Ensure treatment decisions are timely, rely on evidence-basedguidelines, and are made . PDF Di abe te s Cl i ni c al P r ac ti c e G ui de l i ne - Capital Health Box 7023 Merrifield, VA 22116-7023. 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 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). Merrifield, VA 22116-7023. B, 15.10 When used in addition to blood glucose monitoring targeting traditional pre- and postprandial targets, real-time continuous glucose monitoring can reduce macrosomia and neonatal hypoglycemia in pregnancy complicated by type 1 diabetes. 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. In women taking insulin, particular attention should be directed to hypoglycemia prevention in the setting of breastfeeding and erratic sleep and eating schedules (126). Additionally, as A1C represents an integrated measure of glucose, it may not fully capture postprandial hyperglycemia, which drives macrosomia. September 2021 . Gestational diabetes mellitus: Glucose management and - UpToDate Concentrations of glyburide in umbilical cord plasma are approximately 5070% of maternal levels (63,64). 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. Both metformin and intensive lifestyle intervention prevent or delay progression to diabetes in women with prediabetes and a history of GDM. E. Diabetes in pregnancy is associated with an increased risk of preeclampsia (95). Not all hybrid closed-loop pumps are able to achieve the pregnancy targets. Low-dose aspirin >100 mg is required (9799). Topics covered are of interest to clinically oriented physicians, researchers, epidemiologists, psychologists, diabetes care and education specialists and other health care professionals. E, 14.12 Commonly used estimated A1C and glucose management indicator calculations should not be used in pregnancy as estimates of A1C. A large study found that after adjusting for confounders, first trimester ACE inhibitor exposure does not appear to be associated with congenital malformations (21). (Evidence A)Long-term use of Metformin may be associated with biochemical vitamin B12 . A key point is the need to incorporate a question about a womans plans for pregnancy into routine primary and gynecologic care. However, lactation can increase the risk of overnight hypoglycemia, and insulin dosing may need to be adjusted. Gestational diabetes can be a scary diagnosis, but like other forms of diabetes, it's one that you can manage. A major barrier to effective preconception care is the fact that the majority of pregnancies are unplanned. 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). 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). PDF Guideline for Detection 3.1.0 Screening for Gestational Diabetes and C, 14.22 A contraceptive plan should be discussed and implemented with all women with diabetes of reproductive potential. Reflecting this physiology, fasting and postprandial monitoring of blood glucose is recommended to achieve metabolic control in pregnant women with diabetes. 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. 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. Review and counseling on the use of nicotine products, alcohol, and recreational drugs, including marijuana, is important. 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. Women with a history of GDM have a greatly increased risk of conversion to type 2 diabetes over time (120). 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. The food plan should be based on a nutrition assessment with guidance from the Dietary Reference Intakes (DRI). Lower limits are based on the mean of normal blood glucoses in pregnancy (35). Gestational diabetes screening is recommended at both 12-16 weeks and 24-48 weeks gestation with a 2h 75g-OGTT and 0, 1, and 2h glucose measures. This Guideline was approved November 13, 2016, and updated February 12, 2018. There are no adequate data on optimal weight gain versus weight maintenance in women with BMI >35 kg/m2. 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. On the basis of available evidence, statins should also be avoided in pregnancy (118). Women with GDM have a 10-fold increased risk of developing type 2 diabetes compared with women without GDM (107). DKA carries a high risk of stillbirth. 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 (120). Prescription of prenatal vitamins (with at least 400 g of folic acid and 150 g of potassium iodide [18]) is recommended prior to conception. 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). Sulfonylureas are known to cross the placenta and have been associated with increased neonatal hypoglycemia. Women with GDM have a 10-fold increased risk of developing type 2 diabetes compared with women without GDM (119). B. It is required that all programs that are accredited/recognized by ADCES and ADA meet these guidelines in order to bill for Medicare. By continuing to use our website, you are agreeing to, Justice, Equity, Diversity, and Inclusion, Institutional Subscriptions and Site Licenses, Management of Gestational Diabetes Mellitus, Management of Preexisting Type 1 Diabetes and Type 2 Diabetes in Pregnancy, PREGNANCY AND ANTIHYPERTENSIVE MEDICATIONS, https://clinicaltrials.gov/ct2/show/NCT01353391, https://clinicaltrials.gov/ct2/show/NCT02932475, https://www.ncbi.nlm.nih.gov/books/NBK196392/, https://www.diabetesjournals.org/content/license. 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. 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. The 2021 Standards of Care is now live online in Diabetes Care. About Diabetes Care A Other oral and noninsulin injectable glucose-lowering medications lack long-term safety data. If the pregnancy has motivated the adoption of a healthier diet, building on these gains to support weight loss is recommended in the postpartum period. This update presents: Today, the Standards of Care is available online and is published as a supplement to the January 2021 issue of Diabetes Care. Taking all of this into account, a target of <6% (42 mmol/mol) is optimal during pregnancy if it can be achieved without significant hypoglycemia. 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). 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 (102104). 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. Join us to develop and nurture an open dialogue between industry and AACE to advance patient care. B, 14.10 When used in addition to self-monitoring of blood glucose targeting traditional pre- and postprandial targets, continuous glucose monitoring can reduce macrosomia and neonatal hypoglycemia in pregnancy complicated by type 1 diabetes. 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). Furthermore, glyburide and metformin failed to provide adequate glycemic control in separate RCTs in 23% and 2528% of women with GDM, respectively (63,64). 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. Suggested citation: American Diabetes Association. However, in women with diabetes, hyperglycemia occurs if treatment is not adjusted appropriately. The risk of an unplanned pregnancy outweighs the risk of any given contraception option. . . Appropriate use of over-the-counter medications and supplements, Evaluation of diabetes and its comorbidities and complications, including: DKA/severe hyperglycemia; severe hypoglycemia/hypoglycemia unawareness; barriers to care; comorbidities such as hyperlipidemia, hypertension, NAFLD, PCOS, and thyroid dysfunction; complications such as macrovascular disease, nephropathy, neuropathy (including autonomic bowel and bladder dysfunction), and retinopathy, Evaluation of obstetric/gynecologic history, including history of: cesarean section, congenital malformations or fetal loss, current methods of contraception, hypertensive disorders of pregnancy, postpartum hemorrhage, preterm delivery, previous macrosomia, Rh incompatibility, and thrombotic events (DVT/PE), Review of current medications and appropriateness during pregnancy, Diabetes complications and comorbidities, including: comprehensive foot exam; comprehensive ophthalmologic exam; ECG in women starting at age 35 years who have cardiac signs/symptoms or risk factors and, if abnormal, further evaluation; lipid panel; serum creatinine; TSH; and urine protein-to-creatinine ratio.