ada gestational diabetes guidelines 2021

Comprehensive nutrition assessment and recommendations for: Correction of dietary nutritional deficiencies, Comprehensive diabetes self-management education. As part of the American Diabetes Association Precision Medicine in Diabetes Initiative (PMDI) - a partnership with the European Association for the Study of Diabetes (EASD) - this systematic review is part of a comprehensive evidence evaluation in support of the 2nd International Consensus Report on Precision Diabetes Medicine. Join the fight with us on Facebook (American Diabetes Association), Twitter (@AmDiabetesAssn) and Instagram (@AmDiabetesAssn). A, 14.3 Preconception counseling should address the importance of achieving glucose levels as close to normal as is safely possible, ideally A1C <6.5% (48 mmol/mol), to reduce the risk of congenital anomalies, preeclampsia, macrosomia, preterm birth, and other complications. Antihypertensive drugs known to be effective and safe in pregnancy include methyldopa, nifedipine, labetalol, diltiazem, clonidine, and prazosin. However, predictive low glucose suspend (PLGS) technology has been shown in nonpregnant people to be better than sensor augment technology (SAP) for reducing low glucoses (103). The importance of preconception care for all women is highlighted by the American College of Obstetricians and Gynecologists (ACOG) Committee Opinion 762, Prepregnancy Counseling (17). Concentrations of glyburide in umbilical cord plasma are approximately 5070% of maternal levels (70,71). Insulin sensitivity then returns to prepregnancy levels over the following 12 weeks. Blood pressure should be measured at routine diabetes visits per ADA guidelines. DKA carries a high risk of stillbirth. The U.S. Preventive Services Task Force recommends the use of low-dose aspirin (81 mg/day) as a preventive medication at 12 weeks of gestation in women who are at high risk for preeclampsia (108). Patterns of glycemia in normal pregnancy: should the current therapeutic targets be challenged? Diabetes has brought us together. Offspring with exposure to untreated GDM have reduced insulin sensitivity and -cell compensation and are more likely to have impaired glucose tolerance in childhood (51). Referral to an RD/RDN is important in order to establish a food plan and insulin-to-carbohydrate ratio and to determine weight gain goals. 112). Type 2 diabetes is often associated with obesity. In women with normal pancreatic function, insulin production is sufficient to meet the challenge of this physiological insulin resistance and to maintain normal glucose levels. Management of diabetes in pregnancy: Standards of Medical Care in Diabetes2022. The insulin requirement levels off toward the end of the third trimester with placental aging. Women of reproductive age with prediabetes may develop type 2 diabetes by the time of their next pregnancy and will need preconception evaluation. 2021; 44 (Supplement 1):S15-S33. By continuing to use our website, you are agreeing to, Justice, Equity, Diversity, and Inclusion, Institutional Subscriptions and Site Licenses, Management of Gestational Diabetes Mellitus, Management of Preexisting Type 1 Diabetes and Type 2 Diabetes in Pregnancy, https://www.ncbi.nlm.nih.gov/books/NBK196392/, https://diabetesjournals.org/journals/pages/license. Pregnancy is a ketogenic state, and women with type 1 diabetes, and to a lesser extent those with type 2 diabetes, are at risk for diabetic ketoacidosis (DKA) at lower blood glucose levels than in the nonpregnant state. B. C. Pregnancy in women with normal glucose metabolism is characterized by fasting levels of blood glucose that are lower than in the nonpregnant state, due to insulin-independent glucose uptake by the fetus and placenta, and by mild postprandial hyperglycemia and carbohydrate intolerance as a result of diabetogenic placental hormones. There are no adequate data on optimal weight gain versus weight maintenance in women with BMI >35 kg/m2. E, 14.12 Commonly used estimated A1C and glucose management indicator calculations should not be used in pregnancy as estimates of A1C. All women of childbearing age with diabetes should be informed about the importance of achieving and maintaining as near euglycemia as safely possible prior to conception and throughout pregnancy. None of the current hybrid closed-loop insulin pump systems achieve pregnancy targets. 190: Gestational Diabetes Mellitus. A recent meta-analysis concluded that metformin exposure resulted in smaller neonates with acceleration of postnatal growth resulting in higher BMI in childhood (74). In a pregnancy complicated by diabetes and chronic hypertension, a target goal blood pressure of 110135/85 mmHg is suggested to reduce the risk of uncontrolled maternal hypertension and minimize impaired fetal growth (102104). Given that early pregnancy is a time of enhanced insulin sensitivity and lower glucose levels, many women with type 1 diabetes will have lower insulin requirements and increased risk for hypoglycemia (29). More information is available at, This site uses cookies. Due to the complexity of insulin management in pregnancy, referral to a specialized center offering team-based care (with team members including maternal-fetal medicine specialist, endocrinologist or other provider experienced in managing pregnancy in women with preexisting diabetes, dietitian, nurse, and social worker, as needed) is recommended if this resource is available. Due to the complexity of insulin management in pregnancy, referral to a specialized center offering team-based care (with team members including maternal-fetal medicine specialist, endocrinologist or other provider experienced in managing pregnancy in women with preexisting diabetes, dietitian, nurse, and social worker, as needed) is recommended if this resource is available. Therefore, all women with diabetes of childbearing potential should have family planning options reviewed at regular intervals to make sure that effective contraception is implemented and maintained. However, there are insufficient data regarding the benefits of aspirin in women with preexisting diabetes (110). On the basis of available evidence, statins should also be avoided in pregnancy (106). Target range 63140 mg/dL (3.57.8 mmol/L): TIR, goal >70%, Time below range (<63 mg/dL [3.5 mmol/L]), goal <4%, Time below range (<54 mg/dL [3.0 mmol/L]), goal <1%, Time above range (>140 mg/dL [7.8 mmol/L]), goal <25%, 15.13 Lifestyle behavior change is an essential component of management of gestational diabetes mellitus and may suffice for the treatment of many women. Evolving evidence for diabetes treatment for people also managing chronic kidney disease and heart failure; The use of technology for diabetes management and individualized care as well as recommendations for continuous glucose monitoring (CGM) for people with diabetes based on therapy; Important information on addressing social determinants of health in diabetes; Barriers to and critical times for diabetes self-management education and support (DSMES); Vaccine-specific updates, including those related to COVID-19. The international consensus on time in range (49) endorses pregnancy target ranges and goals for TIR for patients with type 1 diabetes using CGM as reported on the ambulatory glucose profile. In normal pregnancy, blood pressure is lower than in the nonpregnant state. This applies to women in the immediate postpartum period. Therefore, all women should be screened as outlined in Section 2, Classification and Diagnosis of Diabetes (https://doi.org/10.2337/dc22-S002). The American Diabetes Association (ADA) recently released its 2021 Standards of Medical Care, which provides healthcare professionals, researchers, and insurers with updated guidelines on diabetes care and management. 11 Once women achieve and maintain good glycemic control, the frequency of testing can be decreased. A complete list of members of the American Diabetes Association Professional Practice Committee can be found at https://doi.org/10.2337/dc22-SPPC. Women of reproductive age with prediabetes may develop type 2 diabetes by the time of their next pregnancy and will need preconception evaluation. Not only is the prevalence of type 1 diabetes and type 2 diabetes increasing in women of reproductive age, but there is also a dramatic increase in the reported rates of gestational diabetes mellitus. Why Does Exercise Sometimes Raise Blood Glucose (Blood Sugar)? However, due to the potential for growth restriction or acidosis in the setting of placental insufficiency, metformin should not be used in women with hypertension or preeclampsia or at risk for intrauterine growth restriction (88,89). One study showed that care of preexisting diabetes in clinics that included diabetes and obstetric specialists improved care (28). A recent Cochrane systematic review was not able to recommend any specific insulin regimen over another for the treatment of diabetes in pregnancy (90). Women with type 1 diabetes have an increased risk of hypoglycemia in the first trimester and, like all women, have altered counterregulatory response in pregnancy that may decrease hypoglycemia awareness. Preconception counseling using developmentally appropriate educational tools enables adolescent girls to make well-informed decisions (8). A cost-benefit analysis has concluded that this approach would reduce morbidity, save lives, and lower health care costs (100). In women taking insulin, particular attention should be directed to hypoglycemia prevention in the setting of breastfeeding and erratic sleep and eating schedules (115). Diabetes mellitus (also called "diabetes") is a condition in which too much glucose (sugar) stays in the blood instead of being used for energy. Clinical trials have not evaluated the risks and benefits of achieving these targets, and treatment goals should account for the risk of maternal hypoglycemia in setting an individualized target of <6% (42 mmol/mol) to <7% (53 mmol/mol). A. Although there is some heterogeneity, many randomized controlled trials (RCTs) suggest that the risk of GDM may be reduced by diet, exercise, and lifestyle counseling, particularly when interventions are started during the first or early in the second trimester (5254). In practice, it may be challenging for women with type 1 diabetes to achieve these targets without hypoglycemia, particularly women with a history of recurrent hypoglycemia or hypoglycemia unawareness. It may be suited for pregnancy because the predict low glucose threshold for suspending insulin is in the range of premeal and overnight glucoses targets in pregnancy and may allow for more aggressive prandial dosing. However, a meta-analysis and an additional trial demonstrate that low-dose aspirin <100 mg is not effective in reducing preeclampsia. 14.15 Metformin, when used to treat polycystic ovary syndrome and induce ovulation, should be discontinued by the end of the first trimester. In general, specific risks of diabetes in pregnancy include spontaneous abortion, fetal anomalies, preeclampsia, fetal demise, macrosomia, neonatal hypoglycemia, hyperbilirubinemia, and neonatal respiratory distress syndrome, among others. Gestational diabetes occurs when your body can't make enough insulin during your pregnancy. A meta-analysis of 32 RCTs evaluating the effectiveness of telehealth visits for GDM demonstrated reduction of incidences of cesarean delivery, neonatal hypoglycemia, premature rupture of membranes, macrosomia, pregnancy-induced hypertension or preeclampsia, preterm birth, neonatal asphyxia, and polyhydramnios compared with standard in-person care (57). B, 14.26 Women with a history of gestational diabetes mellitus should seek preconception screening for diabetes and preconception care to identify and treat hyperglycemia and prevent congenital malformations. Genetic carrier status (based on history): Nutrition and medication plan to achieve glycemic targets prior to conception, including appropriate implementation of monitoring, continuous glucose monitoring, and pump technology, Contraceptive plan to prevent pregnancy until glycemic targets are achieved, Management plan for general health, gynecologic concerns, comorbid conditions, or complications, if present, including: hypertension, nephropathy, retinopathy; Rh incompatibility; and thyroid dysfunction, Copyright American Diabetes Association. 2451 Crystal Drive, Suite 900 Arlington, VA 22202. Long-acting, reversible contraception may be ideal for many women. University of North Carolina, Chapel Hill. An observational cohort study that evaluated the glycemic variables reported using CGM found that lower mean glucose, lower standard deviation, and a higher percentage of time in target range were associated with lower risk of large-for-gestational-age births and other adverse neonatal outcomes (48). Diabetes-specific counseling should include an explanation of the risks to mother and fetus related to pregnancy and the ways to reduce risk including glycemic goal setting, lifestyle management, and medical nutrition therapy. Use of the CGM-reported mean glucose is superior to the use of estimated A1C, glucose management indicator, and other calculations to estimate A1C given the changes to A1C that occur in pregnancy (48). The 2015 study (116) excluded pregnancies complicated by preexisting diabetes, and only 6% had GDM at enrollment. E, 14.20 Potentially harmful medications in pregnancy (i.e., ACE inhibitors, angiotensin receptor blockers, statins) should be stopped at conception and avoided in sexually active women of childbearing age who are not using reliable contraception. Gestational diabetes mellitus (GDM) is a serious and frequent pregnancy complication that can lead to short and long-term risks for both mother and fetus. Every day more than 4,000 people are newly diagnosed with diabetes in America. After diagnosis, treatment starts with medical nutrition therapy, physical activity, and weight management, depending on pregestational weight, as outlined in the section below on preexisting type 2 diabetes, as well as glucose monitoring aiming for the targets recommended by the Fifth International Workshop-Conference on Gestational Diabetes Mellitus (54): Fasting glucose <95 mg/dL (5.3 mmol/L) and either, One-hour postprandial glucose <140 mg/dL (7.8 mmol/L) or, Two-hour postprandial glucose <120 mg/dL (6.7 mmol/L). Counseling on diabetes in pregnancy per current standards, including: natural history of insulin resistance in pregnancy and postpartum; preconception glycemic targets; avoidance of DKA/severe hyperglycemia; avoidance of severe hypoglycemia; progression of retinopathy; PCOS (if applicable); fertility in patients with diabetes; genetics of diabetes; risks to pregnancy including miscarriage, still birth, congenital malformations, macrosomia, preterm labor and delivery, hypertensive disorders in pregnancy, etc. Antihypertensive drugs known to be effective and safe in pregnancy include methyldopa, nifedipine, labetalol, diltiazem, clonidine, and prazosin. E, 14.27 Postpartum care should include psychosocial assessment and support for self-care. See pregnancy and antihypertensive medications in Section 10, Cardiovascular Disease and Risk Management (https://doi.org/10.2337/dc22-S010), for more information on managing blood pressure in pregnancy. These values represent optimal control if they can be achieved safely. Glyburide was associated with a higher rate of neonatal hypoglycemia and macrosomia than insulin or metformin in a 2015 meta-analysis and systematic review (65). Comprehensive nutrition assessment and recommendations for: Correction of dietary nutritional deficiencies, Comprehensive diabetes self-management education. Partner with Us. The diet should emphasize monounsaturated and polyunsaturated fats while limiting saturated fats and avoiding trans fats. Chronic diuretic use during pregnancy is not recommended as it has been associated with restricted maternal plasma volume, which may reduce uteroplacental perfusion (105). However, untreated or uncontrolled blood sugar levels can cause problems for you and your baby. As treatable as it is, gestational diabetes can hurt you and your baby. In the prospective Nurses' Health Study II (NHS II), subsequent diabetes risk after a history of GDM was significantly lower in women who followed healthy eating patterns (109). The American Diabetes Association (ADA) Standards of Medical Care in Diabetes includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Insulin resistance drops rapidly with delivery of the placenta. Given that early pregnancy is a time of enhanced insulin sensitivity and lower glucose levels, many women with type 1 diabetes will have lower insulin requirements and an increased risk for hypoglycemia (30). Long-term safety data for offspring exposed to glyburide are not available (66). Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. It is required that all programs that are accredited/recognized by ADCES and ADA meet these guidelines in order to bill for Medicare. Diabetes-specific counseling should include an explanation of the risks to mother and fetus related to pregnancy and the ways to reduce risk, including glycemic goal setting, lifestyle and behavioral management, and medical nutrition therapy. The food plan should provide adequate calorie intake to promote fetal/neonatal and maternal health, achieve glycemic goals, and promote weight gain according to 2009 Institute of Medicine recommendations (58). Insulin sensitivity then returns to prepregnancy levels over the following 12 weeks. The OGTT is recommended over A1C at 412 weeks postpartum because A1C may be persistently impacted (lowered) by the increased red blood cell turnover related to pregnancy, by blood loss at delivery, or by the preceding 3-month glucose profile. 15.14 Insulin is the preferred medication for treating hyperglycemia in gestational diabetes mellitus. If the pregnancy has motivated the adoption of a healthier diet, building on these gains to support weight loss is recommended in the postpartum period. Gestational diabetes mellitus is a condition in which carbohydrate intolerance develops during pregnancy. Standard care includes screening for sexually transmitted diseases and thyroid disease, recommended vaccinations, routine genetic screening, a careful review of all prescription and nonprescription medications and supplements used, and a review of travel history and plans with special attention to areas known to have Zika virus, as outlined by ACOG. The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Although observational studies are confounded by the association between elevated periconceptional A1C and other poor self-care behavior, the quantity and consistency of data are convincing and support the recommendation to optimize glycemia prior to conception, given that organogenesis occurs primarily at 58 weeks of gestation, with an A1C <6.5% (48 mmol/mol) being associated with the lowest risk of congenital anomalies, preeclampsia, and preterm birth (37). In the Metformin in Gestational Diabetes: The Offspring Follow-Up (MiG TOFU) studys analyses of 7- to 9-year-old offspring, the 9-year-old offspring exposed to metformin for the treatment of GDM in the Auckland cohort were heavier and had a higher waist-to-height ratio and waist circumference than those exposed to insulin (80). Women with preexisting diabetic retinopathy will need close monitoring during pregnancy to assess for progression of retinopathy and provide treatment if indicated (24). American Diabetes Association. Counseling on the specific risks of obesity in pregnancy and lifestyle interventions to prevent and treat obesity, including referral to a registered dietitian nutritionist (RD/RDN), is recommended when indicated. Health problems can occur when blood sugar is too high. Referral to an RD/RDN is important in order to establish a food plan and insulin-to-carbohydrate ratio and to determine weight gain goals. 203: Chronic Hypertension in Pregnancy, Less-tight versus tight control of hypertension in pregnancy, Treatment of hypertension in pregnant women, Risks of statin use during pregnancy: a systematic review, Progression to type 2 diabetes in women with a known history of gestational diabetes: systematic review and meta-analysis, Incidence rate of type 2 diabetes mellitus after gestational diabetes mellitus: a systematic review and meta-analysis of 170,139 women, Healthful dietary patterns and type 2 diabetes mellitus risk among women with a history of gestational diabetes mellitus, Interpregnancy weight change and risk of adverse pregnancy outcomes: a population-based study, Diabetes Prevention Program Research Group, Prevention of diabetes in women with a history of gestational diabetes: effects of metformin and lifestyle interventions, The effect of lifestyle intervention and metformin on preventing or delaying diabetes among women with and without gestational diabetes: the Diabetes Prevention Program outcomes study 10-year follow-up, Peripartum management of glycemia in women with type 1 diabetes, Changes in postpartum insulin requirements for patients with well-controlled type 1 diabetes, Breastfeeding and the basal insulin requirement in type 1 diabetic women, Duration of lactation and incidence of type 2 diabetes, Does breastfeeding influence the risk of developing diabetes mellitus in children? Metformin and glyburide should not be used as first-line agents, as both cross the placenta to the fetus.
Norwalk Shooting Yesterday, Extraordinary Times Fanfic, Seacroft Tip Shop, Michael Ealy Twin Brother, Conciertos En Guadalajara 2021, Articles A