Latest ADA Guidelines, published January 2015…
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The prevalence of diabetes during pregnancy is becoming more common in the U.S.
Studies are showing an increase in diabetes in pregnancy. The most common is gestational diabetes mellitus (GDM) and the others are split between pre-gestational type 1 and 2 diabetes. Pre-gestational types are shown to be of greater risk than GDM, although they are less prevalent.
All women of childbearing age with diabetes should receive preconception counseling on the importance of maintaining good glycemic control prior to conception.
Observational studies have shown increased risk of diabetic embryopathy, anencephaly, microcephaly, and congenital heart disease, with elevations in A1C. Spontaneous abortion has also been identified in the setting of uncontrolled diabetes. Based on these studies, recommendations have been to aim for an A1C <7% prior to conception to minimize risk.
Goals for glycemic control for GDM have the following targets for maternal capillary glucose concentrations: Preprandial ≤95 mg/dL (5.3 mmol/L) and either; One-hour post-meal ≤140 mg/ dL (7.8 mmol/L) or; Two-hour post-meal ≤120 mg/dL (6.7 mmol/L).
Women with preexisting type 1 or 2 diabetes who become pregnant, the following are recommended goals if the patient can do so without risking excessive hypoglycemia: Pre-meal, bedtime, and overnight glucose 60–99 mg/dL (3.3–5.4 mmol/L); Peak postprandial glucose 100–129 mg/dL (5.4–7.1 mmol/L) and; A1C of <6%.
GDM should first be managed with exercise and diet modifications, and medications should only be added if needed. Some of the medications widely used in pregnancy include insulin, metformin, and glyburide. Most oral agents cross the placenta or lack long-term safety data.
Insulin sensitivity increases in the immediate postpartum period and then returns to normal over the following 1–2 weeks. Many women will require significantly less insulin at this time than during the prepartum period. Breastfeeding can cause hypoglycemia, so eating a small snack or drinking milk prior to breastfeeding can reduce the risk.
- For women who are of childbearing age and planning to conceive or are pregnant, if hypertension is an issue as well, ACEI’s/ARB’s should not be taken.
- Treatment should start with medical nutrition therapy, exercise, and glucose monitoring aiming for the targets described previously.
- Women with GDM are at higher risk of conversion to type 2 diabetes thereafter, and should be screened 6-12 weeks postpartum and every 1-3 years after.
American Diabetes Association. Management of diabetes in pregnancy. Sec. 12. In Standards of Medical Care in Diabetes—2015. Diabetes Care 2015;38 (Suppl. 1):S77–S79