Management of Type 2 Diabetes in Pregnancy

Primary Treatment Approach

The American Diabetes Association recommends insulin as the preferred and first-line pharmacologic agent for managing type 2 diabetes in pregnancy, as it does not cross the placenta and provides the safest option for both mother and fetus 1, 2, 3

The American College of Obstetricians and Gynecologists recommends achieving the following blood glucose targets through frequent monitoring: fasting glucose 70-95 mg/dL, one-hour postprandial 110-140 mg/dL, and two-hour postprandial 100-120 mg/dL 1, 4
The American Diabetes Association recommends an A1C target of <6% to <7% (42-53 mmol/mol), individualized to avoid hypoglycemia 4, 3

The American College of Obstetricians and Gynecologists recommends beginning with medical nutrition therapy, physical activity, and weight management before initiating pharmacologic therapy, with minimum nutritional requirements of 175g carbohydrate, 71g protein, and 28g fiber daily 5
The American Diabetes Association recommends weight gain targets of 15-25 lb (6.8-11.3 kg) for overweight and 10-20 lb (4.5-9.1 kg) for obesity, and never recommending weight loss during pregnancy due to increased risk of small-for-gestational-age infants 1

The American Diabetes Association recommends using multiple daily injections with basal-bolus regimen or insulin pump technology, and expecting insulin requirements to double by the third trimester, with linear increases of approximately 5% per week starting around 16 weeks gestation 1, 2, 4

The American College of Obstetricians and Gynecologists recommends considering metformin as adjunctive therapy to insulin in type 2 diabetes, but not as monotherapy, due to lack of long-term safety data and potential risks 1, 2, 5

The American Heart Association recommends prescribing low-dose aspirin 100-150 mg daily starting at 12-16 weeks gestation to reduce preeclampsia risk, as diabetes significantly increases this risk 1, 2
The American College of Obstetricians and Gynecologists recommends immediately discontinuing ACE inhibitors, angiotensin receptor blockers, and statins at conception due to fetal risks 2

The American Diabetes Association recommends rapid implementation of euglycemia to avoid worsening retinopathy in those with existing disease, and screening for retinopathy before pregnancy and monitoring closely throughout 1
The American College of Obstetricians and Gynecologists recommends educating patients and family members on hypoglycemia prevention, recognition, and treatment before, during, and after pregnancy, as counter-regulatory responses are altered in pregnancy 1, 3

The American Diabetes Association recommends reducing insulin to 50% of end-pregnancy doses or 80% of pre-pregnancy doses after delivery, and monitoring closely for hypoglycemia, especially during breastfeeding 6

The American College of Obstetricians and Gynecologists recommends referring to a specialized center with multidisciplinary team due to the complexity of insulin management and high-risk nature of diabetic pregnancy 2