Management of Diabetes in Pregnancy

Preconception Planning

The American Diabetes Association recommends that women with preexisting diabetes achieve optimal glycemic control before conception to reduce risks of congenital malformations and spontaneous abortion, with a target A1C <6.5% before conception 3, 1
Women with preexisting diabetes should discontinue teratogenic medications including ACE inhibitors and statins, and initiate folic acid supplementation at 400 mg daily 4, 5, 1, 4
Comprehensive screening, including thyroid function, renal function, ophthalmologic examination, and cardiovascular assessment, should be completed before conception 1, 4
Effective contraception should be established until glycemic targets are achieved 1

The American College of Obstetricians and Gynecologists recommends glycemic targets of fasting glucose <95 mg/dL, 1-hour postprandial <140 mg/dL, and 2-hour postprandial <120 mg/dL for gestational diabetes mellitus (GDM) 3, 1
For preexisting type 1 or type 2 diabetes, the recommended glycemic targets are fasting 70-95 mg/dL, 1-hour postprandial 110-140 mg/dL, and 2-hour postprandial 100-120 mg/dL 6
The primary A1C target is <6% if achievable without significant hypoglycemia, with an alternative target of <7% if necessary to prevent hypoglycemia 3, 1

The American Diabetes Association recommends self-monitoring of blood glucose as the primary tool for glycemic management, with a focus on postprandial monitoring 7, 6
Continuous glucose monitoring (CGM) should be used as an adjunct to, not a replacement for, self-monitoring of blood glucose 3, 1
CGM reduces large-for-gestational-age births, neonatal hypoglycemia, and length of hospital stay in type 1 diabetes 8, 6

The American College of Obstetricians and Gynecologists recommends insulin as the preferred first-line medication for managing diabetes during pregnancy, with strict glycemic targets 1, 2
Insulin does not cross the placenta and is the safest pharmacologic option 2
Physiologic basal-bolus regimens with rapid-acting insulin for meals and long-acting insulin for basal coverage are recommended 4

The American College of Obstetricians and Gynecologists recommends initial management with medical nutrition therapy, exercise, and glucose monitoring, with insulin initiation if glucose targets are not achieved within 1-2 weeks 7
Treatment improves perinatal outcomes, including reduced macrosomia and birth complications 7

The American Diabetes Association recommends consistent carbohydrate intake to match insulin dosing and prevent glucose fluctuations, as well as regular moderate exercise 2, 1
Education on hypoglycemia recognition, prevention, and treatment is mandatory for all pregnant women with diabetes and their family members 2
Comprehensive ophthalmologic examination at baseline and as needed throughout pregnancy is recommended, with monitoring for progression of diabetic retinopathy 1

The American College of Obstetricians and Gynecologists recommends close monitoring and rapid insulin dose reduction in the immediate postpartum period to prevent hypoglycemia, as insulin requirements decrease dramatically after placental delivery 2
Women with GDM have an increased risk of developing type 2 diabetes and require postpartum screening 7