In the update, certain methodology was used e.g. BMJ 1990;301:1070–4. Pregnancy in women with type 1 and type 2 diabetes in 2002-03, England, Wales and Northern Ireland. One study of pregnant women with type 1 diabetes showed overnight closed-loop therapy resulted in better glycemic control than sensor-augmented pump therapy (115). Cochrane Database Syst Rev 2007;(6):CD005542. Unspecified antihyperglycemic medications were either not associated with ASD (463) or not independently associated with ASD risk (462,463), but merit further investigation to assess if there are differences in the association between different types of antihyperglycemic agents and ASD. If glycemic targets are not met, insulin or metformin can then be used. Finally, a study examining CGM use to prevent episodes of severe hypoglycemia early in pregnancy in women with a history of episodes in the year prior to pregnancy did not demonstrate benefit. Diabetologia 2015;58:2229–37. First trimester hemoglobin A1c prediction of gestational diabetes. Thus, advice on meal planning for women with GDM should emphasize a healthy diet during pregnancy, with a minimum of 175 g/day of carbohydrate (321) distributed over 3 moderate-sized meals and 2 or more snacks (1 of which should be at bedtime), (304,311) as well as replacing high-GI foods with low-GI ones. The best type of intervention that should be recommended is unclear since all the successful programs used different exercise modalities in terms of intensity, type, duration and frequency. Kernaghan D, Farrell T, Hammond P, et al. The National Institute of Health (NIH) 2013 Consensus Conference summary statement stated that “at present, the panel believes that there is not sufficient evidence to adopt a 1-step approach, such as that proposed by the IADPSG” (275). First-trimester exposure to metformin and risk of birth defects: A systematic review and meta-analysis. Knip M, Akerblom HK, Becker D, et al. A comparison of lispro and regular insulin for the management of type 1 and type 2 diabetes in pregnancy. Curr Diab Rep 2013;13:6–11. 2018 Nov;40(11):1484-1489. doi: 10.1016/j.jogc.2018.06.024. Women with type 1 and type 2 diabetes have a 40% to 45% incidence of hypertension complicating pregnancy (31). Diagnostic value of haemoglobin A1c in postpartum screening of women with gestational diabetes mellitus. First-trimester fasting hyperglycemia and adverse pregnancy outcomes. Werner EF, Has P, Tarabulsi G, et al. Hod M, Damm P, Kaaja R, et al. Furthermore, a subanalysis of another trial follow-up study revealed that comparison by age at follow up 5 to 6 vs. 7 to 10 years old did not influence their findings (458). … The HAPO offspring study extended their follow up to 5- to 7-year-olds and found that after adjustment for maternal BMI, higher maternal plasma glucose (PG) concentrations during pregnancy were not a risk for childhood obesity (455). Gestational diabetes mellitus in early pregnancy: Evidence for poor pregnancy outcomes despite treatment. This rapid increase in insulin sensitivity is related to the drop in circulating placental hormones (hPL, HGH) and, as a result, intravenous insulin infusion or CSII basal insulin should be immediately decreased by at least 50% after delivery to avoid hypoglycemia (175,178). Overall, it is understood that pregnant women have lower BG values that can be judged as normal even if below the traditional level of 4.0 mmol/L. Coop C, Edlin R, Brown J, et al. Brunner S, Stecher L, Ziebarth S, et al. It can be argued that these studies were not powered enough to demonstrate any impact on birthweight or on adverse pregnancy outcomes. Observational studies have linked maternal GDM with poor metabolic outcomes in offspring (451). Association of breastfeeding and early childhood overweight in children from mothers with gestational diabetes mellitus. Management of the insulindependent diabetic during labor and delivery. Jovanovic L, Druzin M, Peterson CM. J Clin Endocrinol Metab 2016;101:1598–605. Diabetes Care 2016;39:75–81. The cumulative risk increases markedly in the first 5 years and more slowly after 10 years (404,405). Bullo M, Tschumi S, Bucher BS, et al. J Am Diet Assoc 1995;95:460–7. Lassi ZS, Imam AM, Dean SV, et al. Lancet 1982;1:1150–2. Silver Spring: U.S. Food and Drug Administration, 2015 https://www.accessdata.fda.gov/scripts/cder/safetylabelingchanges/. Catalano PM, Drago NM, Amini SB. Exclusive breastfeeding to reduce the risk of childhood overweight and obesity. Effective contraception should be provided until the woman is ready for pregnancy. Schoen S, Sichert-HellertW, Hummel S, et al. Patient education with prenatal information and postnatal counselling on breastfeeding have been shown to lead to similar breastfeeding rates in women with type 1 diabetes as the population without diabetes (181). Gestational diabetes and the incidence of type 2 diabetes: A systematic review. There is insufficient evidence to confirm safety or harm from the use of intravitreal antivascular endothelial growth factor (anti-VEGF) injections for diabetic macular edema or proliferative diabetic retinopathy during pregnancy (35). Feng Y, Yang H. Metformin—a potentially effective drug for gestational diabetes mellitus: A systematic review and meta-analysis. The research evidence for glargine are more limited (cohort and case control studies); however, in a meta-analysis of cohort studies comparing glargine to NPH, maternal and fetal outcomes were similar (142) and no adverse maternal or fetal effects have been described to date. Women with type 2 diabetes who conceive on metformin or glyburide can continue these agents until insulin is initiated. The impact of ethnicity on glucose regulation and the metabolic syndrome following gestational diabetes. Carral F, Ayala Mdel C, Fernández JJ, et al. The Toronto Tri-Hospital Gestational Diabetes Project. Diabet Med 2000;17:26–32. PLoS ONE 2014;9:e102144. Findings of cohort studies with pregnant women with type 2 diabetes who had overweight or obesity showed that weight gain greater than the IOM recommendations was associated with increased macrosomia (122–124), LGA (124), adverse neonatal outcomes (123) and higher rates of caesarean deliveries (122,123). Preconception care should also include advice regarding folic acid supplementation. Diabetes Care 2013;36:1384–95. Preconception care: Screening and management of chronic disease and promoting psychological health. Evaluation of the value of fasting plasma glucose in the first prenatal visit to diagnose gestational diabetes mellitus in China. This guideline aims to improve the diagnosis of gestational diabetes and help women with diabetes to self-manage their blood glucose levels before and during pregnancy. Justification for supporting universal screening for GDM is outlined in detail in the 2013 CPG (260). Am J Obstet Gynecol 2009;201:339, e1-14. The outcomes of gestational diabetes mellitus after a telecare approach are not inferior to traditional outpatient clinic visits. BMC Public Health 2014;14:1267. WHO Technical Staff. Neubauer SH, Ferris AM, Chase CG, et al. Frequent SMBG is essential to guide therapy of GDM (331,333). Alberico S, Erenbourg A, Hod M, et al. Screening for gestational diabetes mellitus: Are the criteria proposed by the international association of the Diabetes and Pregnancy Study groups cost-effective? However, since the hypoglycemia level is often individualized to each person with diabetes, with consideration of symptoms, therapy, medical condition and associated risk; the official lower limit of BG level during pregnancy is difficult to clearly establish. A larger cohort trial using a 75 g OGTT for screening high-risk women earlier in pregnancy continued to show higher rates of hypertensive disorders, preterm delivery, caesarean section rates, macrosomia, and neonatal intensive care despite intervention (254). However, a study of intermittent real-time CGM did not demonstrate benefit (112). There are no data to date on faster-acting insulin aspart. Diabetes Control and Complications Trial Research Group, The Diabetes Control and Complications Trial Research Group. However, a large retrospective cohort (166) showed an increased risk of stillbirth in women with GDM between 36 to 39 weeks of gestation (unadjusted OR 1.1–2.00). CPG Diabetes in Pregnancy: Management of Diabetes and its Complications from Preconception to the Postnatal Period [NICE NG3] Dec 16, 2020 . Until this data are available, women with GDM should be encouraged to gain weight as per the IOM guidelines for the BMI category to reduce adverse maternal and neonatal outcomes and postpartum weight retention. Obstet Gynecol 2012;120:746–52. However, large, well-conducted and randomized controlled trials comparing different BG targets are needed to directly address optimal fasting and postprandial BG targets. J Clin Endocrinol Metab 2013;98:4319–24. The effect of lifestyle intervention and metformin on preventing or delaying diabetes among women with and without gestational diabetes: The Diabetes Prevention Program outcomes study 10-year follow-up. quiz 57-9. There are very few studies (although many published protocols) that examine the best method of managing glycemia during labour (387,388). Clinical value of detecting microalbuminuria as a risk factor for pregnancy-induced hypertension in insulintreated diabetic pregnancies. Langer O, Yogev Y, Most O, et al. Lawrence JM, Black MH, Hsu JW, et al. Diabet Med 2016;33: Fresa R, Visalli N, Di Blasi V, et al. Nat Rev Endocrinol 2012;8:659–67. An analysis of more than 1,000 women found that a history of gestational diabetes (diabetes during pregnancy) doubled the risk of heart artery calcification – a marker of increased risk for heart disease – many years after pregnancy, at the average age of 48, even if blood sugar returned to healthy levels. Included are recommendations for blood glucose targets and monitoring … No benefit was observed for women planning a pregnancy (113). Hypertens Pregnancy 2015;34:181–203. During pregnancy, serum creatinine (not eGFR) should be used, as eGFR will underestimate GFR in pregnancy (57,58). Noninsulin antihyperglycemic agents should only be discontinued once insulin is started [Grade D, Consensus]. Diabet Med 2009;26:824–6. In women suspected of preterm delivery, 2 doses of betamethasone is often given to aid in the maturation of the fetal lungs. After 16 years, 40% of women with prior GDM will develop type 2 diabetes (413). Acceptable methods of assessment of fetal well-being near term can include the nonstress test, amniotic fluid index, biophysical profile or a combination of these. Data are lacking to guide treatment recommendations for diabetic macular edema during pregnancy. Maternal and neonatal outcomes in women undergoing bariatric surgery: A systematic review and meta-analysis. Diabetes Care 1992;15:1323–7. Markedly different rates of incident insulin treatment based on universal gestational diabetes mellitus screening in a diverse HMO population. Bao W, Bowers K, Tobias DK, et al. Does insulin secretion in patients with one abnormal glucose tolerance test value mimic gestational diabetes mellitus? Differences in breast-feeding initiation and continuation by maternal diabetes status. Pregnancy reduces the accuracy of the estimated glomerular filtration rate based on Cockroft-Gault and MDRD formulas. In conclusion, diabetic and hyperlipidemic pregnancy induces neurological, metabolic, and epigenetic alterations in the rat fetus. Clin Invest Med 1996;19:406–15. Dietary insulin as an immunogen and tolerogen. Farrar D, Duley L, Medley N, et al. Gestational diabetes diagnostic criteria: Long-term maternal follow-up. Efficacy, safety and lack of immunogenicity of insulin aspart compared with regular human insulin for women with gestational diabetes mellitus. Hormonal counterregulation and subjective symptoms during induced hypoglycemia in insulin-dependent diabetes mellitus patients during and after pregnancy. In 1 small cohort study, early intervention appeared to lower the risk of preeclampsia (249). Although the rapid-acting bolus analogues aspart and lispro can help achieve postprandial targets without causing severe hypoglycemia (356–358), improvements in fetal outcomes have not been demonstrated with the use of aspart or lispro compared to regular insulin (356,357) (see Pre-Existing Diabetes (Type 1 and Type 2) in Pregnancy: Pharmacological therapy). Strategies in the nutritional management of gestational diabetes. Painful peripheral neuropathy management. Considering the heterogeneity of GDM, it seems obvious that tailored recommendations will emerge for each identified group of at-risk women. Since no exercise-related injuries were experienced during pregnancy in all those studies, physical activity intervention seems safe to recommend. Dunne FP, Chowdhury TA, Hartland A, et al. Thaware PK, McKenna S, Patterson CC, et al. Acta Obstet Gynecol Scand 2014;93:144–51. London, UK: National Institute for Health and Care Excellence (NICE), 2015. https://www.nice.org.uk/guidance/ng3. More studies are needed to assess the benefits of CGM in this population. Sometimes a woman with gestational diabetes must also take insulin. Cochrane Database Syst Rev 2015;(4):CD010443. However, it was recognized that the IADPSG 1-step strategy has the potential to identify a subset of women who would not otherwise be identified as having GDM and could potentially benefit with regards to certain perinatal outcomes. [Grade C, Level 3]. Gestational diabetes screening with the new IADPSG guidelines: A cost-effectiveness analysis. LeFevre ML, U.S. Preventive Services Task Force. Hypertension. Breastfeeding habits in families with Type 1 diabetes. Results of a systematic review of studies examining the 1990 IOM recommendations for maternal weight gain in women without diabetes, showed that those who followed guidelines were more likely to have good infant birthweight and fetal growth, and decreased the amount of weight loss required postpartum (118). Women with diabetes should be helped to achieve optimal glycemic control preconception as this is associated with a reduction of congenital anomalies by 70% (6–9). Obstet Gynecol 2006;108:1456–62. polycystic ovary syndrome, women with overweight or obesity, some specific ethnic groups), A combination of factors (e.g. Mello G, Biagioni S, Ottanelli S, et al. Phone: (632) 89212479; 89219420; 73415341; 89220195 Fax: (632) 89219089 Email: [email protected] Health Promot J Austr 2009;20:20–5. SMBG 4 to 7 times per day is also recommended for pregnant women with type 2 diabetes (i.e. Diabetes Care 2010;33:2514–20. Update to CDC’s U.S. medical eligibility criteria for contraceptive use, 2010: revised recommendations for the use of contraceptivemethods during the postpartum period. Lowe WL Jr, Scholtens DM, Sandler V, et al. Gunderson EP, Jacobs DR Jr, Chiang V, et al. Nutrition for healthy term infants, birth to six months: An overview. Feghali M, Khoury JC, Shveiky D, et al. Mar 1, 2018 . Long-term metabolic impact of fetal exposure to maternal GDM. Restricted Content News (18) Events (63) Guidelines (22) Programmes (6) Career & Practices (10) Useful Links Technical Problems? Kekäläine P, Juuti M, Walle T, et al. Asbjörnsdóttir B, Rasmussen SS, Kelstrup L, et al. Krakowiak P,Walker CK, Bremer AA, et al. Finally, results of meta-analyses on interventions based solely on physical activity programs to prevent GDM are not impressive (small protective effect [230] vs. nonsignificant impact [225]) and studies seem often underpowered with suspected low protocol adherence. Patterns of glycemia in normal pregnancy: Should the current therapeutic targets be challenged? CPG Diabetes in Pregnancy: Management of Diabetes and its Complications from Preconception to the Postnatal Period [NICE NG3] Dec 16, 2020 . A low glycemic index staple diet reduces postprandial glucose values in Asian women with gestational diabetes mellitus. Longer duration and more intense breastfeeding is associated with less diabetes in the mother with hazard ratios as low as 0.43 (395). Neff KJ, Forde R, Gavin C, et al. Evers IM, de Valk HW, Visser GH. Diabetes Care 2013;36:1102–6. Atlanta: Centers for Disease Control and Prevention, 2011. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6026a3.htm?s_cid=mm6026a3_w. In addition, most women are unable to return to prepregnancy weight (183). Breastfeeding and the maternal risk of type 2 diabetes: A systematic review and dose-responsemeta-analysis of cohort studies. Lv S, Wang J, Xu Y. In another follow-up study of infants exposed to metformin during pregnancies with gestational diabetes, children exposed to metformin weighed more at the age of 12 months, and were heavier and taller at 18 months, however, body composition was similar (368) as was motor, social and linguistic development. Diabetologia 2010;53:452–7. However, a nonsignificant trend toward lower requirements in exclusively breastfeeding mothers compared to partial or full formula feeding was also noted (176). Previous vol/issue. Venous thrombo-embolic disease during pregnancy and the puerperium. All together, current knowledge suggests that physical activity interventions in women with GDM should be encouraged unless obstetrical contraindications exist as physical activity may be an important component of GDM management. For women with type 1 or type 2 diabetes, it’s important to see your doctor before getting pregnant. Fetal and perinatal outcomes in type 1 diabetes pregnancy: A randomized study comparing insulin aspart with human insulin in 322 subjects. Treatment reduces these adverse pregnancy outcomes. They found that significantly less women developed glycemic disorders in the intervention group (42% vs. 58%) (450). Use of new technologies and web-based platforms for BG monitoring in pregnant women with diabetes in Canada and worldwide is rapidly increasing. It is difficult to apply the results of these studies to clinical practice due to their retrospective nature and the wide variation in the comparison groups used. Diabetes Technol Ther 2016;18:144–50. Riddle SW, Nommsen-Rivers LA. In contrast, results from other studies found no association with decreasing insulin requirements and birthweight, and neonatal weight distribution (i.e. Handisurya A, Bancher-Todesca D, Schober E, et al. The best way to manage women with GCK mutation during pregnancy has yet to be established, but regular fetal growth assessment can aid in the establishment of appropriate glucose targets during pregnancy for women with documented or strongly suspected GCK mutations. The HAPO study was the largest prospective study of glycemia in pregnancy and reported a mean FBG of 4.5±0.4 mmol/L, derived from 23,316 pregnant women (273). Studies comparing pregnancy outcomes before and after changing from a variety of different GDM diagnostic criteria to the IADPSG criteria show differing results. First Nations offspring had … Longer-term follow up is not yet available. Obstet Gynecol 2016;127:10–17. Weight gain during pregnancy: reexamining the guidelines. Assessment and management of complications, Fetal surveillance and timing of delivery, Fetal surveillance and timing of delivery in GDM. Ann Pharmacother 2011;45:9–16. All women at risk for or diagnosed with GDM should be assessed, counselled and followed up by a registered dietitian when possible (304–306). It aims to improve the diagnosis of gestational diabetes and help women with diabetes to self-manage their blood glucose levels before and during pregnancy. BJOG 2007;114:104–7. Fadl H, Ostlund I, Nilsson K, et al. J Endocrinol Invest 2004;27:629–35. When making decisions regarding timing of delivery before 40 weeks' gestation, the benefits with regards to prevention of stillbirth and a possible decrease in the caesarean rate need to be weighed against the likely increase in neonatal complications. Inadequate weight gain in overweight and obese pregnant women: What is the effect on fetal growth? Breastfeeding and the basal insulin requirement in type 1 diabetic women. Retrospective cohort studies of GDM pregnancies show that only 31.7% (296) to 42% (297) had GWG within IOM guidelines. Biological, behavioural and contextual rationale. Probiotics combined with diet and myo-inositol have shown benefit for GDM prevention (226), but these nutritional supplements were assessed in only 1 trial each. A diagnosis of GDM is made if one plasma glucose value is abnormal (i.e. Untreated gestational diabetes leads to increased maternal and perinatal morbidity. Diabetes Care 2014;37:3345–55. Obstet Gynecol 2015;125:576–82. All rights reserved. Obstet Gynecol 2005;105:1437–41. Ratner RE, Christophi CA, Metzger BE, et al. Intrapartum maternal glycemic control in women with insulin requiring diabetes: A randomized clinical trial of rotating fluids versus insulin drip. A Look at Two New Diabetes and Pregnancy Guidelines Gestational diabetes mellitus (GDM) is one of the most common medical complications of pregnancy. Randomized trial evidence suggests levemir is safe and may afford less maternal hypoglycemia compared to neutral protamine hagedorn (NPH), while observational studies suggest that glargine, although theoretically less desirable, is also safe. Metabolic control and progression of retinopathy. McGovern A, Butler L, Jones S, et al. Acta Paediatr 2015;104:30–7. Diabetes Care 2010;33:9–16. Three case series found metformin in the milk and plasma of breastfeeding women who were taking metformin 500 mg 2 or 3 times daily, but infant exposure was well below the 10% “level of concern” (0.182% to 0.65%) (200–202). Further studies are needed involving larger populations to enable the prescription of an evidence-based physical activity intervention. Breastfeeding for more than 4 months has also been shown to be protective against the development of diabetes (OR 0.29, 95% CI 0.13–0.63) at 21 years of age in a cohort of 3,595 young adults (212). Diabetes Technol Ther 2012;14:624–9. Bagg W, Henley PG, Macpherson P, et al. [2008] 1.1.3 . Holing EV, Beyer CS, Brown ZA, et al. congenital heart disease, and caudal re-gression, directly proportional to eleva-tions in A1C during the first 10 weeks of ... S138 Management of Diabetes in Pregnancy Diabetes Care Volume 41, Supplement 1, January 2018. Excretion of metformin into breast milk and the effect on nursing infants. Risk of postpartum thyroid dysfunction. Longitudinal changes in pancreatic betacell function and metabolic clearance rate of insulin in pregnant women with normal and abnormal glucose tolerance. Diabetes Care 2001;24:1904–10. Diet and exercise interventions for preventing gestational diabetes mellitus. For more information on the Diabetes Pregnancy conference, download our programme. Prevention of diabetes in women with a history of gestational diabetes: Effects of metformin and lifestyle interventions. Similarly, another retrospective study found that women using CSII had excellent glycemic control without hypoglycemia (173). Diabet Med 2013;30:1374–81. Given the lack of agreement that persists in the international community, the 2013 Canadian Diabetes Association Expert Committee acknowledged the controversy and opted to continue to recommend the “preferred” sequential 2-step approach (Figure 1) while recognizing the option of the 1-step IADPSG approach as an “alternative” strategy (Figure 2) (260). HAPO Study Cooperative Research Group, Metzger BE, Lowe LP, et al. Therefore, a diagnostic strategy consistent with the IADPSG approach of a 1-step 75 g OGTT using the glucose thresholds that result in an OR of 1.75 for the risk of LGA and cord C-peptide was added as an “alternative” method (Figure 2). All women with pre-existing type 1 or type 2 diabetes should receive preconception care to optimize glycemic control, assess for complications, review medications and begin folic acid supplementation. Kachoria R, Oza-Frank R. Receipt of preconception care among women with prepregnancy and gestational diabetes. PLoS ONE 2014;9:e109985. Horvath K, Koch K, Jeitler K, et al. Milk insulin, GH and TSH: Relationship to changes in milk lactose, glucose and protein during lactogenesis in women. Biesenbach G, Grafinger P, Stöger H, et al. The International Federation of Gynecology and Obstetrics (FIGO) Initiative on gestational diabetes mellitus: A pragmatic guide for diagnosis, management, and care. Targets for Glycemic Control A1C Targets ≤6.5 Adults with type 2 diabetes to reduce the risk of CKD and retinopathy if at low risk of hypoglycemia Avoid higher A1C to minimize risk of symptomatic hyperglycemia and acute Sacks DA, Chen W, Wolde-Tsadik G, et al. Curet LB, Izquierdo LA, Gilson GJ, et al. Feig DS, Briggs GG, Kraemer JM, et al. Stewart ZA, Wilinska ME, Hartnell S, et al. N Engl J Med 2009;361:1339–48. Hod M, Kapur A, Sacks DA, et al. Falavigna M, Schmidt MI, Trujillo J, et al. Rapid-acting bolus analogues (e.g. Health-care providers should discuss appropriate weight gain and healthy lifestyle interventions regularly throughout pregnancy [Grade D, Consensus]. These forms of monogenetic diabetes have greater increased risk of macrosomia and neonatal hypoglycemia that may be prolonged especially in neonates that have MODY 1 (HNF4 alpha mutation). Wong T, Barnes RA, Ross GP, et al. Recurrence of gestational diabetes mellitus. Laser photocoagulation for severe nonproliferative or proliferative retinopathy prior to pregnancy reduces the risk of visual impairment in pregnancy (34); if not performed prior to pregnancy, it is still considered safe to receive during pregnancy. In combination with nutritional intervention, physical activity appears to be more effective for GDM management than GDM prevention. Long-acting insulin analogues, glargine and detemir, appear safe with similar maternal and fetal outcomes compared to neutral protamine hagedorn (NPH) insulin. The optimal frequency of A1C measurement is not known; however, testing more than the usual every 3 months may be appropriate (see Monitoring Glycemic Control chapter, p. S47).
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