Standards of Care in Diabetes - 2024

S282 Diabetes Care Volume 47, Supplement 1, January 2024
15. Management of Diabetes in American Diabetes Association

Professional Practice Committee*
Pregnancy: Standards of Care in
Diabetes—2024
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Diabetes Care 2024;47(Suppl. 1):S282–S294 | https://doi.org/10.2337/dc24-S015
15. MANAGEMENT OF DIABETES IN PREGNANCY
The American Diabetes Association (ADA) “Standards of 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. Members of the ADA Professional Practice Committee, an
interprofessional expert committee, are responsible for updating the Standards of
Care annually, or more frequently as warranted. For a detailed description of ADA
standards, statements, and reports, as well as the evidence-grading system for ADA’s
clinical practice recommendations and a full list of Professional Practice Committee
members, please refer to Introduction and Methodology. Readers who wish to com-
ment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
DIABETES IN PREGNANCY
The prevalence of diabetes in pregnancy has been increasing in the U.S. in parallel
with the worldwide epidemic of obesity. Not only is the prevalence of type 1 diabetes
and type 2 diabetes increasing in individuals of reproductive age, but there is also a
dramatic increase in the reported rates of gestational diabetes mellitus (GDM). Diabe-
tes confers significantly greater maternal and fetal risk largely related to the degree of
hyperglycemia but also related to chronic complications and comorbidities of diabe-
tes. In general, specific risks of diabetes in pregnancy include spontaneous abortion,
fetal anomalies, preeclampsia, fetal demise, macrosomia, neonatal hypoglycemia, neo-
natal hyperbilirubinemia, and neonatal respiratory distress syndrome, among others.
In addition, diabetes in pregnancy increases the risks of obesity, hypertension, and
type 2 diabetes in offspring later in life (1,2).
*A complete list of members of the American
Diabetes Association Professional Practice Committee
Preconception Counseling can be found at https://doi.org/10.2337/dc24-SINT.
Recommendations Duality of interest information for each author is
15.1 Starting at puberty and continuing in all people with diabetes and child- available at https://doi.org/10.2337/dc24-SDIS.
bearing potential, preconception counseling should be incorporated into rou- Suggested citation: American Diabetes Association
tine diabetes care. A Professional Practice Committee. 15. Manage-
ment of diabetes in pregnancy: Standards of Care in
15.2 Family planning should be discussed, and effective contraception (with con- Diabetes—2024. Diabetes Care 2024;47(Suppl. 1):
sideration of long-acting, reversible contraception) should be prescribed and used S282–S294
until an individual’s treatment plan and A1C are optimized for pregnancy. A
© 2023 by the American Diabetes Association.
15.3 Preconception counseling should address the importance of achieving Readers may use this article as long as the
glucose levels as close to normal as is safely possible, ideally A1C <6.5% work is properly cited, the use is educational
(<48 mmol/mol), to reduce the risk of congenital anomalies, preeclampsia, and not for profit, and the work is not altered.
macrosomia, preterm birth, and other complications. A More information is available at https://www
.diabetesjournals.org/journals/pages/license.
diabetesjournals.org/care Management of Diabetes in Pregnancy S283
All individuals with diabetes and childbear- and even with mild hyperglycemia and care units. Preconception counseling is
ing potential should be informed about 2) the use of effective contraception at also associated with reductions in perina-
the importance of achieving and maintain- all times when trying to prevent a preg- tal mortality and small-for-gestational-age
ing as near euglycemia as safely possible nancy. Preconception counseling using birth weight (18). A key point is the
prior to conception and throughout preg- developmentally appropriate educational need to incorporate a question about
nancy. Observational studies show an tools enables adolescent girls to make plans for pregnancy into the routine pri-
increased risk of diabetic embryopathy, well-informed decisions (9). Preconcep- mary and gynecologic care of people
especially anencephaly, microcephaly, tion counseling resources tailored for with diabetes. Preconception care for
congenital heart disease, renal anoma- adolescents are available at no cost people with diabetes should include the
lies, and caudal regression, directly pro- through the American Diabetes Associ- standard screening and care recom-

portional to elevations in A1C during the ation (ADA) (17). mended for any person planning preg-
first 10 weeks of pregnancy (3). Although nancy (10). Prescription of prenatal
observational studies are confounded by Preconception Care vitamins with at least 400 mg of folic
the association between elevated peri- acid (10) and 150 mg of potassium io-
Recommendations
conceptional A1C and other engagement dide (19) is recommended prior to con-
15.4 Individuals with preexisting diabe-
in self-care behaviors, the quantity and ception. Review and counseling on the
tes who are planning a pregnancy
consistency of data are convincing and abstinence of use of nicotine products,
should ideally begin receiving interpro-
support the recommendation to opti- alcohol, and recreational drugs, includ-
fessional care for preconception, which
mize glycemia prior to conception with ing marijuana, is important. Standard
includes an endocrinology health care
an A1C <6.5% (<48 mmol/mol), as this care includes screening for sexually
professional, maternal-fetal medicine
is associated with the lowest risk of con- transmitted diseases and thyroid dis-
specialist, registered dietitian nutrition- ease, recommended vaccinations, rou-
genital anomalies (given that organogen- ist, and diabetes care and education tine genetic screening, a careful review
esis occurs primarily at 5–8 weeks of specialist, when available. B of all prescription and nonprescription
gestation), preeclampsia, and preterm 15.5 In addition to focused attention medications, herbal supplements, and
birth (3–7). In a systematic review and on achieving glycemic targets, A stan- nonherbal supplements used, and a re-
meta-analysis of observational studies, dard preconception care should be view of travel history and plans with
preconception care for pregnant individ- augmented with extra focus on nutri- special attention to areas known to
uals with preexisting diabetes was asso- tion, physical activity, diabetes self- have Zika virus, as outlined by ACOG.
ciated with lower A1C and reduced risks care education, and screening for See Table 15.1 for additional details on
of birth defects, preterm delivery, peri- diabetes comorbidities and compli- elements of preconception care (10,20).
natal mortality, small-for-gestational-age cations. B Counseling on the specific risks of
births, and neonatal intensive care unit 15.6 Individuals with preexisting type 1 obesity in pregnancy and lifestyle inter-
admissions (8). or type 2 diabetes who are planning a ventions to prevent and treat obesity,
There are opportunities at any health pregnancy or who have become preg- including referral to a registered dieti-
care visit to educate all adults and ado- nant should be counseled on the risk tian nutritionist (RDN), is recommended
lescents with diabetes and childbearing of development and/or progression (21).
potential about the risks of unplanned of diabetic retinopathy. Dilated eye Diabetes-specific counseling should
pregnancies and about improved mater- examinations should occur ideally include an explanation of the risks to
nal and fetal outcomes with pregnancy before pregnancy or in the first tri- mother and fetus related to pregnancies
planning (9). Education and counseling mester, and then pregnant indivi- associated with diabetes and the ways
should be offered, even when individu- duals should be monitored every to reduce risks, including glycemic goal
als already use contraception or do not trimester and for 1 year postpartum setting, lifestyle and behavioral man-
intend to conceive. Effective preconcep- as indicated by the degree of reti- agement, and medical nutrition therapy
tion counseling could avert substantial nopathy and as recommended by (18). The most important diabetes-
health and associated cost (10) burdens the eye care health care profes- specific component of preconception
in the offspring (11). Family planning sional. B care is the attainment of glycemic
should be discussed, including the bene- goals prior to conception. In addition,
fits of long-acting, reversible contracep- the presence of microvascular compli-
tion, and effective contraception should The importance of preconception care cations is associated with higher risk of
be prescribed and used until the individ- for all pregnant people is highlighted by disease progression and adverse preg-
ual is prepared and ready to become American College of Obstetricians and nancy outcomes (22). Diabetes-specific
pregnant (12–16). Gynecologists (ACOG) Committee Opinion testing should include A1C, creatinine, and
To minimize the occurrence of com- 762, “Prepregnancy Counseling” (10). Pre- urinary albumin-to-creatinine ratio. Special
plications, beginning at the onset of conception counseling for pregnant peo- attention should be paid to the review of
puberty or at diagnosis, all adults and ple with preexisting type 1 or type 2 the medication list for potentially harmful
adolescents with diabetes of childbear- diabetes is highly effective in reducing drugs, i.e., ACE inhibitors (23,24), angio-
ing potential should receive education the risk of congenital malformations tensin receptor blockers (23), and statins
about 1) the risks of malformations and decreasing the risk of preterm deliv- (24,25). A referral for a comprehensive
associated with unplanned pregnancies ery and admission to neonatal intensive eye exam is recommended. Individuals
S284 Management of Diabetes in Pregnancy Diabetes Care Volume 47, Supplement 1, January 2024
with preexisting diabetic retinopathy

Table 15.1—Checklist for preconception care for people with diabetes
will need close monitoring during preg-
Preconception education should include:
nancy to assess stability or progression w Comprehensive nutrition assessment and recommendations for:
of retinopathy and provide treatment if Overweight/obesity or underweight

indicated (26). Meal planning
Correction of dietary nutritional deficiencies
Caffeine intake
Safe food preparation technique
GLYCEMIC GOALS IN PREGNANCY w Lifestyle recommendations for:
Regular moderate exercise

Recommendations
Avoidance of hyperthermia (hot tubs)
15.7 Fasting, preprandial, and postpran- Adequate sleep

dial blood glucose monitoring are rec- w Comprehensive diabetes self-management education
w Counseling on diabetes in pregnancy per current standards, including: natural history of
ommended in individuals with diabetes
insulin resistance in pregnancy and postpartum; preconception glycemic goals; avoidance of
in pregnancy to achieve optimal glucose DKA/severe hyperglycemia; avoidance of severe hypoglycemia; progression of retinopathy;
levels. Glucose goals are fasting plasma PCOS (if applicable); fertility in people with diabetes; genetics of diabetes; risks to
glucose <95 mg/dL (<5.3 mmol/L) pregnancy including miscarriage, still birth, congenital malformations, macrosomia, preterm
and either 1-h postprandial glucose labor and delivery, hypertensive disorders in pregnancy, etc.
w Supplementation
<140 mg/dL (<7.8 mmol/L) or 2-h Folic acid supplement (400 mg routine)
postprandial glucose <120 mg/dL Appropriate use of over-the-counter medications and supplements
(<6.7 mmol/L). B Health assessment and plan should include:
15.8 Due to increased red blood cell w General evaluation of overall health
turnover, A1C is slightly lower during w Evaluation of diabetes and its comorbidities and complications, including DKA/severe
pregnancy in people with and with- hyperglycemia; severe hypoglycemia/hypoglycemia unawareness; barriers to care;
comorbidities such as hyperlipidemia, hypertension, NAFLD, PCOS, and thyroid
out diabetes. Ideally, the A1C goal in dysfunction; complications such as macrovascular disease, nephropathy, neuropathy
pregnancy is <6% (<42 mmol/mol) (including autonomic bowel and bladder dysfunction), and retinopathy
if this can be achieved without signifi- w Evaluation of obstetric/gynecologic history, including a history of cesarean section,
cant hypoglycemia, but the goal may congenital malformations or fetal loss, current methods of contraception, hypertensive
disorders of pregnancy, postpartum hemorrhage, preterm delivery, previous
be relaxed to <7% (<53 mmol/mol) if macrosomia, Rh incompatibility, and thrombotic events (DVT/PE)
necessary to prevent hypoglycemia. B w Review of current medications and appropriateness during pregnancy
15.9 When used in addition to pre- Screening should include:

and postprandial blood glucose moni- w Diabetes complications and comorbidities, including comprehensive foot exam;
toring, continuous glucose monitoring comprehensive ophthalmologic exam; ECG in individuals starting at age 35 years who
(CGM) can help to achieve the A1C have cardiac signs/symptoms or risk factors and, if abnormal, further evaluation; lipid
panel; serum creatinine; TSH; and urine albumin-to-creatinine ratio
goal in diabetes and pregnancy. B w Anemia
15.10 CGM is recommended in preg- w Genetic carrier status (based on history):
nancies associated with type 1 diabe- Cystic fibrosis

tes. A When used in addition to blood Sickle cell anemia
Tay-Sachs disease
glucose monitoring, achieving tradi- Thalassemia
tional pre- and postprandial goals, Others if indicated
real-time CGM can reduce the risk for w Infectious disease
large-for-gestational age infants and Neisseria gonorrhoeae/Chlamydia trachomatis

Hepatitis B and hepatitis C
neonatal hypoglycemia in pregnancy HIV
complicated by type 1 diabetes. A Pap smear
15.11 CGM metrics may be used in Syphilis
addition to but should not be used as Immunizations should include:
a substitute for blood glucose moni- w Inactivated influenza
w Tdap (tetanus, diphtheria, and pertussis)
toring to achieve optimal pre- and
w COVID-19 (certain populations)
postprandial glycemic goals. E w Hepatitis A and hepatitis B (certain populations)
15.12 Commonly used estimated A1C w Others if indicated
and glucose management indicator cal- Preconception plan should include:

culations should not be used in preg- w Nutrition and medication plan to achieve glycemic goals prior to conception, including appropriate
nancy as estimates of A1C. C implementation of monitoring, continuous glucose monitoring, and pump technology
w Contraceptive plan to prevent pregnancy until glycemic goals are achieved
15.13 Nutrition counseling should
w Management plan for general health, gynecologic concerns, comorbid conditions, or
endorse a balance of macronutrients complications, if present, including hypertension, nephropathy, retinopathy; Rh
including nutrient-dense fruits, vege- incompatibility; and thyroid dysfunction
tables, legumes, whole grains, and
Created using information from American College of Obstetricians and Gynecologists (10) and Ra-
healthy fats with n-3 fatty acids that mos (20). COVID-19, coronavirus disease 2019; DKA, diabetic ketoacidosis; DVT/PE, deep vein
include nuts and seeds and fish in thrombosis/pulmonary embolism; ECG, electrocardiogram; NAFLD, nonalcoholic fatty liver disease;
the eating pattern. E PCOS, polycystic ovary syndrome; TSH, thyroid-stimulating hormone.
Pregnancy in people with normal glu- hypoglycemia (29). At around 16 weeks, pregnancy is as defined and treated in Rec-
cose metabolism is characterized by insulin resistance begins to increase, and ommendations 6.11–6.17 (see Section 6,
fasting levels of blood glucose that are total daily insulin doses increase linearly “Glycemic Goals and Hypoglycemia”). The
lower than in the nonpregnant state 5% per week through week 36. This most appropriate hypoglycemia threshold
due to insulin-independent glucose up- usually results in a doubling of daily insu- level in pregnancy has not been validated
take by the fetus and placenta and by lin dose compared with the prepregnancy but has ranged from <60 to <70 mg/dL
mild postprandial hyperglycemia and requirement. While there is an increase in (<3.3 to <3.9 mmol/L) in the past.
carbohydrate intolerance as a result of both basal and bolus insulin requirements, Current recommendations for hypogly-
diabetogenic placental factors. In peo- bolus insulin requirements take up a larger cemia thresholds include blood glucose
ple with preexisting diabetes, glycemic proportion of overall total daily insulin <70 mg/dL (<3.9 mmol/L) and sensor

goals are usually achieved through a needs in individuals with preexisting diabe- glucose <63 mg/dL (<3.5 mmol/L)
combination of insulin administration tes as pregnancy progresses (30,31). The (36,37). These fasting/premeal and post-
and medical nutrition therapy. Because insulin requirement levels off toward the prandial glucose values represent opti-
glycemic goals in pregnancy are stricter end of the third trimester. A rapid reduc- mal levels if they can be achieved safely.
than in nonpregnant individuals, it is tion in insulin requirements can indicate In practice, it may be challenging for a
important that pregnant people with dia- the development of placental insufficiency person with type 1 diabetes to achieve
betes eat consistent amounts of carbo- (32). In people with normal pancreatic these goals without hypoglycemia, par-
hydrates to match with insulin dosage function, insulin production is sufficient to ticularly those with a history of recurrent
and to avoid hyperglycemia or hypogly- meet the challenge of this physiological in- hypoglycemia or hypoglycemia unaware-
cemia. Referral to an RDN is important sulin resistance and to maintain normal ness. If an individual cannot achieve
to establish a food plan and insulin-to- glucose levels. However, in people with di- these goals without significant hypogly-
carbohydrate ratio and determine weight abetes, hyperglycemia occurs if treatment cemia, the ADA suggests less stringent
gain goals. The quality of the carbohy- is not adjusted appropriately. goals based on clinical experience and
drates should be evaluated. A subgroup individualization of care.
analysis of the Continuous Glucose Mon- Glucose Monitoring
itoring in Pregnant Women With Type 1 Reflecting this physiology, fasting and A1C in Pregnancy
Diabetes Trial (CONCEPTT) study demon- postprandial blood glucose monitoring In studies of individuals without preex-
strated that the diets of individuals plan- is recommended to achieve metabolic isting diabetes, increasing A1C levels
ning pregnancy and currently pregnant control in pregnant people with diabe- within the normal range are associated
assessed during the run-in phase prior tes. Preprandial testing is also recom- with adverse outcomes (38). In the
to randomization were characterized by mended when using insulin pumps or Hyperglycemia and Adverse Pregnancy
high-fat, low-fiber, and poor-quality car- basal-bolus therapy so that premeal Outcome (HAPO) study, increasing levels
bohydrate intakes. Fruit and vegetable rapid-acting insulin dosage can be ad- of glycemia were also associated with
consumption was inadequate, with one justed. Postprandial monitoring is asso- worsening outcomes (39). Observational
in four participants at risk for micronutri- ciated with better glycemic outcomes studies in preexisting diabetes and preg-
ent deficiencies, highlighting the impor- and a lower risk of preeclampsia (32–34). nancy show the lowest rates of adverse
tance of medical nutrition therapy (27). There are no adequately powered ran- fetal outcomes in association with A1C
An expert panel on nutrition in preg- domized trials comparing different fasting <6–6.5% (<42–48 mmol/mol) early in
nancy recommends a balance of macro- and postmeal glycemic goals for pre- gestation (4–6,40). Clinical trials have
nutrients. A diet that severely restricts existing diabetes in pregnancy. not evaluated the risks and benefits of
any macronutrient class should be avoided, Similar to the targets recommended achieving these goals, and treatment
specifically the ketogenic diet that lacks by ACOG (upper limits are the same as goals should account for the risk of ma-
carbohydrates, the Paleo diet because of for GDM, described below) (35), the ternal hypoglycemia in setting an individ-
dairy restriction, and any diet characterized ADA-recommended targets for pregnant ualized goal of <6% (<42 mmol/mol) to
by excess saturated fats. Nutrient-dense, people with type 1 or type 2 diabetes <7% (<53 mmol/mol). Due to physiolog-
whole foods are recommended, includ- are as follows: ical increases in red blood cell turnover,
ing fruits, vegetables, legumes, whole A1C levels fall during normal pregnancy
grains, and healthy fats with n-3 fatty • Fasting glucose 70–95 mg/dL (3.9–5.3 (41,42). Additionally, as A1C represents
acids that include nuts and seeds and mmol/L) and either an integrated measure of glucose, it may
fish, which are less likely to promote ex- • One-hour postprandial glucose 110–140 not fully capture postprandial hyperglyce-
cessive weight gain. Processed foods, mg/dL (6.1–7.8 mmol/L) or mia, which drives macrosomia. Thus, al-
fatty red meat, and sweetened foods • Two-hour postprandial glucose 100–120 though A1C may be useful, it should be
and beverages should be limited (28). mg/dL (5.6–6.7 mmol/L) used as a secondary measure of glycemic
Insulin Physiology outcomes in pregnancy, after blood glu-
Given that early pregnancy may be a Lower limits are based on the mean cose monitoring.
time of enhanced insulin sensitivity and of normal blood glucose in pregnancy In the second and third trimesters, A1C
lower glucose levels, many people with (36). Lower limits do not apply to indi- <6% (<42 mmol/mol) has the lowest
type 1 diabetes will have lower insulin re- viduals with type 2 diabetes treated risk of large-for-gestational-age infants
quirements and an increased risk for with nutrition alone. Hypoglycemia in (40,43,44), preterm delivery (45), and
preeclampsia (1,46). Taking all of this into individuals with type 2 diabetes or GDM cross the placenta to the fetus. A
account, a goal of <6% (<42 mmol/mol) should be individualized based on treat- Other oral and noninsulin injectable
is optimal during pregnancy if it can be ment regimen, circumstances, preferen- glucose-lowering medications lack long-
achieved without significant hypoglyce- ces, and needs. term safety data. E
mia. The A1C goal in a given individual The international consensus on TIR 15.16 Metformin, when used to treat
should be achieved without hypoglyce- (37) endorses pregnancy target ranges polycystic ovary syndrome and induce
mia, which, in addition to the usual ad- and goals for TIR for people with type 1 ovulation, should be discontinued by
verse sequelae, may increase the risk of diabetes using CGM as reported on the the end of the first trimester. A
low birth weight (47,48). Given the alter- ambulatory glucose profile; however, it 15.17 Telehealth visits used in combi-
ation in red blood cell kinetics during does not specify the type or accuracy of nation with in-person visits for preg-

pregnancy and physiological changes in the device or need for alarms and alerts. nant people with GDM can improve
glycemic parameters, A1C levels may A prospective, observational study in- outcomes compared with standard in-
need to be monitored more frequently cluding 20 pregnant people with type 1
person care alone. A
than usual (e.g., monthly). diabetes simultaneously monitored with
intermittently scanning CGM (isCGM) and
Continuous Glucose Monitoring in real-time CGM (rtCGM) for 7 days in
Pregnancy early pregnancy demonstrated a higher GDM is characterized by an increased risk
CONCEPTT was a randomized controlled percentage of time-below-range in the of large-for-gestational-age birth weight
trial (RCT) of real-time continuous glu- isCGM group. Asymptomatic hypoglyce- and neonatal and pregnancy complica-
cose monitoring (CGM) in addition to mia measured by isCGM should therefore tions and an increased risk of long-term
standard care, including optimization of not necessarily lead to a reduction of in- maternal type 2 diabetes and abnormal
pre- and postprandial glucose goals ver- sulin dose and/or increased carbohydrate glucose metabolism of offspring in child-
sus standard care for pregnant people intake at bedtime unless these episodes hood. These associations with maternal
with type 1 diabetes. It demonstrated are confirmed by blood glucose meter oral glucose tolerance test (OGTT) results
the value of real-time CGM in pregnancy measurements (55). Selection of CGM are continuous with no clear inflection
complicated by type 1 diabetes by show- device should be based on an individual’s points (39,56). Offspring with exposure
ing a mild improvement in A1C and a circumstances, preferences, and needs. to untreated GDM have reduced insulin
significant improvement in the maternal sensitivity and b-cell compensation and
glucose time in range (TIR), without an • Target sensor glucose range 63–140 mg/dL are more likely to have impaired glucose
increase in hypoglycemia, and reductions (3.5–7.8 mmol/L): TIR, goal >70%
tolerance in childhood (57). In other words,
in large-for-gestational-age births, length • Time below range (<63 mg/dL [<3.5
short-term and long-term risks increase
of infant hospital stays, and severe mmol/L]): level 1 TBR, goal <4%
with progressive maternal hyperglycemia.
neonatal hypoglycemia (49). An obser- • Time below range (<54 mg/dL [<3.0
Therefore, all pregnant people should
vational cohort study that evaluated mmol/L]): level 2 TBR, goal <1%
be screened as outlined in Section 2,
the glycemic variables reported using • Time above range (>140 mg/dL [>7.8
mmol/L]): TAR, goal <25% “Diagnosis and Classification of Diabetes.”
CGM systems found that lower mean Although there is some heterogeneity,
glucose, lower standard deviation, and a many RCTs and a Cochrane review suggest
higher percentage of time in range were The international consensus on TIR
(37) endorsed the same sensor glucose that the risk of GDM may be reduced by
associated with lower risks of large-for-
target ranges for individuals with type 2 diet, exercise, and lifestyle counseling, par-
gestational-age births and other adverse
diabetes in pregnancy and GDM but ticularly when interventions are started
neonatal outcomes (50). Data from one
could not quantify the goal of amount during the first or early in the second tri-
study suggest that the use of the CGM-
of time spent within each category be- mester (58–60). There are no intervention
reported mean glucose is superior to the
cause of insufficient data. trials in offspring of mothers with GDM. A
use of estimated A1C, glucose manage-
meta-analysis of 11 RCTs demonstrated
ment indicator, and other calculations to
estimate A1C, given the changes to MANAGEMENT OF GESTATIONAL that metformin treatment in pregnancy
A1C that occur in pregnancy (51). CGM DIABETES MELLITUS does not reduce the risk of GDM in high-
TIR can be used for assessment of gly- risk individuals with obesity, polycystic ovary
Recommendations
cemic outcomes in people with type 1 syndrome, or preexisting insulin resistance
15.14 Lifestyle behavior change is an (61). A meta-analysis of 32 RCTs evaluating
diabetes, but it does not provide action- essential component of management
able data to address fasting and post- the effectiveness of telemedicine interven-
of gestational diabetes mellitus (GDM) tions, which ranged from telemedicine visits
prandial hypoglycemia or hyperglycemia. and may suffice as treatment for many
The cost of CGM in pregnancies compli- to the use of health apps, used in combina-
individuals. Insulin should be added if
cated by type 1 diabetes is offset by im- tion with in-person visits for GDM demon-
needed to achieve glycemic goals. A
proved maternal and neonatal outcomes strated reduced incidences of cesarean
15.15 Insulin is the preferred medica-
(52). delivery, premature rupture of membranes,
tion for treating hyperglycemia in
There are insufficient data to support pregnancy-induced hypertension or pre-
GDM. Metformin and glyburide, indi-
the use of CGM in all people with type 2 eclampsia, preterm birth, neonatal asphyxia,
vidually or in combination, should not
diabetes or GDM (53,54). The decision of and polyhydramnios compared with stan-
be used as first-line agents, as both
whether to use CGM in pregnant dard in-person care alone (62).
Lifestyle and Behavioral Management people with diabetes, the amount and and systematic reviews, glyburide was
After diagnosis, treatment starts with type of carbohydrate will impact associated with a higher rate of neonatal
medical nutrition therapy, physical activ- glucose levels. Promoting higher-quality, hypoglycemia, macrosomia, and increased
ity, and weight management, depending nutrient-dense carbohydrates results in neonatal abdominal circumference than
on pregestational weight, as outlined in controlled fasting/postprandial glucose, insulin or metformin (78,79).
the section below on preexisting type 2 lower free fatty acids, improved insulin Glyburide failed to be found noninfe-
diabetes, as well as glucose monitoring action, and vascular benefits and may re- rior to insulin based on a composite
aiming for the goals recommended by the duce excess infant adiposity. Individuals outcome of neonatal hypoglycemia, mac-
Fifth International Workshop-Conference who substitute fat for carbohydrates may rosomia, and hyperbilirubinemia (80).
on Gestational Diabetes Mellitus (63): unintentionally enhance lipolysis, promote Long-term safety data for offspring ex-

elevated free fatty acids, and worsen ma- posed to glyburide are not available (80).
• Fasting glucose <95 mg/dL (<5.3 mmol/L) ternal insulin resistance (69,70). Fasting
and either urine ketone testing may be useful to Metformin
• One-hour postprandial glucose <140 identify those who are severely restrict- Metformin was associated with a lower
mg/dL (<7.8 mmol/L) or ing carbohydrates to manage blood glu- risk of neonatal hypoglycemia and less
• Two-hour postprandial glucose <120 cose. Simple carbohydrates will result in maternal weight gain than insulin in sys-
mg/dL (<6.7 mmol/L) higher postmeal excursions. tematic reviews and RCTs (78,81–83).
However, metformin readily crosses the
The glycemic goal lower limits defined Physical Activity placenta, resulting in umbilical cord
above for preexisting diabetes apply for A systematic review demonstrated im- blood levels of metformin as high or
GDM treated with insulin. Depending provements in glucose outcomes and re- higher than simultaneous maternal lev-
on the population, studies suggest that els (84,85). In the Metformin in Gesta-
ductions in need to start insulin or insulin
70–85% of people diagnosed with GDM tional Diabetes: The Offspring Follow-
dose requirements with an exercise inter-
under Carpenter-Coustan criteria can Up (MiG TOFU) study’s analyses of 7- to
vention. There was heterogeneity in the
manage GDM with lifestyle modification 9-year-old offspring, the 9-year-old off-
types of effective exercise (aerobic, resis-
alone; it is anticipated that this propor- spring exposed to metformin for the
tance, or both) and duration of exercise
tion will be even higher if the lower In- treatment of GDM in the Auckland co-
(20–50 min/day, 2–7 days/week of mod-
ternational Association of the Diabetes hort were heavier and had a higher
erate intensity) (71).
and Pregnancy Study Groups (64) diag- waist-to-height ratio and waist circum-
nostic thresholds are used. ference than those exposed to insulin
Pharmacologic Therapy
(86). This difference was not found in
Treatment of GDM with lifestyle and in-
Medical Nutrition Therapy the Adelaide cohort. In one RCT of met-
sulin has been demonstrated to im-
Medical nutrition therapy for GDM is an formin use in pregnancy for polycystic
prove perinatal outcomes in two large
individualized nutrition plan developed ovary syndrome, follow-up of 4-year-old
between the pregnant person and an randomized studies, as summarized in a offspring demonstrated higher BMI and
RDN familiar with the management of U.S. Preventive Services Task Force re- increased obesity in the offspring ex-
GDM (65,66). The food plan should view (72). Insulin is the first-line agent posed to metformin (87). A follow-up
provide adequate calorie intake to pro- recommended for the treatment of study at 5–10 years showed that the
mote fetal/neonatal and maternal health, GDM in the U.S. While individual RCTs offspring had higher BMI, weight-to-
achieve glycemic goals, and promote ap- support limited efficacy of metformin height ratios, waist circumferences,
propriate weight gain, according to the (73,74) and glyburide (75) in reducing and a borderline increase in fat mass
2009 National Academy of Medicine rec- glucose levels for the treatment of (88,89). A meta-analysis demonstrated
ommendations (67). There is no definitive GDM, these agents are not recom- that metformin exposure resulted in
research that identifies a specific optimal mended as the first-line treatment for smaller neonates with an acceleration
calorie intake for people with GDM or GDM because they are known to cross of postnatal growth, resulting in higher
suggests that their calorie needs are dif- the placenta and data on long-term BMI in childhood (88). Follow-up of off-
ferent from those of pregnant individuals safety for offspring is of some concern spring from the Metformin in Women
without GDM. The food plan should be (35). Furthermore, in separate RCTs, gly- with Type 2 Diabetes in Pregnancy
based on a nutrition assessment with di- buride and metformin failed to provide (MiTy Kids) trial showed no differ-
etary reference intake guidance from adequate glycemic outcomes in 23% ences in anthropometrics of children
the National Academy of Medicine. and 25–28% of participants with GDM, at 24 months (90).
The recommended dietary reference respectively (76,77). Randomized, double-blind, controlled
intake for all pregnant people is a mini- trials comparing metformin with other
mum of 175 g of carbohydrate (35% of Sulfonylureas therapies for ovulation induction in indi-
a 2,000-calorie diet), a minimum of 71 g Sulfonylureas are known to cross the viduals with polycystic ovary syndrome
of protein, and 28 g of fiber (68). The nu- placenta and have been associated with have not demonstrated benefit in pre-
trition plan should emphasize monoun- increased neonatal hypoglycemia. Con- venting spontaneous abortion or GDM
saturated and polyunsaturated fats while centrations of glyburide in umbilical cord (91), and there is no evidence-based
limiting saturated fats and avoiding trans plasma are approximately 50–70% of need to continue metformin in these in-
fats. As is true for all nutrition therapy in maternal levels (76,77). In meta-analyses dividuals (92–94).
There are some people with GDM re- team members at different centers may people with diabetes and family mem-
quiring medical therapy who may not be still be beneficial. bers about the prevention, recognition,
able to use insulin safely or effectively None of the currently available human and treatment of hypoglycemia is impor-
during pregnancy due to cost, language insulin preparations have been demon- tant before, during, and after pregnancy
barriers, comprehension, or cultural in- strated to cross the placenta (93–98). to help prevent and manage hypoglyce-
fluences. Oral agents may be an alterna- Insulins studied in RCTs are preferred mia risk. Insulin resistance drops rapidly
tive for these individuals after discussing (97,99–103) over those studied in cohort with the delivery of the placenta.
the known risks and the need for more studies (104), which are preferred over Pregnancy is a ketogenic state, and
long-term safety data in offspring. How- those studied in case reports only. people with type 1 diabetes, and to a
ever, due to the potential for growth re- While many health care professionals lesser extent those with type 2 diabe-

striction or acidosis in the setting of prefer insulin pumps in pregnancy, it is tes, are at risk for diabetic ketoacidosis
placental insufficiency, metformin should not clear that they are superior to multi- (DKA) at lower blood glucose levels
not be used in pregnant people with hy- ple daily injections (105,106). None of than in the nonpregnant state. Pregnant
pertension or preeclampsia or those at the current automated insulin delivery people with type 1 diabetes should be
risk for intrauterine growth restriction (AID) systems approved by the U.S. Food advised to obtain ketone test strips and
(90,95,96). and Drug Administration (FDA) have al- receive education on DKA prevention
gorithms set to achieve pregnancy goals. and detection. DKA carries a high risk of
Insulin It may be appropriate to continue or ini- stillbirth. Those in DKA who are unable
Insulin use should follow the guidelines tiate AID therapy in carefully selected to eat often require 10% dextrose with
below. Both multiple daily insulin injec- pregnant individuals with type 1 diabetes an insulin drip to adequately meet the
tions and continuous subcutaneous in- in the setting of using assistive techni- higher carbohydrate demands of the
sulin infusion are reasonable delivery ques with expert guidance (107). Assess- placenta and fetus in the third trimester
strategies, and neither has been shown ments of potential candidates for AID in order to resolve their ketosis.
to be superior to the other during preg- wear in pregnancy should include rele- Retinopathy is a special concern in
nancy (97). vant parameters such as glycemic levels, pregnancy. The necessary rapid imple-
presence or absence of severe hypogly- mentation of euglycemia in the setting of
MANAGEMENT OF PREEXISTING cemic or hyperglycemic events, ability or retinopathy is associated with worsening
TYPE 1 DIABETES AND TYPE 2 comfort in engaging with diabetes tech- of retinopathy (109). Meta-analyses have
DIABETES IN PREGNANCY
nology, psychosocial determinants, cost, also demonstrated a high risk of new-
Recommendations individual preference, and other factors as onset retinopathy and progression of ex-
15.18 Insulin should be used to man- relevant. In addition, individuals who use isting retinopathy in pregnant individuals
age type 1 diabetes in pregnancy. A AID systems that do not have pregnancy- with type 1 or type 2 diabetes (110,111).
Insulin is the preferred agent for the specific glucose targets often benefit from
management of type 2 diabetes in assistive techniques for pump manage- Type 2 Diabetes
pregnancy. B ment as determined by expert guidance Type 2 diabetes is often associated with
15.19 Either multiple daily injections from an experienced interprofessional obesity. Recommended weight gain dur-
or insulin pump technology can be team (107). Partial closed-loop therapy, ing pregnancy for people with overweight
used in pregnancy complicated by such as predictive low-glucose suspend is 15–25 lb (6.8–11.3 kg) and for those
type 1 diabetes. C (PLGS) technology, has been shown in non- with obesity is 10–20 lb (4.5–9.1 kg)
pregnant people to be better than sensor- (67). There are no adequate data on op-
augmented insulin pumps (SAP) for reduc- timal weight gain versus weight mainte-
The physiology of pregnancy necessitates ing low glucose values (108). It may be nance in pregnant people with BMI
frequent titration of insulin to match suited for pregnancy because the predic- >35 kg/m2; however, losing weight is
changing requirements and underscores tive low-glucose threshold for suspending not recommended because of the in-
the importance of daily and frequent insulin is in the range of premeal and over- creased risk of small-for-gestational age
blood glucose monitoring. Due to the night glucose value targets in pregnancy infants (21).
complexity of insulin management in and may allow for more aggressive prandial Optimal glycemic goals are often easier
pregnancy, referral to a specialized cen- dosing. See SENSOR-AUGMENTED PUMPS and AUTO- to achieve during pregnancy with type 2
ter offering team-based care (with team MATED INSULIN DELIVERY SYSTEMS in Section 7, diabetes than with type 1 diabetes but
members including a maternal-fetal med- “Diabetes Technology,” for more informa- can require much higher doses of insulin,
icine specialist, endocrinologist or other tion on these systems. sometimes necessitating concentrated
health care professional experienced in insulin formulations. Insulin is the pre-
managing pregnancy and preexisting dia- Type 1 Diabetes ferred treatment for type 2 diabetes in
betes, RDN, diabetes care and education Pregnant individuals with type 1 diabetes pregnancy. An RCT of metformin added to
specialist, and social worker, as needed) is have an increased risk of hypoglycemia in insulin for the treatment of type 2 diabe-
recommended if this resource is available. the first trimester and, like all pregnant tes found less maternal weight gain and
When a single specialized center is not people, have altered counter-regulatory fewer cesarean births. There were fewer
available, providing a interprofessional response in pregnancy that may decrease macrosomic neonates, but there was
team approach through interprofessional hypoglycemia awareness. Education for a doubling of small-for-gestational-age
neonates (112). As in type 1 diabetes, insu- Services Task Force (116). More studies as the threshold for initiation or titra-
lin requirements drop dramatically after are needed to assess the long-term ef- tion of medical therapy for chronic hy-
delivery. fects of prenatal aspirin exposure on off- pertension in pregnancy (124) rather
The risk for associated hypertension spring (121). than their previously recommended
and other comorbidities may be as high threshold of 160/110 mmHg (125).
or higher with type 2 diabetes com- PREGNANCY AND DRUG The CHAP study provides additional
pared with type 1 diabetes, even if dia- CONSIDERATIONS guidance for the management of hyper-
betes is better managed and of shorter tension in pregnancy. Data from the pre-
apparent duration, with pregnancy loss Recommendations viously published Control of Hypertension
appearing to be more prevalent in the 15.21 In pregnant individuals with dia- in Pregnancy Study (CHIPS) supports a

third trimester in those with type 2 diabetes and chronic hypertension, a target blood pressure goal of 110–135/85
betes, compared with the first trimester blood pressure threshold of 140/90 mmHg to reduce the risk of uncontrolled
in those with type 1 diabetes (113,114). mmHg for initiation or titration of ther- maternal hypertension and minimize im-
apy is associated with better preg- paired fetal growth (125–127). The 2015
PREECLAMPSIA AND ASPIRIN nancy outcomes than reserving study (126) excluded pregnancies compli-
treatment for severe hypertension, cated by preexisting diabetes, and only
Recommendation with no increase in risk of small-for- 6% of participants had GDM at enroll-
15.20 Pregnant individuals with type 1 gestational-age birth weight. A There ment. There was no difference in preg-
or type 2 diabetes should be pre- are limited data on the optimal lower nancy loss, neonatal care, or other
scribed low-dose aspirin 100–150 mg/ limit, but therapy should be deintensified neonatal outcomes between the groups
day starting at 12 to 16 weeks of ges- for blood pressure <90/60 mmHg. E A with tighter versus less tight control of
tation to lower the risk of preeclamp- blood pressure target of 110–135/ hypertension (126).
sia. E A dosage of 162 mg/day may 85 mmHg is suggested in the interest During pregnancy, treatment with ACE
be acceptable; E currently, in the of reducing the risk for accelerated ma- inhibitors and angiotensin receptor block-
U.S., low-dose aspirin is available in ternal hypertension. A ers is contraindicated because they may
81-mg tablets. 15.22 Potentially harmful medica- cause fetal renal dysplasia, oligohydram-
tions in pregnancy (i.e., ACE inhibi- nios, pulmonary hypoplasia, and intra-
tors, angiotensin receptor blockers, uterine growth restriction (23).
Diabetes in pregnancy is associated with statins) should be stopped prior to A large study found that after adjust-
an increased risk of preeclampsia (115). conception and avoided in sexually ing for confounders, first trimester ACE
The U.S. Preventive Services Task Force active individuals of childbearing inhibitor exposure does not appear to be
recommends using low-dose aspirin (81 potential who are not using reliable associated with congenital malforma-
mg/day) as a preventive medication at contraception. B tions (128). However, ACE inhibitors and
12 weeks of gestation in individuals at angiotensin receptor blockers should be
high risk for preeclampsia, such as those In normal pregnancy, blood pressure is stopped as soon as possible in the first
with type 1 or type 2 diabetes (116). lower than in the nonpregnant state. trimester to avoid second and third tri-
However, a meta-analysis and an addi- The Chronic Hypertension and Preg- mester fetopathy (128). Antihypertensive
tional trial demonstrate that low-dose nancy (CHAP) Trial Consortium’s RCT on drugs known to be effective and safe in
aspirin <100 mg is not effective in re- treatment for mild chronic hypertension pregnancy include methyldopa, nifedi-
ducing preeclampsia. Low-dose aspirin during pregnancy demonstrated that pine, labetalol, diltiazem, clonidine, and
>100 mg is required (117–119). A cost- a blood pressure of 140/90 mmHg, as prazosin. Atenolol is not recommended,
benefit analysis has concluded that the threshold for initiation or titration but other b-blockers may be used, if
this approach would reduce morbidity, of treatment, reduces the incidence of necessary. Chronic diuretic use during
save lives, and lower health care costs adverse pregnancy outcomes without pregnancy is not recommended as it has
(120). There are insufficient data about compromising fetal growth (123). The been associated with restricted maternal
whether the use of aspirin specifically CHAP Consortium’s study mitigates con- plasma volume, which may reduce ute-
cerns about small-for-gestational-age birth roplacental perfusion (129). On the basis
in pregnant people with preexisting dia-
weight. Attained mean ± SD blood pres- of available evidence, statins should also
betes ultimately reduces the incidence
be avoided in pregnancy (130).
of preeclampsia (121,122), although a sure measurements in the treated versus
See pregnancy and antihypertensive
meta-analysis showed that preeclampsia untreated groups were systolic 129.5 ±
medications in Section 10, “Cardiovascular
reductions occurred with aspirin adminis- 10.0 vs. 132.6 ± 10.1 mmHg (between-
Disease and Risk Management,” for more
tration in high-risk groups overall (115). group difference 3.11 [95% CI 3.95 to
information on managing blood pressure
Individuals with GDM may be candidates 2.28]) and diastolic 79.1 ± 7.4 vs. 81.5 ±
in pregnancy.
for aspirin therapy for preeclampsia pre- 8.0 mmHg ( 2.33 [95% CI 2.97 to
vention if they have a single high risk fac- 0.04]) (123). Individuals with diabetes had
POSTPARTUM CARE
tor, such as chronic hypertension or an an even better composite outcome score
autoimmune disease, or multiple moder- than those without diabetes (123). Recommendations
ate risk factors, such as being nulliparous, As a result of the CHAP study, ACOG 15.23 Insulin resistance decreases
having obesity, being age $35 years, or issued a Practice Advisory recommend- dramatically immediately postpartum,
other factors per the U.S. Preventive ing a blood pressure of 140/90 mmHg
and insulin requirements need to be the preceding 3-month glucose profile. effective weight management after GDM
evaluated and adjusted as they are The OGTT is more sensitive at detecting (138). In addition, postdelivery lifestyle in-
often roughly half the prepregnancy glucose intolerance, including both predia- terventions are effective in reducing risk of
requirements for the initial few days betes and diabetes. In the absence of un- type 2 diabetes (139).
postpartum. C equivocal hyperglycemia, a positive screen Both metformin and intensive life-
15.24 A contraceptive plan should for diabetes requires two abnormal val- style intervention prevent or delay pro-
ues. If both the fasting plasma glucose gression to diabetes in individuals with
be discussed and implemented with
($126 mg/dL [$7.0 mmol/L]) and 2-h prediabetes and a history of GDM. Only
all people with diabetes of childbear-
plasma glucose ($200 mg/dL [$11.1 five to six individuals with prediabetes
ing potential. A
mmol/L]) are abnormal in a single screen- and a history of GDM need to be treated
15.25 Screen individuals with a recent

ing test, then the diagnosis of diabetes is with either intervention to prevent one
history of GDM at 4–12 weeks post-
made. If only one abnormal value in the case of diabetes over 3 years (140). In
partum, using the 75-g oral glucose
OGTT meets diabetes criteria, the test these individuals, lifestyle intervention
tolerance test and clinically appropri-
should be repeated to confirm that the and metformin reduced progression to di-
ate nonpregnancy diagnostic criteria. B abnormality persists. OGTT testing imme- abetes by 35% and 40%, respectively,
15.26 Individuals with overweight/ diately postpartum, while still hospitalized, over 10 years compared with placebo
obesity and a history of GDM found has demonstrated improved engagement (141). If the pregnancy has motivated the
to have prediabetes should receive in testing but also variably reduced sensi- adoption of healthy nutrition, building on
intensive lifestyle interventions and/or tivity to the diagnosis of impaired fasting these gains to support weight loss is rec-
metformin to prevent diabetes. A glucose, impaired glucose tolerance, and ommended in the postpartum period.
15.27 Breastfeeding efforts are rec- type 2 diabetes (131,132). (See Section 3, “Prevention or Delay of
ommended for all individuals with Individuals with a history of GDM should Diabetes and Associated Comorbidities.”)
diabetes. A Breastfeeding is recom- have ongoing screening for prediabetes or Individuals with prediabetes or a his-
mended for individuals with a his- type 2 diabetes every 1–3 years, even if tory of GDM will need preconception
tory of GDM for multiple benefits, A the results of the initial 4–12 week post- evaluation for as long as they have child-
including a reduced risk for type 2 partum 75-g OGTT are normal. Ongoing bearing potential.
diabetes later in life. B evaluation may be performed with any rec-
15.28 Individuals with a history of ommended glycemic test (e.g., annual A1C, Preexisting Type 1 and Type 2
GDM should have lifelong screening annual fasting plasma glucose, or triennial Diabetes Postpartum Care
for the development of type 2 diabe- 75-g OGTT using thresholds for nonpreg- Insulin sensitivity increases dramatically
tes or prediabetes every 1–3 years. B nant individuals). with the delivery of the placenta. In one
15.29 Individuals with a history of Individuals with a history of GDM study, insulin requirements in the imme-
GDM should seek preconception have an increased lifetime maternal diate postpartum period are roughly
screening for diabetes and precon- risk for diabetes estimated at 50–60% 34% lower than prepregnancy insulin re-
ception care to identify and treat hy- (133,134), and those with GDM have quirements (142). Insulin sensitivity then
perglycemia and prevent congenital a 10-fold increased risk of developing returns to prepregnancy levels over the
malformations. E type 2 diabetes compared with those following 1–2 weeks. For individuals tak-
15.30 Postpartum care should include without GDM (133). Absolute risk of ing insulin, particular attention should
psychosocial assessment and support developing type 2 diabetes after GDM be directed to hypoglycemia prevention
for self-care. E increases linearly through a person’s in the setting of breastfeeding and er-
lifetime, being approximately 20% at ratic sleep and eating schedules (143).
10 years, 30% at 20 years, 40% at 30 years,
Gestational Diabetes Mellitus 50% at 40 years, and 60% at 50 years Lactation
Postpartum Care (134). In the prospective Nurses’ Health Considering the immediate nutritional and
Because GDM often represents previ- Study II (NHS II), subsequent diabetes immunological benefits of breastfeeding
ously undiagnosed prediabetes, type 2 risk after a history of GDM was signifi- for the baby, all mothers, including those
diabetes, maturity-onset diabetes of the cantly lower in those who followed with diabetes, should be supported in at-
young, or even developing type 1 diabe- healthy eating patterns (135). Adjusting tempts to breastfeed. An analysis of 28
tes, individuals with GDM should be for BMI attenuated this association mod- systematic reviews and meta-analyses of
tested for persistent diabetes or predia- erately, but not completely. Interpreg- associations between breastfeeding and
betes at 4–12 weeks postpartum with a nancy weight gain is associated with outcomes in children found that breast-
fasting 75-g OGTT using nonpregnancy increased risk of adverse pregnancy out- feeding was associated with numerous
criteria as outlined in Section 2, “Diagnosis comes (136) and higher risk of GDM, health benefits for children such as re-
and Classification of Diabetes,” specifically while in people with BMI >25 kg/m2, duced infant mortality due to infectious
Tables 2.1 and 2.2. The OGTT is recom- weight loss is associated with lower risk diseases at <6 months of age (odds ratio
mended over A1C at 4–12 weeks postpar- of developing GDM in the subsequent [OR] 0.22–0.59 across studies), reduced
tum because A1C may be persistently pregnancy (137). Development of type 2 respiratory infections in children aged
impacted (lowered) by the increased red diabetes is 18% higher per unit of BMI <2 years, and reduced asthma or wheez-
blood cell turnover related to preg- increase from prepregnancy BMI at ing in children aged 5–18 years (OR 0.91,
nancy, by blood loss at delivery, or by follow-up, highlighting the importance of 0.85–0.98) (144). The same analysis found
that breastfeeding was associated with 5. Suhonen L, Hiilesmaa V, Teramo K. Glycaemic 21. Obesity in pregnancy: ACOG Practice Bulletin,
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S282 Diabetes Care Volume 47, Supplement 1, January 2024

15. Management of Diabetes in American Diabetes Association

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The American Diabetes Association (ADA) “Standards of Care in Diabetes” includes

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with preexisting diabetic retinopathy

of retinopathy and provide treatment if  Overweight/obesity or underweight

 Regular moderate exercise

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15.9 When used in addition to pre- Screening should include:

nancies associated with type 1 diabe-  Cystic ﬁbrosis

large-for-gestational age infants and  Neisseria gonorrhoeae/Chlamydia trachomatis

and glucose management indicator cal- Preconception plan should include:

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of retinopathy and provide treatment if Overweight/obesity or underweight

Regular moderate exercise

nancies associated with type 1 diabe- Cystic ﬁbrosis

large-for-gestational age infants and Neisseria gonorrhoeae/Chlamydia trachomatis