Management of Diabetes in Pregnancy

Introduction to Glycemic Control

The American Diabetes Association recommends intensive glycemic control with insulin as first-line therapy, targeting fasting glucose <95 mg/dL and 1-hour postprandial <140 mg/dL, with preconception A1C <6.5% to minimize congenital malformations and adverse maternal-fetal outcomes 1, 2
Preconception counseling is essential for all women of childbearing age with diabetes to achieve near-euglycemia before pregnancy, as organogenesis occurs at 5-8 weeks gestation 1, 2

Target A1C <6.5% before conception to achieve the lowest risk of congenital anomalies, preeclampsia, and preterm birth 1, 2, 3
Effective contraception must be prescribed and used until glycemic targets are achieved 1, 3
Immediately discontinue ACE inhibitors, angiotensin receptor blockers, and statins due to teratogenic risk 1, 2, 3

Fasting plasma glucose should be <95 mg/dL and 1-hour postprandial <140 mg/dL 1, 3, 5, 6
Optimal target A1C is <6% if achievable without significant hypoglycemia 1, 3, 5, 6

Insulin is the preferred medication for managing both type 1 and type 2 diabetes in pregnancy because it does not cross the placenta to a measurable extent 7, 5, 6, 8
Either multiple daily injections or insulin pump technology can be used in type 1 diabetes 7

Consistent carbohydrate intake is important to match insulin dosing and avoid glucose fluctuations 8
The food plan should provide adequate calories to promote fetal/neonatal and maternal health, achieve glycemic goals, and promote appropriate gestational weight gain 5, 6

Women with type 1 or type 2 diabetes should be prescribed low-dose aspirin 60-150 mg/day by the end of the first trimester to lower the risk of preeclampsia 7

Women with preexisting diabetic retinopathy need close monitoring during pregnancy to assess for progression and provide treatment if indicated 1, 3, 2
Rapid implementation of euglycemia in the setting of retinopathy is associated with worsening of retinopathy 7

Insulin requirements decrease dramatically after delivery of the placenta 7, 8
Women with GDM should be tested for persistent diabetes or prediabetes at 4-12 weeks postpartum with a 75-g oral glucose tolerance test 9
A contraceptive plan should be discussed and implemented with all women with diabetes of reproductive potential 7