The American Diabetes Association (ADA) recently released its 2021 Standards of Medical Care, which provides healthcare professionals, researchers, and insurers with updated guidelines on diabetes care and management. 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. However, lactation can increase the risk of overnight hypoglycemia, and insulin dosing may need to be adjusted. Special attention should be paid to the review of the medication list for potentially harmful drugs (i.e., ACE inhibitors [20,21], angiotensin receptor blockers [20], and statins [22,23]). 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. 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. E, 14.27 Postpartum care should include psychosocial assessment and support for self-care. Metformin was associated with a lower risk of neonatal hypoglycemia and less maternal weight gain than insulin in systematic reviews (72,7577). For 82 years, the ADA has driven discovery and research to treat, manage, and prevent diabetes while working relentlessly for a cure. B, 15.5 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 ADA's 2022 Standards of Medical Care in Diabetes Update 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. Observational studies in preexisting diabetes and pregnancy show the lowest rates of adverse fetal outcomes in association with A1C <66.5% (4248 mmol/mol) early in gestation (46,38). 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. A large study found that after adjusting for confounders, first trimester ACE inhibitor exposure does not appear to be associated with congenital malformations (20). B. American Diabetes Association. 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. As is true for all nutrition therapy in patients with diabetes, the amount and type of carbohydrate will impact glucose levels. 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. Sulfonylureas are known to cross the placenta and have been associated with increased neonatal hypoglycemia. Hypoglycemia in pregnancy is as defined and treated in Recommendations 6.96.14 (Section 6 Glycemic Targets, https://doi.org/10.2337/dc21-S006). 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 (96). 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. Most women who have gestational diabetes deliver healthy babies. Rockville, MD, Agency for Healthcare Research and Quality, 2014 (Evidence Syntheses, No. Postprandial monitoring is associated with better glycemic control and lower risk of preeclampsia (3133). E. Diabetes in pregnancy is associated with an increased risk of preeclampsia (95). 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). 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). The DRI for all pregnant women recommends a minimum of 175 g of carbohydrate, a minimum of 71 g of protein, and 28 g of fiber. 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). https://doi.org/10.2337/dc22-S015.
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