ada gestational diabetes guidelines 2021

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 (DKA) at lower blood glucose levels than in the nonpregnant state. A, 15.3 Preconception counseling should address the importance of achieving glucose levels as close to normal as is safely possible, ideally A1C <6.5% (48 mmol/mol), to reduce the risk of congenital anomalies, preeclampsia, macrosomia, preterm birth, and other complications. 14.4 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. Accessed 21 June 2020. In normal pregnancy, blood pressure is lower than in the nonpregnant state. The prevalence of diabetes in pregnancy has been increasing in the U.S. in parallel with the worldwide epidemic of obesity. Periodontal disease is commonly seen in people with diabetes, 22-24 and is considered a complication of diabetes. One study showed that care of preexisting diabetes in clinics that included diabetes and obstetric specialists improved care (28). This difference was not found in the Adelaide cohort. 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. 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. 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. 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. 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. The guidelines provided by the American Diabetes Association (ADA) on diagnosis and management of hyperglycemia in pregnancy are widely followed. 14.19 In pregnant patients with diabetes and chronic hypertension, a blood pressure target of 110135/85 mmHg is suggested in the interest of reducing the risk for accelerated maternal hypertension A and minimizing impaired fetal growth. Moderate exercise is recommended by the American Diabetes Association (ADA): However, a meta-analysis and an additional trial demonstrate that low-dose aspirin <100 mg is not effective in reducing preeclampsia. A Insulin is the preferred agent for the management of type 2 diabetes in pregnancy. There are opportunities to educate all women and adolescents of reproductive age with diabetes about the risks of unplanned pregnancies and about improved maternal and fetal outcomes with pregnancy planning (9). 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. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. Due to physiological increases in red blood cell turnover, A1C levels fall during normal pregnancy (40,41). As is true for all nutrition therapy in patients with diabetes, the amount and type of carbohydrate will impact glucose levels. Reflecting this physiology, fasting and postprandial monitoring of blood glucose is recommended to achieve metabolic control in pregnant women with diabetes. Additionally, as A1C represents an integrated measure of glucose, it may not fully capture postprandial hyperglycemia, which drives macrosomia. Diabetes has brought us together. Women with diabetes have the same contraception options and recommendations as those without diabetes. Gestational Diabetes | CDC There was heterogeneity in the types of effective exercise (aerobic, resistance, or both) and duration of exercise (2050 min/day, 27 days/week of moderate intensity) (65). Women with preexisting diabetic retinopathy will need close monitoring during pregnancy to assess for progression of retinopathy and provide treatment if indicated (23). More recently, glyburide failed to be found noninferior to insulin based on a composite outcome of neonatal hypoglycemia, macrosomia, and hyperbilirubinemia (66). 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 (93,94). A Other oral and noninsulin injectable glucose-lowering medications lack long-term safety data. Search for other works by this author on: Intrauterine exposure to diabetes conveys risks for type 2 diabetes and obesity: a study of discordant sibships, 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, 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, Glycaemic control during early pregnancy and fetal malformations in women with type I diabetes mellitus, Maternal glycemic control in type 1 diabetes and the risk for preterm birth: a population-based cohort study, Systematic review and meta-analysis of the effectiveness of pre-pregnancy care for women with diabetes for improving maternal and perinatal outcomes, 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, Contraceptive use among women with prediabetes and diabetes in a US national sample, Description and comparison of postpartum use of effective contraception among women with and without diabetes, The intrauterine device in women with diabetes mellitus type i and ii: a systematic review, Long-acting reversible contraceptionhighly efficacious, safe, and underutilized, American College of Obstetricians and Gynecologists Committee on Practice BulletinsObstetrics, ACOG Practice Bulletin No. 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). . DKA, diabetic ketoacidosis; DVT/PE, deep vein thrombosis/pulmonary embolism; ECG, electrocardiogram; NAFLD, nonalcoholic fatty liver disease; PCOS, polycystic ovary syndrome; TSH, thyroid-stimulating hormone. A major barrier to effective preconception care is the fact that the majority of pregnancies are unplanned. B, 15.8 Due to increased red blood cell turnover, A1C is slightly lower in normal pregnancy than in normal nonpregnant women. Insulin should be added if needed to achieve glycemic targets. 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. More studies are needed to assess the long-term effects of prenatal aspirin exposure on offspring (101). Referral to an RD/RDN is important in order to establish a food plan and insulin-to-carbohydrate ratio and to determine weight gain goals. 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). Due to physiological increases in red blood cell turnover, A1C levels fall during normal pregnancy (39,40). In other words, short-term and long-term risks increase with progressive maternal hyperglycemia. 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. There are no data to support the use of TIR in women with type 2 diabetes or GDM. C. 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 mild postprandial hyperglycemia and carbohydrate intolerance as a result of diabetogenic placental hormones. Referral to an RD/RDN is important in order to establish a food plan and insulin-to-carbohydrate ratio and to determine weight gain goals. 762: Prepregnancy counseling, 2017 guidelines of the American Thyroid Association for the diagnosis and management of thyroid disease during pregnancy and the postpartum, Preconception health: changing the paradigm on well-woman health, Pregnancy outcome following exposure to angiotensin-converting enzyme inhibitors or angiotensin receptor antagonists: a systematic review, Angiotensin-converting enzyme inhibitors and the risk of congenital malformations, Prenatal exposure to HMG-CoA reductase inhibitors: effects on fetal and neonatal outcomes, Statins and congenital malformations: cohort study, National Institute of Child Health and Human Development Diabetes in Early Pregnancy Study, Metabolic control and progression of retinopathy. 112). 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. Women with type 1 diabetes should be prescribed ketone strips and receive education on DKA prevention and detection. Prescription of prenatal vitamins (with at least 400 g of folic acid and 150 g of potassium iodide [17]) is recommended prior to conception. 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. E, 15.12 Commonly used estimated A1C and glucose management indicator calculations should not be used in pregnancy as estimates of A1C. Lower limits do not apply to diet-controlled type 2 diabetes. These associations with maternal oral glucose tolerance test (OGTT) results are continuous with no clear inflection points (38,51). Women with type 1 diabetes should be prescribed ketone strips and receive education on DKA prevention and detection. . 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. Long-acting, reversable contraception may be ideal for many women. Members of the ADA P In the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study, increasing levels of glycemia were also associated with worsening outcomes (37). B. Glyburide was associated with a higher rate of neonatal hypoglycemia and macrosomia than insulin or metformin in a 2015 meta-analysis and systematic review (65). Insulin sensitivity then returns to prepregnancy levels over the following 12 weeks. Adjusting for BMI attenuated this association moderately, but not completely. 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). None of the currently available human insulin preparations have been demonstrated to cross the placenta (9095). An RCT of metformin added to insulin for the treatment of type 2 diabetes found less maternal weight gain and fewer cesarean births. 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. A review of current evidence, 2021 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. Insulin is the first-line agent recommended for treatment of GDM in the U.S. 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. Antihypertensive drugs known to be effective and safe in pregnancy include methyldopa, nifedipine, labetalol, diltiazem, clonidine, and prazosin. ADA Releases 2021 Standards of Medical Care in Diabetes Centered on 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 1) the risks of malformations associated with unplanned pregnancies and even mild hyperglycemia and 2) the use of effective contraception at all times when preventing a pregnancy. . 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. Chronic diuretic use during pregnancy is not recommended as it has been associated with restricted maternal plasma volume, which may reduce uteroplacental perfusion (105). Simple carbohydrates will result in higher postmeal excursions. Furthermore, glyburide and metformin failed to provide adequate glycemic control in separate RCTs in 23% and 2528% of women with GDM, respectively (63,64). Glycemic target lower limits defined above for preexisting diabetes apply for GDM that is treated with insulin. 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 studies of women without preexisting diabetes, increasing A1C levels within the normal range are associated with adverse outcomes (37). women with prior gestational diabetes. 15.1 Starting at puberty and continuing in all women with diabetes and reproductive potential, preconception counseling should be incorporated into routine diabetes care. Sulfonylureas are known to cross the placenta and have been associated with increased neonatal hypoglycemia. Counseling on diabetes in pregnancy per current standards, including: natural history of insulin resistance in pregnancy and postpartum; preconception glycemic targets; avoidance of DKA/severe hyperglycemia; avoidance of severe hypoglycemia; progression of retinopathy; PCOS (if applicable); fertility in patients with diabetes; genetics of diabetes; risks to pregnancy including miscarriage, still birth, congenital malformations, macrosomia, preterm labor and delivery, hypertensive disorders in pregnancy, etc. Gestational diabetes can be a scary diagnosis, but like other forms of diabetes, it's one that you can manage. Although there is some heterogeneity, many RCTs and a Cochrane review 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 (5355). 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). 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). Patterns of glycemia in normal pregnancy: should the current therapeutic targets be challenged? The ADA also publishes the abridgedStandards of Care yearly for primary care providers in its journal, Clinical Diabetes, and offers a convenient Standards of Care appas well as a Standards of Care pocket chart. 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 (74,75). E, 14.17 Either multiple daily injections or insulin pump technology can be used in pregnancy complicated by type 1 diabetes. 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. As is true for all nutrition therapy in patients with diabetes, the amount and type of carbohydrate will impact glucose levels. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC. B, 14.9 When used in addition to pre- and postprandial self-monitoring of blood glucose, continuous glucose monitoring can help to achieve A1C targets in diabetes and pregnancy. 3/6/18, 3/12/2019, 3/9/2021.

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