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In patients with preexisting diabetes, glycemic targets are usually achieved through a combination of insulin administration and medical nutrition therapy. Other Standards of Care resources, including a webcast with continuing education credit and a full slide deck, can be found on DiabetesPro. 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. 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. While many providers prefer insulin pumps in pregnancy, it is not clear that they are superior to multiple daily injections (91,92). Time above range (>140 mg/dL [7.8 mmol/L]), goal <25%. Classification and Diagnosis of Diabetes:Standards of Medical Care in Diabetes2021. 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. A, 15.2 Family planning should be discussed, and effective contraception (with consideration of long-acting, reversible contraception) should be prescribed and used until a womans treatment regimen and A1C are optimized for pregnancy. Several studies have shown improved diabetes and pregnancy outcomes when care has been delivered from preconception through pregnancy by a multidisciplinary group focused on improved glycemic control (2427). Complications of gestational diabetes. 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 (29). Accessed 17 October 2021. See Table 14.1 for additional details on elements of preconception care (16,18). American Diabetes Association. The U.S. Preventive Services Task Force recommends the use of low-dose aspirin (81 mg/day) as a preventive medication at 12 weeks of gestation in women who are at high risk for preeclampsia (108). However, in women with diabetes, hyperglycemia occurs if treatment is not adjusted appropriately. E A dosage of 162 mg/day may be acceptable E; currently, in the U.S., low-dose aspirin is available in 81-mg tablets. Insulin use should follow the guidelines below. 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. B. E, 15.21 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. Read the Standards. This was not found in the Adelaide cohort. It is required that all programs that are accredited/recognized by ADCES and ADA meet these guidelines in order to bill for Medicare. These associations with maternal oral glucose tolerance test (OGTT) results are continuous with no clear inflection points (38,51). 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). Breastfeeding may also confer longer-term metabolic benefits to both mother (116) and offspring (117). Some women with preexisting diabetes should also test blood glucose preprandially. In the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study, increasing levels of glycemia were also associated with worsening outcomes (38). 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. Preconception counseling using developmentally appropriate educational tools enables adolescent girls to make well-informed decisions (9). The online version of the Standards of Care will continue to be annotated in real-time with necessary updates if new evidence or regulatory changes merit immediate incorporation through the living Standards of Care process. Similar to the targets recommended by ACOG (upper limits are the same as for GDM, described below) (35), 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). Most women who have gestational diabetes deliver healthy babies. 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). Antihypertensive drugs known to be effective and safe in pregnancy include methyldopa, nifedipine, labetalol, diltiazem, clonidine, and prazosin. 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. Oral agents may be an alternative in these women after a discussion of the known risks and the need for more long-term safety data in offspring. 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. 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. 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. In one study, insulin requirements in the immediate postpartum period are roughly 34% lower than prepregnancy insulin requirements (125). 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). As is true for all nutrition therapy in patients with diabetes, the amount and type of carbohydrate will impact glucose levels. 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). 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. The A1C target in a given patient should be achieved without hypoglycemia, which, in addition to the usual adverse sequelae, may increase the risk of low birth weight (46). Not all hybrid closed-loop pumps are able to achieve the pregnancy targets. Target range 63140 mg/dL (3.57.8 mmol/L): TIR, goal >70%, Time below range (<63 mg/dL [3.5 mmol/L]), goal <4%, Time below range (<54 mg/dL [3.0 mmol/L]), goal <1%. Atenolol is not recommended, but other -blockers may be used, if necessary. Therefore, all women should be screened as outlined in Section 2, Classification and Diagnosis of Diabetes (https://doi.org/10.2337/dc22-S002). American Diabetes Association; 14. For 80 years the ADA has been driving discovery and research to treat, manage and prevent diabetes, while working relentlessly for a cure. Women with type 1 diabetes should be prescribed ketone strips and receive education on DKA prevention and detection. 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. This applies to women in the immediate postpartum period. Reflecting this physiology, fasting and postprandial monitoring of blood glucose is recommended to achieve metabolic control in pregnant women with diabetes. 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). Low-dose aspirin >100 mg is required (9799). The OGTT is more sensitive at detecting glucose intolerance, including both prediabetes and diabetes. 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). Recommended weight gain during pregnancy for women with overweight is 1525 lb and for women with obesity is 1020 lb (62). 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). On the basis of available evidence, statins should also be avoided in pregnancy (106). Guidelines are systematically developed statements to assist patients and providers in choosing appropriate health . Glyburide was associated with a higher rate of neonatal hypoglycemia, macrosomia, and increased neonatal abdominal circumference than insulin or metformin in meta-analyses and systematic reviews (72,73). In women taking insulin, particular attention should be directed to hypoglycemia prevention in the setting of breastfeeding and erratic sleep and eating schedules (126). 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. 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). . 15.4 Women with preexisting diabetes who are planning a pregnancy should ideally be managed beginning in preconception in a multidisciplinary clinic including an endocrinologist, maternal-fetal medicine specialist, registered dietitian nutritionist, and diabetes care and education specialist, when available. In normal pregnancy, blood pressure is lower than in the nonpregnant state. The pharmacologic basis for better clinical practice, Pharmacokinetics, efficacy and safety of glyburide for treatment of gestational diabetes mellitus, Glibenclamide, metformin, and insulin for the treatment of gestational diabetes: a systematic review and meta-analysis, Comparative impact of pharmacological treatments for gestational diabetes on neonatal anthropometry independent of maternal glycaemic control: a systematic review and meta-analysis, Groupe de Recherche en Obsttrique et Gyncologie (GROG), Effect of glyburide vs subcutaneous insulin on perinatal complications among women with gestational diabetes: a randomized clinical trial, Metformin compared with glyburide for the management of gestational diabetes, Glyburide versus metformin and their combination for the treatment of gestational diabetes mellitus: a randomized controlled study, Comparative efficacy and safety of OADs in management of GDM: network meta-analysis of randomized controlled trials, Placental passage of metformin in women with polycystic ovary syndrome, Population pharmacokinetics of metformin in late pregnancy, Metformin in gestational diabetes: the offspring follow-up (MiG TOFU): body composition and metabolic outcomes at 7-9 years of age, Metformin use in PCOS pregnancies increases the risk of offspring overweight at 4 years of age: follow-up of two RCTs, Neonatal, infant, and childhood growth following metformin versus insulin treatment for gestational diabetes: a systematic review and meta-analysis, Intrauterine metformin exposure and offspring cardiometabolic risk factors (PedMet study): a 5-10 year follow-up of the PregMet randomised controlled trial, 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, A cautionary response to SMFM statement: pharmacological treatment of gestational diabetes, Metformin for gestational diabetes mellitus: progeny, perspective, and a personalized approach, Continuous subcutaneous insulin infusion versus multiple daily injections of insulin for pregnant women with diabetes, Insulin glargine safety in pregnancy: a transplacental transfer study, Transfer of insulin lispro across the human placenta, Transfer of insulin lispro across the human placenta: in vitro perfusion studies, Evaluation of insulin antibodies and placental transfer of insulin aspart in pregnant women with type 1 diabetes mellitus, Insulin detemir does not cross the human placenta, Maternal efficacy and safety outcomes in a randomized, controlled trial comparing insulin detemir with NPH insulin in 310 pregnant women with type 1 diabetes, A randomized trial comparing perinatal outcomes using insulin detemir or neutral protamine Hagedorn in type 1 diabetes, Fetal and perinatal outcomes in type 1 diabetes pregnancy: a randomized study comparing insulin aspart with human insulin in 322 subjects, Insulin lispro therapy in pregnancies complicated by type 1 diabetes mellitus, Safety of insulin glargine use in pregnancy: a systematic review and meta-analysis, Continuous subcutaneous insulin infusion versus intensive conventional insulin therapy in type I and type II diabetic pregnancy, Fetal growth in women managed with insulin pump therapy compared to conventional insulin, Predictive low-glucose suspend reduces hypoglycemia in adults, adolescents, and children with type 1 diabetes in an at-home randomized crossover study: results of the PROLOG trial, Metformin in women with type 2 diabetes in pregnancy (MiTy): a multicentre, international, randomised, placebo-controlled trial, Poor pregnancy outcome in women with type 2 diabetes, Differing causes of pregnancy loss in type 1 and type 2 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, Rockville, MD, Agency for Healthcare Research and Quality, 2014.

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