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Diabetes mellitus in pregnancy

Definition
Diabetes during pregnancy is characterized by newly recognized hyperglycemia during pregnancy associated with an increased risk of maternal and neonatal morbidities.
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Pathophysiology
Diabetes during pregnancy is caused due to insulin resistance (due to maternal obesity or increased production of diabetogenic placental hormone) in pregnancy and pancreatic β-cell dysfunction.
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Disease course
Diabetes during pregnancy is related to several maternal complications including diabetic ketoacidosis, hypoglycemia, retinopathy, deterioration of nephropathy, gastric neuropathy, miscarriages, pre-eclampsia, polyhydramnios, premature delivery; and perinatal complications including stillbirth, neonatal death, shoulder dystocia, bone fracture, nerve palsy, neonatal hypoglycemia.
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Prognosis and risk of recurrence
There is an increased risk of stillbirth from 36-42 weeks in women with diabetes during pregnancy with a relative risk of 1.34 (95% CI 1.2-1.5) and 17.1 per 10,000 deliveries.
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Key sources
The following summarized guidelines for the evaluation and management of diabetes mellitus in pregnancy are prepared by our editorial team based on guidelines from the American Diabetes Association (ADA 2024; 2023), the American Academy of Family Physicians (AAFP 2023), the European Association for the Study of the Liver (EASL 2023), the Society of Obstetricians and Gynaecologists of Canada (SOGC 2019), the U.S. Preventive Services Task Force (USPSTF 2014), and the Endocrine Society (ES 2013).
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Guidelines

1.Screening and diagnosis

Indications for screening: as per ADA 2024 guidelines, obtain screening for undiagnosed diabetes in individuals with risk factors planning pregnancy.
B
consider testing all individuals of childbearing potential for undiagnosed diabetes.
B
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2.Diagnostic investigations

Renal function assessment: consider obtaining renal function assessment (urine albumin-to-creatinine ratio, serum creatinine, andEGFR ) in all individuals with diabetes planning conception, before withdrawing contraceptive measures or otherwise trying to conceive.
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  • Thyroid function assessment

  • Screening for coronary artery disease

  • Screening for diabetic retinopathy

3.Medical management

Setting of care
Manage patients with preexisting diabetes planning a pregnancy ideally beginning in preconception in a multidisciplinary clinic including an endocrinologist, maternal-fetal medicine specialist, registered dietitian nutritionist, and diabetes care and education specialist, when available.
B
Recognize that telehealth visits for pregnant patients with GDM improve outcomes compared with standard in-person care.
A

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  • Glycemic targets, before pregnancy

  • Glycemic targets, during pregnancy

  • Glycemic targets, after pregnancy

  • Initial management, gestational diabetes

  • Initial management, preexisting diabetes

  • Insulin therapy (before pregnancy)

  • Insulin therapy (during pregnancy)

  • Oral hypoglycemics

  • Low-dose aspirin

  • Management of hypertension

  • Medications to avoid

4.Nonpharmacologic interventions

Dietary modifications: as per ADA 2023 guidelines, encourage a balanced intake of macronutrients including nutrient-dense fruits, vegetables, legumes, whole grains, and healthy fats with omega-3 fatty acids (including nuts, seeds, and fish) in the eating pattern.
B

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  • Weight reduction

5.Therapeutic procedures

Considerations for delivery
As per AAFP 2023 guidelines:
Consider offering induction at or after 39 weeks of gestation in patients with GDM.
C
Offer induction before 41 weeks of gestation in patients with diet-controlled GDM and before 40 weeks in patients with medication-controlled GDM.
B

6.Patient education

General counseling: as per ADA 2023 guidelines, incorporate preconception counseling into routine diabetes care starting at puberty and continuing in all patients with diabetes and reproductive potential.
A
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7.Preventative measures

Preconception care: as per ADA 2023 guidelines, augment standard preconception care with extra focus on nutrition, diabetes education, and screening for diabetes comorbidities and complications,
B
in addition to focused attention on achieving glycemic targets.
A

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  • Lifestyle modifications

8.Follow-up and surveillance

Monitoring of glycemic control: as per ADA 2023 guidelines, consider obtaining continuous glucose monitoring in addition to pre- and postprandial blood glucose monitoring to achieve HbA1c targets in diabetes and pregnancy.
C
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More topics in this section

  • Monitoring of fetal health

  • Postpartum care (evaluation of glycemic control)

  • Postpartum care (screening for postpartum thyroiditis)

  • Postpartum care (breastfeeding)

  • Postpartum care (contraception)

  • Postpartum care (prevention of T2DM)