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1.0.0.0 Di­a­betes in 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. 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. 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. Read­ers who wish to com­ment on the Stan­dards of Care are in­vit­ed to do so at pro­fes­sion­al.di­a­betes.org/‍SOC.

DI­A­BETES IN PREG­NAN­CY

The preva­lence of di­a­betes in preg­nan­cy has been in­creas­ing in the U.S. The ma­jor­i­ty is ges­ta­tion­al di­a­betes mel­li­tus (GDM) with the re­main­der pri­mar­i­ly pre­ex­ist­ing type 1 di­a­betes and type 2 di­a­betes. The rise in GDM and type 2 di­a­betes in par­al­lel with obe­si­ty both in the U.S. and world­wide is of par­tic­u­lar con­cern. Both type 1 di­a­betes and type 2 di­a­betes in preg­nan­cy con­fer significant­ly greater ma­ter­nal and fetal risk than GDM, with some dif­fer­ences ac­cord­ing to type of di­a­betes. In gen­er­al, specific risks of un­con­trolled di­a­betes in preg­nan­cy in­clude spon­ta­neous abor­tion, fetal anoma­lies, preeclamp­sia, fetal demise, macro­so­mia, neona­tal hy­po­glycemia, and neona­tal hy­per­biliru­bine­mia, among oth­ers. In ad­di­tion, di­a­betes in preg­nan­cy may in­crease the risk of obe­si­ty and type 2 di­a­betes in off­spring later in life (1,2).

Sug­gest­ed ci­ta­tion: Amer­i­can Di­a­betes As­so­ci­a­tion. 14. Man­age­ment of di­a­betes in preg­nan­cy: Stan­dards of Med­i­cal Care in Di­a­betesd2019. Di­a­betes Care 2019;42(Suppl. 1):S165–S172 © 2018 by the Amer­i­can Di­a­betes As­so­ci­a­tion. Read­ers may use this ar­ti­cle as long as the work is prop­er­ly cited, the use is ed­u­ca­tion­al and not for prof­it, and the work is not al­tered. More in­for­ma­tion is avail­able at http://www.di­a­betesjournals .org/‍content/‍license.

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2.0.0.0 PRE­CON­CEP­TION COUN­SEL­ING

2.1.0.0 Rec­om­men­da­tions

All women of child­bear­ing age with di­a­betes should be coun­seled about the im­por­tance of tight glycemic con­trol prior to con­cep­tion. Ob­ser­va­tion­al stud­ies show an in­creased risk of di­a­bet­ic em­bry­opa­thy, es­pe­cial­ly anen­cephaly, mi­cro­cephaly, con­gen­i­tal heart dis­ease, and cau­dal re­gres­sion, di­rect­ly pro­por­tion­al to el­e­va­tions in A1C dur­ing the first 10 weeks of preg­nan­cy (3). Al­though ob­ser­va­tion­al stud­ies are con­found­ed by the as­so­ci­a­tion be­tween el­e­vat­ed pericon­cep­tional A1C and other poor self-‍care be­hav­iors, the quan­ti­ty and con­sis­ten­cy of data are con­vinc­ing and sup­port the rec­om­men­da­tion to op­ti­mize glycemic con­trol prior to con­cep­tion, with A1C <6.5% (48 mmol/‍mol) as­so­ci­at­ed with the low­est risk of con­gen­i­tal anoma­lies (3-6).

There are op­por­tu­ni­ties to ed­u­cate all women and ado­les­cents of re­pro­duc­tive age with di­a­betes about the risks of un­planned preg­nan­cies and im­proved ma­ter­nal and fetal out­comes with preg­nan­cy plan­ning (7). Ef­fec­tive pre­con­cep­tion coun­sel­ing could avert sub­stan­tial health and as­so­ci­at­ed cost bur­dens in off­spring (8). Fam­i­ly plan­ning should be dis­cussed, and ef­fec­tive con­tra­cep­tion should be pre­scribed and used until a woman is pre­pared and ready to be­come preg­nant.

To min­i­mize the oc­cur­rence of com­pli­ca­tions, be­gin­ning at the onset of pu­ber­ty or at di­ag­no­sis, all girls and women with di­a­betes of child­bear­ing po­ten­tial should re­ceive ed­u­ca­tion about 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. Pre­con­cep­tion coun­sel­ing using de­vel­op­men­tal­ly ap­pro­pri­ate ed­u­ca­tion­al tools en­ables ado­les­cent girls to make well-‍in­formed de­ci­sions (7). Pre­con­cep­tion coun­sel­ing re­sources tai­lored for ado­les­cents are avail­able at no cost through the Amer­i­can Di­a­betes As­so­ci­a­tion (ADA) (9).

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2.2.0.0 Pre­con­cep­tion Care

Pre­con­cep­tion vis­its should in­clude rubel­la, syphilis, hep­ati­tis B virus, and HIV test­ing, as well as Pap test, cer­vi­cal cul­tures, blood typ­ing, pre­scrip­tion of pre­na­tal vi­ta­mins (with at least 400 mg of folic acid), and smok­ing ces­sa­tion coun­sel­ing if in­di­cat­ed. Di­a­betes-‍specific test­ing should in­clude A1C, thy­roid­stim­u­lat­ing hor­mone, cre­a­ti­nine, and uri­nary albumin-to-cre­a­ti­nine ratio; re­view of the med­i­ca­tion list for po­ten­tially ter­ato­genic drugs, i.e., ACE in­hibitors (10), an­giotensin re­cep­tor block­ers (10), and statins (11,12); and re­fer­ral for a com­pre­hen­sive eye exam. Women with pre­ex­ist­ing di­a­bet­ic retinopa­thy will need close mon­i­tor­ing dur­ing preg­nan­cy to en­sure that retinopa­thy does not progress (13). Pre­con­cep­tion coun­sel­ing should in­clude an ex­pla­na­tion of the risks to moth­er and fetus re­lat­ed to preg­nan­cy and the ways to re­duce risk and in­clude glycemic goal set­ting, lifestyle man­age­ment, and med­i­cal nu­tri­tion ther­apy.

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 (14-16). One study showed that care of pre­ex­ist­ing di­a­betes in clin­ics that in­cluded di­a­betes and ob­stet­ric spe­cial­ists im­proved care (17). 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 (18).

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3.0.0.0 GLYCEMIC TAR­GETS IN PREG­NAN­CY

3.1.0.0 Rec­om­men­da­tions

Preg­nan­cy in women with nor­mal glu­cose metabolism is char­ac­ter­ized by fast­ing lev­els of blood glu­cose that are lower than in the nonpreg­nant state due to in­sulin-‍in­de­pen­dent glu­cose up­take by the fetus and pla­cen­ta and by post­pran­di­al hy­per­glycemia and car­bo­hy­drate in­tol­er­ance as a re­sult of di­a­beto­genic pla­cen­tal hor­mones. In pa­tients with pre­ex­ist­ing di­a­betes, glycemic tar­gets are usu­al­ly achieved through a com­bi­na­tion of in­sulin ad­min­is­tra­tion and med­i­cal nu­tri­tion ther­apy. 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. Re­fer­ral to a reg­is­tered di­eti­tian is im­por­tant in order to es­tab­lish a food plan and in­sulin-tocar­bo­hy­drate ratio and to de­ter­mine weight gain goals.

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3.2.0.0 In­sulin Phys­i­ol­o­gy

Early preg­nan­cy is a time of en­hanced in­sulin sen­si­tiv­i­ty, lower glu­cose lev­els, and lower in­sulin re­quire­ments in women with type 1 di­a­betes. 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. 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. How­ev­er, in women with GDM or pre­ex­ist­ing di­a­betes, hy­per­glycemia oc­curs if treat­ment is not ad­just­ed ap­pro­pri­ately.

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3.3.0.0 Glu­cose Mon­i­tor­ing

Reflect­ing this phys­i­ol­o­gy, fast­ing and post­pran­di­al mon­i­tor­ing of blood glu­cose is rec­om­mend­ed to achieve metabol­ic con­trol in preg­nant women with di­a­betes. Prepran­di­al test­ing is also rec­om­mend­ed for women with pre­ex­ist­ing di­a­betes using in­sulin pumps or basal-‍bolus ther­apy, so that pre­meal rap­i­dact­ing in­sulin dosage can be ad­just­ed. Post­pran­di­al mon­i­tor­ing is as­so­ci­at­ed with bet­ter glycemic con­trol and lower risk of preeclamp­sia (19-21). There are no ad­e­quate­ly pow­ered ran­dom­ized tri­als com­par­ing dif­fer­ent fast­ing and post­meal glycemic tar­gets in di­a­betes in preg­nan­cy.

Sim­i­lar to the tar­gets rec­om­mend­ed by the Amer­i­can Col­lege of Ob­ste­tri­cians and Gy­ne­col­o­gists (the same as for GDM; de­scribed below) (22), the ADA-‍rec­om­mend­ed tar­gets for women with type 1 or type 2 di­a­betes 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)

These val­ues rep­re­sent op­ti­mal con­trol if they can be achieved safe­ly. 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.

If women can­not achieve these tar­gets with­out significant hy­po­glycemia, the ADA sug­gests less strin­gent tar­gets based on clin­i­cal ex­pe­ri­ence and in­di­vid­u­al­iza­tion of care.

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3.4.0.0 A1C in Preg­nan­cy

In stud­ies of women with­out pre­ex­ist­ing di­a­betes, in­creas­ing A1C lev­els with­in the nor­mal range is as­so­ci­at­ed with ad­verse out­comes (23). In the Hy­per­glycemia and Ad­verse Preg­nan­cy Out­come (HAPO) study, in­creas­ing lev­els of glycemia were as­so­ci­at­ed with wors­en­ing out­comes (24). Ob­ser­va­tion­al stud­ies in pre­ex­ist­ing di­a­betes and preg­nan­cy show the low­est rates of ad­verse fetal out­comes in as­so­ci­a­tion with A1C <6–6.5% (42–48 mmol/‍mol) early in ges­ta­tion (4–6,25). 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). Due to phys­i­o­log­i­cal in­creases in red blood cell turnover, A1C lev­els fall dur­ing nor­mal preg­nan­cy (26,27). Ad­di­tion­al­ly, as A1C rep­re­sents an in­te­grat­ed mea­sure of glu­cose, it may not fully cap­ture post­pran­di­al hy­per­glycemia, which drives macro­so­mia. Thus, al­though A1C may be use­ful, it should be used as a sec­ondary mea­sure of glycemic con­trol in preg­nan­cy, after self-‍mon­i­tor­ing of blood glu­cose.

In the sec­ond and third trimesters, A1C <6% (42 mmol/‍mol) has the low­est risk of large-for-ges­ta­tion­al-age in­fants (25,28,29), preterm de­liv­ery (30), and preeclamp­sia (1,31). Tak­ing all of this into ac­count, a tar­get of <6% (42 mmol/‍mol) is op­ti­mal dur­ing preg­nan­cy if it can be achieved with­out signifi- cant hy­po­glycemia. 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 (32). 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).

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4.0.0.0 Mgmt. of Ges­ta­tion­al Di­a­betes Mel­li­tus

4.1.0.0 Rec­om­men­da­tions

GDM is char­ac­ter­ized by in­creased risk of macro­so­mia and birth com­pli­ca­tions and an in­creased risk of ma­ter­nal type 2 di­a­betes after preg­nan­cy. The as­so­ci­a­tion of macro­so­mia and birth com­pli­ca­tions with oral glu­cose tol­er­ance test (OGTT) re­sults is con­tin­u­ous with no clear inflec­tion points (24). In other words, risks in­crease with pro­gres­sive hy­per­glycemia. There­fore, all women should be test­ed as out­lined in Sec­tion 2 “Clas­sification and Di­ag­no­sis of Di­a­betes.” Al­though there is some het­ero­gene­ity, many ran­dom­ized con­trolled tri­als (RCTs) sug­gest that the risk of GDM may be re­duced by diet, ex­er­cise, and life-‍style coun­sel­ing, par­tic­u­larly when in­ter­ven­tions are start­ed dur­ing the first or early in the sec­ond trimester (33-35).

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4.2.0.0 Lifestyle Man­age­ment

After di­ag­no­sis, treat­ment starts with med­i­cal nu­tri­tion ther­apy, phys­i­cal ac­tiv­i­ty, and weight man­age­ment de­pend­ing on preges­ta­tion­al weight, as out­lined in the sec­tion below on pre­ex­ist­ing type 2 di­a­betes, and glu­cose mon­i­tor­ing aim­ing for the tar­gets rec­om­mend­ed by the Fifth In­ter­na­tion­al Work­shop-‍Con­fer­ence on Ges­ta­tion­al Di­a­betes Mel­li­tus (36):

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)

De­pend­ing on the pop­u­la­tion, stud­ies sug­gest that 70–85% of women di­ag­nosed with GDM under Car­pen­ter-‍ Cous­tan or Na­tion­al Di­a­betes Data Group (NDDG) cri­te­ria can con­trol GDM with lifestyle modification alone; it is an­tic­i­pat­ed that this pro­por­tion will be even high­er if the lower In­ter­na­tion­al As­so­ci­a­tion of Di­a­betes and Preg­nan­cy Study Groups (IADPSG) (37) di­ag­nos­tic thresh­olds are used.

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4.3.0.0 Med­i­cal Nu­tri­tion Ther­a­py

Med­i­cal nu­tri­tion ther­apy for GDM is an in­di­vid­u­al­ized nu­tri­tion plan de­vel­oped be­tween the woman and a reg­is­tered di­eti­tian fa­mil­iar with the man­age­ment of GDM (38,39). The food plan should pro­vide ad­e­quate calo­rie in­take to pro­mote fetal/neona­tal and ma­ter­nal health, achieve glycemic goals, and pro­mote ap­pro­pri­ate ges­ta­tion­al weight gain. There is no defini­tive re­search that iden­tifies a specific op­ti­mal calo­rie in­take for women with GDM or sug­gests that their calo­rie needs are dif­fer­ent from those of preg­nant women with­out GDM. The food plan should be based on a nu­tri­tion as­sess­ment with guid­ance from the Di­etary Ref­er­ence In­takes (DRI). 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. As is true for all nu­tri­tion ther­apy in pa­tients with di­a­betes, the amount and type of car­bo­hy­drate will im­pact glu­cose lev­els, es­pe­cial­ly post­meal ex­cur­sions.

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4.4.0.0 Phar­ma­co­log­ic Ther­a­py

4.4.1.0 Overview

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 (40). In­sulin is the first-‍line agent rec­om­mend­ed for treat­ment of GDM in the U.S. While in­di­vid­u­al RCTs sup­port lim­it­ed efficacy of met­formin (41,42) and gly­buride (43) 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 safe­ty for off­spring is lack­ing (22). Fur­ther­more, in two RCTs, gly­buride and met­formin failed to pro­vide ad­e­quate glycemic con­trol in 23% and 25– 28%, re­spec­tive­ly (44,45), of women with GDM.

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4.4.2.0 Sul­fony­lureas

Sul­fony­lureas are known to cross the pla­cen­ta and have been as­so­ci­at­ed with in­creased neona­tal hy­po­glycemia. Con­cen­tra­tions of gly­buride in um­bil­i­cal cord plas­ma are ap­prox­i­mate­ly 70% of ma­ter­nal lev­els (44,45). Gly­buride was as­so­ci­at­ed with a high­er rate of neona­tal hy­po­glycemia and macro­so­mia than in­sulin or met­formin in a 2015 meta­anal­y­sis and sys­tematic re­view (46). More re­cent­ly, gly­buride failed to be found non­in­fe­ri­or to in­sulin based on a com­pos­ite out­come of neona­tal hy­po­glycemia, macro­so­mia, and hy­per­biliru­bine­mia. Long-‍term safe­ty data for off­spring are not avail­able (47,48).

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4.4.3.0 Met­formin

Met­formin was as­so­ci­at­ed with a lower risk of neona­tal hy­po­glycemia and less ma­ter­nal weight gain than in­sulin in sys­tematic re­views (46,49,50); how­ev­er, met­formin may slight­ly in­crease the risk of pre­ma­tu­ri­ty. Like gly­buride, met­formin cross­es the pla­cen­ta, and um­bil­i­cal cord blood lev­els of met­formin are high­er than si­mul­ta­ne­ous ma­ter­nal lev­els (51,52). In the Met­formin in Ges­ta­tion­al Di­a­betes: The Off­spring Fol­low-‍Up (MiG TOFU) study’s anal­y­ses of 7- to 9-‍year-‍old off­spring, 9-‍year-‍old off­spring ex­posed to met­formin for the treat­ment of GDM were larg­er (based on a num­ber of mea­surements) than those ex­posed to in­sulin (53). 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 (53,54). Fur­ther study of long-‍term out­comes in the off­spring is need­ed (53,54).

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 (55), and there is no ev­i­dence-‍based need to con­tin­ue met­formin in such pa­tients once preg­nan­cy has been con- firmed (56-58).

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4.4.4.0 In­sulin

In­sulin use should fol­low the guide­lines below. Both mul­ti­ple daily in­sulin injec­tions and con­tin­u­ous sub­cu­ta­neous in­sulin in­fu­sion are rea­son­able de­liv­ery strate­gies, and nei­ther has been shown to be su­pe­ri­or dur­ing preg­nan­cy (59).

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5.0.0.0 Preexis­ting T1D & T2D Mgmt.

5.1.0.0 In­sulin Use

The phys­i­ol­o­gy of preg­nan­cy ne­ces­si­tates fre­quent titra­tion of in­sulin to match chang­ing re­quire­ments and un­der­scores the im­por­tance of daily and fre­quent self-‍mon­i­tor­ing of blood glu­cose. Early in the first trimester, there is an in­crease in in­sulin re­quire­ments, fol­lowed by a de­crease in weeks 9 through 16 (60). Women, par­tic­u­larly those with type 1 di­a­betes, may ex­pe­ri­ence in­creased hy­po­glycemia. After 16 weeks, rapid­ly in­creas­ing in­sulin re­sis­tance re­quires week­ly in­creases in in­sulin dose of about 5% per week to achieve glycemic tar­gets. There is rough­ly a dou­bling of in­sulin re­quire­ments by the late third trimester. In gen­er­al, a small­er pro­por­tion of the total daily dose should be given as basal in­sulin (<50%) and a greater pro­por­tion (>50%) as pran­di­al in­sulin. Late in the third trimester, there is often a lev­el­ing off or small de­crease in in­sulin re­quire­ments. Due to the com­plex­i­ty of in­sulin man­age­ment in preg­nan­cy, re­fer­ral to a spe­cial­ized cen­ter of­fer­ing team-‍based care (with team mem­bers in­clud­ing ma­ter­nal-‍fetal medicine spe­cial­ist, en­docri­nol­o­gist, or other pro­vider ex­pe­ri­enced in man­ag­ing preg­nan­cy in women with pre­ex­ist­ing di­a­betes, di­eti­tian, nurse, and so­cial work­er, as need­ed) is rec­om­mend­ed if this re­source is avail­able.

None of the cur­rently avail­able human in­sulin prepa­ra­tions have been demon­strat­ed to cross the pla­cen­ta (61-66).

A re­cent Cochrane sys­tematic re­view was not able to rec­om­mend any specific in­sulin reg­i­men over an­oth­er for the treat­ment of di­a­betes in preg­nan­cy (67).

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5.2.0.0 Preeclamp­sia and As­pirin

Di­a­betes in preg­nan­cy is as­so­ci­at­ed with an in­creased risk of preeclamp­sia (68). 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 (69). A cost-‍benefit anal­y­sis has con­clud­ed that this ap­proach would re­duce mor­bid­i­ty, save lives, and lower health care costs (70).

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5.3.0.0 Type 1 Di­a­betes

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. 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. In­sulin re­sis­tance drops rapid­ly with de­liv­ery of the pla­cen­ta. Women be­come very in­sulin sen­si­tive im­me­di­ate­ly fol­lowing de­liv­ery and may ini­tial­ly re­quire much less in­sulin than in the prepar­tum pe­ri­od.

Preg­nan­cy is a ke­to­genic state, and women with type 1 di­a­betes, and to a less­er ex­tent those with type 2 di­a­betes, are at risk for di­a­bet­ic ke­toaci­do­sis at lower blood glu­cose lev­els than in the nonpreg­nant state. Women with pre­ex­ist­ing di­a­betes, es­pe­cial­ly type 1 di­a­betes, need ke­tone strips at home and ed­u­ca­tion on di­a­bet­ic ke­toaci­do­sis pre­vention and detec­tion. In ad­di­tion, rapid im­ple­men­ta­tion of tight glycemic con­trol in the set­ting of retinopa­thy is as­so­ci­at­ed with wors­en­ing of retinopa­thy (13).

The role of con­tin­u­ous glu­cose mon­i­tor­ing in preg­nan­cies im­pacted by di­a­betes is still being stud­ied. In one RCT, con­tin­u­ous glu­cose mon­i­tor­ing use in preg­nan­cies com­pli­cat­ed by type 1 di­a­betes showed im­proved neona­tal out­comes and a slight re­duc­tion in A1C, but in­ter­est­ing­ly no dif­fer­ence in se­vere hy­po­glycemic events com­pared with con­trol sub­jects (71).

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5.4.0.0 Type 2 Di­a­betes

Type 2 di­a­betes is often as­so­ci­at­ed with obe­si­ty. Rec­om­mend­ed weight gain dur­ing preg­nan­cy for over­weight women is 15–25 lb and for obese women is 10–20 lb (72). 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. As in type 1 di­a­betes, in­sulin re­quire­ments drop dra­mat­i­cal­ly after de­liv­ery. The risk for as­so­ci­at­ed hy­per­ten­sion and other co­mor­bidi­ties may be as high or high­er with type 2 di­a­betes as with type 1 di­a­betes, even if di­a­betes is bet­ter con­trolled and of short­er ap­par­ent du­ra­tion, with preg­nan­cy loss ap­pear­ing to be more preva­lent in the third trimester in women with type 2 di­a­betes com­pared with the first trimester in women with type 1 di­a­betes (73,74).

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6.0.0.0 PREG­NAN­CY AND DRUG CON­SID­ER­A­TIONS

In nor­mal preg­nan­cy, blood pres­sure is lower than in the nonpreg­nant state. In a preg­nan­cy com­pli­cat­ed by di­a­betes and chron­ic hy­per­ten­sion, tar­get goals for sys­tolic blood pres­sure 120–160 mmHg and di­as­tolic blood pres­sure 80–105 mmHg are rea­son­able (75). Lower blood pres­sure lev­els may be as­so­ci­at­ed with im­paired fetal growth. 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 (76).

Dur­ing preg­nan­cy, treat­ment with ACE in­hibitors and an­giotensin re­cep­tor block­ers is contrain­di­cat­ed be­cause they may cause fetal renal dys­pla­sia, oligo­hy­dram­nios, and in­trauter­ine growth re­stric­tion (10). An­ti­hy­per­ten­sive drugs known to be ef­fec­tive and safe in preg­nan­cy in­clude methyl­dopa, nifedip­ine, la­betalol, dil­ti­azem, cloni­dine, and pra­zosin. Atenolol is not rec­om­mend­ed. Chron­ic di­uret­ic use dur­ing preg­nan­cy is not rec­om­mend­ed as it has been as­so­ci­at­ed with re­strict­ed ma­ter­nal plas­ma vol­ume, which may re­duce uteropla­cen­tal per­fu­sion (77). On the basis of avail­able ev­i­dence, statins should also be avoid­ed in preg­nan­cy (78).

Please see PREG­NAN­CY AND AN­TI­HY­PER­TEN­SIVE MED­I­CA­TIONS in Sec­tion 10 “Car­dio­vas­cu­lar Dis­ease and Risk Man­age­ment” for more in­for­ma­tion on man­ag­ing blood pres­sure in preg­nan­cy.

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7.0.0.0 POST­PAR­TUM CARE

7.1.0.0 Lac­ta­tion

Post­par­tum care should in­clude psychoso­cial as­sess­ment and sup­port for self-‍care.

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. Breast­feed­ing may also con­fer longer-‍term metabol­ic benefits to both moth­er (79) and off­spring (80).

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7.2.0.0 Ges­ta­tion­al Di­a­betes Mel­li­tus

7.2.1.0 Ini­tial Test­ing

Be­cause GDM may rep­re­sent pre­ex­ist­ing undi­ag­nosed type 2 or even type 1 di­a­betes, women with GDM should be test­ed for per­sis­tent di­a­betes or predi­a­betes at 4–12 weeks post­par­tum with a 75-g OGTT using nonpreg­nan­cy cri­te­ria as out­lined in Sec­tion 2 “Clas­sification and Di­ag­no­sis of Di­a­betes.”

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7.2.2.0 Post­par­tum Fol­low-‍up

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. Re­pro­duc­tive-‍aged women with predi­a­betes may de­vel­op type 2 di­a­betes by the time of their next preg­nan­cy and will need pre­con­cep­tion eval­u­a­tion. Be­cause GDM is as­so­ci­at­ed with an in­creased life-‍time ma­ter­nal risk for di­a­betes es­ti­mat­ed at 50–70% after 15–25 years (81,82), women should also be test­ed every 1–3 years there­after if the 4- to 12-week post­par­tum 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. On­go­ing eval­u­a­tion may be per­formed with any rec­om­mend­ed glycemic test (e.g., A1C, fast­ing plas­ma glu­cose, or 75-g OGTT using nonpreg­nant thresh­olds).

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7.3.0.0 Ges­ta­tion­al Di­a­betes Mel­li­tus & T2D

Women with a his­to­ry of GDM have a great­ly in­creased risk of con­ver­sion to type 2 di­a­betes over time (81). In the prospec­tive Nurs­es’ Health Study II (NHS II), sub­se­quent di­a­betes risk after a his­to­ry of GDM was significant­ly lower in women who fol­lowed healthy eat­ing pat­terns (83). Ad­just­ing for BMI mod­er­ate­ly, but not com­plete­ly, at­ten­u­at­ed this as­so­ci­a­tion. Interpreg­nan­cy or post­par­tum weight gain is as­so­ci­at­ed with in­creased risk of ad­verse preg­nan­cy out­comes in sub­se­quent preg­nan­cies (84) and ear­li­er pro­gres­sion to type 2 di­a­betes.

Both met­formin and in­ten­sive lifestyle in­ter­ven­tion pre­vent or delay pro­gres­sion to di­a­betes in women with predi­a­betes and a his­to­ry of GDM. 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 (85). In these women, lifestyle in­ter­ven­tion and met­formin re­duced pro­gres­sion to di­a­betes by 35% and 40%, re­spec­tive­ly, over 10 years com­pared with place­bo (86). 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.

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7.4.0.0 Preexis­ting Type 1 and Type 2 Di­a­betes

In­sulin sen­si­tiv­i­ty in­creases dra­mat­i­cal­ly with de­liv­ery of the pla­cen­ta. Thus, in­sulin re­quire­ments in the im­me­di­ate post­par­tum pe­ri­od are rough­ly 34% lower than prepreg­nan­cy in­sulin re­quire­ments (87). In­sulin sen­si­tiv­i­ty then re­turns to prepreg­nan­cy lev­els over the fol­lowing 1–2 weeks. In women tak­ing in­sulin, par­tic­u­lar at­ten­tion should be di­rect­ed to hy­po­glycemia pre­vention in the set­ting of breast­feed­ing and er­rat­ic sleep and eat­ing sched­ules (88).

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7.5.0.0 Con­tra­cep­tion

A major bar­ri­er to ef­fec­tive pre­con­cep­tion care is the fact that the ma­jor­i­ty of preg­nan­cies are un­planned. 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. There­fore, all women with di­a­betes of child­bear­ing po­ten­tial should have fam­i­ly plan­ning op­tions re­viewed at reg­u­lar in­ter­vals. This ap­plies to women in the im­me­di­ate post­par­tum pe­ri­od. Women with di­a­betes have the same con­tra­cep­tion op­tions and rec­om­men­da­tions as those with­out di­a­betes. The risk of an un­planned preg­nan­cy out­weighs the risk of any given con­tra­cep­tion option.

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8.0.0.0 Ref­er­ences

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