Women with greater initial degrees of hyperglycemia may require earlier initiation of pharmacologic therapy. 2 0 obj The situation rapidly reverses as insulin resistance increases exponentially during the second and early third trimesters and levels off toward the end of the third trimester. Fcr_sSf3,Te)C5BkPoR(_o.#/P^3RY\dERq+8g4E[smAWEHI Both multiple daily insulin injections and continuous subcutaneous insulin infusion are reasonable alternatives, and neither has been shown to be superior during pregnancy (46). Gross, MD, FRCSC, FACOG, FACMG. Long-term safety data are not available for any oral agent (35). /CropBox [0 0 593.9719848633 782.9860229492] /Resources 41 0 R /Rotate 0 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. Postpartum care should include psychosocial assessment and support for self-care. Eapen DJ, Valian K, Reddy S, Sperling L. Management of familial hypercholesterolemia during pregnancy: case series and discussion. Of women with a history of GDM and prediabetes, only 5–6 women need to be treated with either intervention to prevent one case of diabetes over 3 years (64). /MediaBox [0 0 593.9719848633 782.9860229492] Insulin is the preferred agent for management of both type 1 diabetes and type 2 diabetes in pregnancy because it does not cross the placenta, and because oral agents are generally insufficient to overcome the insulin resistance in type 2 diabetes and are ineffective in type 1 diabetes. 2017-11-21 false /Type /Page Metformin was associated with a lower risk of neonatal hypoglycemia and less maternal weight gain than insulin in 2015 systematic reviews (37–39); however, metformin may slightly increase the risk of prematurity. 10.2337/dc18-S013 13. In a 2015 study targeting diastolic blood pressure of 100 mmHg versus 85 mmHg in pregnant women, only 6% of whom had GDM at enrollment, there was no difference in pregnancy loss, neonatal care, or other neonatal outcomes, although women in the less intensive treatment group had a higher rate of uncontrolled hypertension (55). >> Worldwide, one in 10 pregnancies is associated with diabetes, 90% of which are GDM. << /CropBox [0 0 593.9719848633 782.9860229492] The National Institute of Child Health and Human Development--Diabetes in Early Pregnancy Study, Committee on Practice Bulletins--Obstetrics, Practice Bulletin No. endobj 2017-11-21 /Contents 33 0 R doi: 10.2337/dc21-S014. care.diabetesjournals.org This applies to women in the immediate postpartum period. Lower blood pressure levels may be associated with impaired fetal growth. A cost-benefit analysis has concluded that this approach would reduce morbidity, save lives, and lower health care costs (49). 2EVj(J#m$`mU#=[%>(iG`G_f)_h8!5WrpO$:I@:%\X3P /Nums [0 12 0 R] TE>0j2-BS!D!ct#[G1(eI94rX-?W/8lVeCJC@sCj_t3J0?ss\sf>OIV9MZ]V+n"@8 endobj The A1C target in pregnancy is 6–6.5% (42–48 mmol/mol); <6% (42 mmol/mol) may be optimal if this can be achieved without significant hypoglycemia, but the target may be relaxed to <7% (53 mmol/mol) if necessary to prevent hypoglycemia. care.diabetesjournals.org A, Insulin is the preferred medication for treating hyperglycemia in gestational diabetes mellitus as it does not cross the placenta to a measurable extent. 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. In patients with preexisting diabetes, glycemic targets are usually achieved through a combination of insulin administration and medical nutrition therapy. /CropBox [0 0 593.9719848633 782.9860229492] Reflecting this physiology, fasting and postprandial monitoring of blood glucose is recommended to achieve metabolic control in pregnant women with diabetes. /Type /Metadata These are mainly the result of early fetal exposure to maternal hyperglycaemia. Diabetes Care Print ISSN: 0149-5992, Online ISSN: 1935-5548. /Parent 2 0 R These values represent optimal control if they can be achieved safely. endobj /Thumb 13 0 R 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. /CropBox [0 0 593.9719848633 782.9860229492] /Metadata 4 0 R 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. 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. The physiology of pregnancy requires frequent titration of insulin to match changing requirements. /Properties 62 0 R There are various types of diabetes insipidus that occur due to different pathology that occurs outside of, during, and as a result of pregnancy. Preconception counseling is essential for women with T1DM to minimize pregnancy risks. Surveillance report. 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. These levels should be achieved without hypoglycemia, which, in addition to the usual adverse sequelae, may increase the risk of low birth weight. /MediaBox [0 0 593.9719848633 782.9860229492] 10.2337/dc18-S013 /CropBox [0 0 593.9719848633 782.9860229492] /MediaBox [0 0 593.9719848633 782.9860229492] endstream In addition, rapid implementation of tight glycemic control in the setting of retinopathy is associated with worsening of retinopathy (50). Retinopathy. PDF 903.13 KB. 1):S137–S143. Breastfeeding may also confer longer-term metabolic benefits to both mother (58) and offspring (59). /ColorSpace 60 0 R /Type /Page View This Abstract Online; 13. 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). /Rotate 0 Concentrations of glyburide in umbilical cord plasma are approximately 70% of maternal levels (36). Fasting and postprandial self-monitoring of blood glucose are recommended in both gestational diabetes mellitus and preexisting diabetes in pregnancy to achieve glycemic control. Type 2 diabetes is often associated with obesity. Thank you for your interest in spreading the word about Diabetes Care. >> >> 2018 Jan;41(Suppl 1):S137-S143. Gestational diabetes mellitus (GDM), or diabetes first recognised during pregnancy, is being diagnosed with increasing frequency. In addition, diabetes in pregnancy may increase the risk of obesity and type 2 diabetes in offspring later in life (1,2). If women cannot achieve these targets without significant hypoglycemia, the ADA suggests less stringent targets based on clinical experience and individualization of care. 13. /ExtGState 59 0 R endobj Estimated time to complete activity: 0.5 hours. Question What are evidence-based approaches to managing preexisting diabetes in pregnancy?. Adjusting for BMI moderately, but not completely, attenuated this association. Preconception counseling using developmentally appropriate educational tools enables adolescent girls to make well-informed decisions (5). 2018 surveillance of diabetes in pregnancy: management from preconception to the postnatal period (NICE guideline NG3) Appendix A: Summary of evidence from surveillance. 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. /Parent 2 0 R 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. This guideline covers managing diabetes and its complications in women who are planning pregnancy or are already pregnant. 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. 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. There are no adequately powered randomized trials comparing different fasting and postmeal glycemic targets in diabetes in pregnancy. 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. 1 In addition, new diagnostic criteria, now widely adopted in Australia, 2–4 have greatly increased diagnosis of GDM. © 2021 by the American Diabetes Association. Gestational Diabetes Mellitus (GDM) is defined as Impaired Glucose Tolerance (IGT) with onset or first recognition during 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. 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 Type 1 Diabetes in Pregnancy

Women with type 1 diabetes (T1DM) have unique needs during the preconception, pregnancy, and postpartum periods. endobj Rockville, MD: Agency for Healthcare Research and Quality, A cost-benefit analysis of low-dose aspirin prophylaxis for the prevention of preeclampsia in the United States, Metabolic control and progression of retinopathy: The Diabetes in Early Pregnancy Study, Institute of Medicine and National Research Council, Weight Gain during Pregnancy: Reexamining the Guidelines, Poor pregnancy outcome in women with type 2 diabetes, Differing causes of pregnancy loss in type 1 and type 2 diabetes, Less-tight versus tight control of hypertension in pregnancy, Treatment of hypertension in pregnant women, Risks of statin use during pregnancy: a systematic review, Duration of lactation and incidence of type 2 diabetes, Does breastfeeding influence the risk of developing diabetes mellitus in children? Because GDM is associated with an increased lifetime maternal risk for diabetes estimated at 50–70% after 15–25 years (60,61), women should also be tested every 1–3 years thereafter if the 4- to 12-week 75-g OGTT is normal, with frequency of testing depending on other risk factors including family history, prepregnancy BMI, and need for insulin or oral glucose-lowering medication during pregnancy. 12 0 obj Holmsen ST, Bakkebo T, Seferowicz M, Retterstol K. Statins and breastfeeding in familial hypercholesterolaemia. Abstract. << /CropBox [0 0 593.9719848633 782.9860229492] Based upon the results of clinical trials, the U.S. Preventive Services Task Force recommends the use of low-dose aspirin (81 mg/day) as a preventive medication after 12 weeks of gestation in women who are at high risk for preeclampsia (48). >> While individual randomized controlled trials support the efficacy and short-term safety of metformin (30,31) and glyburide (32) for the treatment of GDM, both agents cross the placenta. 10 0 obj The association of macrosomia and birth complications with oral glucose tolerance test (OGTT) results is continuous with no clear inflection points (20). Faculty: Susan J. << /Annots [57 0 R] 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. B. Preconception counseling visits should include rubella, syphilis, hepatitis B virus, and HIV testing, as well as Pap smear, cervical cultures, blood typing, prescription of prenatal vitamins (with at least 400 μg of folic acid), and smoking cessation counseling if indicated. Lifestyle change is an essential component of management of gestational diabetes mellitus and may suffice for the treatment of many women. >> http://dx.doi.org/10.2337/dc18-S013 >> doi:10.2337/dc18-S013 /MediaBox [0 0 593.9719848633 782.9860229492] 2018; 41(Suppl 1):S137-S143 (ISSN: 1935-5548). Summary Pregnancy represents a challenge in management of monogenic diabetes, where factors of maternal glycemic control, fetal mutation status, and transplacental transfer of medication must all be taken into consideration. << %PDF-1.4 Diabetes and Pregnancy. Family planning should be discussed, and effective contraception should be prescribed and used until a woman is prepared and ready to become pregnant. However, in women with GDM or preexisting diabetes, hyperglycemia occurs if treatment is not adjusted appropriately. /ProcSet [/PDF /Text] Diabetes Care 2018;41(Suppl. >> 14 0 obj /Parent 2 0 R B. 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). This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. A major barrier to effective preconception care is the fact that the majority of pregnancies are unplanned. Medications should be added if needed to achieve glycemic targets. /Parent 2 0 R The food plan should be based on a nutrition assessment with guidance from the Dietary Reference Intakes (DRI). Effect of intensive diabetes management on macrovascular events and risk factors in the Diabetes Control and Complications Trial. << /Type /Catalog Metformin and glyburide may be used, but both cross the placenta to the fetus, with metformin likely crossing to a greater extent than glyburide. In the second and third trimesters, A1C <6% (42 mmol/mol) has the lowest risk of large-for-gestational-age infants, whereas other adverse outcomes increase with A1C ≥6.5% (48 mmol/mol). © 2017 by the American Diabetes Association. 6 0 obj << Referral to a registered dietitian is important in order to establish a food plan and insulin-to-carbohydrate ratio and to determine weight gain goals. Insulin may be required to treat hyperglycemia, and its use should follow the guidelines below. >> << endobj endobj Therefore, all women with diabetes of childbearing potential should have family planning options reviewed at regular intervals. 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, Intrauterine exposure to diabetes conveys risks for type 2 diabetes and obesity: a study of discordant sibships, 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, 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, Diabetes and Reproductive Health for Girls, Pregnancy outcome following exposure to angiotensin-converting enzyme inhibitors or angiotensin receptor antagonists: a systematic review, Prenatal exposure to HMG-CoA reductase inhibitors: effects on fetal and neonatal outcomes, Statins and congenital malformations: cohort study, 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, Maternal postprandial glucose levels and infant birth weight: the Diabetes in Early Pregnancy Study. Taking all of this into account, a target of 6–6.5% (42–48 mmol/mol) is recommended but <6% (42 mmol/mol) may be optimal as pregnancy progresses. 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. The physiology of pregnancy requires frequent titration of insulin to match changing requirements. Recommended weight gain during pregnancy for overweight women is 15–25 lb and for obese women is 10–20 lb (51). Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes—2018 Achieving maternal euglycemia in women with pregestational and gestational diabetes mellitus is critical to decreasing the risk of neonatal hypoglycemia, as maternal blood glucose levels around the time of delivery are directly related to the risk of hypoglycemia in the neonate. Effective preconception counseling could avert substantial health and associated cost burdens in offspring (6). A, Preconception counseling should address the importance of glycemic control as close to normal as is safely possible, ideally A1C <6.5% (48 mmol/mol), to reduce the risk of congenital anomalies. In women taking insulin, particular attention should be directed to hypoglycemia prevention in the setting of breastfeeding and erratic sleep and eating schedules. /Annots [46 0 R 47 0 R 48 0 R] The rise in GDM and type 2 diabetes in parallel with obesity both in the U.S. and worldwide is of particular concern. 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. endobj Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes-2018.
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