Guidelines on the management of diabetes in pregnancy

These guidelines presented recommendations for the management of diabetes in pregnancy. It was concluded that counselling before pregnancy, appropriate care during pregnancy, and follow-up after delivery is needed.

Diabetes in pregnancy is increasing in the United States. Most of this is due to gestational diabetes mellitus (GDM; diabetes first seen in pregnancy). The remainder is mostly type 1 diabetes (T1D) and type 2 diabetes (T2D).

Diabetes in pregnancy presents a number of risks to both mother and child. These include miscarriage, structural anomalies in newborns, and increased risk of T2D and obesity later in the child’s life. 

The American Diabetes Association (ADA) has published their 2017 guidelines on the management of diabetes during pregnancy.

All women of childbearing-age should be made aware of the importance of glycemic control before conception. Tight glycemic control lowers the risk of congenital (present at birth) anomalies. Effective contraception should be discussed, prescribed, and used, until a woman is ready to become pregnant.

Treatment of GDM should start with diet and exercise management. Some women may require drug treatment. Insulin is the safest agent, as this does not cross the placenta. Glucophage (Metformin) and glyburide (DiaBeta) are also options. However, glyburide is associated with higher risks of hypoglycemia (dangerously low blood glucose) in the newborn. Metformin slightly increases the risk of prematurity. Long-term safety data is not available for either glyburide or metformin.

Insulin is also preferred for treating T1D and T2D during pregnancy. Insulin needs change during pregnancy. They usually decrease in the first trimester, rise rapidly in the second, before levelling off or decreasing slightly in the third. Thus monitoring of blood glucose levels is important to adjust insulin dose. Women with T1D have an increased risk of hypoglycemia (dangerously low blood glucose levels) in the first trimester. They may be less likely to notice the symptoms of this condition.

During pregnancy monitoring blood glucose levels after fasting and after meals is recommended. For some women with pre-existing diabetes testing of blood glucose before meals is also recommended. Women with pre-existing diabetes who have diabetic retinopathy (condition affecting blood vessels of the eye) should be referred for eye exams during and after pregnancy. Women with pre-existing diabetes are at risk of diabetic ketoacidosis (a life-threatening emergency). They should thus receive education on detection and prevention.

After delivery women with GDM should be tested for ongoing diabetes. Women with pre-existing diabetes should pay attention to reduced insulin requirements after delivery to prevent hypoglycemia.

The ADA concluded that appropriate counselling before pregnancy, care during pregnancy, and follow-up after delivery is needed for pregnant women with diabetes.

The recommendations in these guidelines are guides only, and may not apply to all patients. They should not replace a physician’s opinion and care.