Prenatal Care and Gestational Diabetes Management

Preconception Counseling and Medication Management

The American College of Obstetricians and Gynecologists recommends that women with preexisting diabetes discontinue ACE inhibitors and statins before conception, as they are associated with severe fetal malformations, and instead use pregnancy-safe antihypertensives like extended-release nifedipine 1, 2, 3
Women with type 2 diabetes should aim for an A1C target of <6.5% before conception to reduce the risk of congenital malformations 1, 4
Long-acting reversible contraception should be prescribed immediately to prevent pregnancy until optimization of glycemic control is achieved 3, 5

The American College of Obstetricians and Gynecologists recommends initiating low-dose aspirin (81-150 mg daily) before 16 weeks gestation in women with multiple major risk factors for preeclampsia, including prior preeclampsia, chronic hypertension, and BMI >35 4, 6

The American Diabetes Association recommends targeting fasting plasma glucose <95 mg/dL and either 1-hour postprandial <140 mg/dL OR 2-hour postprandial <120 mg/dL to minimize maternal and fetal complications 7, 4
The A1C target during pregnancy should ideally be <6% (42 mmol/mol) if achievable without significant hypoglycemia, but may be relaxed to <7% (53 mmol/mol) if necessary to prevent hypoglycemia 7

Women with preexisting diabetes should undergo dilated eye examination ideally before pregnancy or in the first trimester, then monitor every trimester throughout pregnancy and for 1 year postpartum, as pregnancy can accelerate diabetic retinopathy progression 1, 2, 7

The Society for Maternal-Fetal Medicine emphasizes the importance of multidisciplinary care, including an endocrinologist, maternal-fetal medicine specialist, registered dietitian nutritionist, and diabetes care and education specialist, for optimal management of pregestational diabetes in pregnancy 8, 2, 6

Women with pregestational diabetes require detailed fetal anatomy ultrasound between 16-22 weeks to detect congenital anomalies, and fetal echocardiogram should be scheduled between 16-22 weeks gestation 4, 6
Antepartum fetal surveillance should begin at 32-34 weeks for high-risk pregnancies, including pregestational diabetes 4, 6

The American College of Obstetricians and Gynecologists recommends prescribing folic acid 400-800 mg daily and potassium iodide 150 mg daily prior to conception or as soon as pregnancy is confirmed to reduce the risk of congenital malformations 2, 4

Women with gestational diabetes should undergo 75g oral glucose tolerance test at 4-12 weeks postpartum to reassess glucose tolerance, then continue glucose assessment every 2-3 years if glucose tolerance is normal 9