diabetes care, the ADA is proud to set the standards!, said Boris Draznin, MD, PhD, Chair of the Professional Practice Committee. A blood sugar level of 190 milligrams per deciliter (mg/dL), or 10.6 millimoles per liter (mmol/L), indicates gestational diabetes. This applies to women in the immediate postpartum period. Treatment aims to keep your blood glucose (blood sugar) levels normal. In a pregnancy complicated by diabetes and chronic hypertension, a target goal blood pressure of 110135/85 mmHg is suggested to reduce the risk of uncontrolled maternal hypertension and minimize impaired fetal growth (114116). The OGTT is more sensitive at detecting glucose intolerance, including both prediabetes and diabetes. Not all hybrid closed-loop pumps are able to achieve the pregnancy targets. Classification and Diagnosis of Diabetes:Standards of Medical Care in Diabetes2021. Ideally, the A1C target in pregnancy is <6% (42 mmol/mol) if this can be achieved without significant hypoglycemia, but the target may be relaxed to <7% (53 mmol/mol) if necessary to prevent hypoglycemia. 203: Chronic Hypertension in Pregnancy, Less-tight versus tight control of hypertension in pregnancy, Treatment of hypertension in pregnant women, Risks of statin use during pregnancy: a systematic review, Progression to type 2 diabetes in women with a known history of gestational diabetes: systematic review and meta-analysis, Incidence rate of type 2 diabetes mellitus after gestational diabetes mellitus: a systematic review and meta-analysis of 170,139 women, Healthful dietary patterns and type 2 diabetes mellitus risk among women with a history of gestational diabetes mellitus, Interpregnancy weight change and risk of adverse pregnancy outcomes: a population-based study, Diabetes Prevention Program Research Group, Prevention of diabetes in women with a history of gestational diabetes: effects of metformin and lifestyle interventions, The effect of lifestyle intervention and metformin on preventing or delaying diabetes among women with and without gestational diabetes: the Diabetes Prevention Program outcomes study 10-year follow-up, Peripartum management of glycemia in women with type 1 diabetes, Changes in postpartum insulin requirements for patients with well-controlled type 1 diabetes, Breastfeeding and the basal insulin requirement in type 1 diabetic women, Duration of lactation and incidence of type 2 diabetes, Does breastfeeding influence the risk of developing diabetes mellitus in children? The 2015 study (116) excluded pregnancies complicated by preexisting diabetes, and only 6% had GDM at enrollment. Women with preexisting diabetic retinopathy will need close monitoring during pregnancy to assess for progression of retinopathy and provide treatment if indicated (23). E A dosage of 162 mg/day may be acceptable; currently in the U.S., low-dose aspirin is available in 81-mg tablets. Use of the CGM-reported mean glucose is superior to the use of estimated A1C, glucose management indicator, and other calculations to estimate A1C given the changes to A1C that occur in pregnancy (48). A follow-up study at 510 years showed that the offspring had higher BMI, weight-to-height ratios, waist circumferences, and a borderline increase in fat mass (82,83). The insulin requirement levels off toward the end of the third trimester with placental aging. E, 15.6 Women with preexisting type 1 or type 2 diabetes who are planning pregnancy or who have become pregnant should be counseled on the risk of development and/or progression of diabetic retinopathy. B, 14.5 In addition to focused attention on achieving glycemic targets A, standard preconception care should be augmented with extra focus on nutrition, diabetes education, and screening for diabetes comorbidities and complications. The diet should emphasize monounsaturated and polyunsaturated fats while limiting saturated fats and avoiding trans fats. During pregnancy, your body makes more hormones and goes through other changes, such as weight gain. There was no difference in pregnancy loss, neonatal care, or other neonatal outcomes between the groups with tighter versus less tight control of hypertension (104). . Metformin and glyburide should not be used as first-line agents, as both cross the placenta to the fetus. B, 15.9 When used in addition to pre- and postprandial blood glucose monitoring, continuous glucose monitoring can help to achieve A1C targets in diabetes and pregnancy. 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. The 2023 Standards of Care in Diabetes includes all of ADA's current clinical practice recommendations and is intended to provide clinicians, patients, researchers, payers, and others with the components of diabetes care, general treatment goals, and tools to evaluate the quality of care. A rapid reduction in insulin requirements can indicate the development of placental insufficiency (31). 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. The risk for associated hypertension and other comorbidities may be as high or higher with type 2 diabetes as with type 1 diabetes, even if diabetes is better controlled and of shorter apparent duration, with pregnancy loss appearing to be more prevalent in the third trimester in women with type 2 diabetes compared with the first trimester in women with type 1 diabetes (93,94). 14.21 Insulin resistance decreases dramatically immediately postpartum, and insulin requirements need to be evaluated and adjusted as they are often roughly half the prepregnancy requirements for the initial few days postpartum. Due to the complexity of insulin management in pregnancy, referral to a specialized center offering team-based care (with team members including maternal-fetal medicine specialist, endocrinologist or other provider experienced in managing pregnancy in women with preexisting diabetes, dietitian, nurse, and social worker, as needed) is recommended if this resource is available. A recent meta-analysis concluded that metformin exposure resulted in smaller neonates with acceleration of postnatal growth resulting in higher BMI in childhood (74). Both multiple daily insulin injections and continuous subcutaneous insulin infusion are reasonable delivery strategies, and neither has been shown to be superior to the other during pregnancy (84). In the second and third trimesters, A1C <6% (42 mmol/mol) has the lowest risk of large-for-gestational-age infants (39,42,43), preterm delivery (44), and preeclampsia (1,45). 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. 762: Prepregnancy Counseling, 2017 guidelines of the American Thyroid Association for the diagnosis and management of thyroid disease during pregnancy and the postpartum, Preconception health: changing the paradigm on well-woman health, Pregnancy outcome following exposure to angiotensin-converting enzyme inhibitors or angiotensin receptor antagonists: a systematic review, Angiotensin-converting enzyme inhibitors and the risk of congenital malformations, Prenatal exposure to HMG-CoA reductase inhibitors: effects on fetal and neonatal outcomes, Statins and congenital malformations: cohort study, National Institute of Child Health and Human Development Diabetes in Early Pregnancy Study, Metabolic control and progression of retinopathy.