What is the management of diabetes in pregnancy?

Management of Diabetes in Pregnancy

The management of diabetes in pregnancy requires strict glycemic control with target fasting glucose <95 mg/dL, 1-hour postprandial glucose <140 mg/dL, and 2-hour postprandial glucose <120 mg/dL to optimize maternal and fetal outcomes. 1

Preconception Care

Glycemic Targets and Medication Management

• Target A1C <6% if achievable without significant hypoglycemia, or <7% if necessary to prevent hypoglycemia 1, 2
• Discontinue potentially teratogenic medications:
  • ACE inhibitors
  • Angiotensin receptor blockers
  • Statins
  • Non-pregnancy-safe glucose-lowering agents 1, 2
• Implement effective contraception until glycemic targets are achieved 1

Screening and Assessment

• Comprehensive eye examination in first trimester and monitoring each trimester 1
• Screen for nephropathy (urine albumin-to-creatinine ratio) 1
• Evaluate thyroid function (TSH) 1
• Screen for anemia and other comorbidities 1

Management During Pregnancy

Glucose Monitoring

• Fasting and postprandial self-monitoring of blood glucose is essential 1
• Target glucose levels:
  • Fasting: <95 mg/dL (5.3 mmol/L)
  • 1-hour postprandial: <140 mg/dL (7.8 mmol/L)
  • 2-hour postprandial: <120 mg/dL (6.7 mmol/L) 1
• Continuous glucose monitoring can help achieve targets but should not replace self-monitoring 1
• Do not use estimated A1C calculations during pregnancy 1

Medical Nutrition Therapy

• Referral to registered dietitian is important 1
• Establish food plan and insulin-to-carbohydrate ratios 1
• Recommend consistent carbohydrate intake to match insulin dosage 1
• Focus on nutrient-dense whole foods including fruits, vegetables, legumes, whole grains, and healthy fats 1
• Limit processed foods, fatty red meat, and sweetened foods/beverages 1
• Avoid severely restrictive diets (ketogenic, Paleo) 1

Insulin Therapy

• Insulin is the preferred agent for management of both type 1 and type 2 diabetes in pregnancy 1, 3
• Either multiple daily injections or insulin pump technology can be used 1
• Insulin requirements change throughout pregnancy:
  • Early pregnancy: enhanced insulin sensitivity, lower requirements
  • Second and third trimesters: exponential increase in insulin resistance requiring dose adjustments 1
  • Immediate postpartum: rapid drop in insulin requirements 1

Special Considerations

• Risk of hypoglycemia is increased in first trimester with decreased awareness 1
• Pregnancy is a ketogenic state with risk of diabetic ketoacidosis at lower blood glucose levels 1
• Prescribe ketone strips and provide education on DKA prevention and detection for women with type 1 diabetes 1
• Low-dose aspirin (81 mg/day) should be prescribed by the end of the first trimester to reduce preeclampsia risk 1

Management of Gestational Diabetes Mellitus (GDM)

• Initial management with lifestyle changes (diet and exercise) 1
• Add medications if glycemic targets not achieved with lifestyle modifications 1
• Insulin is preferred medication as it does not cross the placenta 1

Postpartum Care

• Insulin requirements drop rapidly with delivery of placenta 1
• Develop contraceptive plan 1, 2
• For GDM: 75g OGTT at 4-12 weeks postpartum 2
• Support breastfeeding 2

Common Pitfalls to Avoid

• Not adjusting insulin doses frequently enough to match changing requirements throughout pregnancy 2
• Relying solely on A1C instead of using both pre- and postprandial glucose values 2
• Using estimated A1C calculations during pregnancy 1, 2
• Inadequate preconception planning 2
• Rapid implementation of euglycemia in the setting of retinopathy (can worsen retinopathy) 1

By implementing these evidence-based strategies, healthcare providers can optimize outcomes for both mother and baby in pregnancies complicated by diabetes.