What is the recommended management for a pregnant woman with diabetes?

From the Guidelines

Pregnant women with diabetes should be managed with a multidisciplinary approach focusing on tight glycemic control, with lifestyle modifications and insulin therapy as the preferred treatment options. The management of diabetes in pregnancy is crucial to minimize the risks of macrosomia, birth defects, and other complications. According to the most recent guidelines, lifestyle behavior change is an essential component of management of gestational diabetes mellitus and may suffice as treatment for many individuals 1. Insulin should be added if needed to achieve glycemic targets.

Key Recommendations

• Insulin is the preferred medication for treating hyperglycemia in gestational diabetes mellitus, as metformin and glyburide should not be used as first-line agents due to their ability to cross the placenta to the fetus 1.
• Telehealth visits for pregnant people with gestational diabetes mellitus can improve outcomes compared with standard in-person care 1.
• Pregnant women with diabetes should maintain tight glycemic control, with fasting blood glucose levels below 95 mg/dL and 1-hour postprandial levels below 140 mg/dL, to minimize risks of complications.
• Regular monitoring is essential, including self-monitoring of blood glucose 4-7 times daily and HbA1c testing each trimester.
• Patients should also receive regular fetal assessment, including ultrasounds to monitor growth and development.

Treatment Options

• For women with type 1 diabetes, insulin remains the gold standard treatment, typically requiring increased dosing throughout pregnancy (often 2-3 times pre-pregnancy requirements by the third trimester) 1.
• For gestational diabetes or type 2 diabetes, lifestyle modifications including medical nutrition therapy and regular physical activity are first-line interventions, with insulin therapy initiated if glycemic targets are not achieved with lifestyle changes 1.

Preconception Counseling

• Preconception counseling for women with pre-existing diabetes is ideal, aiming for HbA1c below 6.5% before conception to reduce congenital malformation risk 1.

From the Research

Management of Diabetes in Pregnant Women

• The management of diabetes in pregnant women is crucial to minimize pregnancy risks and ensure the best possible outcomes for both the mother and the fetus 2.
• Preconception counseling is essential for women with diabetes to achieve tight glycemic control, with a hemoglobin A1c (A1C) level of less than 7% and as close to 6% as possible, without significant hypoglycemia 2.
• During pregnancy, the goal A1C is near-normal at less than 6%, without excessive hypoglycemia, and labor and delivery target plasma glucose levels are 80-110 mg/dl, with an insulin drip recommended to achieve these targets during active labor 2.

Insulin Therapy in Diabetes

• Insulin is the primary treatment in all patients with type 1 diabetes mellitus (T1DM) and is often required in patients with type 2 diabetes mellitus (T2DM) who have not achieved glycemic goals with oral antidiabetic medications 3.
• The target glycated hemoglobin A1c (HbA1c) for patients with T1DM is recommended to be less than 7.5%, and for patients with T2DM, insulin is considered when HbA1c is greater than or equal to 7.5% 3.
• Alternative agents, such as metformin, alpha-glucosidase inhibitors, pioglitazone, GLP-1 agonists, DPP-IV inhibitors, and SGLT-2 inhibitors, may be used in addition to insulin therapy to reduce insulin resistance and prevent or deter weight gain 4.

Glycemic Control in Diabetic Pregnancy

• Glucose is the principal nutrient that the mother supplies to the fetus through the placenta, and maternal hypoglycemia can lead to fetal hypoglycemia and hypoinsulinism, which may have both short- and long-term consequences 5.
• Overzealous glycemic control during pregnancy may raise concerns regarding the possible effects on the infant, and the question arises as to how tight is too tight in terms of glycemic control 5.
• The safety of medications should be assessed prior to conception, and optimal control of retinopathy, hypertension, and nephropathy should be achieved to minimize pregnancy risks 2.

Breastfeeding and Postpartum Care

• Breastfeeding is recommended and should be highly encouraged in women with diabetes due to maternal benefits, including increased insulin sensitivity and weight loss, and infant and childhood benefits, including reduced prevalence of overweight 2.
• Postpartum, insulin doses must be reduced and glucoses closely monitored in women with T1DM because of the enhanced insulin sensitivity after delivery 2.