From the Guidelines
Pregnant women with diabetes should be managed with a multidisciplinary approach focusing on tight glycemic control, with insulin as the preferred medication for treating hyperglycemia in gestational diabetes mellitus, as it does not cross the placenta to the fetus. The management of diabetes in pregnancy is crucial to minimize complications, and the approach should include lifestyle behavior change as an essential component, which may suffice as treatment for many individuals with gestational diabetes mellitus [ 1 ].
Key Recommendations
- Insulin should be added if needed to achieve glycemic targets [ 1 ]
- Metformin and glyburide should not be used as first-line agents, as both cross the placenta to the fetus [ 1 ]
- Telehealth visits for pregnant people with gestational diabetes mellitus improve outcomes compared with standard in-person care [ 1 ]
- Fasting and postprandial self-monitoring of blood glucose are recommended in both gestational diabetes mellitus and preexisting diabetes in pregnancy to achieve glycemic control [ 1 ]
Management Approach
The management approach should include medical nutrition therapy with carbohydrate counting and regular physical activity (30 minutes daily) [ 1 ]. Blood glucose monitoring should occur 4 times daily: fasting and 1 hour after each meal. If lifestyle modifications fail to achieve target glucose levels after 1-2 weeks, medication is indicated, with insulin as the first-line pharmacological treatment [ 1 ].
Insulin Therapy
Insulin therapy should be initiated with basal insulin (NPH or detemir) at 0.2-0.3 units/kg/day, with rapid-acting insulin (aspart or lispro) added before meals if needed [ 1 ]. For women with pre-existing type 1 diabetes, insulin pump therapy or multiple daily injections should be continued with dose adjustments as insulin requirements increase throughout pregnancy. Regular monitoring by an endocrinologist and obstetrician is essential, with fetal growth assessments and maternal HbA1c measurements every 4-6 weeks [ 1 ].
Benefits of Tight Glycemic Control
Tight glycemic control reduces risks of macrosomia, birth injuries, neonatal hypoglycemia, and maternal complications like preeclampsia and cesarean delivery [ 1 ]. The goal is to maintain fasting blood glucose levels below 95 mg/dL and 1-hour postprandial levels below 140 mg/dL to minimize complications.
From the Research
Management of Diabetes in Pregnant Women
- The management of diabetes in pregnant women is crucial to prevent complications for both the mother and the fetus 2.
- Glycemic control is essential, but overzealous control may lead to fetal growth restriction and other complications 2.
- The American College of Obstetricians and Gynecologists (ACOG) recommends that pregnant women with diabetes aim for a blood glucose level of less than 95 mg/dL before meals and less than 120 mg/dL after meals 3.
Glycemic Targets
- The glycemic targets for pregnant women with diabetes are:
- Fasting plasma glucose: ≤ 5.0-5.1 mmol/L
- Postprandial glucose: ≤ 6.7-7.4 mmol/L 3
- Tighter glycemic control may increase the risk of hypertensive disorders of pregnancy, but may also reduce the risk of composite mortality or serious infant morbidity 3.
Insulin Therapy
- Insulin therapy is often necessary for pregnant women with diabetes, especially those with type 1 diabetes 4.
- The goal of insulin therapy is to achieve optimal glycemic control while minimizing the risk of hypoglycemia and other complications 4.
- Alternative agents, such as metformin, alpha-glucosidase inhibitors, and GLP-1 agonists, may be used in addition to insulin therapy to improve glycemic control and reduce insulin resistance 5.
Monitoring and Adherence
- Regular monitoring of blood glucose levels and adherence to treatment plans are crucial for optimal management of diabetes in pregnant women 3, 6.
- Women with diabetes should work closely with their healthcare providers to develop a personalized treatment plan and make adjustments as needed throughout their pregnancy 3, 6.