Section 15: Management of Diabetes in Pregnancy Free

• 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 an individual’s treatment plan and A1C are 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, physical activity, diabetes education, and screening for diabetes comorbidities and complications, in addition to achieving glycemic goals.

• Counsel those with preexisting diabetes on the risk of development and/or progression of diabetic retinopathy. Ideally, a dilated eye examination should occur before pregnancy as well as in the first trimester, with continued monitoring every trimester and for 1 year postpartum based on findings.

The preconception care of people with diabetes is detailed in Table 15.1 of the complete American Diabetes Association Standards of Care in Diabetes—2025.

• 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-hour postprandial glucose <140 mg/dL (<7.8 mmol/L) or 2-hour 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 (CGM) can help to achieve glycemic goals and the A1C goal in type 1 diabetes and may be beneficial for other types of diabetes in pregnancy.

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 24–28 weeks of pregnancy.

• Lifestyle behavior change is an essential component of GDM management and may suffice as treatment.

• Insulin is the preferred medication for treating hyperglycemia in GDM.

• Metformin and glyburide should not be used as first-line agents for diabetes in pregnancy. Other oral and noninsulin injectable glucose-lowering medications lack long-term safety data and are not recommended.

• Initiate or titrate blood pressure medication at a threshold of 140/90 mmHg. A goal of 110–135/85 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 mineralcorticoid receptor antagonists) prior to conception and avoid in sexually active individuals of childbearing potential who are not using reliable contraception.

• In most cases, lipid lowering agents (PCSK9 inhibitor, bempedoic acid, fibrates, and statins should be stopped before conception and avoided in sexually active individuals of child-bearing potential with diabetes who are not using reliable conception). In some circumstances, statin therapy may be continued when benefits outweigh risks.

• Postpartum care should include psychosocial assessment and support for self-care.