Guidelines for Managing Preexisting Diabetes During Pregnancy
Overview
Preexisting diabetes significantly increases maternal and perinatal risks, but optimized glycemic control before and during pregnancy can reduce adverse outcomes. These guidelines provide evidence-based recommendations on screening, contraception, nutrition, glucose monitoring, treatment, delivery timing, and postpartum care for individuals with type 1 and type 2 diabetes.
Background
Preexisting diabetes mellitus (PDM), including type 1 and type 2 diabetes, is associated with increased maternal and neonatal morbidity and mortality. Achieving strict glycemic targets prior to conception and throughout pregnancy reduces risks such as congenital malformations and poor perinatal outcomes. Despite evidence supporting preconception care (PCC), uptake remains low. Additionally, obesity and other metabolic factors contribute to adverse outcomes, necessitating comprehensive management strategies.
Data Highlights
Intervention
Recommendation Strength
Certainty of Evidence
Key Outcome
Screening for pregnancy intention at all visits
Suggested
Low (2 | ⊕OOO)
Improved HbA1c at first prenatal visit, reduced congenital malformations
Use of contraception when pregnancy not desired
Suggested
Moderate (2 | ⊕⊕OO)
Reduced unplanned pregnancies and terminations
Discontinuation of GLP-1RA before conception in T2DM
Suggested
Low (2 | ⊕OOO)
Minimize fetal exposure risks
Against routine addition of metformin to insulin in pregnancy
Suggested
Low (2 | ⊕OOO)
Balance between large and small for gestational age infants
Either carbohydrate-restricted or usual diet during pregnancy
Suggested
Low (2 | ⊕OOO)
Uncertain net benefit or harm
Use of CGM or SMBG in pregnant T2DM
Suggested
Low (2 | ⊕OOO)
Improved glucometrics, neonatal outcomes
Against single 24-hour CGM target <140 mg/dL
Suggested
Low (2 | ⊕OOO)
Maintain standard pregnancy glucose targets
Use of hybrid closed-loop pump in pregnant T1DM
Suggested
Low (2 | ⊕OOO)
Improved time in range and reduced hypoglycemia
Early delivery based on risk assessment
Suggested
Low (2 | ⊕OOO)
Reduce risks beyond 38 weeks gestation
Postpartum endocrine care in PDM
Suggested
Low (2 | ⊕OOO)
Supports glycemic control and preconception care
Key Findings
Screening for pregnancy intention should be performed at all reproductive and diabetes care visits to facilitate preconception care.
Contraception is recommended for individuals with diabetes not planning pregnancy to reduce unplanned pregnancies and improve outcomes.
GLP-1 receptor agonists should be discontinued before conception in type 2 diabetes due to limited safety data during pregnancy.
Routine addition of metformin to insulin therapy in pregnant individuals with type 2 diabetes is not recommended due to uncertain benefit and potential risks.
Either carbohydrate-restricted (<175 g/day) or usual diet (>175 g/day) can be considered during pregnancy, as evidence is insufficient to favor one.
Continuous glucose monitoring (CGM) or self-monitoring of blood glucose (SMBG) are both acceptable for glucose monitoring in pregnant individuals with type 2 diabetes.
Hybrid closed-loop insulin pump systems are suggested over standard insulin pumps or injections with CGM in pregnant individuals with type 1 diabetes to improve glycemic control.
Early delivery based on individualized risk assessment is preferred over expectant management beyond 38 weeks gestation.
Postpartum endocrine care should be integrated with obstetric care to optimize diabetes management and support future pregnancies.
Clinical Implications
Clinicians should incorporate routine pregnancy intention screening and contraception counseling into diabetes care for reproductive-aged individuals. Optimizing glycemic control with appropriate glucose monitoring technologies and individualized treatment plans, including cautious use of medications, can improve maternal and neonatal outcomes. Early delivery decisions and postpartum diabetes management are critical components of comprehensive care.
Conclusion
These guidelines emphasize a multidisciplinary, patient-centered approach to managing preexisting diabetes in pregnancy, highlighting the importance of preconception care, individualized treatment, and coordinated postpartum management to reduce adverse outcomes. Further high-quality research is needed to strengthen the evidence base for these recommendations.
References
Endocrine Society and European Society of Endocrinology, 2024 -- Guidelines for Managing Preexisting Diabetes During Pregnancy
by Jennifer A Wyckoff, Annunziata Lapolla, Bernadette D Asias-Dinh, Linda A Barbour, Florence M Brown, Patrick M Catalano, Rosa Corcoy, Gian Carlo Di Renzo, Nancy Drobycki, Alexandra Kautzky-Willer, M Hassan Murad, Melanie Stephenson-Gray, Adam G Tabák, Emily Weatherup, Chloe Zera, Naykky Singh-Ospina
In a target-trial emulation of more than 600,000 veterans, GLP-1 RA initiators saw fewer new substance use disorders—and patients with existing SUDs had fewer overdoses, hospitalizations, and deaths.
