14.13 Lifestyle behavior change is an essential component of management of gestational diabetes mellitus and may suffice for the treatment of many women. 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. Gestational Diabetes | ADA Simple carbohydrates will result in higher postmeal excursions. 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, 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. Introduction: Gestational diabetes mellitus (GDM) is a major public health problem, affecting about one in every six pregnancies globally. More information is available at, This site uses cookies. 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). The international consensus on time in range (50) endorses pregnancy target ranges and goals for TIR for patients with type 1 diabetes using CGM as reported on the ambulatory glucose profile; however, it does not specify the type or accuracy of the device or need for alarms and alerts. A, 14.2 Family planning should be discussed, and effective contraception (with consideration of long-acting, reversible contraception) should be prescribed and used until a woman's treatment regimen and A1C are optimized for pregnancy. Accessed 21 June 2020. Therefore, all women should be tested as outlined in Section 2 Classification and Diagnosis of Diabetes (https://doi.org/10.2337/dc21-S002). Furthermore, glyburide and metformin failed to provide adequate glycemic control in separate RCTs in 23% and 2528% of women with GDM, respectively (63,64). 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). 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 (90). 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. B, 14.24 Women with a history of gestational diabetes mellitus found to have prediabetes should receive intensive lifestyle interventions and/or metformin to prevent diabetes. As in type 1 diabetes, insulin requirements drop dramatically after delivery. Preconception counseling using developmentally appropriate educational tools enables adolescent girls to make well-informed decisions (9). A. GDM is characterized by increased risk of large-for-gestational-age birth weight and neonatal and pregnancy complications and an increased risk of long-term maternal type 2 diabetes and offspring abnormal glucose metabolism in childhood. On the basis of available evidence, statins should also be avoided in pregnancy (106). In the absence of unequivocal hyperglycemia, a positive screen for diabetes requires two abnormal values. Depending on the population, studies suggest that 7085% of women diagnosed with GDM under Carpenter-Coustan criteria can control GDM with lifestyle modification alone; it is anticipated that this proportion will be even higher if the lower International Association of the Diabetes and Pregnancy Study Groups (59) diagnostic thresholds are used. 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. A. Given that early pregnancy is a time of enhanced insulin sensitivity and lower glucose levels, many women with type 1 diabetes will have lower insulin requirements and increased risk for hypoglycemia (29). E, 14.6 Women with preexisting type 1 or type 2 diabetes who are planning pregnancy or who have become pregnant should be counseled on the risk of development and/or progression of diabetic retinopathy. 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. Metformin was associated with a lower risk of neonatal hypoglycemia and less maternal weight gain than insulin in systematic reviews (72,7577). More than 122 million Americans have diabetes or prediabetes and are striving to manage their lives while living with the disease. 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. C, 14.22 A contraceptive plan should be discussed and implemented with all women with diabetes of reproductive potential. 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 (114116). 190: Gestational diabetes mellitus. A major barrier to effective preconception care is the fact that the majority of pregnancies are unplanned. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC. 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). 14.14 Insulin is the preferred medication for treating hyperglycemia in gestational diabetes mellitus. An RCT of metformin added to insulin for the treatment of type 2 diabetes found less maternal weight gain and fewer cesarean births. 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. It doesn't mean that you had diabetes before you conceived or that you will have diabetes after you give birth. There was no difference in pregnancy loss, neonatal care, or other neonatal outcomes between the groups with tighter versus less tight control of hypertension (104). The committee is a multidisciplinary team of 16 leading U.S. experts in the field of diabetes care and includes physicians, diabetes care and education specialists, registered dietitians, and others with experience in adult and pediatric endocrinology, epidemiology, public health, cardiovascular risk management, microvascular complications, preconception and pregnancy care, weight management and diabetes prevention, and use of technology in diabetes management. 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, 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. 2451 Crystal Drive, Suite 900 Arlington, VA 22202. The purposes of this document are to provide a brief overview of the understanding of GDM, review management guidelines that have been validated by appropriately conducted clinical research, and identify gaps in current knowledge toward which future research can be directed. In studies of women without preexisting diabetes, increasing A1C levels within the normal range are associated with adverse outcomes (36). 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. 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, as well as glucose monitoring aiming for the targets recommended by the Fifth International Workshop-Conference on Gestational Diabetes Mellitus (54): Fasting glucose <95 mg/dL (5.3 mmol/L) and either, One-hour postprandial glucose <140 mg/dL (7.8 mmol/L) or, Two-hour postprandial glucose <120 mg/dL (6.7 mmol/L). 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. As a world leader in diabetes care, the ADA is proud to set the standards!, said Boris Draznin, MD, PhD, Chair of the Professional Practice Committee. Accessed 17 October 2021. In the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study, increasing levels of glycemia were also associated with worsening outcomes (37). Diabetes | American Dental Association On the basis of available evidence, statins should also be avoided in pregnancy (118). 2021 Updates to the ADA Standards of Care - diaTribe However, metformin readily crosses the placenta, resulting in umbilical cord blood levels of metformin as high or higher than simultaneous maternal levels (70,71). 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 risk of an unplanned pregnancy outweighs the risk of any given contraception option. . Practice Guidelines Resources | American Diabetes Association 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). 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). Associations of mid-pregnancy HbA1c with gestational diabetes and risk of adverse pregnancy outcomes in high-risk Taiwanese women, Hyperglycemia and adverse pregnancy outcomes, Glycemic targets in the second and third trimester of pregnancy for women with type 1 diabetes, Reference intervals for hemoglobin A1c in pregnant women: data from an Italian multicenter study, Fetal growth is increased by maternal type 1 diabetes and HLA DR4-related gene interactions, Risk of macrosomia remains glucose-dependent in a cohort of women with pregestational type 1 diabetes and good glycemic control, Impact of type 2 diabetes, obesity and glycaemic control on pregnancy outcomes, Glycaemic control throughout pregnancy and risk of pre-eclampsia in women with type I diabetes, Relationship of fetal macrosomia to maternal postprandial glucose control during pregnancy, Continuous glucose monitoring in pregnant women with type 1 diabetes (CONCEPTT): a multicentre international randomised controlled trial, Continuous glucose monitoring in pregnant women with type 1 diabetes: an observational cohort study of 186 pregnancies, Clinical targets for continuous glucose monitoring data interpretation: recommendations from the international consensus on time in range, HAPO Follow-up Study Cooperative Research Group, HAPO Follow-Up Study Cooperative Research Group, Hyperglycemia and Adverse Pregnancy Outcome Follow-up Study (HAPO FUS): maternal glycemia and childhood glucose metabolism, Hyperglycemia and Adverse Pregnancy Outcome Follow-up Study (HAPO FUS): maternal gestational diabetes mellitus and childhood glucose metabolism, Gestational diabetes mellitus can be prevented by lifestyle intervention: the Finnish Gestational Diabetes Prevention Study (RADIEL): a randomized controlled trial, A randomized clinical trial of exercise during pregnancy to prevent gestational diabetes mellitus and improve pregnancy outcome in overweight and obese pregnant women, Summary and recommendations of the Fifth International Workshop-Conference on Gestational Diabetes Mellitus, The impact of adoption of the International Association of Diabetes In Pregnancy Study Group criteria for the screening and diagnosis of gestational diabetes, Different types of dietary advice for women with gestational diabetes mellitus, Dietary intervention in patients with gestational diabetes mellitus: a systematic review and meta-analysis of randomized clinical trials on maternal and newborn outcomes, Institute of Medicine and National Research Council, Weight Gain During Pregnancy: Reexamining the Guidelines, Benefits and harms of treating gestational diabetes mellitus: a systematic review and meta-analysis for the U.S. Preventive Services Task Force and the National Institutes of Health Office of Medical Applications of Research, Metformin versus insulin for the treatment of gestational diabetes, Metformin vs insulin in the management of gestational diabetes: a meta-analysis, A comparison of glyburide and insulin in women with gestational diabetes mellitus, Obstetric-Fetal Pharmacology Research Unit Network, Are we optimizing gestational diabetes treatment with glyburide?
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