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Family Management of Childhood Diabetes\nStudy Steering Committee. Dietary behaviorspredict glycemic control in youth with type 1diabetes. Diabetes Care 2008;31:1318– 1320\n12. Bell KJ, Smart CE, Steil GM, Brand-Miller JC,King B, Wolpert HA. Impact of fat, protein, andglycemic index on postprandial glucose control in | [
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type 1 diabetes: implications for intensive diabetes\nmanagement in the continuous glucose monitoringera. Diabetes Care 2015;38:1008– 1015\n13. Smith TA, Marlow AA, King BR, Smart CE.Insulin strategies for dietary fat and protein intype 1 diabetes: a systematic review. Diabet Med\n2021;38:e14641\n14. Paterson MA, Smart... | [
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2021;38:e14641\n14. Paterson MA, Smart CEM, Lopez PE, et al.\nIncreasing the protein quantity in a meal results indose-dependent effects on postprandial glucoselevels in individuals with type 1 diabetes mellitus.Diabet Med 2017;34:851 –854\n15. Paterson MA, King BR, Smart CEM, Smith T,\nRafferty J, Lopez PE. Impact of ... | [
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Rafferty J, Lopez PE. Impact of dietary protein\non postprandial glycaemic control and insulinrequirements in type 1 diabetes: a systematicreview. Diabet Med 2019;36:1585 –1599\n16. Reddy M, Jugnee N, El Laboudi A, SpanudakisE, Anantharaja S, Oliver N. A randomized controlled\npilot study of continuous glucose monitori... | [
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pilot study of continuous glucose monitoring and\nflash glucose monitoring in people with Type 1\ndiabetes and impaired awareness of hypo-glycaemia. Diabet Med 2018;35:483– 490\n17. Smith TA, Blowes AA, King BR, Howley PP ,Smart CE. Families ’reports of problematic foods, | [
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management strategies and continuous glucosemonitoring in type 1 diabetes: a cross-sectionalstudy. Nutr Diet 2021;78:449– 457\n18. Bao J, Gilbertson HR, Gray R, et al. Improvingthe estimation of mealtime insulin dose in adultswith type 1 diabetes: the Normal Insulin Demand\nfor Dose Adjustment (NIDDA) study. Diabetes\n... | [
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for Dose Adjustment (NIDDA) study. Diabetes\nCare 2011;34:2146– 2151\n19. Kordonouri O, Hartmann R, Remus K, Bl €asig\nS, Sadeghian E, Danne T. Benefi t of supplementary\nfat plus protein counting as compared withconventional carbohydrate counting for insulin\nbolus calculation in children with pump therapy.\nPediatr Di... | [
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Pediatr Diabetes 2012;13:540 –544\n20. Lundgren M, Sahlin Å, Svensson C, et al.;DiPiS study group. Reduced morbidity at diagnosisa n di m p r o v e dg l y c e m i cc o n t r o li nc h i l d r e np r e -viously enrolled in DiPiS follow-up. Pediatr Dia-\nbetes 2014;15:494 –501\n2 1 .B e l lK J ,G r a yR ,M u n n sD ,e ta... | [
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2 1 .B e l lK J ,G r a yR ,M u n n sD ,e ta l .C l i n i c a l\napplication of the food insulin index for mealtimeinsulin dosing in adults with type 1 diabetes: arandomized controlled trial. Diabetes TechnolTher 2016;18:218– 225 | [
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22. Bell KJ, Gray R, Munns D, et al. Estimatinginsulin demand for protein-containing foodsusing the food insulin index. Eur J Clin Nutr2014;68:1055– 1059\n23. Lopez PE, Evans M, King BR, et al. Arandomized comparison of three prandial insulin\ndosing algorithms for children and adolescents with\ntype 1 diabetes. Diabet... | [
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type 1 diabetes. Diabet Med 2018;35:1440– 1447\n24. Paterson MA, Smart CE, Lopez PE, et al.Influence of dietary protein on postprandial\nblood glucose levels in individuals with type 1diabetes mellitus using intensive insulin therapy.\nDiabet Med 2016;33:592– 598\n25. Furthner D, Lukas A, Schneider AM, et al. | [
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25. Furthner D, Lukas A, Schneider AM, et al.\nThe role of protein and fat intake on insulintherapy in glycaemic control of paediatric type 1diabetes: a systematic review and research gaps.Nutrients 2021;13:3558\n26. Smith TA, Smart CE, Fuery MEJ, et al. In\nchildren and young people with type 1 diabetes | [
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children and young people with type 1 diabetes\nusing pump therapy, an additional 40% of theinsulin dose for a high-fat, high-protein breakfastimproves postprandial glycaemic excursions: across-over trial. Diabet Med 2021;38:e14511\n27. Smith TA, Smart CE, Howley PP , Lopez PE,\nKing BR. For a high fat, high protein br... | [
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King BR. For a high fat, high protein breakfast,\npreprandial administration of 125% of the insulindose improves postprandial glycaemic excursionsS274 Children and Adolescents Diabetes Care Volume 47, Supplement 1, January 2024\n©AmericanDiabetesAssociation | [
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15. Management of Diabetes in\nPregnancy: Standards of Care in\nDiabetes— 2024\nDiabetes Care 2024;47(Suppl. 1):S282 –S294 |https://doi.org/10.2337/dc24-S015American Diabetes Association\nProfessional Practice Committee *\nThe American Diabetes Association (ADA) “Standards of Care in Diabetes ”includes | [
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the ADA ’s current clinical practice recommendations and is intended to provide the\ncomponents of diabetes care, general treatment goals and guidelines, and tools to | [
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evaluate quality of care. Members of the ADA Professional Practice Committee, aninterprofessional expert committee, are responsible for updating the Standards ofCare annually, or more frequently as warranted. For a detailed description of ADA\nstandards, statements, and reports, as well as the evidence-grading system f... | [
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clinical practice recommendations and a full list of Professional Practice Committee\nmembers, 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.\nDIABETES IN PREGNANCY | [
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DIABETES IN PREGNANCY\nThe prevalence of diabetes in pregnancy has been increasing in the U.S. in parallel\nwith the worldwide epidemic of obesity. Not only is the prevalence of type 1 diabetes\nand type 2 diabetes increasing in individuals of reproductive age, but there is also a | [
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dramatic increase in the reported rates of gestational diabetes mellitus (GDM). Diabe-tes confers signi ficantly greater maternal and fetal risk largely related to the degree of\nhyperglycemia but also related to chronic complications and comorbidities of diabe-\ntes. In general, specifi c risks of diabetes in pregnancy ... | [
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fetal anomalies, preeclampsia, fetal demise, macrosomia, neonatal hypoglycemia, neo-\nnatal hyperbilirubinemia, and neonatal respiratory distress syndrome, among others.\nIn addition, diabetes in pregnancy increases the risks of obesity, hypertension, and\ntype 2 diabetes in offspring later in life (1,2).\nPreconceptio... | [
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Preconception Counseling\nRecommendations\n15.1 Starting at puberty and continuing in all people with diabetes and child-\nbearing potential, preconception counseling should be incorporated into rou-\ntine diabetes care. A\n15.2 Family planning should be discussed, and effective contraception (with con- | [
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sideration of long-acting, reversible contraception) should be prescribed and useduntil an individual ’s treatment plan and A1C are optimized for pregnancy. A\n15.3 Preconception counseling should address the importance of achieving\nglucose levels as close to normal as is safely possible, ideally A1C <6.5% | [
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(<48 mmol/mol), to reduce the risk of congenital anomalies, preeclampsia,\nmacrosomia, preterm birth, and other complications. A*A complete list of members of the American\nDiabetes Association Professional Practice Committeecan be found at https://doi.org/10.2337/dc24-SINT.\nDuality of interest information for each au... | [
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Duality of interest information for each author is\navailable at https://doi.org/10.2337/dc24-SDIS.\nSuggested citation: American Diabetes Association\nProfessional Practice Committee. 15. Manage-ment of diabetes in pregnancy: Standards of Care in\nDiabetes —2024. Diabetes Care 2024;47(Suppl. 1):\nS282–S294 | [
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Diabetes —2024. Diabetes Care 2024;47(Suppl. 1):\nS282–S294\n© 2023 by the American Diabetes Association.Readers may use this article as long as thework is properly cited, the use is educationaland not for pro fit, and the work is not altered. | [
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More information is available at https://www.diabetesjournals.org/journals/pages/license.15. MANAGEMENT OF DIABETES IN PREGNANCYS282 Diabetes Care Volume 47, Supplement 1, January 2024\n©AmericanDiabetesAssociation | [
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All individuals with diabetes and childbear-\ning potential should be informed about\nthe importance of achieving and maintain-ing as near euglycemia as safely possible\nprior to conception and throughout preg-\nnancy. Observational studies show an\nincreased risk of diabetic embryopathy,\nespecially anencephaly, micro... | [
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especially anencephaly, microcephaly,\ncongenital heart disease, renal anoma-\nlies, and caudal regression, directly pro-portional to elevations in A1C during the\nfirst 10 weeks of pregnancy (3). Although\nobservational studies are confounded bythe association between elevated peri-\nconceptional A1C and other engageme... | [
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conceptional A1C and other engagement\nin self-care behaviors, the quantity and\nconsistency of data are convincing andsupport the recommendation to opti-\nmize glycemia prior to conception with\nan A1C <6.5% (<48 mmol/mol), as this\nis associated with the lowest risk of con-genital anomalies (given that organogen- | [
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esis occurs primarily at 5 –8 weeks of\ngestation), preeclampsia, and pretermbirth (3 –7). In a systematic review and\nmeta-analysis of observational studies,\npreconception care for pregnant individ-\nuals with preexisting diabetes was asso-\nciated with lower A1C and reduced risks\nof birth defects, preterm delivery,... | [
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of birth defects, preterm delivery, peri-\nnatal mortality, small-for-gestational-age\nbirths, and neonatal intensive care unit\nadmissions (8).\nThere are opportunities at any health\ncare visit to educate all adults and ado-\nlescents with diabetes and childbearing\npotential about the risks of unplanned\npregnancies... | [
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0.08525091409683228,
0.02265779860317707,
0.05213414505124092,
-0.12896603345870972,
-0.025840... |
pregnancies and about improved mater-\nnal and fetal outcomes with pregnancy\nplanning (9). Education and counseling\nshould be offered, even when individu-als already use contraception or do not\nintend to conceive. Effective preconcep-\ntion counseling could avert substantial\nhealth and associated cost (10) burdens | [
-0.036323778331279755,
0.0615743026137352,
-0.03920651972293854,
0.029729068279266357,
-0.026078755035996437,
0.12943296134471893,
-0.00846151914447546,
0.10198117047548294,
-0.004568933043628931,
0.06764679402112961,
0.037603575736284256,
0.019412674009799957,
-0.09332921355962753,
-0.040... |
health and associated cost (10) burdens\nin the offspring (11). Family planning\nshould be discussed, including the bene-\nfits of long-acting, reversible contracep-\ntion, and effective contraception should\nbe prescribed and used until the individ-\nual is prepared and ready to become\npregnant (12 –16).\nTo minimize ... | [
-0.0694860890507698,
0.10498295724391937,
-0.038905851542949677,
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0.13403812050819397,
0.015456059016287327,
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0.05419212207198143,
0.06416749954223633,
-0.003020582487806678,
-0.04976256936788559,
0.01449... |
pregnant (12 –16).\nTo minimize the occurrence of com-\nplications, beginning at the onset of\npuberty or at diagnosis, all adults and\nadolescents with diabetes of childbear-ing potential should receive education\nabout 1) the risks of malformations\nassociated with unplanned pregnanciesand even with mild hyperglycemi... | [
-0.019296450540423393,
0.12003282457590103,
-0.052545107901096344,
0.015918871387839317,
-0.006651246454566717,
0.05574214830994606,
0.0723087415099144,
0.07279928773641586,
-0.019811438396573067,
0.04144136980175972,
-0.005977441091090441,
0.06050886586308479,
-0.08771282434463501,
-0.027... |
2) the use of effective contraception at\nall times when trying to prevent a preg-\nnancy. Preconception counseling using\ndevelopmentally appropriate educational\ntools enables adolescent girls to makewell-informed decisions (9). Preconcep-tion counseling resources tailored for\nadolescents are available at no cost | [
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0.08349280804395676,
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0.03271391615271568,
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0.13260002434253693,
0.03752517327666283,
0.08344905823469162,
0.04700199142098427,
0.04405829310417175,
0.09552595019340515,
0.048763521015644073,
-0.05374708026647568,
0.021044977... |
adolescents are available at no cost\nthrough the American Diabetes Associ-ation (ADA) (17).\nPreconception Care\nRecommendations\n15.4 Individuals with preexisting diabe-\ntes who are planning a pregnancy\nshould ideally begin receiving interpro-\nfessional care for preconception, which | [
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0.08206555247306824,
-0.03754131868481636,
0.01172726508229971,
-0.03236813470721245,
0.05379779636859894,
0.05991565063595772,
0.06773053109645844,
0.01721424236893654,
0.00536755844950676,
0.0656701996922493,
0.023747265338897705,
-0.12363138794898987,
0.0286002755... |
fessional care for preconception, which\nincludes an endocrinology health careprofessional, maternal-fetal medicine\nspecialist, registered dietitian nutrition-\nist, and diabetes care and education\nspecialist, when available. B\n15.5 In addition to focused attention\non achieving glycemic targets, Astan-\ndard precon... | [
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0.057610489428043365,
-0.045138392597436905,
0.06175053119659424,
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0.06561711430549622,
0.031432099640369415,
0.09288634359836578,
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0.02749367244541645,
-0.15191365778446198,
-0.03... |
dard preconception care should be\na u g m e n t e dw i t he x t r af o c u so nn u t r i -\ntion, physical activity, diabetes self-\ncare education, and screening for\ndiabetes comorbidities and compli-\ncations. B\n15.6 Individuals with preexisting type 1\nor type 2 diabetes who are planning a\npregnancy or who have ... | [
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0.06351180374622345,
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0.011711997911334038,
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0.09275451302528381,
0.06255558133125305,
0.05230668932199478,
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0.05530351772904396,
0.007915521040558815,
0.07428080588579178,
-0.14962199330329895,
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pregnancy or who have become preg-\nnant should be counseled on the risk\nof development and/or progression\nof diabetic retinopathy. Dilated eye\nexaminations should occur ideally\nbefore pregnancy or in the first tri-\nmester, and then pregnant indivi-duals should be monitored every\ntrimester and for 1 year postpartu... | [
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0.010459909215569496,
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trimester and for 1 year postpartum\nas indicated by the degree of reti-\nnopathy and as recommended by\nthe eye care health care profes-\nsional. B\nThe importance of preconception care\nfor all pregnant people is highlighted by\nAmerican College of Obstetricians andGynecologists (ACOG) Committee Opinion762, “Prepregn... | [
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0.012876950204372406,
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0.028811808675527573,
0.020772520452737808,
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-0.... |
conception counseling for pregnant peo-ple with preexisting type 1 or type 2diabetes is highly effective in reducingthe risk of congenital malformations\nand decreasing the risk of preterm deliv-\nery and admission to neonatal intensivecare units. Preconception counseling is | [
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0.00013708391634281725,
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-0.013704609125852585,
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0.06130575016140938,
0.03288736939430237,
0.10269288718700409,
0.01862817257642746,
0.05472325161099434,
-0.009015767835080624,
0.04064803197979927,
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also associated with reductions in perina-tal mortality and small-for-gestational-agebirth weight (18). A key point is theneed to incorporate a question about\nplans for pregnancy into the routine pri-\nmary and gynecologic care of peoplewith diabetes. Preconception care forpeople with diabetes should include the\nstan... | [
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0.0903831347823143,
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0.03156358003616333,
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0.04781719669699669,
0.051921747624874115,
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0.03662935271859169,
0.03528347238898277,
0.0610809400677681,
-0.13074691593647003,
-0.062477... |
standard screening and care recom-\nmended for any person planning preg-nancy (10). Prescription of prenatalvitamins with at least 400 mgo ff o l i c\nacid (10) and 150 mg of potassium io-dide (19) is recommended prior to con-ception. Review and counseling on theabstinence of use of nicotine products,alcohol, and recre... | [
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0.039089102298021317,
-0.01241161860525608,
-0.03606832027435303,
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0.06768248975276947,
-0.025972120463848114,
0.1362832486629486,
-0.03874405100941658,
0.03187926858663559,
0.003787481226027012,
-0.006404164247214794,
-0.051521800458431244,
-0.01... |
ing marijuana, is important. Standard\ncare includes screening for sexuallytransmitted diseases and thyroid dis-ease, recommended vaccinations, rou-\ntine genetic screening, a careful review\nof all prescription and nonprescriptionmedications, herbal supplements, andnonherbal supplements used, and a re-\nview of travel... | [
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0.08210862427949905,
-0.016923600807785988,
-0.016116375103592873,
0.01963385008275509,
0.10187634825706482,
0.017276505008339882,
0.03516535088419914,
-0.10881761461496353,
0.006214937660843134,
0.021504580974578857,
0.05414557456970215,
-0.11405479162931442,
0.055199... |
view of travel history and plans with\nspecial attention to areas known tohave Zika virus, as outlined by ACOG.SeeTable 15.1 for additional details on\nelements of preconception care (10,20).\nCounseling on the speci fic risks of | [
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0.08303781598806381,
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0.06650379300117493,
0.028892403468489647,
0.04823356121778488,
0.009366624988615513,
0.07164010405540466,
-0.06519456952810287,
0.040965937077999115,
0.08220057934522629,
0.013063878752291203,
-0.021152976900339127,
0.0602996... |
Counseling on the speci fic risks of\nobesity in pregnancy and lifestyle inter-ventions to prevent and treat obesity,including referral to a registered dieti-tian nutritionist (RDN), is recommended\n(21).\nDiabetes-speci ficc o u n s e l i n gs h o u l d\ninclude an explanation of the risks to | [
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0.03410762548446655,
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0.06797603517770767,
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0.0725998654961586,
0.05311569571495056,
0.05546373873949051,
-0.06831715255975723,
0.018936803564429283,
-0.02727319486439228,
-0.04572266712784767,
-0.0933912917971611,
-0.030269... |
include an explanation of the risks to\nmother and fetus related to pregnanciesassociated with diabetes and the ways\nto reduce risks, including glycemic goal\nsetting, lifestyle and behavioral man-agement, and medical nutrition therapy(18). The most important diabetes-\nspeci fic component of preconception\ncare is the... | [
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0.12328601628541946,
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0.0550222173333168,
0.007010767236351967,
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0.04789853096008301,
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0.04160480573773384,
-0.02517029084265232,
0.03560084104537964,
-0.10037268698215485,
-0.0635238... |
care is the attainment of glycemic\ngoals prior to conception. In addition,the presence of microvascular compli-\ncations is associated with higher risk of\ndisease progression and adverse preg-nancy outcomes (22). Diabetes-speci fic\ntesting should include A1C, creatinine, andurinary albumin-to-creatinine ratio. Specia... | [
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0.013477656058967113,
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0.03158821538090706,
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0.024075057357549667,
0.12067745625972748,
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0.017093950882554054,
-0.06891196221113205,
-0.05... |
attention should be paid to the review of\nthe medication list for potentially harmfuldrugs, i.e., ACE inhibitors (23,24), angio-tensin receptor blockers (23), and statins\n(24,25). A referral for a comprehensive\neye exam is recommended. Individualsdiabetesjournals.org/care Management of Diabetes in Pregnancy S283\n©A... | [
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-0.07382335513830185,
0.023720886558294296,
0.026192672550678253,
0.04288124293088913,
0.005652324762195349,
0.14799317717552185,
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0.019075555726885796,
-0.09074711054563522,
0.007445116993039846,
-0.09716731309890747,
0.027... |
with preexisting diabetic retinopathy\nwill need close monitoring during preg-nancy to assess stability or progression\nof retinopathy and provide treatment if\nindicated (26).\nGLYCEMIC GOALS IN PREGNANCY\nRecommendations\n15.7 Fasting, preprandial, and postpran-\ndial blood glucose monitoring are rec-\nommended in in... | [
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0.01246727630496025,
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0.06551148742437363,
0.06533258408308029,
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0.05899800732731819,
-0.03920154646039009,
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-0.12657935917377472,
-0.000914... |
ommended in individuals with diabetes\nin pregnancy to achieve optimal glucoselevels. Glucose goals are fasting plasma\nglucose <95 mg/dL ( <5.3 mmol/L)\nand either 1-h postprandial glucose<140 mg/dL ( <7.8 mmol/L) or 2-h\npostprandial glucose <120 mg/dL\n(<6.7 mmol/L). B\n15.8 Due to increased red blood cell\nturnover... | [
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0.020486274734139442,
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0.048174068331718445,
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0.009615627117455006,
0.03523250296711922,
0.08596041053533554,
0.028290610760450363,
0.007711125537753105,
-0.07106804847717285,
0.005104239098727703,
-0.0925300195813179,
-0.054... |
turnover, A1C is slightly lower during\npregnancy in people with and with-\nout diabetes. Ideally, the A1C goal in\npregnancy is <6% (<42 mmol/mol)\nif this can be achieved without signifi -\ncant hypoglycemia, but the goal maybe relaxed to <7% (<53 mmol/mol) if\nnecessary to prevent hypoglycemia. B\n15.9 When used in a... | [
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0.05068597197532654,
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0.010855626314878464,
0.06241835653781891,
0.10872085392475128,
0.019803106784820557,
-0.006520275492221117,
-0.03594675287604332,
0.03174113109707832,
-0.04834146425127983,
0.015... |
15.9 When used in addition to pre-\nand postprandial blood glucose moni-toring, continuous glucose monitoring\n(CGM) can help to achieve the A1C\ngoal in diabetes and pregnancy. B\n15.10 CGM is recommended in preg-\nnancies associated with type 1 diabe-\ntes.AWhen used in addition to blood\nglucose monitoring, achievin... | [
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0.055702224373817444,
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0.03180127590894699,
0.05140107125043869,
0.13076746463775635,
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0.... |
glucose monitoring, achieving tradi-\ntional pre- and postprandial goals,\nreal-time CGM can reduce the risk for\nlarge-for-gestational age infants and\nneonatal hypoglycemia in pregnancy\ncomplicated by type 1 diabetes. A\n15.11 CGM metrics may be used in\naddition to but should not be used as\na substitute for blood ... | [
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0.04083341360092163,
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0.03... |
a substitute for blood glucose moni-\ntoring to achieve optimal pre- and\npostprandial glycemic goals. E\n15.12 Commonly used estimated A1C\nand glucose management indicator cal-\nculations should not be used in preg-\nnancy as estimates of A1C. C\n15.13 Nutrition counseling should\nendorse a balance of macronutrients | [
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0.018079515546560287,
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0.0026311068795621395,
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... |
15.13 Nutrition counseling should\nendorse a balance of macronutrients\nincluding nutrient-dense fruits, vege-\ntables, legumes, whole grains, and\nhealthy fats with n-3 fatty acids that\ni n c l u d en u t sa n ds e e d sa n d fish in\nthe eating pattern. ETable 15.1 —Checklist for preconception care for people with di... | [
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0.029448561370372772,
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0.07170496881008148,
0.05598254129290581,
0.022482603788375854,
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0.060536324977874756,
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-0.11200660467147827,
-0.0716... |
Preconception education should include:\nwComprehensive nutrition assessment and recommendations for:\n/C15Overweight/obesity or underweight\n/C15Meal planning\n/C15Correction of dietary nutritional de ficiencies\n/C15Caffeine intake\n/C15Safe food preparation technique\nwLifestyle recommendations for:\n/C15Regular mode... | [
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0.018300453200936317,
0.05274400860071182,
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0.07723300904035568,
-0.021748583763837814,
0.07188942283391953,
-0.07437610626220703,
0.010733078233897686,
0.07557410001754761,
-0.026611225679516792,
-0.05251596122980118,
-0.059... |
wLifestyle recommendations for:\n/C15Regular moderate exercise\n/C15Avoidance of hyperthermia (hot tubs)\n/C15Adequate sleep\nwComprehensive diabetes self-management education\nwCounseling on diabetes in pregnancy per current standards, including: natural history of | [
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0.09591035544872284,
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0.05810373276472092,
0.02769145742058754,
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0.007500011008232832,
-0.08884423971176147,
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-0.12984387576580048,
0.022274... |
insulin resistance in pregnancy and postpartum; preconception glycemic goals; avoidance of\nDKA/severe hyperglycemia; avoidance of severe hypoglycemia; progression of retinopathy;\nPCOS (if applicable); fertility in people with diabetes; genetics of diabetes; risks to | [
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0.03273729234933853,
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0.06113549694418907,
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0.029624242335557938,
0.0016092070145532489,
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pregnancy including miscarriage, still birth, congenital malformations, macrosomia, pretermlabor and delivery, hypertensive disorders in pregnancy, etc.\nwSupplementation\n/C15Folic acid supplement (400 mg routine)\n/C15Appropriate use of over-the-counter medications and supplements\nHealth assessment and plan should i... | [
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-0.... |
Health assessment and plan should include:\nwGeneral evaluation of overall health\nwEvaluation of diabetes and its comorbidities and complications, including DKA/severe\nhyperglycemia; severe hypoglycemia/hypoglycemia unawareness; barriers to care;\ncomorbidities such as hyperlipidemia, hypertension, NAFLD, PCOS, and t... | [
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0.09877839684486389,
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0.061666153371334076,
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0.07463544607162476,
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-0... |
dysfunction; complications such as macrovascular disease, nephropathy, neuropathy\n(including autonomic bowel and bladder dysfunction), and retinopathy\nwEvaluation of obstetric/gynecologic history, including a history of cesarean section, | [
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0.023707348853349686,
0.0898541584610939,
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0.029198074713349342,
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0.03253998979926109,
-0.06433183699846268,
-0.00179818... |
congenital malformations or fetal loss, current methods of contraception, hypertensivedisorders of pregnancy, postpartum hemorrhage, preterm delivery, previous\nmacrosomia, Rh incompatibility, and thrombotic events (DVT/PE)\nwReview of current medications and appropriateness during pregnancy\nScreening should include: | [
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-0.1159186139702797,
-0.00055... |
Screening should include:\nwDiabetes complications and comorbidities, including comprehensive foot exam;\ncomprehensive ophthalmologic exam; ECG in individuals starting at age 35 years who\nhave cardiac signs/symptoms or risk factors and, if abnormal, further evaluation; lipid\npanel; serum creatinine; TSH; and urine a... | [
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panel; serum creatinine; TSH; and urine albumin-to-creatinine ratio\nwAnemia\nwGenetic carrier status (based on history):\n/C15Cystic fibrosis\n/C15Sickle cell anemia\n/C15Tay-Sachs disease\n/C15Thalassemia\n/C15Others if indicated\nwInfectious disease\n/C15Neisseria gonorrhoeae/Chlamydia trachomatis\n/C15Hepatitis B an... | [
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0.... |
/C15Hepatitis B and hepatitis C\n/C15HIV\n/C15Pap smear\n/C15Syphilis\nImmunizations should include:\nwInactivated infl uenza\nwTdap (tetanus, diphtheria, and pertussis)\nwCOVID-19 (certain populations)\nwHepatitis A and hepatitis B (certain populations)\nwOthers if indicated\nPreconception plan should include: | [
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0.05... |
wOthers if indicated\nPreconception plan should include:\nwNutrition and medication plan to achieve glycemic goals prior to conception, including appropriateimplementation of monitoring, continuous glucose monitoring, and pump technology\nwContraceptive plan to prevent pregnancy until glycemic goals are achieved | [
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wManagement plan for general health, gynecologic concerns, comorbid conditions, or\ncomplications, if present, including hypertension, nephropathy, retinopathy; Rh\nincompatibility; and thyroid dysfunction\nCreated using information from American College of Obstetricians and Gynecologists (10) and Ra- | [
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mos (20). COVID-19, coronavirus disease 2019; DKA, diabetic ketoacidosis; DVT/PE, deep vein\nthrombosis/pulmonary embolism; ECG, electrocardiogram; NAFLD, nonalcoholic fatty liver disease;PCOS, polycystic ovary syndrome; TSH, thyroid-stimulating hormone.S284 Management of Diabetes in Pregnancy Diabetes Care Volume 47, ... | [
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0.00... |
©AmericanDiabetesAssociation | [
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Pregnancy in people with normal glu-\ncose metabolism is characterized byfasting levels of blood glucose that arelower than in the nonpregnant statedue to insulin-independent glucose up-take by the fetus and placenta and by\nmild postprandial hyperglycemia and | [
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mild postprandial hyperglycemia and\ncarbohydrate intolerance as a result ofdiabetogenic placental factors. In peo-ple with preexisting diabetes, glycemicgoals are usually achieved through acombination of insulin administrationand medical nutrition therapy. Becauseglycemic goals in pregnancy are stricter\nthan in nonpr... | [
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than in nonpregnant individuals, it is\nimportant that pregnant people with dia-betes eat consistent amounts of carbo-hydrates to match with insulin dosageand to avoid hyperglycemia or hypogly-cemia. Referral to an RDN is importantto establish a food plan and insulin-to-carbohydrate ratio and determine weight\ngain goa... | [
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gain goals. The quality of the carbohy-\ndrates should be evaluated. A subgroupanalysis of the Continuous Glucose Mon-itoring in Pregnant Women With Type 1Diabetes Trial (CONCEPTT) study demon-strated that the diets of individuals plan-ning pregnancy and currently pregnantassessed during the run-in phase prior\nto rand... | [
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to randomization were characterized by\nhigh-fat, low- fiber, and poor-quality car-\nbohydrate intakes. Fruit and vegetableconsumption was inadequate, with onein four participants at risk for micronutri-ent de ficiencies, highlighting the impor-\ntance of medical nutrition therapy (27).An expert panel on nutrition in pre... | [
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nancy recommends a balance of macro-\nnutrients. A diet that severely restrictsany macronutrient class should be avoided,specifically the ketogenic diet that lacks\ncarbohydrates, the Paleo diet because ofdairy restriction, and any diet characterizedby excess saturated fats. Nutrient-dense,whole foods are recommended, i... | [
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ing fruits, vegetables, legumes, whole\ngrains, and healthy fats with n-3 fattyacids that include nuts and seeds andfish, which are less likely to promote ex-\ncessive weight gain. Processed foods,fatty red meat, and sweetened foodsand beverages should be limited (28).\nInsulin Physiology | [
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Insulin Physiology\nGiven that early pregnancy may be atime of enhanced insulin sensitivity and\nlower glucose levels, many people with\ntype 1 diabetes will have lower insulin re-quirements and an increased risk forhypoglycemia (29). At around 16 weeks,\ninsulin resistance begins to increase, and | [
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insulin resistance begins to increase, and\ntotal daily insulin doses increase linearly/C245% per week through week 36. This | [
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usually results in a doubling of daily insu-lin dose compared with the prepregnancyrequirement. While there is an increase inboth basal and bolus insulin requirements,bolus insulin requirements take up a largerproportion of overall total daily insulinneeds in individuals with preexisting diabe-t e sa sp r e g n a n c y... | [
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diabe-t e sa sp r e g n a n c yp r o g r e s s e s( 3 0 , 3 1 ) .T h einsulin requirement levels off toward the | [
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e n do ft h et h i r dt r i m e s t e r .Ar a p i dr e d u c -\ntion in insulin requirements can indicatethe development of placental insuffi ciency\n( 3 2 ) .I np e o p l ew i t hn o r m a lp a n c r e a t i cfunction, insulin production is suf ficient to | [
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meet the challenge of this physiological in-sulin resistance and to maintain normalglucose levels. However, in people with di-abetes, hyperglycemia occurs if treatmentis not adjusted appropriately.\nGlucose Monitoring\nReflecting this physiology, fasting and | [
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Glucose Monitoring\nReflecting this physiology, fasting and\npostprandial blood glucose monitoringis recommended to achieve metaboliccontrol in pregnant people with diabe-tes. Preprandial testing is also recom-\nmended when using insulin pumps or | [
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mended when using insulin pumps or\nbasal-bolus therapy so that premealrapid-acting insulin dosage can be ad-justed. Postprandial monitoring is asso-ciated with better glycemic outcomesand a lower risk of preeclampsia (32 –34). | [
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There are no adequately powered ran-domized trials comparing different fastingand postmeal glycemic goals for pre-existing diabetes in pregnancy.\nSimilar to the targets recommended\nby ACOG (upper limits are the same asfor GDM, described below) (35), theADA-recommended targets for pregnant\npeople with type 1 or type ... | [
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people with type 1 or type 2 diabetes\nare as follows:\n\x81Fasting glucose 70 –95 mg/dL (3.9– 5.3\nmmol/L) and either\n\x81One-hour postprandial glucose 110 –140\nmg/dL (6.1 –7.8 mmol/L) or\n\x81Two-hour postprandial glucose 100 –120\nmg/dL (5.6 –6.7 mmol/L)\nLower limits are based on the mean\nof normal blood glucose... | [
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of normal blood glucose in pregnancy\n(36). Lower limits do not apply to indi-viduals with type 2 diabetes treatedwith nutrition alone. Hypoglycemia inpregnancy is as de fin e da n dt r e a t e di nR e c -\nommendations 6.11 –6.17 (see Section 6,\n“Glycemic Goals and Hypoglycemia ”). The | [
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“Glycemic Goals and Hypoglycemia ”). The\nmost appropriate hypoglycemia thresholdlevel in pregnancy has not been validatedbut has ranged from <60 to<70 mg/dL\n(<3.3 to <3.9 mmol/L) in the past.\nCurrent recommendations for hypogly-cemia thresholds include blood glucose<70 mg/dL ( <3.9 mmol/L) and sensor\nglucose <63 mg... | [
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glucose <63 mg/dL ( <3.5 mmol/L)\n(36,37). These fasting/premeal and post-\nprandial glucose values represent opti-\nmal levels if they can be achieved safely.In practice, it may be challenging for aperson with type 1 diabetes to achievethese goals without hypoglycemia, par-\nticularly those with a history of recurrent | [
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ticularly those with a history of recurrent\nhypoglycemia or hypoglycemia unaware-ness. If an individual cannot achievethese goals without signi ficant hypogly-\ncemia, the ADA suggests less stringentgoals based on clinical experience and\nindividualization of care.\nA1C in Pregnancy\nIn studies of individuals without p... | [
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A1C in Pregnancy\nIn studies of individuals without preex-\nisting diabetes, increasing A1C levelswithin the normal range are associatedwith adverse outcomes (38). In theHyperglycemia and Adverse PregnancyOutcome (HAPO) study, increasing levels\nof glycemia were also associated with | [
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of glycemia were also associated with\nworsening outcomes (39). Observationalstudies in preexisting diabetes and preg-nancy show the lowest rates of adversefetal outcomes in association with A1C\n<6–6.5% (<42–48 mmol/mol) early in\ngestation (4 –6,40). Clinical trials have\nnot evaluated the risks and bene fits of\nachi... | [
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achieving these goals, and treatment\ngoals should account for the risk of ma-ternal hypoglycemia in setting an individ-\nualized goal of <6% (<42 mmol/mol) to\n<7% (<53 mmol/mol). Due to physiolog-\nical increases in red blood cell turnover,\nA1C levels fall during normal pregnancy(41,42). Additionally, as A1C represe... | [
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an integrated measure of glucose, it may\nnot fully capture postprandial hyperglyce-mia, which drives macrosomia. Thus, al-though A1C may be useful, it should beused as a secondary measure of glycemicoutcomes in pregnancy, after blood glu-\ncose monitoring.\nIn the second and third trimesters, A1C\n<6% (<42 mmol/mol) h... | [
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... |
<6% (<42 mmol/mol) has the lowest\nrisk of large-for-gestational-age infants\n(40,43,44), preterm delivery (45), anddiabetesjournals.org/care Management of Diabetes in Pregnancy S285\n©AmericanDiabetesAssociation | [
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preeclampsia (1,46). Taking all of this into\naccount, a goal of <6% (<42 mmol/mol)\nis optimal during pregnancy if it can be\nachieved without signi ficant hypoglyce-\nmia. The A1C goal in a given individualshould be achieved without hypoglyce-\nmia, which, in addition to the usual ad-verse sequelae, may increase the r... | [
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low birth weight (47,48). Given the alter-\na t i o ni nr e db l o o dc e l lk i n e t i c sd u r i n gpregnancy and physiological changes in\nglycemic parameters, A1C levels may\nneed to be monitored more frequently\nthan usual (e.g., monthly).\nContinuous Glucose Monitoring in\nPregnancy\nCONCEPTT was a randomized co... | [
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Pregnancy\nCONCEPTT was a randomized controlled\ntrial (RCT) of real-time continuous glu-cose monitoring (CGM) in addition to\nstandard care, including optimization of\npre- and postprandial glucose goals ver-\nsus standard care for pregnant people\nwith type 1 diabetes. It demonstratedthe value of real-time CGM in pre... | [
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