Guidelines for diabetes during pregnancy

The authors aimed to formulate a clinical practice guideline for the management of the pregnant woman with diabetes.

Women with diabetes have an increased risk of problems during pregnancy. Those with gestational, type 1 or type 2 diabetes should learn how to take care of themselves and their baby before, during and after pregnancy. This article outlines some guidelines that expecting mothers should adhere to in order to ensure the health of both themselves and their baby.

Preconception care: Preconception counseling is recommended for all women with diabetes who are considering pregnancy. It is also recommended that those with diabetes seeking to conceive should strive to achieve blood glucose levels as close to normal as possible and should take a daily folic acid supplement up to 3 months before conception to reduce the risk of neural tube defects. This can be reduced to 0.4-1.0 mg per day at 12 weeks gestation. In women treated with insulin, multiple daily doses of insulin or continuous insulin infusion is preferred. Those using insulin detemir or insulin glargine before conception may continue this therapy before and during pregnancy.

All women with diabetes who are seeking pregnancy should have a detailed ocular (eye) assessment. Women with established retinopathy (diabetic disease of the eyes) should be seen by their eye specialist every trimester, then within 3 months of delivering and then as needed. Women without established retinopathy should have ocular assessment performed soon after assessment and then periodically during the pregnancy.

All women with diabetes who are seeking pregnancy should have their renal (kidney) function assessed. Women with renal dysfunction before conception should have their renal function monitored regularly during pregnancy.

It is recommended that blood pressure of less than 130/80 mmHg be achieved before trying to conceive. Those on angiotensin-converting-enzyme inhibitors (Lotensin, Capoten, Zestril; for treatment of high blood pressure) or angiotensin-blockers (Diovan, Avapro, Benicar; for treatment of high blood pressure) in almost all cases should discontinue medication while trying to conceive and during pregnancy. It is recommended that statins (Lipitor, Crestor, Zocor) not be used during pregnancy in view of their unproven safety during pregnancy.

Gestational Diabetes: It is recommended that all women get tested for diabetes at the first prenatal visit. Women not previously identified with diabetes should be tested for gestational diabetes at 24 to 28 weeks gestation. Blood glucose targets should be as close to normal as possible, with initial treatment consisting of medical nutritional therapy and daily moderate exercise for 30 minutes or more. Pharmacological (drug) therapy is warranted when lifestyle modifications are insufficient. Blood glucose medication should be discontinued immediately after delivery for women with gestational diabetes unless overt diabetes is suspected.

Glucose Monitoring: Self-monitoring of blood glucose is recommended for gestational and overt type 1 and type 2 diabetes, and testing is recommended before and 1 to 2 hours after the start of each meal. Testing is also recommended at bedtime and, as indicated, during the night. Pregnant women should strive to achieve a target preprandial (pre-meal) blood glucose level of less than or equal to 95 mg/dL (5.3 mmmol/L). Fasting blood glucose should be less than or equal to 90 mg/dL (5 mmol/L). Blood glucose 1 hour after the start of a meal should be less than or equal to 140 mg/dL (7.8 mmol/L) and less than or equal to 120 mg/dL (6.7 mmol/L) 2 hours after the start of the meal. It is recommended that HbA1c level (a measurement of average blood glucose levels over the past 3 months) is less than or equal to 7% (ideally 6.5%).

Nutrition: It is suggested obese women reduce their calorie intake by approximately one third while maintaining a minimum intake of 1600 to 1800 kcal per day. In all women, carbohydrate intake should be 35-45% of total calories, distributed in 3 small- to moderate-sized meals and 2-4 snacks. Guidelines for the intake of vitamins and minerals are the same as for those without diabetes.

Drug therapy: Insulin detemir and insulin glargine are both deemed safe during pregnancy. Glyburide (Diabeta) is a suitable non-insulin oral antidiabetic drug in those who cannot achieve blood glucose targets with lifestyle modifications.

Labor, delivery, lactation: Blood glucose levels during labor and delivery should be 72-126 mg/dL (4-7 mmol/L). Breasfeeding is recommended whenever possible in women with diabetes. If metformin (Glucophage) or glyburide have been used successfully during pregnancy, they should be continued during breastfeeding.

The authors provided a brief summary of guidelines for pregnant women with diabetes.

If you are a diabetic patient who wants to become, or is, pregnant, discuss these guidelines with your physician.