false Women with a history of GDM have a greatly increased risk of conversion to type 2 diabetes over time and not solely within the 4- to 12-week postpartum time frame (60). << Dilated eye examinations should occur 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. 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. To minimize the occurrence of complications, beginning at the onset of puberty or at diagnosis, all women with diabetes of childbearing potential should receive education about 1) the risks of malformations associated with unplanned pregnancies and poor metabolic control and 2) the use of effective contraception at all times when preventing a pregnancy. 10 0 obj Preconception counseling using developmentally appropriate educational tools enables adolescent girls to make well-informed decisions (5). /Annots [37 0 R 38 0 R 39 0 R] Women are entering pregnancy at an older age, are more likely to be obese or overweight and are often from a high‑risk ethnic background. As is true for all nutrition therapy in patients with diabetes, the amount and type of carbohydrate will impact glucose levels, especially postmeal excursions. Chronic diuretic use during pregnancy is not recommended as it has been associated with restricted maternal plasma volume, which may reduce uteroplacental perfusion (56). Patients treated with oral agents should be informed that they cross the placenta, and although no adverse effects on the fetus have been demonstrated, long-term studies are lacking. Metformin and glyburide may be used, but both cross the placenta to the fetus, with metformin likely crossing to a greater extent than glyburide. Randomized, double-blind, controlled trials comparing metformin with other therapies for ovulation induction in women with polycystic ovary syndrome have not demonstrated benefit in preventing spontaneous abortion or GDM (42), and there is no evidence-based need to continue metformin in such patients once pregnancy has been confirmed (43–45). 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. The majority is gestational diabetes mellitus (GDM) with the remainder primarily preexisting type 1 diabetes and type 2 diabetes. There is not agreement regarding the comparative advantages and disadvantages of the two oral agents; the most recent systematic review of randomized controlled trials comparing metformin and glyburide for GDM found no clear differences in maternal or neonatal outcomes (33). The OGTT is recommended over A1C at the time of the 4- to 12-week postpartum visit because A1C may be persistently impacted (lowered) by the increased red blood cell turnover related to pregnancy or blood loss at delivery and because the OGTT is more sensitive at detecting glucose intolerance, including both prediabetes and diabetes. 2018 Diabetes Canada CPG – Chapter 36. Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes—2018 << As your pregnancy progresses, your health care team can help you manage your blood sugar levels and adjust your diabetes treatment plan as needed. /Thumb 34 0 R /Resources 14 0 R 2018 surveillance of diabetes in pregnancy: management from preconception to the postnatal period (NICE guideline NG3) Appendix A: Summary of evidence from surveillance. Hypertension in pregnancy. 137: Gestational diabetes mellitus, HbA1c in early diabetic pregnancy and pregnancy outcomes: a Danish population-based cohort study of 573 pregnancies in women with type 1 diabetes, Glycaemic control during early pregnancy and fetal malformations in women with type I diabetes mellitus, Glycemic targets in the second and third trimester of pregnancy for women with type 1 diabetes, HbA1c levels are significantly lower in early and late pregnancy, Reference intervals for hemoglobin A1c in pregnant women: data from an Italian multicenter study, Hyperglycemia and adverse pregnancy outcomes, Diet and exercise interventions for preventing gestational diabetes mellitus, Gestational diabetes mellitus can be prevented by lifestyle intervention: the Finnish Gestational Diabetes Prevention Study (RADIEL): a randomized controlled trial, A randomized clinical trial of exercise during pregnancy to prevent gestational diabetes mellitus and improve pregnancy outcome in overweight and obese pregnant women, Summary and recommendations of the Fifth International Workshop-Conference on Gestational Diabetes Mellitus, The impact of adoption of the International Association of Diabetes in Pregnancy Study Group criteria for the screening and diagnosis of gestational diabetes, Gestational diabetes mellitus and frequency of blood glucose monitoring: a randomized controlled trial, Different types of dietary advice for women with gestational diabetes mellitus, Dietary intervention in patients with gestational diabetes mellitus: a systematic review and meta-analysis of randomized clinical trials on maternal and newborn outcomes, Benefits and harms of treating gestational diabetes mellitus: a systematic review and meta-analysis for the U.S. Preventive Services Task Force and the National Institutes of Health Office of Medical Applications of Research, Metformin versus insulin for the treatment of gestational diabetes, Metformin vs insulin in the management of gestational diabetes: a meta-analysis, A comparison of glyburide and insulin in women with gestational diabetes mellitus, Oral anti-diabetic pharmacological therapies for the treatment of women with gestational diabetes, Glyburide versus metformin and their combination for the treatment of gestational diabetes mellitus: a randomized controlled study, Pharmacological management of gestational diabetes: an overview, Obstetric-Fetal Pharmacology Research Unit Network, Are we optimizing gestational diabetes treatment with glyburide? Lifestyle change is an essential component of management of gestational diabetes mellitus and may suffice for the treatment of many women. Diabetes Care. /Subtype /XML Optimization of glycemic control prior to pregnancy is a very important step, with a target hemoglobin A 1c of less than 6.5% at conception. Diabetes and Pregnancy. Treatment has been demonstrated to improve perinatal outcomes in two large randomized studies as summarized in a U.S. Preventive Services Task Force review (29). Abstract. 10.2337/dc18-S013 Gross, MD, FRCSC, FACOG, FACMG. %���� Women with preexisting diabetic retinopathy will need close monitoring during pregnancy to ensure that retinopathy does not progress. A review of current evidence, Gestational diabetes and the incidence of type 2 diabetes: a systematic review, Carbohydrate Metabolism in Pregnancy and the Newborn IV, 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. >> Clinical trials have not evaluated the risks and benefits of achieving these targets, and treatment goals should account for the risk of maternal hypoglycemia in setting an individualized target of <6% (42 mmol/mol) to <7% (53 mmol/mol). It aims to improve the diagnosis of gestational diabetes and help women with diabetes to self-manage their blood glucose levels before and during pregnancy. 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. © 2021 by the American Diabetes Association. 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 … Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes-2018. A recent randomized controlled trial suggests that women with mild GDM (fasting plasma glucose <95 mg/dL [5.3 mmol/L]) who meet glucose goals after a week of medical nutrition therapy can safely perform self-monitoring of blood glucose every other day, rather than daily (26). Insulin may be required to treat hyperglycemia, and its use should follow the guidelines below. /CropBox [0 0 593.9719848633 782.9860229492] >> /Annots [52 0 R 53 0 R] /Thumb 40 0 R Gestational diabetes mellitus (GDM), or diabetes first recognised during pregnancy, is being diagnosed with increasing frequency. >> << Similar to the targets recommended by the American College of Obstetricians and Gynecologists (14), the ADA-recommended targets for women with type 1 or type 2 diabetes (the same as for GDM; described below) are as follows: ○ Fasting <95 mg/dL (5.3 mmol/L) and either, ○ One-hour postprandial <140 mg/dL (7.8 mmol/L) or, ○ Two-hour postprandial <120 mg/dL (6.7 mmol/L). The pharmacologic basis for better clinical practice, Glibenclamide, metformin, and insulin for the treatment of gestational diabetes: a systematic review and meta-analysis, Comparative efficacy and safety of OADs in management of GDM: network meta-analysis of randomized controlled trials, Association of adverse pregnancy outcomes with glyburide vs insulin in women with gestational diabetes, Placental passage of metformin in women with polycystic ovary syndrome, Population pharmacokinetics of metformin in late pregnancy, Metformin versus placebo from first trimester to delivery in polycystic ovary syndrome: a randomized, controlled multicenter study, Cooperative Multicenter Reproductive Medicine Network, Clomiphene, metformin, or both for infertility in the polycystic ovary syndrome, Prospective parallel randomized, double-blind, double-dummy controlled clinical trial comparing clomiphene citrate and metformin as the first-line treatment for ovulation induction in nonobese anovulatory women with polycystic ovary syndrome, Metformin administration versus laparoscopic ovarian diathermy in clomiphene citrate-resistant women with polycystic ovary syndrome: a prospective parallel randomized double-blind placebo-controlled trial, Continuous subcutaneous insulin infusion versus multiple daily injections of insulin for pregnant women with diabetes, Risk factors for pre-eclampsia at antenatal booking: systematic review of controlled studies, Low-dose aspirin for the prevention of morbidity and mortality from preeclampsia: a systematic evidence review for the U.S. Preventive Services Task Force [article online], 2014. 10.2337/dc18-S013 American College of Obstetricians and Gynecologists; Task Force on Hypertension in Pregnancy. In the prospective Nurses' Health Study II, subsequent diabetes risk after a history of GDM was significantly lower in women who followed healthy eating patterns (62). Diabetes Care Print ISSN: 0149-5992, Online ISSN: 1935-5548. Gestational Diabetes Mellitus. In other words, risks increase with progressive hyperglycemia. /Parent 2 0 R /ColorSpace 60 0 R endobj /Resources 50 0 R << Planning pregnancy is critical in women with preexisting diabetes due to the need for preconception glycemic control and preventive health services. PDF 903.13 KB. /Type /Page Surveillance report. /Thumb 49 0 R /Count 7 endobj >> endobj /Parent 2 0 R In the second trimester, rapidly increasing insulin resistance requires weekly or biweekly increases in insulin dose to achieve glycemic targets. /Contents 51 0 R Diabetes Canada 2018 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada Volume 42, Supplement 1, Pages A1-A18, S1-S326 (April 2018) 2021 Jan;44 (Suppl 1):S200-S210. Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes-2021. monitoring for women with type 1 diabetes who are planning to become pregnant or already pregnant. Diabetes Care 2018;41(Suppl. There are no adequately powered randomized trials comparing different fasting and postmeal glycemic targets in diabetes in pregnancy. 2017-11-21 Retinopathy. Early pregnancy is a time of insulin sensitivity, lower glucose levels, and lower insulin requirements in women with type 1 diabetes. This applies to women in the immediate postpartum period. doi: 10.2337/dc21-S014. Due to physiological increases in red blood cell turnover, A1C levels fall during normal pregnancy (18,19). A cost-benefit analysis has concluded that this approach would reduce morbidity, save lives, and lower health care costs (49). 13. 3 0 obj /Pages 2 0 R Detemir[Grade B, Level 2] or glargine[Grade C, Level 3] may be used in women with pre-existing diabetes as an alternative to NPH and is associated with similar perinatal outcomes. Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes-2018. /Thumb 13 0 R 2. 2017-11-21 The National Institute of Child Health and Human Development--Diabetes in Early Pregnancy Study, Committee on Practice Bulletins--Obstetrics, Practice Bulletin No. In women taking insulin, particular attention should be directed to hypoglycemia prevention in the setting of breastfeeding and erratic sleep and eating schedules. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. /Contents 45 0 R endstream 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). Fcr_sSf3,Te)C5BkPoR(_o.#/P^3RY\dERq+8g4E[smAWEHI In these women, lifestyle intervention and metformin reduced progression to diabetes by 35% and 40%, respectively, over 10 years compared with placebo (65). All women of childbearing age with diabetes should be counseled about the importance of tight glycemic control prior to conception. Undiagnosed or inadequately treated GDM … Elixhauser A, Weschler JM, Kitzmiller JL, et al. In addition, diabetes in pregnancy may increase the risk of obesity and type 2 diabetes in offspring later in life (1,2). Some women with preexisting diabetes should also test blood glucose preprandially. Effect of intensive diabetes management on macrovascular events and risk factors in the Diabetes Control and Complications Trial. None of the currently available insulin preparations have been demonstrated to cross the placenta. Starting at puberty, preconception counseling should be incorporated into routine diabetes care for all girls of childbearing potential. In the first trimester, there is often a decrease in total daily dose of insulin. 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. 2EVj(J#m$`mU#=[%>(iG`G_f)_h8!5WrpO$:I@:%\X3P /CropBox [0 0 593.9719848633 782.9860229492] We do not capture any email address. This guideline covers managing diabetes and its complications in women who are planning pregnancy or are already pregnant. endobj care.diabetesjournals.org /Kids [5 0 R 6 0 R 7 0 R 8 0 R 9 0 R 10 0 R 11 0 R] During pregnancy, treatment with ACE inhibitors and angiotensin receptor blockers is contraindicated because they may cause fetal renal dysplasia, oligohydramnios, and intrauterine growth restriction (8). /Contents [15 0 R 16 0 R 17 0 R 18 0 R 19 0 R 20 0 R 21 0 R 22 0 R] stream Diabetes in pregnancy is increasing and therefore it is important to raise awareness of the associated health risks to the mother, the growing fetus, and the future child. /Type /Page Enter multiple addresses on separate lines or separate them with commas. endobj /Filter /FlateDecode All pregnant women presenting with polyuria and polydipsia should be investigated with blood tests including urea and electrolytes, calcium levels and thyroid function tests. Evidence 2018 surveillance of diabetes in pregnancy: management from preconception to the postnatal period (NICE guideline NG3) Overview of 2018 surveillance methods NICE's surveillance team checked whether recommendations in diabetes in … Members of the ADA Profe … As in type 1 diabetes, insulin requirements drop dramatically after delivery. /ExtGState 59 0 R TE>0j2-BS!D!ct#[G1(eI94rX-?W/8lVeCJC@sCj_t3J0?ss\sf>OIV9MZ]V+n"@8 Postpartum care should include psychosocial assessment and support for self-care. /MediaBox [0 0 593.9719848633 782.9860229492] Type 2 diabetes is often associated with obesity. >> 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. << Suggested citation: American Diabetes Association. The food plan should be based on a nutrition assessment with guidance from the Dietary Reference Intakes (DRI). /MediaBox [0 0 593.9719848633 782.9860229492] Insulin sensitivity increases with delivery of the placenta and then returns to prepregnancy levels over the following 1–2 weeks. stream Education for patients and family members about the prevention, recognition, and treatment of hypoglycemia is important before, during, and after pregnancy to help to prevent and manage the risks of hypoglycemia. In normal pregnancy, blood pressure is lower than in the nonpregnant state. feq;9n^eG,].Ur7iJo_acb#R4+1U@RM/dr9BKF[8A]gLd1GQCtePkc4NA[u#h5*u2 /Parent 2 0 R If women cannot achieve these targets without significant hypoglycemia, the ADA suggests less stringent targets based on clinical experience and individualization of care. Diabetes Care. /Width 74 10.2337/dc18-S013 Long-term safety data are not available for any oral agent (35). Family planning should be discussed, and effective contraception should be prescribed and used until a woman is prepared and ready to become pregnant. care.diabetesjournals.org /MediaBox [0 0 593.9719848633 782.9860229492] The prevalence of diabetes in pregnancy has been increasing in the U.S.