Preconception Counseling:
Incorporate preconception counseling into diabetes care starting at puberty and continuing in all people with diabetes and childbearing potential.
Discuss family planning and prescribe effective contraception to be used until A1C is optimized for pregnancy.
Address the importance of achieving glucose levels as close to normal as is safely possible, ideally A1C <6.5% (<48 mmol/mol) to reduce the risk of congenital anomalies, preeclampsia, macrosomia, preterm birth, and other complications.
Focus on nutrition, diabetes education, and screening for diabetes comorbidities and complications, in addition to achieving glycemic targets.
Counsel on the risk of development and/or progression of diabetic retinopathy. A dilated eye examination should occur before pregnancy or in the first trimester, with continued monitoring every trimester and for 1 year postpartum based on findings.
Glycemic Management and Goals in Pregnancy
Perform fasting, preprandial, and postprandial blood glucose monitoring (BGM).- Glucose goals are fasting plasma glucose <95 mg/dL (<5.3 mmol/L) and either 1-h postprandial glucose <140 mg/dL (<7.8 mmol/L) or 2-h postprandial glucose <120 mg/dL (<6.7 mmol/L).
- Ideally, the A1C goal in pregnancy is <6% (<42 mmol/mol) if this can be achieved without significant hypoglycemia; the goal may be relaxed to <7% (<53 mmol/mol) to prevent hypoglycemia.
- When used in addition to pre- and postprandial BGM, continuous glucose monitoring can help to achieve the A1C goal in diabetes and pregnancy.
Management of Gestational Diabetes Mellitus (GDM)
GDM refers specifically to diabetes diagnosed after the first trimester of pregnancy in individuals who did not have diabetes before pregnancy. Diabetes detected before or in early pregnancy is usually considered to be preexisting type 2 diabetes.
Individuals without diabetes before or early in pregnancy should be screened for GDM at 24 to 28 weeks of pregnancy.
Lifestyle behavior change is an essential component of GDM management.
Insulin is the preferred medication for treating hyperglycemia in GDM.
Metformin and glyburide should not be used as first-line agents in GDM. Other oral and noninsulin injectable glucose- lowering medications lack long-term safety data for use in GDM.
Additional Drug Considerations During Pregnancy
- Initiate or titrate blood pressure medication at a threshold of 140/90 mmHg. A target of 110–135/84 mmHg is suggested. Therapy should be reduced if blood pressure is <90/60 mmHg.
- Stop potentially harmful medications in pregnancy (i.e., ACE inhibitors, angiotensin receptor blockers, and statins) prior to conception and avoid in sexually active individuals of childbearing potential who are not using reliable contraception.
Postpartum Care
Postpartum care should include psychosocial assessment and support for self-care.
