Standards of Care in Diabetes - 2023

S254 Diabetes Care Volume 46, Supplement 1, January 2023
15. Management of Diabetes in Nuha A. ElSayed, Grazia Aleppo,

Vanita R. Aroda, Raveendhara R. Bannuru,
Pregnancy: Standards of Care in Florence M. Brown, Dennis Bruemmer,
Billy S. Collins, Marisa E. Hilliard,
Diabetes—2023 Diana Isaacs, Eric L. Johnson, Scott Kahan,
Kamlesh Khunti, Jose Leon, Sarah K. Lyons,
Diabetes Care 2023;46(Suppl. 1):S254–S266 | https://doi.org/10.2337/dc23-S015 Mary Lou Perry, Priya Prahalad,
Richard E. Pratley, Jane Jeffrie Seley,
Robert C. Stanton, and Robert A. Gabbay,
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on behalf of the American Diabetes
Association
15. MANAGEMENT OF DIABETES IN PREGNANCY
The American Diabetes Association (ADA) “Standards of Care in Diabetes” in-

cludes the ADA’s current clinical practice recommendations and is intended to
provide the components of diabetes care, general treatment goals and guide-
lines, and tools to evaluate quality of care. Members of the ADA Professional
Practice Committee, a multidisciplinary expert committee, are responsible for up-
dating the Standards of Care annually, or more frequently as warranted. For a de-
tailed description of ADA standards, statements, and reports, as well as the
evidence-grading system for ADA’s clinical practice recommendations and a full
list of Professional Practice Committee members, please refer to Introduction
and Methodology. 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. in parallel
with the worldwide epidemic of obesity. Not only is the prevalence of type 1 diabe-
tes and type 2 diabetes increasing in individuals of reproductive age, but there is
also a dramatic increase in the reported rates of gestational diabetes mellitus
(GDM). Diabetes confers significantly greater maternal and fetal risk largely related
to the degree of hyperglycemia but also related to chronic complications and co-
morbidities of diabetes. In general, specific risks of diabetes in pregnancy include
spontaneous abortion, fetal anomalies, preeclampsia, fetal demise, macrosomia,
neonatal hypoglycemia, hyperbilirubinemia, and neonatal respiratory distress syn-
drome, among others. In addition, diabetes in pregnancy may increase the risk of
obesity, hypertension, and type 2 diabetes in offspring later in life (1,2).
Preconception Counseling
Recommendations
15.1 Starting at puberty and continuing in all people with diabetes and re- Disclosure information for each author is
available at https://doi.org/10.2337/dc23-SDIS.
productive potential, preconception counseling should be incorporated
into routine diabetes care. A Suggested citation: ElSayed NA, Aleppo G, Aroda
VR, et al., American Diabetes Association. 15.
15.2 Family planning should be discussed, and effective contraception (with Management of diabetes in pregnancy: Standards
consideration of long-acting, reversible contraception) should be pre- of Care in Diabetes—2023. Diabetes Care 2023;
scribed and used until an individual’s treatment plan and A1C are opti- 46(Suppl. 1):S254–S266
mized for pregnancy. A © 2022 by the American Diabetes Association.
15.3 Preconception counseling should address the importance of achieving Readers may use this article as long as the
glucose levels as close to normal as is safely possible, ideally A1C work is properly cited, the use is educational
<6.5% (48 mmol/mol), to reduce the risk of congenital anomalies, pre- and not for profit, and the work is not altered.
eclampsia, macrosomia, preterm birth, and other complications. A More information is available at https://www.
diabetesjournals.org/journals/pages/license.
diabetesjournals.org/care Management of Diabetes in Pregnancy S255
All individuals with diabetes and repro- to make well-informed decisions (8). Pre- point is the need to incorporate a ques-
ductive potential should be informed conception counseling resources tailored tion about plans for pregnancy into the
about the importance of achieving and for adolescents are available at no cost routine primary and gynecologic care of
maintaining as near euglycemia as safely through the American Diabetes Associa- people with diabetes. Preconception
possible prior to conception and through- tion (ADA) (15). care for people with diabetes should in-
out pregnancy. Observational studies show clude the standard screenings and care
an increased risk of diabetic embryopathy, Preconception Care recommended for any person planning
especially anencephaly, microcephaly, con- pregnancy (16). Prescription of prenatal
Recommendations
genital heart disease, renal anomalies, vitamins with at least 400 mg of folic
15.4 Individuals with preexisting
and caudal regression, directly propor- acid and 150 mg of potassium iodide
diabetes who are planning a
tional to elevations in A1C during the (18) is recommended prior to concep-
pregnancy should ideally begin
first 10 weeks of pregnancy (3). Although tion. Review and counseling on the use
receiving care in preconception
observational studies are confounded by

at a multidisciplinary clinic in- of nicotine products, alcohol, and recrea-
the association between elevated peri-
cluding an endocrinologist, ma- tional drugs, including marijuana, is im-
conceptional A1C and other engagement
ternal-fetal medicine specialist, portant. Standard care includes screening
in self-care behaviors, the quantity and
registered dietitian nutritionist, for sexually transmitted diseases and thy-
consistency of data are convincing and
and diabetes care and education roid disease, recommended vaccinations,
support the recommendation to opti-
mize glycemia prior to conception, specialist, when available. B routine genetic screening, a careful re-
given that organogenesis occurs pri- 15.5 In addition to focused attention view of all prescription and nonprescrip-
marily at 5–8 weeks of gestation, with on achieving glycemic targets tion medications and supplements used,
an A1C <6.5% (48 mmol/mol), which A, standard preconception care and a review of travel history and plans
is associated with the lowest risk of should be augmented with ex- with special attention to areas known to
congenital anomalies, preeclampsia, tra focus on nutrition, diabetes have Zika virus, as outlined by ACOG. See
and preterm birth (3–7). A systematic education, and screening for Table 15.1 for additional details on ele-
review and meta-analysis of observa- diabetes comorbidities and ments of preconception care (16,19).
tional studies of preconception care for complications. B Counseling on the specific risks of
pregnant individuals with preexisting dia- 15.6 Individuals with preexisting type 1 obesity in pregnancy and lifestyle inter-
betes demonstrated lower A1C and re- or type 2 diabetes who are ventions to prevent and treat obesity, in-
duced risk of birth defects, preterm planning a pregnancy or who cluding referral to a registered dietitian
delivery, perinatal mortality, small-for-ges- have become pregnant should nutritionist (RDN), is recommended.
tational-age births, and neonatal inten- be counseled on the risk of de- Diabetes-specific counseling should
sive care unit admission (8). velopment and/or progression include an explanation of the risks to
There are opportunities to educate of diabetic retinopathy. Dilated mother and fetus related to pregnancy
all adults and adolescents with diabetes eye examinations should occur and the ways to reduce risk, including
and reproductive potential about the ideally before pregnancy or in glycemic goal setting, lifestyle and be-
risks of unplanned pregnancies and the first trimester, and then havioral management, and medical
about improved maternal and fetal out- pregnant individuals should be nutrition therapy (17). The most impor-
comes with pregnancy planning (8). Ef- monitored every trimester and tant diabetes-specific component of
fective preconception counseling could for 1 year postpartum as indi- preconception care is the attainment
avert substantial health and associated cated by the degree of reti- of glycemic goals prior to conception.
cost burdens in offspring (9). Family nopathy and as recommended In addition, the presence of microvas-
planning should be discussed, including by the eye care health care cular complications is associated with
the benefits of long-acting, reversible professional. B higher risk of disease progression and
contraception, and effective contracep-
adverse pregnancy outcomes (20). Dia-
tion should be prescribed and used until
The importance of preconception care for betes-specific testing should include
the individual is prepared and ready to
all pregnant people is highlighted by A1C, creatinine, and urinary albumin-
become pregnant (10–14).
To minimize the occurrence of compli- American College of Obstetricians and Gy- to-creatinine ratio. Special attention
cations, beginning at the onset of puberty necologists (ACOG) Committee Opinion should be paid to the review of the
or at diagnosis, all adults and adolescents 762, “Prepregnancy Counseling” (16). Pre- medication list for potentially harmful
with diabetes of childbearing potential conception counseling for pregnant peo- drugs, i.e., ACE inhibitors (21,22), an-
should receive education about 1) the ple with preexisting type 1 or type 2 giotensin receptor blockers (21), and
risks of malformations associated with un- diabetes is highly effective in reducing the statins (22,23). A referral for a compre-
planned pregnancies and even mild hy- risk of congenital malformations and de- hensive eye exam is recommended. Indi-
perglycemia and 2) the use of effective creasing the risk of preterm delivery and viduals with preexisting diabetic retino-
contraception at all times when prevent- admission to neonatal intensive care units. pathy will need close monitoring during
ing a pregnancy. Preconception counsel- Preconception counseling likely also re- pregnancy to assess for the progression
ing using developmentally appropriate duces perinatal mortality and small-for- of retinopathy and provide treatment if
educational tools enables adolescent girls gestational-age birth weight (17). A key indicated (24).
S256 Management of Diabetes in Pregnancy Diabetes Care Volume 46, Supplement 1, January 2023
GLYCEMIC TARGETS IN
Table 15.1—Checklist for preconception care for people with diabetes (16,19)
PREGNANCY
Preconception education should include:
w Comprehensive nutrition assessment and recommendations for:
Recommendations
Overweight/obesity or underweight
15.7 Fasting and postprandial blood Meal planning
glucose monitoring are recom- Correction of dietary nutritional deficiencies
mended in both gestational Caffeine intake
diabetes mellitus and pre- Safe food preparation technique
w Lifestyle recommendations for:
existing diabetes in pregnancy
Regular moderate exercise
to achieve optimal glucose lev- Avoidance of hyperthermia (hot tubs)
els. Glucose targets are fasting Adequate sleep
plasma glucose <95 mg/dL w Comprehensive diabetes self-management education
w Counseling on diabetes in pregnancy per current standards, including natural history of
(5.3 mmol/L) and either 1-h post-
insulin resistance in pregnancy and postpartum; preconception glycemic targets; avoidance
prandial glucose <140 mg/dL

of DKA/severe hyperglycemia; avoidance of severe hypoglycemia; progression of
(7.8 mmol/L) or 2-h post- retinopathy; PCOS (if applicable); fertility in people with diabetes; genetics of diabetes;
prandial glucose <120 mg/dL risks to pregnancy including miscarriage, still birth, congenital malformations, macrosomia,
(6.7 mmol/L). Some individ- preterm labor and delivery, hypertensive disorders in pregnancy, etc.
w Supplementation
uals with preexisting diabetes
Folic acid supplement (400 mg routine)
should also check blood glu-
Appropriate use of over-the-counter medications and supplements
cose preprandially. B
Health assessment and plan should include:
15.8 Due to increased red blood
w General evaluation of overall health
cell turnover, A1C is slightly w Evaluation of diabetes and its comorbidities and complications, including DKA/severe
lower during pregnancy in peo- hyperglycemia; severe hypoglycemia/hypoglycemia unawareness; barriers to care;
ple with and without diabetes. comorbidities such as hyperlipidemia, hypertension, NAFLD, PCOS, and thyroid
Ideally, the A1C target in preg- dysfunction; complications such as macrovascular disease, nephropathy, neuropathy
(including autonomic bowel and bladder dysfunction), and retinopathy
nancy is <6% (42 mmol/mol) w Evaluation of obstetric/gynecologic history, including a history of: cesarean section,
if this can be achieved with- congenital malformations or fetal loss, current methods of contraception, hypertensive
out significant hypoglycemia, disorders of pregnancy, postpartum hemorrhage, preterm delivery, previous
but the target may be relaxed macrosomia, Rh incompatibility, and thrombotic events (DVT/PE)
to <7% (53 mmol/mol) if neces- w Review of current medications and appropriateness during pregnancy
sary to prevent hypoglycemia. B Screening should include:

w Diabetes complications and comorbidities, including comprehensive foot exam;
15.9 When used in addition to pre-
and postprandial blood glucose comprehensive ophthalmologic exam; ECG in individuals starting at age 35 years who have
cardiac signs/symptoms or risk factors and, if abnormal, further evaluation; lipid panel;
monitoring, continuous glucose serum creatinine; TSH; and urine protein-to-creatinine ratio
monitoring can help to achieve w Anemia
the A1C target in diabetes and w Genetic carrier status (based on history):
pregnancy. B Cystic fibrosis

Sickle cell anemia
15.10 When used in addition to blood
Tay-Sachs disease
glucose monitoring, targeting Thalassemia
traditional pre- and postpran- Others if indicated
dial targets, real-time continu- w Infectious disease
ous glucose monitoring can Neisseria gonorrhoeae/Chlamydia trachomatis

Hepatitis C
reduce macrosomia and neo-
HIV
natal hypoglycemia in preg- Pap smear
nancy complicated by type 1 Syphilis
diabetes. B Immunizations should include:
15.11 Continuous glucose monitoring w Rubella
metrics may be used in addi- w Varicella

w Hepatitis B
tion to but should not be used
w Influenza
as a substitute for blood glu- w Others if indicated
cose monitoring to achieve
Preconception plan should include:
optimal pre- and postprandial
w Nutrition and medication plan to achieve glycemic targets prior to conception, including
glycemic targets. E appropriate implementation of monitoring, continuous glucose monitoring, and pump technology
15.12 Commonly used estimated A1C w Contraceptive plan to prevent pregnancy until glycemic targets are achieved
and glucose management indi- w Management plan for general health, gynecologic concerns, comorbid conditions, or
cator calculations should not complications, if present, including hypertension, nephropathy, retinopathy; Rh
be used in pregnancy as es- incompatibility; and thyroid dysfunction
timates of A1C. C DKA, diabetic ketoacidosis; DVT/PE, deep vein thrombosis/pulmonary embolism; ECG, elec-
15.13 Nutrition counseling should en- trocardiogram; NAFLD, nonalcoholic fatty liver disease; PCOS, polycystic ovary syndrome;
dorse a balance of macronutrients TSH, thyroid-stimulating hormone.
including nutrient-dense fruits, Processed foods, fatty red meat, and Lower limits are based on the mean
vegetables, legumes, whole sweetened foods and beverages should of normal blood glucose in pregnancy
grains, and healthy fats with be limited (26). (33). Lower limits do not apply to individ-
n-3 fatty acids that include uals with type 2 diabetes treated with
nuts and seeds and fish in the Insulin Physiology nutrition alone. Hypoglycemia in preg-
eating pattern. E Given that early pregnancy is a time of nancy is as defined and treated in Rec-
enhanced insulin sensitivity and lower ommendations 6.10–6.15 (Section 6,
glucose levels, many people with type 1 “Glycemic Targets”). These values repre-
Pregnancy in people with normal glu- diabetes will have lower insulin require- sent optimal control if they can be
cose metabolism is characterized by ments and an increased risk for hypo- achieved safely. In practice, it may be
fasting levels of blood glucose that are glycemia (27). Around 16 weeks, insulin challenging for a person with type 1 dia-
lower than in the nonpregnant state resistance begins to increase, and total betes to achieve these targets without
due to insulin-independent glucose up- daily insulin doses increase linearly 5% hypoglycemia, particularly those with a

take by the fetus and placenta and by per week through week 36. This usually history of recurrent hypoglycemia or hy-
mild postprandial hyperglycemia and car- results in a doubling of daily insulin dose poglycemia unawareness. If an individual
bohydrate intolerance as a result of dia- compared with the prepregnancy require- cannot achieve these targets without sig-
betogenic placental hormones. In people ment. The insulin requirement levels off nificant hypoglycemia, the ADA suggests
with preexisting diabetes, glycemic tar- toward the end of the third trimester less-stringent targets based on clinical
gets are usually achieved through a com- with placental aging. A rapid reduction in experience and individualization of care.
bination of insulin administration and insulin requirements can indicate the de-
medical nutrition therapy. Because glyce- velopment of placental insufficiency (28). A1C in Pregnancy
mic targets in pregnancy are stricter than In studies of individuals without preexist-
In people with normal pancreatic func-
in nonpregnant individuals, it is impor- ing diabetes, increasing A1C levels within
tion, insulin production is sufficient to
tant that pregnant people with diabetes the normal range are associated with ad-
meet the challenge of this physiological
eat consistent amounts of carbohy- verse outcomes (34). In the Hyperglyce-
insulin resistance and to maintain normal
drates to match with insulin dosage mia and Adverse Pregnancy Outcome
glucose levels. However, in people with
and to avoid hyperglycemia or hypo- (HAPO) study, increasing levels of glyce-
diabetes, hyperglycemia occurs if treat-
glycemia. Referral to an RDN is impor- mia were also associated with worsening
ment is not adjusted appropriately.
tant to establish a food plan and outcomes (35). Observational studies in
insulin-to-carbohydrate ratio and de- preexisting diabetes and pregnancy show
Glucose Monitoring
termine weight gain goals. The quality the lowest rates of adverse fetal out-
Reflecting this physiology, fasting and
of the carbohydrates should be evaluated. comes in association with A1C <6–6.5%
postprandial blood glucose monitoring
A subgroup analysis of the Continuous (42–48 mmol/mol) early in gestation
is recommended to achieve metabolic
Glucose Monitoring in Pregnant Women (4–6,36). Clinical trials have not evalu-
control in pregnant people with diabe- ated the risks and benefits of achieving
With Type 1 Diabetes Trial (CONCEPTT)
tes. Preprandial testing is also recom- these targets, and treatment goals
study demonstrated that the diets of indi-
viduals planning pregnancy and currently mended when using insulin pumps or should account for the risk of maternal
pregnant assessed during the run-in basal-bolus therapy so that premeal hypoglycemia in setting an individualized
phase prior to randomization were char- rapid-acting insulin dosage can be ad- target of <6% (42 mmol/mol) to <7%
acterized by high-fat, low-fiber, and poor- justed. Postprandial monitoring is asso- (53 mmol/mol). Due to physiological in-
quality carbohydrate intakes. Fruit and ciated with better glycemic outcomes creases in red blood cell turnover, A1C
vegetable consumption was inadequate, and a lower risk of preeclampsia levels fall during normal pregnancy
with one in four participants at risk for (29–31). There are no adequately pow- (37,38). Additionally, as A1C represents
micronutrient deficiencies, highlighting ered randomized trials comparing differ- an integrated measure of glucose, it may
the importance of medical nutrition ent fasting and postmeal glycemic not fully capture postprandial hyperglyce-
therapy (25). An expert panel on nutri- targets in diabetes in pregnancy. mia, which drives macrosomia. Thus, al-
tion in pregnancy recommends a balance Similar to the targets recommended though A1C may be useful, it should be
of macronutrients. A diet that severely by ACOG (upper limits are the same as used as a secondary measure of glycemic
restricts any macronutrient class should for GDM, described below) (32), the outcomes in pregnancy, after blood glu-
be avoided, specifically the ketogenic diet ADA-recommended targets for pregnant cose monitoring.
that lacks carbohydrates, the Paleo diet people with type 1 or type 2 diabetes In the second and third trimesters,
because of dairy restriction, and any are as follows: A1C <6% (42 mmol/mol) has the lowest
diet characterized by excess saturated risk of large-for-gestational-age infants
fats. Nutrient-dense, whole foods are • Fasting glucose 70–95 mg/dL (3.9–5.3 (36,39,40), preterm delivery (41), and
recommended, including fruits, vegeta- mmol/L) and either preeclampsia (1,42). Taking all of this into
bles, legumes, whole grains, and healthy • One-hour postprandial glucose 110–140 account, a target of <6% (42 mmol/mol)
fats with n-3 fatty acids that include nuts mg/dL (6.1–7.8 mmol/L) or is optimal during pregnancy if it can be
and seeds and fish, which are less • Two-hour postprandial glucose 100–120 achieved without significant hypoglyce-
likely to promote excessive weight gain. mg/dL (5.6–6.7 mmol/L) mia. The A1C target in a given individual
should be achieved without hypoglyce- alerts. A prospective, observational study GDM is characterized by an increased risk
mia, which, in addition to the usual ad- including 20 pregnant people with type 1 of large-for-gestational-age birth weight
verse sequelae, may increase the risk of diabetes simultaneously monitored with and neonatal and pregnancy complica-
low birth weight (43). Given the alter- intermittently scanning CGM (isCGM) and tions and an increased risk of long-term
ation in red blood cell kinetics during real-time CGM (rtCGM) for 7 days in maternal type 2 diabetes and abnormal
pregnancy and physiological changes in early pregnancy demonstrated a higher glucose metabolism of offspring in child-
glycemic parameters, A1C levels may percentage of time below range in the hood. These associations with maternal
need to be monitored more frequently isCGM group. Asymptomatic hypoglyce- oral glucose tolerance test (OGTT) results
than usual (e.g., monthly). mia measured by isCGM should there- are continuous with no clear inflection
fore not necessarily lead to a reduction points (35,52). Offspring with exposure to
Continuous Glucose Monitoring in
of insulin dose and/or increased carbo- untreated GDM have reduced insulin sen-
hydrate intake at bedtime unless these
Pregnancy sitivity and b-cell compensation and are
CONCEPTT was a randomized controlled episodes are confirmed by blood glucose

more likely to have impaired glucose tol-
trial (RCT) of real-time continuous glu- meter measurements (51). Selection of
erance in childhood (53). In other words,
cose monitoring (CGM) in addition to CGM device should be based on an indi-
short-term and long-term risks increase
vidual’s circumstances, preferences, and
standard care, including optimization of with progressive maternal hyperglycemia.
needs.
pre- and postprandial glucose targets Therefore, all pregnant people should
versus standard care for pregnant peo- be screened as outlined in Section 2,
• Target range 63–140 mg/dL (3.5–7.8
ple with type 1 diabetes. It demon-
mmol/L): TIR, goal >70% “Classification and Diagnosis of Diabetes.”
strated the value of real-time CGM in Although there is some heterogeneity,
• Time below range (<63 mg/dL [3.5
pregnancy complicated by type 1 dia- mmol/L]), goal <4% many RCTs and a Cochrane review sug-
betes by showing a mild improvement • Time below range (<54 mg/dL [3.0 gest that the risk of GDM may be re-
in A1C without an increase in hypogly- mmol/L]), goal <1% duced by diet, exercise, and lifestyle
cemia and reductions in large-for-ges- • Time above range (>140 mg/dL [7.8 counseling, particularly when interven-
tational-age births, length of stay, and mmol/L]), goal <25% tions are started during the first or early
neonatal hypoglycemia (44). An obser- in the second trimester (54–56). There
vational cohort study that evaluated MANAGEMENT OF GESTATIONAL are no intervention trials in offspring of
the glycemic variables reported using DIABETES MELLITUS mothers with GDM. A meta-analysis of
CGM found that lower mean glucose, 11 RCTs demonstrated that metformin
lower standard deviation, and a higher Recommendations treatment in pregnancy does not reduce
percentage of time in target range 15.14 Lifestyle behavior change is the risk of GDM in high-risk individuals
were associated with lower risk of an essential component of with obesity, polycystic ovary syndrome,
large-for-gestational-age births and other management of gestational or preexisting insulin resistance (57). A
adverse neonatal outcomes (45). Use of diabetes mellitus and may meta-analysis of 32 RCTs evaluating the
the CGM-reported mean glucose is supe- suffice as treatment for many effectiveness of telehealth visits for GDM
rior to the use of estimated A1C, glucose individuals. Insulin should be demonstrated reduction of incidences of
management indicator, and other calcula- added if needed to achieve cesarean delivery, neonatal hypoglycemia,
tions to estimate A1C, given the changes glycemic targets. A premature rupture of membranes, mac-
to A1C that occur in pregnancy (46). 15.15 Insulin is the preferred medica- rosomia, pregnancy-induced hypertension
CGM time in range (TIR) can be used for tion for treating hyperglycemia or preeclampsia, preterm birth, neonatal
assessment of glycemic outcomes in peo- in gestational diabetes melli- asphyxia, and polyhydramnios compared
ple with type 1 diabetes, but it does not tus. Metformin and glyburide with standard in-person care (58).
provide actionable data to address fasting should not be used as first-line
and postprandial hypoglycemia or hyper- agents, as both cross the pla-
Lifestyle and Behavioral Management
glycemia. The cost of CGM in pregnancies centa to the fetus. A Other After diagnosis, treatment starts with
oral and noninsulin injectable
complicated by type 1 diabetes is offset medical nutrition therapy, physical activity,
glucose-lowering medications
by improved maternal and neonatal out- and weight management, depending on
lack long-term safety data.
comes (47). pregestational weight, as outlined in the
15.16 Metformin, when used to treat
There are insufficient data to support section below on preexisting type 2 diabe-
polycystic ovary syndrome and
the use of CGM in people with type 2 tes, as well as glucose monitoring aiming
induce ovulation, should be
diabetes or GDM (48,49). for the targets recommended by the
discontinued by the end of the
The international consensus on TIR Fifth International Workshop-Conference
first trimester. A
(50) endorses pregnancy target ranges on Gestational Diabetes Mellitus (59):
15.17 Telehealth visits for pregnant
and goals for TIR for people with type 1
people with gestational diabe-
diabetes using CGM as reported on the tes mellitus improve outcomes • Fasting glucose <95 mg/dL (5.3 mmol/L)
ambulatory glucose profile; however, it compared with standard in- and either
does not specify the type or accuracy person care. A • One-hour postprandial glucose <140
of the device or need for alarms and mg/dL (7.8 mmol/L) or
• Two-hour postprandial glucose <120 testing may be useful to identify those Metformin
mg/dL (6.7 mmol/L) who are severely restricting carbohy- Metformin was associated with a lower
drates to control blood glucose. Sim- risk of neonatal hypoglycemia and less
The glycemic target lower limits de- ple carbohydrates will result in higher maternal weight gain than insulin in sys-
fined above for preexisting diabetes apply postmeal excursions. tematic reviews (74,77–79). However,
for GDM treated with insulin. Depending metformin readily crosses the placenta,
on the population, studies suggest that Physical Activity resulting in umbilical cord blood levels
70–85% of people diagnosed with GDM A systematic review demonstrated im- of metformin as high or higher than si-
under Carpenter-Coustan criteria can provements in glucose control and reduc- multaneous maternal levels (80,81). In
manage GDM with lifestyle modification tions in need to start insulin or insulin the Metformin in Gestational Diabetes:
alone; it is anticipated that this propor- dose requirements with an exercise inter- The Offspring Follow-Up (MiG TOFU)
tion will be even higher if the lower Inter- vention. There was heterogeneity in the study’s analyses of 7- to 9-year-old off-
national Association of the Diabetes and types of effective exercise (aerobic, resis- spring, the 9-year-old offspring exposed

Pregnancy Study Groups (60) diagnostic tance, or both) and duration of exercise to metformin for the treatment of GDM
thresholds are used. (20–50 min/day, 2–7 days/week of mod- in the Auckland cohort were heavier
erate intensity) (67). and had a higher waist-to-height ratio
Medical Nutrition Therapy and waist circumference than those ex-
Medical nutrition therapy for GDM is an posed to insulin (82). This difference
Pharmacologic Therapy
individualized nutrition plan developed Treatment of GDM with lifestyle and in- was not found in the Adelaide cohort.
between the pregnant person and an sulin has been demonstrated to improve In two RCTs of metformin use in preg-
RDN familiar with the management of nancy for polycystic ovary syndrome,
perinatal outcomes in two large random-
GDM (61,62). The food plan should pro- follow-up of 4-year-old offspring dem-
ized studies, as summarized in a U.S. Pre-
vide adequate calorie intake to promote onstrated higher BMI and increased
ventive Services Task Force review (68).
fetal/neonatal and maternal health, obesity in the offspring exposed to met-
Insulin is the first-line agent recom-
achieve glycemic goals, and promote formin (83,84). A follow-up study at
mended for the treatment of GDM in
weight gain, according to the 2009 Insti- 5–10 years showed that the offspring
the U.S. While individual RCTs support
tute of Medicine recommendations (63). had higher BMI, weight-to-height ratios,
limited efficacy of metformin (69,70) and
There is no definitive research that iden- waist circumferences, and a borderline
glyburide (71) in reducing glucose levels
tifies a specific optimal calorie intake for increase in fat mass (84,85). A recent
for the treatment of GDM, these agents
people with GDM or suggests that their meta-analysis concluded that metformin
are not recommended as the first-line
calorie needs are different from those of exposure resulted in smaller neonates
treatment for GDM because they are with an acceleration of postnatal growth,
pregnant individuals without GDM. The
known to cross the placenta and data on resulting in higher BMI in childhood
food plan should be based on a nutri-
tion assessment with dietary reference long-term safety for offspring is of some (84).
intake guidance from the National Insti- concern (32). Furthermore, in separate Randomized, double-blind, controlled
tute of Medicine. The recommended di- RCTs, glyburide and metformin failed to trials comparing metformin with other
etary reference intake for all pregnant provide adequate glycemic outcomes in therapies for ovulation induction in indi-
people is a minimum of 175 g of carbo- 23% and 25–28% of participants with viduals with polycystic ovary syndrome
hydrate, a minimum of 71 g of protein, GDM, respectively (72,73). have not demonstrated benefit in pre-
and 28 g of fiber (64). The nutrition plan venting spontaneous abortion or GDM
should emphasize monounsaturated and Sulfonylureas (86), and there is no evidence-based
polyunsaturated fats while limiting satu- Sulfonylureas are known to cross the need to continue metformin in these in-
rated fats and avoiding trans fats. As is placenta and have been associated with dividuals (87–89).
true for all nutrition therapy in people increased neonatal hypoglycemia. Con- There are some people with GDM re-
with diabetes, the amount and type of centrations of glyburide in umbilical quiring medical therapy who may not be
carbohydrate will impact glucose levels. cord plasma are approximately 50–70% able to use insulin safely or effectively
The current recommended amount of of maternal levels (72,73). In meta- during pregnancy due to cost, language
carbohydrates is 175 g, or 35% of a analyses and systematic reviews, gly- barriers, comprehension, or cultural in-
2,000-calorie diet. Liberalizing higher buride was associated with a higher fluences. Oral agents may be an alterna-
quality, nutrient-dense carbohydrates re- rate of neonatal hypoglycemia, macroso- tive for these individuals after discussing
sults in controlled fasting/postprandial mia, and increased neonatal abdominal the known risks and the need for more
glucose, lower free fatty acids, improved circumference than insulin or metformin long-term safety data in offspring. How-
insulin action, and vascular benefits and (74,75). ever, due to the potential for growth re-
may reduce excess infant adiposity. Indi- Glyburide failed to be found noninferior striction or acidosis in the setting of
viduals who substitute fat for carbohy- to insulin based on a composite outcome placental insufficiency, metformin should
drates may unintentionally enhance of neonatal hypoglycemia, macrosomia, not be used in pregnant people with hy-
lipolysis, promote elevated free fatty and hyperbilirubinemia (76). Long-term pertension or preeclampsia or those at
acids, and worsen maternal insulin re- safety data for offspring exposed to gly- risk for intrauterine growth restriction
sistance (65,66). Fasting urine ketone buride are not available (76). (90,91).
Insulin It may be suited for pregnancy because the but can require much higher doses of in-
Insulin use should follow the guidelines predictive low-glucose threshold for sus- sulin, sometimes necessitating concen-
below. Both multiple daily insulin injec- pending insulin is in the range of premeal trated insulin formulations. Insulin is the
tions and continuous subcutaneous insulin and overnight glucose value targets in preferred treatment for type 2 diabetes
infusion are reasonable delivery strategies, pregnancy and may allow for more in pregnancy. An RCT of metformin
and neither has been shown to be supe- aggressive prandial dosing. See SENSOR- added to insulin for the treatment of
rior to the other during pregnancy (92). AUGMENTED PUMPS and AUTOMATED INSULIN DELIVERY type 2 diabetes found less maternal
SYSTEMS in Section 7, “Diabetes Technology,” weight gain and fewer cesarean births.
MANAGEMENT OF PREEXISTING for more information on these systems. There were fewer macrosomic neonates,
TYPE 1 DIABETES AND TYPE 2
but there was a doubling of small-for-
DIABETES IN PREGNANCY Type 1 Diabetes gestational-age neonates (107). As in
Insulin Use Pregnant individuals with type 1 diabe- type 1 diabetes, insulin requirements
tes have an increased risk of hypoglyce-

Recommendations drop dramatically after delivery.
15.18 Insulin should be used to man- mia in the first trimester and, like all The risk for associated hypertension
age type 1 diabetes in preg- pregnant people, have altered counter- and other comorbidities may be as high
nancy. A Insulin is the preferred regulatory response in pregnancy that or higher with type 2 diabetes as with
agent for the management of may decrease hypoglycemia awareness. type 1 diabetes, even if diabetes is bet-
type 2 diabetes in pregnancy. B Education for people with diabetes and ter managed and of shorter apparent
15.19 Either multiple daily injections family members about the prevention, duration, with pregnancy loss appearing
or insulin pump technology recognition, and treatment of hypogly-
to be more prevalent in the third tri-
can be used in pregnancy com- cemia is important before, during, and
mester in those with type 2 diabetes,
plicated by type 1 diabetes. C after pregnancy to help prevent and
compared with the first trimester in
manage hypoglycemia’s risks. Insulin re-
those with type 1 diabetes (108,109).
sistance drops rapidly with the delivery
The physiology of pregnancy necessitates of the placenta.
frequent titration of insulin to match Pregnancy is a ketogenic state, and PREECLAMPSIA AND ASPIRIN
changing requirements and underscores people with type 1 diabetes, and to a Insulin Use
the importance of daily and frequent lesser extent those with type 2 diabe-
Recommendation
blood glucose monitoring. Due to the tes, are at risk for diabetic ketoacidosis
15.20 Pregnant individuals with type 1
complexity of insulin management in (DKA) at lower blood glucose levels
or type 2 diabetes should be
pregnancy, referral to a specialized cen- than in the nonpregnant state. Pregnant
prescribed low-dose aspirin
ter offering team-based care (with team people with type 1 diabetes should be
100–150 mg/day starting at 12
members including a maternal-fetal med- prescribed ketone strips and receive ed-
to 16 weeks of gestation to
icine specialist, endocrinologist or other ucation on DKA prevention and detec-
lower the risk of preeclampsia.
health care professional experienced in tion. DKA carries a high risk of stillbirth.
E A dosage of 162 mg/day
managing pregnancy and preexisting dia- Those in DKA who are unable to eat of- may be acceptable E; currently,
betes, RDN, diabetes care and education ten require 10% dextrose with an insu- in the U.S., low-dose aspirin is
specialist, and social worker, as needed) lin drip to adequately meet the higher available in 81-mg tablets.
is recommended if this resource is carbohydrate demands of the placenta
available. and fetus in the third trimester in order
None of the currently available human to resolve their ketosis.
Diabetes in pregnancy is associated with
insulin preparations have been demon- Retinopathy is a special concern in preg-
an increased risk of preeclampsia (110).
strated to cross the placenta (92–97). In- nancy. The necessary rapid implementation
of euglycemia in the setting of retinopa- The U.S. Preventive Services Task Force
sulins studied in RCTs are preferred
(98–101) over those studied in cohort thy is associated with worsening of reti- recommends using low-dose aspirin
studies (102), which are preferred over nopathy (106). (81 mg/day) as a preventive medication
those studied in case reports only. at 12 weeks of gestation in individuals at
While many health care professionals Type 2 Diabetes high risk for preeclampsia (111). How-
prefer insulin pumps in pregnancy, it is Type 2 diabetes is often associated with ever, a meta-analysis and an additional
not clear that they are superior to multi- obesity. Recommended weight gain dur- trial demonstrate that low-dose aspirin
ple daily injections (103,104). None of ing pregnancy for people with overweight <100 mg is not effective in reducing
the current hybrid closed-loop insulin pump is 15–25 lb and for those with obesity is preeclampsia. Low-dose aspirin >100
systems approved by the U.S. Food and 10–20 lb (63). There are no adequate mg is required (112–114). A cost-benefit
Drug Administration (FDA) achieve preg- data on optimal weight gain versus analysis has concluded that this ap-
nancy targets. However, predictive low- weight maintenance in pregnant peo- proach would reduce morbidity, save
glucose suspend (PLGS) technology has ple with BMI >35 kg/m2. lives, and lower health care costs (115).
been shown in nonpregnant people to be Optimal glycemic targets are often eas- However, there is insufficient data regard-
better than sensor-augmented insulin pumps ier to achieve during pregnancy with ing benefits of aspirin in pregnant people
(SAP) for reducing low glucose values (105). type 2 diabetes than with type 1 diabetes with preexisting diabetes (116,117). More
studies are needed to assess the long- had an even better composite outcome POSTPARTUM CARE
term effects of prenatal aspirin exposure score than those without diabetes (118).
Recommendations
on offspring (116). As a result of the CHAP study, ACOG
15.23 Insulin resistance decreases
issued a Practice Advisory recommend-
dramatically immediately post-
PREGNANCY AND DRUG ing a blood pressure of 140/90 mmHg
as the threshold for initiation or titration partum, and insulin require-
CONSIDERATIONS
of medical therapy for chronic hyperten- ments need to be evaluated
Recommendations sion in pregnancy (119) rather than their and adjusted as they are often
15.21 In pregnant individuals with previously recommended threshold of roughly half the prepregnancy
diabetes and chronic hyper- 160/110 mmHg (120). requirements for the initial
tension, a blood pressure The CHAP study provides additional few days postpartum. C
threshold of 140/90 mmHg for guidance for the management of hyper- 15.24 A contraceptive plan should be
initiation or titration of ther- tension in pregnancy. Data from the discussed and implemented

apy is associated with better previously published Control of Hyperten- with all people with diabetes
pregnancy outcomes than re- sion in Pregnancy Study (CHIPS) supports of reproductive potential. A
serving treatment for severe a target blood pressure goal of 110–135/ 15.25 Screen individuals with a re-
hypertension, with no increase 85 mmHg to reduce the risk of uncon- cent history of gestational dia-
in risk of small-for-gestational- trolled maternal hypertension and mini- betes mellitus at 4–12 weeks
age birth weight. A There are mize impaired fetal growth (120–122). postpartum, using the 75-g
limited data on the optimal The 2015 study (121) excluded pregnan- oral glucose tolerance test and
cies complicated by preexisting diabetes, clinically appropriate nonpreg-
lower limit, but therapy should
and only 6% of participants had GDM at nancy diagnostic criteria. B
be lessened for blood pressure
enrollment. There was no difference in 15.26 Individuals with overweight/
<90/60 mmHg. E A blood pres-
pregnancy loss, neonatal care, or other obesity and a history of gesta-
sure target of 110–135/85 mmHg
neonatal outcomes between the groups tional diabetes mellitus found
is suggested in the interest of
with tighter versus less tight control of to have prediabetes should re-
reducing the risk for acceler-
hypertension (121). ceive intensive lifestyle inter-
ated maternal hypertension. A
During pregnancy, treatment with ACE ventions and/or metformin to
15.22 Potentially harmful medica-
inhibitors and angiotensin receptor block- prevent diabetes. A
tions in pregnancy (i.e., ACE
ers is contraindicated because they may 15.27 Breastfeeding is recommended
inhibitors, angiotensin receptor to reduce the risk of maternal
cause fetal renal dysplasia, oligohydram-
blockers, statins) should be nios, pulmonary hypoplasia, and intra- type 2 diabetes and should
stopped prior to conception uterine growth restriction (21). be considered when choosing
and avoided in sexually active A large study found that after adjust- whether to breastfeed or for-
individuals of childbearing po- ing for confounders, first trimester ACE mula feed. B
tential who are not using reli- inhibitor exposure does not appear to 15.28 Individuals with a history of
able contraception. B be associated with congenital malforma- gestational diabetes mellitus
tions (123). However, ACE inhibitors and should have lifelong screen-
In normal pregnancy, blood pressure is angiotensin receptor blockers should be ing for the development of
stopped as soon as possible in the first type 2 diabetes or prediabe-
lower than in the nonpregnant state.
trimester to avoid second and third tri- tes every 1–3 years. B
The Chronic Hypertension and Preg-
mester fetopathy (123). Antihyperten- 15.29 Individuals with a history of ges-
nancy (CHAP) Trial Consortium’s RCT on
sive drugs known to be effective and tational diabetes mellitus should
treatment for mild chronic hypertension
safe in pregnancy include methyldopa, seek preconception screening
during pregnancy demonstrated that a
nifedipine, labetalol, diltiazem, clonidine, for diabetes and preconception
blood pressure of 140/90 mmHg, as the
and prazosin. Atenolol is not recom- care to identify and treat hyper-
threshold for initiation or titration of mended, but other b-blockers may be glycemia and prevent congenital
treatment, reduces the incidence of ad- used, if necessary. Chronic diuretic use malformations. E
verse pregnancy outcomes without com- during pregnancy is not recommended 15.30 Postpartum care should include
promising fetal growth (118). The CHAP as it has been associated with restricted psychosocial assessment and
Consortium’s study mitigates concerns maternal plasma volume, which may re- support for self-care. E
about small-for-gestational-age birth duce uteroplacental perfusion (124). On
weight. Attained mean ± SD blood the basis of available evidence, statins
pressure measurements in the treated should also be avoided in pregnancy Gestational Diabetes Mellitus
versus untreated groups were systolic (125). Initial Testing
129.5 ± 10.0 vs. 132.6 ± 10.1 mmHg See pregnancy and antihypertensive Because GDM often represents previ-
(between-group difference 3.11 [95% medications in Section 10, “Cardiovascular ously undiagnosed prediabetes, type 2
CI 3.95 to 2.28]) and diastolic 79.1 ± Disease and Risk Management,” for more diabetes, maturity-onset diabetes of the
7.4 vs. 81.5 ± 8.0 mmHg ( 2.33 [ 2.97 information on managing blood pressure young, or even developing type 1 diabe-
to 0.04]) (118). Individuals with diabetes in pregnancy. tes, individuals with GDM should be
tested for persistent diabetes or predia- 20% at 10 years, 30% at 20 years, 40% those with diabetes, should be supported
betes at 4–12 weeks postpartum with a at 30 years, 50% at 40 years, and 60% at in attempts to breastfeed. Breastfeeding
fasting 75-g OGTT using nonpregnancy cri- 50 years (129). In the prospective Nurses’ may also confer longer-term metabolic
teria as outlined in Section 2, “Classification Health Study II (NHS II), subsequent dia- benefits to both mother (139) and off-
and Diagnosis of Diabetes,” specifically betes risk after a history of GDM was sig- spring (140). Breastfeeding reduces the
Table 2.2. In the absence of unequivocal nificantly lower in those who followed risk of developing type 2 diabetes in
hyperglycemia, a positive screen for dia- healthy eating patterns (130). Adjusting mothers with previous GDM. It may
betes requires two abnormal values. If for BMI attenuated this association mod- improve the metabolic risk factors
both the fasting plasma glucose ($126 erately, but not completely. Interpreg- of offspring, but more studies are
mg/dL [7.0 mmol/L]) and 2-h plasma glu- nancy weight gain is associated with needed (141). However, lactation can
cose ($200 mg/dL [11.1 mmol/L]) are ab- increased risk of adverse pregnancy out- increase the risk of overnight hypo-
normal in a single screening test, then comes (131) and higher risk of GDM, glycemia, and insulin dosing may need
the diagnosis of diabetes is made. If only while in people with BMI >25 kg/m2,

to be adjusted.
one abnormal value in the OGTT meets weight loss is associated with lower risk
diabetes criteria, the test should be re- of developing GDM in the subsequent
Contraception
peated to confirm that the abnormality pregnancy (132). Development of type 2
A major barrier to effective preconcep-
persists. OGTT testing immediately post- diabetes is 18% higher per unit of BMI
tion care is the fact that the majority of
partum, while still hospitalized, has increase from prepregnancy BMI at
pregnancies are unplanned. Planning
demonstrated improved engagement in follow-up, highlighting the importance
pregnancy is critical in individuals with
testing but also variably reduced sensi- of effective weight management after
preexisting diabetes to achieve the opti-
tivity to the diagnosis of impaired fast- GDM (133). In addition, postdelivery
ing glucose, impaired glucose tolerance, lifestyle interventions are effective in mal glycemic targets necessary to pre-
and type 2 diabetes (126,127). reducing risk of type 2 diabetes (134). vent congenital malformations and reduce
Both metformin and intensive lifestyle the risk of other complications. Therefore,
Postpartum Follow-up intervention prevent or delay progression all individuals with diabetes of child-
The OGTT is recommended over A1C at to diabetes in individuals with prediabetes bearing potential should have family
4–12 weeks postpartum because A1C and a history of GDM. Only five to six indi- planning options reviewed at regular
may be persistently impacted (lowered) viduals with prediabetes and a history of intervals to make sure that effective
by the increased red blood cell turnover GDM need to be treated with either inter- contraception is implemented and main-
related to pregnancy, by blood loss at de- vention to prevent one case of diabetes tained. This applies to individuals in the
livery, or by the preceding 3-month glu- over 3 years (135). In these individuals, life- immediate postpartum period. Individu-
cose profile. The OGTT is more sensitive style intervention and metformin reduced als with diabetes have the same contra-
at detecting glucose intolerance, including progression to diabetes by 35% and 40%, ception options and recommendations as
both prediabetes and diabetes. Individu- respectively, over 10 years compared with those without diabetes. Long-acting, re-
als of childbearing potential with predia- placebo (136). If the pregnancy has moti- versible contraception may be ideal for
betes may develop type 2 diabetes by vated the adoption of healthy nutrition, individuals with diabetes and childbear-
the time of their next pregnancy and will building on these gains to support weight ing potential. The risk of an unplanned
need preconception evaluation. Because loss is recommended in the postpartum pregnancy outweighs the risk of any cur-
GDM is associated with an increased life- period. (See Section 3, “Prevention or rently available contraception option.
time maternal risk for diabetes estimated Delay of Type 2 Diabetes and Associated
at 50–60% (128,129), individuals should Comorbidities.”) References
also be tested every 1–3 years thereafter 1. Dabelea D, Hanson RL, Lindsay RS, et al.
if the 4–12 weeks postpartum 75-g OGTT Preexisting Type 1 and Type 2 Diabetes Intrauterine exposure to diabetes conveys risks for
is normal. Ongoing evaluation may be Insulin sensitivity increases dramatically type 2 diabetes and obesity: a study of discordant
sibships. Diabetes 2000;49:2208–2211
performed with any recommended glyce- with the delivery of the placenta. In one
2. Holmes VA, Young IS, Patterson CC, et al.;
mic test (e.g., annual A1C, annual fasting study, insulin requirements in the immedi- Diabetes and Pre-eclampsia Intervention Trial
plasma glucose, or triennial 75-g OGTT us- ate postpartum period are roughly 34% Study Group. Optimal glycemic control, pre-
ing nonpregnant thresholds). lower than prepregnancy insulin require- eclampsia, and gestational hypertension in
ments (137). Insulin sensitivity then re- women with type 1 diabetes in the diabetes and
Gestational Diabetes Mellitus and Type 2 turns to prepregnancy levels over the pre-eclampsia intervention trial. Diabetes Care
2011;34:1683–1688
Diabetes following 1–2 weeks. For individuals tak-
3. Guerin A, Nisenbaum R, Ray JG. Use of
Individuals with a history of GDM have a ing insulin, particular attention should be maternal GHb concentration to estimate the risk
greatly increased risk of conversion to directed to hypoglycemia prevention in of congenital anomalies in the offspring of
type 2 diabetes over time (129), and the setting of breastfeeding and erratic women with prepregnancy diabetes. Diabetes
those with GDM have a 10-fold increased sleep and eating schedules (138). Care 2007;30:1920–1925
risk of developing type 2 diabetes com- 4. Jensen DM, Korsholm L, Ovesen P, et al. Peri-
conceptional A1C and risk of serious adverse
pared with those without GDM (128). Lactation
pregnancy outcome in 933 women with type 1
Absolute risk of developing type 2 diabe- Considering the immediate nutritional diabetes. Diabetes Care 2009;32:1046–1048
tes after GDM increases linearly through and immunological benefits of breastfeed- 5. Nielsen GL, Møller M, Sørensen HT. HbA1c in
a person’s lifetime, being approximately ing for the baby, all mothers, including early diabetic pregnancy and pregnancy outcomes:
a Danish population-based cohort study of 573 exposure to angiotensin-converting enzyme inhi- and adverse pregnancy outcomes. N Engl J Med
pregnancies in women with type 1 diabetes. bitors or angiotensin receptor antagonists: a 2008;358:1991–2002
Diabetes Care 2006;29:2612–2616 systematic review. Hypertension 2012;60:444–450 36. Maresh MJA, Holmes VA, Patterson CC,
6. Suhonen L, Hiilesmaa V, Teramo K. Glycaemic 22. Bateman BT, Hernandez-Diaz S, Fischer MA, et al.; Diabetes and Pre-eclampsia Intervention
control during early pregnancy and fetal mal- et al. Statins and congenital malformations: Trial Study Group. Glycemic targets in the second
formations in women with type I diabetes cohort study. BMJ 2015;350:h1035 and third trimester of pregnancy for women with
mellitus. Diabetologia 2000;43:79–82 23. Taguchi N, Rubin ET, Hosokawa A, et al. type 1 diabetes. Diabetes Care 2015;38:34–42
7. Ludvigsson JF, Neovius M, S€ oderling J, Prenatal exposure to HMG-CoA reductase in- 37. Nielsen LR, Ekbom P, Damm P, et al. HbA1c
Gudbj€ ornsdottir S, Svensson AM, Franzen S, et al. hibitors: effects on fetal and neonatal outcomes. levels are significantly lower in early and late
Maternal glycemic control in type 1 diabetes and Reprod Toxicol 2008;26:175–177 pregnancy. Diabetes Care 2004;27:1200–1201
the risk for preterm birth: a population-based 24. Widyaputri F, Rogers SL, Kandasamy R, Shub 38. Mosca A, Paleari R, Dalfra MG, et al.
cohort study. Ann Intern Med. 2019;170: A, Symons RCA, Lim LL. Global estimates of Reference intervals for hemoglobin A1c in
691–701 diabetic retinopathy prevalence and progression pregnant women: data from an Italian multicenter
8. Charron-Prochownik D, Sereika SM, Becker D, in pregnant women with preexisting diabetes: a study. Clin Chem 2006;52:1138–1143
et al. Long-term effects of the booster-enhanced systematic review and meta-analysis. JAMA 39. Hummel M, Marienfeld S, Huppmann M,

READY-Girls preconception counseling program Ophthalmol 2022;140:486–494 et al. Fetal growth is increased by maternal type 1
on intentions and behaviors for family planning 25. Neoh SL, Grisoni JA, Feig DS; CONCEPTT diabetes and HLA DR4-related gene interactions.
in teens with diabetes. Diabetes Care 2013;36: Collaborative Group. Dietary intakes of women Diabetologia 2007;50:850–858
3870–3874 with type 1 diabetes before and during pregnancy: 40. Cyganek K, Skupien J, Katra B, et al. Risk of
9. Peterson C, Grosse SD, Li R, et al. Preventable a pre-specified secondary subgroup analysis macrosomia remains glucose-dependent in a
health and cost burden of adverse birth outcomes among CONCEPTT participants. Diabet Med 2020; cohort of women with pregestational type 1
associated with pregestational diabetes in the 37:1841–1848 diabetes and good glycemic control. Endocrine
United States. Am J Obstet Gynecol 2015;212: 26. Marshall NE, Abrams B, Barbour LA, et al. 2017;55:447–455
74.e1–74.e9 The importance of nutrition in pregnancy and 41. Abell SK, Boyle JA, de Courten B, et al.
10. Britton LE, Hussey JM, Berry DC, Crandell JL, lactation: lifelong consequences. Am J Obstet Impact of type 2 diabetes, obesity and glycaemic
Brooks JL, Bryant AG. Contraceptive use among Gynecol 2022;226:607–632 control on pregnancy outcomes. Aust N Z J
women with prediabetes and diabetes in a US 27. Garcıa-Patterson A, Gich I, Amini SB, Obstet Gynaecol 2017;57:308–314
national sample. J Midwifery Womens Health Catalano PM, de Leiva A, Corcoy R. Insulin 42. Temple RC, Aldridge V, Stanley K, Murphy
2019;64:36–45 requirements throughout pregnancy in women HR. Glycaemic control throughout pregnancy and
11. Morris JR, Tepper NK. Description and with type 1 diabetes mellitus: three changes of risk of pre-eclampsia in women with type I
comparison of postpartum use of effective diabetes. BJOG 2006;113:1329–1332
direction. Diabetologia 2010;53:446–451
contraception among women with and without 43. Combs CA, Gunderson E, Kitzmiller JL, Gavin
28. Padmanabhan S, Lee VW, Mclean M, et al.
diabetes. Contraception 2019;100:474–479 LA, Main EK. Relationship of fetal macrosomia to
The association of falling insulin requirements
12. Goldstuck ND, Steyn PS. The intrauterine maternal postprandial glucose control during
with maternal biomarkers and placental dys-
device in women with diabetes mellitus type i pregnancy. Diabetes Care 1992;15:1251–1257
function: a prospective study of women with
and ii: a systematic review. ISRN Obstet Gynecol 44. Feig DS, Donovan LE, Corcoy R, et al.;
preexisting diabetes in pregnancy. Diabetes Care
2013;2013:814062 CONCEPTT Collaborative Group. Continuous
2017;40:1323–1330
13. Wu JP, Moniz MH, Ursu AN. Long-acting glucose monitoring in pregnant women with
29. Manderson JG, Patterson CC, Hadden DR,
reversible contraception—highly efficacious, safe, type 1 diabetes (CONCEPTT): a multicentre
Traub AI, Ennis C, McCance DR. Preprandial
and underutilized. JAMA. 2018 24;320:397–398 international randomised controlled trial. Lancet
versus postprandial blood glucose monitoring in
14. American College of Obstetricians and 2017;390:2347–2359
type 1 diabetic pregnancy: a randomized con- €
Gynecologists’ Committee on Practice Bulletins— 45. Kristensen K, Ogge LE, Sengpiel V, et al.
Obstetrics. ACOG Practice Bulletin No. 201: trolled clinical trial. Am J Obstet Gynecol 2003; Continuous glucose monitoring in pregnant
Pregestational diabetes mellitus. Obstet Gynecol 189:507–512 women with type 1 diabetes: an observational
2018;132:e228–e248 30. de Veciana M, Major CA, Morgan MA, et al. cohort study of 186 pregnancies. Diabetologia
15. Charron-Prochownik D, Downs J. Diabetes Postprandial versus preprandial blood glucose 2019;62:1143–1153
and Reproductive Health for Girls. Alexandria, VA, monitoring in women with gestational diabetes 46. Law GR, Gilthorpe MS, Secher AL, et al.
American Diabetes Association, 2016 mellitus requiring insulin therapy. N Engl J Med Translating HbA1c measurements into estimated
16. ACOG Committee Opinion No. 762: Pre- 1995;333:1237–1241 average glucose values in pregnant women with
pregnancy counseling. Obstet Gynecol 2019;133: 31. Jovanovic-Peterson L, Peterson CM, Reed diabetes. Diabetologia 2017;60:618–624
e78–e89 GF, et al. Maternal postprandial glucose levels 47. Ahmed RJ, Gafni A, Hutton EK, et al.;
17. Wahabi HA, Fayed A, Esmaeil S, et al. and infant birth weight: the Diabetes in Early CONCEPTT Collaborative Group. The cost im-
Systematic review and meta-analysis of the Pregnancy Study. The National Institute of Child plications of continuous glucose monitoring in
effectiveness of pre-pregnancy care for women Health and Human Development–Diabetes in pregnant women with type 1 diabetes in 3
with diabetes for improving maternal and Early Pregnancy Study. Am J Obstet Gynecol Canadian provinces: a posthoc cost analysis of the
perinatal outcomes. PLoS One 2020;15:e0237571 1991;164:103–111 CONCEPTT trial. CMAJ Open 2021;9:E627–E634
18. Alexander EK, Pearce EN, Brent GA, et al. 32. Committee on Practice Bulletins—Obstetrics. 48. Garcıa-Moreno RM, Benıtez-Valderrama P,
2017 Guidelines of the American Thyroid ACOG Practice Bulletin No. 190: Gestational Barquiel B, et al. Efficacy of continuous glucose
Association for the diagnosis and management of diabetes mellitus. Obstet Gynecol 2018;131: monitoring on maternal and neonatal outcomes
thyroid disease during pregnancy and the e49–e64 in gestational diabetes mellitus: a systematic
postpartum. Thyroid 2017;27:315–389 33. Hernandez TL, Friedman JE, Van Pelt RE, review and meta-analysis of randomized clinical
19. Ramos DE. Preconception health: changing Barbour LA. Patterns of glycemia in normal trials. Diabet Med 2022;39:e14703
the paradigm on well-woman health. Obstet pregnancy: should the current therapeutic 49. Wyckoff JA, Brown FM. Time in range in
Gynecol Clin North Am 2019;46:399–408 targets be challenged? Diabetes Care 2011;34: pregnancy: is there a role? Diabetes Spectr
20. Relph S, Patel T, Delaney L, Sobhy S, 1660–1668 2021;34:119–132
Thangaratinam S. Adverse pregnancy outcomes 34. Ho YR, Wang P, Lu MC, Tseng ST, Yang CP, Yan 50. Battelino T, Danne T, Bergenstal RM, et al.
in women with diabetes-related microvascular YH. Associations of mid-pregnancy HbA1c with Clinical targets for continuous glucose monitoring
disease and risks of disease progression in gestational diabetes and risk of adverse pregnancy data interpretation: recommendations from the
pregnancy: a systematic review and meta- outcomes in high-risk Taiwanese women. PLoS International Consensus on Time in Range.
analysis. PLoS Med 2021;18:e1003856 One 2017;12:e0177563 Diabetes Care 2019;42:1593–1603
21. Bullo M, Tschumi S, Bucher BS, Bianchetti MG, 35. Metzger BE, Lowe LP, Dyer AR, et al.; HAPO 51. Nørgaard SK, Mathiesen ER, Nørgaard K,
Simonetti GD. Pregnancy outcome following Study Cooperative Research Group. Hyperglycemia Ringholm L. Comparison of glycemic metrics
measured simultaneously by intermittently 64. Institute of Medicine. Dietary Reference randomized controlled study. Diabetes Care
scanned continuous glucose monitoring and real- Intakes: The Essential Guide to Nutrient 2017;40:332–337
time continuous glucose monitoring in pregnant Requirements. The National Academies Press; 79. Jiang YF, Chen XY, Ding T, Wang XF, Zhu ZN,
women with type 1 diabetes. Diabetes Technol Washington, DC, 2006. p. 1344 Su SW. Comparative efficacy and safety of OADs
Ther 2021;23:665–672 65. Hernandez TL, Mande A, Barbour LA. in management of GDM: network meta-analysis
52. Scholtens DM, Kuang A, Lowe LP, et al.; Nutrition therapy within and beyond gestational of randomized controlled trials. J Clin Endocrinol
HAPO Follow-up Study Cooperative Research diabetes. Diabetes Res Clin Pract 2018;145:39–50 Metab 2015;100:2071–2080
Group; HAPO Follow-Up Study Cooperative 66. Hernandez TL, Van Pelt RE, Anderson MA, 80. Vanky E, Zahlsen K, Spigset O, Carlsen SM.
Research Group. Hyperglycemia and Adverse et al. A higher-complex carbohydrate diet in Placental passage of metformin in women with
Pregnancy Outcome Follow-up Study (HAPO gestational diabetes mellitus achieves glucose polycystic ovary syndrome. Fertil Steril 2005;83:
FUS): Maternal glycemia and childhood glucose targets and lowers postprandial lipids: a ran- 1575–1578
metabolism. Diabetes Care 2019;42:381–392 domized crossover study. Diabetes Care 2014;37: 81. Charles B, Norris R, Xiao X, Hague W.
53. Lowe WL Jr, Scholtens DM, Kuang A, et al.; 1254–1262 Population pharmacokinetics of metformin in
HAPO Follow-up Study Cooperative Research 67. Laredo-Aguilera JA, Gallardo-Bravo M, late pregnancy. Ther Drug Monit 2006;28:67–72
Group. Hyperglycemia and Adverse Pregnancy Rabanales-Sotos JA, Cobo-Cuenca AI, Carmona- 82. Rowan JA, Rush EC, Plank LD, et al.

Outcome Follow-up Study (HAPO FUS): Maternal Torres JM. Physical activity programs during Metformin in gestational diabetes: the offspring
gestational diabetes mellitus and childhood pregnancy are effective for the control of follow-up (MiG TOFU): body composition and
glucose metabolism. Diabetes Care 2019;42: gestational diabetes mellitus. Int J Environ Res metabolic outcomes at 7-9 years of age. BMJ
372–380 Public Health 2020;17:E6151 Open Diabetes Res Care 2018;6:e000456
54. Koivusalo SB, R€ on€o K, Klemetti MM, et al. 68. Hartling L, Dryden DM, Guthrie A, Muise M, 83. Hanem LGE, Stridsklev S, J ulıusson PB, et al.
Gestational diabetes mellitus can be prevented Vandermeer B, Donovan L. Benefits and harms of Metformin use in PCOS pregnancies increases
by lifestyle intervention: The Finnish Gestational treating gestational diabetes mellitus: a sys- the risk of offspring overweight at 4 years of age:
Diabetes Prevention Study (RADIEL): a ran- tematic review and meta-analysis for the U.S. follow-up of two RCTs. J Clin Endocrinol Metab
domized controlled trial. Diabetes Care 2016;39: Preventive Services Task Force and the National 2018;103:1612–1621
24–30 Institutes of Health Office of Medical Applications 84. Tarry-Adkins JL, Aiken CE, Ozanne SE.
55. Wang C, Wei Y, Zhang X, et al. A randomized of Research. Ann Intern Med 2013;159:123–129 Neonatal, infant, and childhood growth following
clinical trial of exercise during pregnancy to 69. Rowan JA, Hague WM, Gao W, Battin MR; metformin versus insulin treatment for ges-
prevent gestational diabetes mellitus and MiG Trial Investigators. Metformin versus insulin tational diabetes: a systematic review and meta-
improve pregnancy outcome in overweight and for the treatment of gestational diabetes. N Engl analysis. PLoS Med 2019;16:e1002848
obese pregnant women. Am J Obstet Gynecol J Med 2008;358:2003–2015 85. Hanem LGE, Salvesen Ø, Juliusson PB, et al.
2017;216:340–351 70. Gui J, Liu Q, Feng L. Metformin vs insulin in Intrauterine metformin exposure and offspring
56. Griffith RJ, Alsweiler J, Moore AE, et al. the management of gestational diabetes: a meta- cardiometabolic risk factors (PedMet study): a
Interventions to prevent women from developing analysis. PLoS One 2013;8:e64585
5-10 year follow-up of the PregMet randomised
gestational diabetes mellitus: an overview of 71. Langer O, Conway DL, Berkus MD, Xenakis
controlled trial. Lancet Child Adolesc Health
Cochrane Reviews. Cochrane Database Syst Rev EMJ, Gonzales O. A comparison of glyburide and
2019;3:166–174
2020;6:CD012394 insulin in women with gestational diabetes
86. Vanky E, Stridsklev S, Heimstad R, et al.
57. Doi SAR, Furuya-Kanamori L, Toft E, et al. mellitus. N Engl J Med 2000;343:1134–1138
Metformin versus placebo from first trimester to
Metformin in pregnancy to avert gestational 72. Hebert MF, Ma X, Naraharisetti SB, et al.;
delivery in polycystic ovary syndrome: a
diabetes in women at high risk: Meta-analysis of Obstetric-Fetal Pharmacology Research Unit
randomized, controlled multicenter study. J Clin
randomized controlled trials. Obes Rev 2020;21: Network. Are we optimizing gestational diabetes
Endocrinol Metab 2010;95:E448–E455
e12964 treatment with glyburide? The pharmacologic
87. Legro RS, Barnhart HX, Schlaff WD, et al.;
58. Xie W, Dai P, Qin Y, Wu M, Yang B, Yu X. basis for better clinical practice. Clin Pharmacol
Cooperative Multicenter Reproductive Medicine
Effectiveness of telemedicine for pregnant women Ther 2009;85:607–614
73. Malek R, Davis SN. Pharmacokinetics, Network. Clomiphene, metformin, or both for
with gestational diabetes mellitus: an updated
meta-analysis of 32 randomized controlled trials efficacy and safety of glyburide for treatment of infertility in the polycystic ovary syndrome. N
with trial sequential analysis. BMC Pregnancy gestational diabetes mellitus. Expert Opin Drug Engl J Med 2007;356:551–566
Childbirth 2020;20:198 Metab Toxicol 2016;12:691–699 88. Palomba S, Orio F Jr, Falbo A, et al.
59. Metzger BE, Buchanan TA, Coustan DR, et al. 74. Balsells M, Garcıa-Patterson A, Sola I, Roque Prospective parallel randomized, double-blind,
Summary and recommendations of the Fifth M, Gich I, Corcoy R. Glibenclamide, metformin, double-dummy controlled clinical trial comparing
International Workshop-Conference on Gestational and insulin for the treatment of gestational clomiphene citrate and metformin as the first-
Diabetes Mellitus. Diabetes Care 2007;30(Suppl. 2): diabetes: a systematic review and meta-analysis. line treatment for ovulation induction in
S251–S260 BMJ 2015;350:h102 nonobese anovulatory women with polycystic
60. Mayo K, Melamed N, Vandenberghe H, 75. Tarry-Adkins JL, Aiken CE, Ozanne SE. ovary syndrome. J Clin Endocrinol Metab 2005;
Berger H. The impact of adoption of the Comparative impact of pharmacological treat- 90:4068–4074
International Association of Diabetes in Pregnancy ments for gestational diabetes on neonatal 89. Palomba S, Orio F Jr, Nardo LG, et al.
Study Group criteria for the screening and anthropometry independent of maternal glyc- Metformin administration versus laparoscopic
diagnosis of gestational diabetes. Am J Obstet aemic control: a systematic review and meta- ovarian diathermy in clomiphene citrate-resistant
Gynecol 2015;212:224.e1–224.e9 analysis. PLoS Med 2020;17:e1003126 women with polycystic ovary syndrome: a
61. Han S, Crowther CA, Middleton P, Heatley E. 76. Senat MV, Affres H, Letourneau A, et al.; prospective parallel randomized double-blind
Different types of dietary advice for women with Groupe de Recherche en Obstetrique et placebo-controlled trial. J Clin Endocrinol Metab
gestational diabetes mellitus. Cochrane Database Gynecologie (GROG). Effect of glyburide vs 2004;89:4801–4809
Syst Rev 2013;3:CD009275 subcutaneous insulin on perinatal complications 90. Barbour LA, Scifres C, Valent AM, et al. A
62. Viana LV, Gross JL, Azevedo MJ. Dietary among women with gestational diabetes: a cautionary response to SMFM statement:
intervention in patients with gestational diabetes randomized clinical trial. JAMA 2018;319: pharmacological treatment of gestational diabetes.
mellitus: a systematic review and meta-analysis 1773–1780 Am J Obstet Gynecol 2018;219:367.e1–367.e7
of randomized clinical trials on maternal and 77. Silva JC, Pacheco C, Bizato J, de Souza BV, 91. Barbour LA, Feig DS. Metformin for gestational
newborn outcomes. Diabetes Care 2014;37: Ribeiro TE, Bertini AM. Metformin compared with diabetes mellitus: progeny, perspective, and a
3345–3355 glyburide for the management of gestational personalized approach. Diabetes Care 2019;42:
63. Weight GDP. Reexamining the Guidelines. diabetes. Int J Gynaecol Obstet 2010;111:37–40 396–399
Washington, D.C., National Academies Press, 78. Nachum Z, Zafran N, Salim R, et al. Glyburide 92. Farrar D, Tuffnell DJ, West J, West HM.
2009. Accessed 5 October 2022. Available from versus metformin and their combination for the Continuous subcutaneous insulin infusion versus
https://www.nap.edu/catalog/12584 treatment of gestational diabetes mellitus: a multiple daily injections of insulin for pregnant
women with diabetes. Cochrane Database Syst international, randomised, placebo-controlled trial. 122. Brown MA, Magee LA, Kenny LC, et al.;
Rev 2016;6:CD005542 Lancet Diabetes Endocrinol 2020;8:834–844 International Society for the Study of Hypertension
93. Pollex EK, Feig DS, Lubetsky A, Yip PM, Koren 108. Clausen TD, Mathiesen E, Ekbom P, in Pregnancy (ISSHP). Hypertensive disorders of
G. Insulin glargine safety in pregnancy: a Hellmuth E, Mandrup-Poulsen T, Damm P. Poor pregnancy: ISSHP classification, diagnosis, and
transplacental transfer study. Diabetes Care 2010; pregnancy outcome in women with type 2 management recommendations for international
33:29–33 diabetes. Diabetes Care 2005;28:323–328 practice. Hypertension 2018;72:24–43
94. Holcberg G, Tsadkin-Tamir M, Sapir O, et al. 109. Cundy T, Gamble G, Neale L, et al. Differing 123. Bateman BT, Patorno E, Desai RJ, et al.
Transfer of insulin lispro across the human causes of pregnancy loss in type 1 and type 2 Angiotensin-converting enzyme inhibitors and
placenta. Eur J Obstet Gynecol Reprod Biol 2004; diabetes. Diabetes Care 2007;30:2603–2607 the risk of congenital malformations. Obstet
115:117–118 110. Duckitt K, Harrington D. Risk factors for Gynecol 2017;129:174–184
95. Boskovic R, Feig DS, Derewlany L, Knie B, pre-eclampsia at antenatal booking: systematic 124. Sibai BM. Treatment of hypertension in
Portnoi G, Koren G. Transfer of insulin lispro review of controlled studies. BMJ 2005;330:565 pregnant women. N Engl J Med 1996;335:257–265
across the human placenta: in vitro perfusion 111. Henderson JT, Whitlock EP, O’Conner E, 125. Kazmin A, Garcia-Bournissen F, Koren G.
studies. Diabetes Care 2003;26:1390–1394 Senger CA, Thompson JH, Rowland MG. Low- Risks of statin use during pregnancy: a systematic
96. McCance DR, Damm P, Mathiesen ER, et al. dose aspirin for the prevention of morbidity and review. J Obstet Gynaecol Can 2007;29:906–908

Evaluation of insulin antibodies and placental mortality from preeclampsia: a systematic 126. Waters TP, Kim SY, Werner E, et al. Should
transfer of insulin aspart in pregnant women evidence review for the U.S. Preventive Services women with gestational diabetes be screened at
with type 1 diabetes mellitus. Diabetologia 2008; Task Force. Rockville,MD, Agency for Healthcare delivery hospitalization for type 2 diabetes? Am J
51:2141–2143 Research and Quality, 2014. Accessed 21 October Obstet Gynecol 2020;222:73.e1–73.e11
97. Suffecool K, Rosenn B, Niederkofler EE, et al. 2022. Available from https://www.ncbi.nlm.nih. 127. Society for Maternal-Fetal Medicine
Insulin detemir does not cross the human gov/books/NBK196392/ (SMFM). Werner EF, Has P, Rouse D, Clark MA.
placenta. Diabetes Care 2015;38:e20–e21 112. Roberge S, Bujold E, Nicolaides KH. Aspirin Two-day postpartum compared with 4- to 12-
98. Mathiesen ER, Hod M, Ivanisevic M, et al.; for the prevention of preterm and term week postpartum glucose tolerance testing for
Detemir in Pregnancy Study Group. Maternal preeclampsia: systematic review and metaanalysis. women with gestational diabetes. Am J Obstet
efficacy and safety outcomes in a randomized, Am J Obstet Gynecol 2018;218:287–293.e1 Gynecol 2020;223:439.e1–439.e7
controlled trial comparing insulin detemir with 113. Rolnik DL, Wright D, Poon LC, O’Gorman N, 128. Vounzoulaki E, Khunti K, Abner SC, Tan BK,
NPH insulin in 310 pregnant women with type 1 Syngelaki A, de Paco Matallana C, et al. Aspirin Davies MJ, Gillies CL. Progression to type 2
diabetes. Diabetes Care 2012;35:2012–2017 versus placebo in pregnancies at high risk for diabetes in women with a known history of
99. Hod M, Mathiesen ER, Jovanovic L, et al. A preterm preeclampsia. N Engl J Med. 2017;377: gestational diabetes: systematic review and
randomized trial comparing perinatal outcomes 613–622 meta-analysis. BMJ 2020;369:m1361
using insulin detemir or neutral protamine 114. Hoffman MK, Goudar SS, Kodkany BS, 129. Li Z, Cheng Y, Wang D, et al. Incidence rate
Hagedorn in type 1 diabetes. J Matern Fetal Metgud M, Somannavar M, Okitawutshu J, et al. of type 2 diabetes mellitus after gestational
Neonatal Med 2014;27:7–13 Low-dose aspirin for the prevention of preterm diabetes mellitus: a systematic review and meta-
100. Hod M, Damm P, Kaaja R, et al.; Insulin delivery in nulliparous women with a singleton analysis of 170,139 women. J Diabetes Res
Aspart Pregnancy Study Group. Fetal and pregnancy (ASPIRIN): a randomised, double-blind, 2020;2020:3076463
perinatal outcomes in type 1 diabetes pregnancy: placebo-controlled trial. Lancet. 2020 25;395: 130. Tobias DK, Hu FB, Chavarro J, Rosner B,
a randomized study comparing insulin aspart 285–293 Mozaffarian D, Zhang C. Healthful dietary
with human insulin in 322 subjects. Am J Obstet 115. Werner EF, Hauspurg AK, Rouse DJ. A cost- patterns and type 2 diabetes mellitus risk among
Gynecol 2008;198:186.e1–186.e7 benefit analysis of low-dose aspirin prophylaxis women with a history of gestational diabetes
101. Persson B, Swahn ML, Hjertberg R, et al. for the prevention of preeclampsia in the United mellitus. Arch Intern Med 2012;172:1566–1572
Insulin lispro therapy in pregnancies complicated States. Obstet Gynecol 2015;126:1242–1250 131. Villamor E, Cnattingius S. Interpregnancy
by type 1 diabetes mellitus. Diabetes Res Clin 116. Zen M, Haider R, Simmons D, et al. Aspirin weight change and risk of adverse pregnancy
Pract 2002;58:115–121 for the prevention of pre-eclampsia in women outcomes: a population-based study. Lancet
102. Pollex E, Moretti ME, Koren G, Feig DS. with pre-existing diabetes: systematic review. 2006;368:1164–1170
Safety of insulin glargine use in pregnancy: a Aust N Z J Obstet Gynaecol 2022;62:12–21 132. Martınez-Hortelano JA, Cavero-Redondo I,
systematic review and meta-analysis. Ann 117. Voutetakis A, Pervanidou P, Kanaka- lvarez-Bueno C, Dıez-Fernandez A, Hernandez-
A
Pharmacother 2011;45:9–16 Gantenbein C. Aspirin for the prevention of Luengo M, Martınez-Vizcaıno V. Interpregnancy
103. Carta Q, Meriggi E, Trossarelli GF, et al. preeclampsia and potential consequences for weight change and gestational diabetes mellitus:
Continuous subcutaneous insulin infusion versus fetal brain development. JAMA Pediatr 2019;173: a systematic review and meta-analysis. Obesity
intensive conventional insulin therapy in type I 619–620 (Silver Spring) 2021;29:454–464
and type II diabetic pregnancy. Diabete Metab 118. Tita AT, Szychowski JM, Boggess K, et al.; 133. Dennison RA, Chen ES, Green ME, et al. The
1986;12:121–129 Chronic Hypertension and Pregnancy (CHAP) Trial absolute and relative risk of type 2 diabetes after
104. Kernaghan D, Farrell T, Hammond P, Owen Consortium. Treatment for mild chronic hyper- gestational diabetes: a systematic review and
P. Fetal growth in women managed with insulin tension during pregnancy. N Engl J Med 2022; meta-analysis of 129 studies. Diabetes Res Clin
pump therapy compared to conventional insulin. 386:1781–1792 Pract 2021;171:108625
Eur J Obstet Gynecol Reprod Biol 2008;137: 119. American College of Obstetricians and 134. Li N, Yang Y, Cui D, et al. Effects of lifestyle
47–49 Gynecologists: Clinical guidance for the integration intervention on long-term risk of diabetes in
105. Forlenza GP, Li Z, Buckingham BA, et al. of the findings of the Chronic Hypertension and women with prior gestational diabetes: a
Predictive low-glucose suspend reduces hypo- Pregnancy (CHAP) study. Acccessed 31 August systematic review and meta-analysis of randomized
glycemia in adults, adolescents, and children with 2022. Available from https://www.acog.org/ controlled trials. Obes Rev 2021;22:e13122
type 1 diabetes in an at-home randomized clinical/clinical-guidance/practice-advisory/articles/ 135. Ratner RE, Christophi CA, Metzger BE,
crossover study: results of the PROLOG Trial. 2022/04/clinical-guidance-for-the-integration-of- et al.; Diabetes Prevention Program Research
Diabetes Care 2018;41:2155–2161 the-findings-of-the-chronic-hypertension-and- Group. Prevention of diabetes in women with
106. Chew EY, Mills JL, Metzger BE, et al. pregnancy-chap-study a history of gestational diabetes: effects of
Metabolic control and progression of retinopathy. 120. American College of Obstetricians and metformin and lifestyle interventions. J Clin
The Diabetes in Early Pregnancy Study. National Gynecologists’ Committee on Practice Bulletins— Endocrinol Metab 2008;93:4774–4779
Institute of Child Health and Human Development Obstetrics. ACOG Practice Bulletin No. 203: Chronic 136. Aroda VR, Christophi CA, Edelstein SL,
Diabetes in Early Pregnancy Study. Diabetes Care hypertension in pregnancy. Obstet Gynecol 2019; et al.; Diabetes Prevention Program Research
1995;18:631–637 133:e26–e50 Group. The effect of lifestyle intervention and
107. Feig DS, Donovan LE, Zinman B, et al.; MiTy 121. Magee LA, von Dadelszen P, Rey E, et al. metformin on preventing or delaying
Collaborative Group. Metformin in women with Less-tight versus tight control of hypertension in diabetes among women with and without
type 2 diabetes in pregnancy (MiTy): a multicentre, pregnancy. N Engl J Med 2015;372:407–417 gestational diabetes: the Diabetes Prevention
Program outcomes study 10-year follow-up. in type 1 diabetic women. Endocr Pract 2009; review of current evidence. J Pediatr (Rio J)
J Clin Endocrinol Metab 2015;100:1646– 15:187–193 2014;90:7–15
1653 139. Stuebe AM, Rich-Edwards JW, Willett WC, 141. Pathirana MM, Ali A, Lassi ZS, Arstall MA,
137. Achong N, Duncan EL, McIntyre HD, Manson JE, Michels KB. Duration of lactation and Roberts CT, Andraweera PH. Protective
Callaway L. Peripartum management of glycemia incidence of type 2 diabetes. JAMA 2005;294: influence of breastfeeding on cardiovascular
in women with type 1 diabetes. Diabetes Care 2601–2610 risk factors in women with previous gesta-
2014;37:364–371 140. Pereira PF, Alfenas R de CG, Ara ujo RMA. tional diabetes mellitus and their children: a
138. Riviello C, Mello G, Jovanovic LG. Does breastfeeding influence the risk of systematic review and meta-analysis. J Hum
Breastfeeding and the basal insulin requirement developing diabetes mellitus in children? A Lact 2022;38:501–512

Standards of Care in Diabetes - 2023

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S254 Diabetes Care Volume 46, Supplement 1, January 2023

15. Management of Diabetes in Nuha A. ElSayed, Grazia Aleppo,

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The American Diabetes Association (ADA) “Standards of Care in Diabetes” in-

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sary to prevent hypoglycemia. B Screening should include:

pregnancy. B  Cystic ﬁbrosis

ous glucose monitoring can  Neisseria gonorrhoeae/Chlamydia trachomatis

metrics may be used in addi- w Varicella

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pregnancy. B Cystic ﬁbrosis

ous glucose monitoring can Neisseria gonorrhoeae/Chlamydia trachomatis