Diabetes and Pregnancy

Publication Date: November 1, 2013
Last Updated: August 22, 2022

Preconception Care

Preconception Care of Women with Diabetes

1.1. The Endocrine Society (ES) recommends preconception counseling be provided to all women with diabetes who are considering pregnancy. ( 1 , L )
  • Preconception counseling can optimally be provided by a multidisciplinary team that includes the diabetes specialist, diabetes educator, dietitian, obstetrician, and other healthcare providers, as indicated.
  • If possible, and with the patient’s consent, the woman’s partner can be included as part of a supportive and mentoring therapeutic relationship.
  • Preconception counseling should include a discussion regarding:
    • the need for pregnancy to be planned and to occur only when the woman has sufficient glycemic control, has had appropriate assessment and management of comorbidities including hypertension and retinopathy, has discontinued potentially unsafe (during pregnancy) medications, and has been taking appropriate folate supplementation beforehand
    • the importance of smoking cessation
    • the major time commitment and effort required by the patient in both self-management and engagement with the healthcare team, both before conception and during pregnancy
    • the importance of notifying the healthcare team without delay in the event of conception.
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Preconception Glycemic Control

1.2. ES suggests women with diabetes seeking to conceive strive to achieve blood glucose and HbA1c levels as close to normal as possible when they can be safely achieved without undue hypoglycemia. ( 2 , L )
(see Recommendations 3.2a-d and Table 3.)
700

Insulin Therapy

1.3a. ES recommends insulin-treated women with diabetes seeking to conceive be treated with multiple daily doses of insulin or continuous SC insulin infusion in preference to split-dose, premixed insulin therapy, because the former are more likely to allow for the achievement and maintenance of target blood glucose levels before conception and, in the event of pregnancy, are more likely to allow for sufficient flexibility or precise adjustment of insulin therapy. ( 1 , L )
700
1.3b. ES suggests a change to a woman’s insulin regimen, particularly when she starts continuous SC insulin infusion, be undertaken well in advance of withdrawing contraceptive measures or otherwise trying to conceive to allow the patient to acquire expertise in, and the optimization of, the chosen insulin regimen. (U, )
700
1.3c. ES suggests insulin-treated women with diabetes seeking to conceive be treated with rapid-acting insulin analog therapy (with insulin aspart or insulin lispro) in preference to regular (soluble) insulin. (2, L)
700
1.3d. ES suggests women with diabetes successfully using the long-acting insulin analogs insulin detemir or insulin glargine before conception may continue with this therapy during pregnancy. (2, L)
700

Folic Acid Supplementation

1.4. ES recommends, beginning 3 months before withdrawing contraceptive measures or otherwise trying to conceive, a woman with diabetes take a daily folic acid supplement to reduce the risk of neural tube defects. (1, L)
700
ES suggests a daily dose of 5 mg based on this dose’s theoretical benefits. (2, L)
700

Ocular Care (preconception, during pregnancy, and postpartum)

1.5a. ES recommends all women with diabetes who are seeking pregnancy have a detailed ocular assessment by a suitably trained and qualified eye care professional in advance of withdrawing contraceptive measures or otherwise trying to conceive, ( 1 , H )
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and if retinopathy is documented, the patient should be apprised of the specific risks to her of this worsening during pregnancy. If the degree of retinopathy warrants therapy, we recommend deferring conception until the retinopathy has been treated and found to have stabilized. ( 1 , H )
700
1.5b. ES recommends women with established retinopathy be seen by their eye specialist every trimester, then within 3 months of delivering, and then as needed. ( 1 , VL )
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1.5c. ES suggests pregnant women with diabetes not known to have retinopathy have ocular assessment performed soon after conception and then periodically as indicated during pregnancy. ( 2 , L )
700

Renal Function (preconception and during pregnancy)

1.6a. ES suggests all women with diabetes considering pregnancy have their renal function assessed (by measuring their urine albumin-to-creatinine ratio, serum creatinine, and estimated GFR) in advance of withdrawing contraceptive measures or otherwise trying to conceive. ( U , )
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ES suggests that a woman with diabetes who has a significantly reduced GFR be assessed by a nephrologist before pregnancy, both for baseline renal assessment and to review the woman’s specific risk of worsening renal function in the event of pregnancy. ( U , )
700
1.6b. ES suggests all women with diabetes and preconception renal dysfunction have their renal function monitored regularly during pregnancy. ( U , )
700

Management of Hypertension

1.7a. ES recommends satisfactory BP control (<130/80 mm Hg) be achieved and maintained before withdrawing contraception or otherwise trying to conceive. (1, L)
700
1.7b. ES recommends a woman with diabetes who is seeking conception while taking an ACE inhibitor or ARB in almost all cases should discontinue the medication before withdrawing contraceptive measures or otherwise trying to conceive. (1, L)
700
1.7c. ES suggests in the exceptional case where the degree of renal dysfunction is severe and there is uncertainty about when conception will occur, physicians and patients be engaged in shared decision-making about whether to continue ACE inhibitors or ARBs. These patients should be informed about the possible loss of renal protective properties if the medication is discontinued and the risk of teratogenesis if it is continued. (U, )
700
1.7d. ES recommends when ACE inhibitors or ARBs have been continued up to the time of conception that the medication should be withdrawn immediately upon the confirmation of pregnancy. (1, L)
700

Elevated Vascular Risk

1.8a. ES recommends that if a woman with diabetes has sufficient numbers of vascular risk factors (particularly the duration of the woman’s diabetes and her age), screening studies for CAD be undertaken in advance of withdrawing contraceptive measures or otherwise trying to conceive. (1, VL)
700
1.8b. ES recommends if a woman with diabetes is seeking pregnancy and has CAD, its severity should be ascertained, treatment instituted, and counseling provided as to the potential risks of pregnancy to the woman and fetus before the woman withdraws contraception or otherwise tries to conceive. ( 1 , H )
700

Management of Dyslipidemia

1.9a. ES recommends against the use of statins in women with diabetes who are attempting to conceive. ( 1 , L )
700
1.9b. In view of their unproven safety during pregnancy, ES suggests against the routine use of fibrates and/or niacin for women with diabetes and hypertriglyceridemia attempting to conceive. ( 2 , L )
700
1.9c. ES suggests bile acid-binding resins may be used in women with diabetes to treat hypercholesterolemia. However, this is seldom warranted. (2, L)
700

Thyroid Function

1.10. For women with type 1 diabetes seeking conception, ES recommends measurement of serum TSH and, if their thyroid peroxidase status is unknown, measurement of thyroid peroxidase antibodies before withdrawing contraceptive measures or otherwise trying to conceive. ( 1 , VL )
700

Overweight and Obesity

1.11. ES recommends weight reduction before pregnancy for overweight and obese women with diabetes. ( 1 , M )
700

Care During Pregnancy

Testing for Overt Diabetes in Early Pregnancy

2.1. ES recommends universal testing for diabetes (see Table 1) with a fasting plasma glucose, an HbA1c, or an untimed random plasma glucose at the first prenatal visit (before 13 weeks gestation or as soon as possible thereafter) for those women not known to already have diabetes. (1, L)
Note: In the case of overt diabetes, but not gestational diabetes, a second test (either fasting plasma glucose, untimed random plasma glucose, HbA1c, or OGTT) must be performed in the absence of symptoms of hyperglycemia and found to be abnormal on another day to confirm the diagnosis.
700

Testing for Gestational Diabetes at 24-28 Weeks Gestation

2.2. ES recommends pregnant women not previously identified (either during testing performed as per recommendation 2.1 or at some other time before 24 weeks gestation) as having overt diabetes or gestational diabetes be tested for gestational diabetes (see Table 2) by having a 2-hour, 75-g OGTT performed at 24-28 weeks gestation. ( 1 , M )
700
ES recommends that gestational diabetes be diagnosed with this test using the IADPSG criteria (majority opinion of this committee). (1, M)
700
Note: The 75-g OGTT should be performed after an overnight fast of 8-14 hours and without having reduced usual carbohydrate intake for the preceding several days. The test should be performed with the patient seated, and the patient should not smoke during the test. One or more abnormal values establishes the diagnosis, with the exception that in the case of overt diabetes, but not gestational diabetes, a second test (either fasting plasma glucose, untimed random plasma glucose, HbA1c or OGTT), in the absence of symptoms of hyperglycemia, must be performed and found to be abnormal on another day to confirm the diagnosis of overt diabetes.

Management of Elevated Blood Glucose

2.3a. ES recommends women with gestational diabetes target blood glucose levels as close to normal as possible. ( 1 , L )
700
2.3b. ES recommends the initial treatment of gestational diabetes should consist of medical nutrition therapy (see Section 4) and daily moderate exercise for 30 minutes or more. ( 1 , M )
700
2.3c. ES recommends using blood glucose-lowering pharmacologic therapy if lifestyle therapy is insufficient to maintain normoglycemia in women with gestational diabetes. (1, H)
700

3.0 Glucose Monitoring and Glycemic Targets

Self-monitoring of Blood Glucose
3.1. ES recommends self-monitoring of blood glucose in all pregnant women with gestational or overt diabetes (1, H)
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and suggests testing before and either 1 or 2 hours after the start of each meal (choosing the postmeal time when it is estimated that peak postprandial blood glucose is most likely to occur) and, as indicated, at bedtime and during the night. (2, L)
700
Glycemic Targets (Table 3)
3.2a. ES recommends pregnant women with overt or gestational diabetes strive to achieve a target preprandial blood glucose <95 mg/dL (5.3 mmol/L). ( 1 , L )
for fasting target,
700
(for other meals)
700
3.2b. ES suggests that an even lower fasting blood glucose target of <90 mg/dL (5.0 mmol/L) be strived for if this can be safely achieved without undue hypoglycemia. ( 2 , VL )
700
3.2c. ES suggests pregnant women with overt or gestational diabetes strive to achieve a target blood glucose level <140 mg/dL (7.8 mmol/L) 1 hour after the start of a meal and <120 mg/dL (6.7 mmol/L) 2 hours after the start of a meal ( 2 , VL )
when these targets can be safely achieved without undue hypoglycemia.
700
3.2d. ES suggests pregnant women with overt diabetes strive to achieve an HbA1c <7% (ideally <6.5%). ( 2 , VL )
700
Continuous Glucose Monitoring
3.3. ES suggests that continuous glucose monitoring be used during pregnancy in women with overt or gestational diabetes when self-monitored blood glucose levels (or, in the case of the woman with overt diabetes, HbA1c values) are not sufficient to assess glycemic control (including both hyperglycemia and hypoglycemia). (2, L)
700

4.0. Nutrition Therapy and Weight Gain Targets for Women With Overt or Gestational Diabetes

Nutrition Therapy

4.1. ES recommends MNT for all pregnant women with overt or gestational diabetes to help achieve and maintain desired glycemic control while providing essential nutrient requirements. ( 1 , L )
700
Weight Management
4.2a. ES suggests women with overt or gestational diabetes follow the IOM revised guidelines for weight gain during pregnancy (Table 4). (U, )
700
4.2b. ES suggests obese women with overt or gestational diabetes reduce their calorie intake by approximately one-third (compared with their usual intake before pregnancy) while maintaining a minimum intake of 1600-1800 kcal/d. (2, L)
700
Carbohydrate Intake
4.3. ES suggests women with overt or gestational diabetes limit carbohydrate intake to 35%-45% of total calories, distributed in 3 small- to moderate-sized meals and 2-4 snacks including an evening snack. (2, L)
700
Nutritional Supplements
4.4a. ES recommends pregnant women with overt or gestational diabetes should follow the same guidelines for the intake of minerals and vitamins as women without diabetes, ( 1 , L )
with the exception of taking folic acid 5 mg/d beginning 3 months before withdrawing contraceptive measures or otherwise trying to conceive (see Recommendation 1.4).
700
4.4b. ES suggests the dose of folic acid be reduced to 0.4-1.0 mg/d at 12 weeks gestation and continued until the completion of breastfeeding. (2, L)
700

5.0. Blood Glucose-Lowering Pharmacological Therapy During Pregnancy

Insulin Therapy

5.1a. ES suggests the long-acting insulin analog detemir may be initiated during pregnancy for those women who require basal insulin and for whom NPHinsulin, in appropriate doses, has previously resulted in, or for whom it is thought NPH insulin may result in, problematic hypoglycemia. Insulin detemir may be continued in those women with diabetes already successfully taking insulin detemir before pregnancy. ( 2 , H )
700
5.1b. ES suggests those pregnant women successfully using insulin glargine before pregnancy may continue it during pregnancy. (2, L)
700
5.1c. ES suggests the rapid-acting insulin analogs lispro and aspart be used in preference to regular (soluble) insulin in pregnant women with diabetes. (2, M)
700
5.1d. ES recommends the ongoing use of continuous SC insulin infusion during pregnancy in women with diabetes when this has been initiated before pregnancy (1, M)
700
but suggests that continuous SC insulin infusion NOT be initiated during pregnancy unless other insulin strategies including multiple daily doses of insulin have first been tried and proven unsuccessful. ( 2 , L )
700
Noninsulin Antihyperglycemic Agent Therapy
5.2a. ES suggests glyburide (glibenclamide) is a suitable alternative to insulin therapy for glycemic control in women with gestational diabetes who fail to achieve sufficient glycemic control after a 1-week trial of MNT and exercise, except for those women with a diagnosis of gestational diabetes before 25 weeks gestation and for those women with fasting plasma glucose levels >110 mg/dL (6.1 mmol/L), in which case insulin therapy is preferred. (2, L)
700
5.2b. ES suggests metformin therapy be used for glycemic control only for those women with gestational diabetes who do not have satisfactory glycemic control despite MNT and who refuse or cannot use insulin or glyburide and are not in the first trimester. (2, L)
700

Intra- and Postpartum Care

6.0 Labor, Delivery, Lactation, and Postpartum Care

Blood Glucose Targets During Labor and Delivery
6.1. ES suggests target blood glucose levels of 72-126 mg/dL (4.0-7.0 mmol/L) during labor and delivery for pregnant women with overt or gestational diabetes. (2, L)
700
Lactation
6.2a. ES recommends women with overt or gestational diabetes, whenever possible, should breastfeed their infants. (1, H)
700
6.2b. ES recommends women with overt diabetes who are breastfeeding and successfully using metformin or glyburide therapy during pregnancy should continue to use these medications, when necessary, during breastfeeding. ( 1 , H )
700
Postpartum Contraception
6.3. ES recommends the choice of a contraceptive method for a woman with overt diabetes or a history of gestational diabetes should not be influenced by virtue of having overt diabetes or a history of gestational diabetes. ( 1 , M )
700
Screening for Postpartum Thyroiditis
6.4. ES suggests women with type 1 diabetes be screened for postpartum thyroiditis with a TSH at 3 and 6 months postpartum. (2, L)
700
Postpartum Care
2.4a. ES recommends postpartum care for women who have had gestational diabetes should include measurement of fasting plasma glucose or fasting self-monitored blood glucose for 24-72 hours after delivery to rule out ongoing hyperglycemia. ( 1 , VL )
700
2.4b. ES recommends a 2-hour, 75-g OGTT should be undertaken 6-12 weeks after delivery in women with gestational diabetes to rule out prediabetes or diabetes. ( 1 , M )
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If results are normal, we recommend this or other diagnostic tests for diabetes should be repeated periodically as well as before future pregnancies. ( 1 , L )
700
2.4c. ES suggests the child’s birth weight and whether or not the child was born to a mother with gestational diabetes become part of the child’s permanent medical record. (U, )
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2.4d. ES recommends all women who have had gestational diabetes receive counseling on lifestyle measures to reduce the risk of type 2 diabetes, the need for future pregnancies to be planned, and the need for regular diabetes screening, especially before any future pregnancies. (1, VL)
700
2.4e. ES suggests blood glucose-lowering medication should be discontinued immediately after delivery for women with gestational diabetes unless overt diabetes is suspected, in which case the decision to continue such medication should be made on a case-by-case basis. (2, L)
700

Recommendation Grading

Overview

Title

Diabetes and Pregnancy

Authoring Organization

Publication Month/Year

November 1, 2013

Last Updated Month/Year

January 10, 2023

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Adolescent, Adult

Health Care Settings

Ambulatory, Hospital

Intended Users

Nurse midwife, nurse, dietician nutritionist, diabetes educator, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Diagnosis, Management

Diseases/Conditions (MeSH)

D011247 - Pregnancy, D011248 - Pregnancy Complications, D016640 - Diabetes, Gestational

Keywords

diabetes, pregnancy, gestational diabetes

Source Citation

Ian Blumer, Eran Hadar, David R. Hadden, Lois Jovanovič, Jorge H. Mestman, M. Hassan Murad, Yariv Yogev, Diabetes and Pregnancy: An Endocrine Society Clinical Practice Guideline, The Journal of Clinical Endocrinology & Metabolism, Volume 98, Issue 11, 1 November 2013, Pages 4227–4249, https://doi.org/10.1210/jc.2013-2465