Clinical Scorecard: Guidelines for Managing Preexisting Diabetes During Pregnancy: A Collaborative Approach by the Endocrine Society and European Society of Endocrinology

At a Glance

Key Highlights

• Preconception care (PCC) including strict glycemic control reduces congenital malformations and adverse pregnancy outcomes but is underutilized.
• Use of continuous glucose monitoring (CGM) and hybrid closed-loop insulin pumps improves glycemic control in pregnancy, especially in type 1 diabetes.
• Early delivery based on individualized risk assessment is preferred over expectant management beyond 38 weeks gestation.

Guideline-Based Recommendations

Diagnosis

• Screen for pregnancy intention at every reproductive, diabetes, primary care, and when appropriate, urgent care visits.

Management

• Use contraception when pregnancy is not desired in individuals with diabetes.
• Discontinue GLP-1 receptor agonists before conception in type 2 diabetes.
• Avoid routine addition of metformin to insulin in pregnant individuals with type 2 diabetes.
• Either carbohydrate-restricted diet (<175 g/day) or usual diet (>175 g/day) may be used during pregnancy; evidence insufficient to recommend one over the other.
• Use either CGM or self-monitoring of blood glucose (SMBG) in pregnant individuals with type 2 diabetes.
• In type 1 diabetes pregnancy, prefer hybrid closed-loop insulin pump systems over insulin pump with CGM without algorithm or multiple daily injections with CGM.
• Suggest early delivery based on risk assessment rather than expectant management beyond 38 weeks gestation.
• Provide postpartum endocrine (diabetes) care in addition to usual obstetric care.

Monitoring & Follow-up

• Do not replace standard pregnancy glucose targets (fasting <95 mg/dL, 1-hour postprandial <140 mg/dL, 2-hour postprandial <120 mg/dL) with a single 24-hour CGM target <140 mg/dL.

Risks

• Adding metformin to insulin may increase risk of small for gestational age infants and adverse childhood outcomes.
• Limited data on GLP-1 receptor agonist exposure during pregnancy; discontinuation before conception is advised.

Patient & Prescribing Data

Individuals with preexisting type 1 or type 2 diabetes who are pregnant or planning pregnancy

Preconception care and glycemic optimization reduce risks; technology such as CGM and hybrid closed-loop pumps improve glucose control; cautious use of medications with consideration of risks is recommended.

Clinical Best Practices

• Incorporate pregnancy intention screening routinely in diabetes and primary care visits.
• Emphasize contraception counseling to prevent unplanned pregnancies in diabetes.
• Optimize glycemic control prior to conception and throughout pregnancy.
• Use individualized risk assessment to guide timing of delivery.
• Provide integrated postpartum diabetes management alongside obstetric care.
• Utilize evolving diabetes technologies to improve maternal and neonatal outcomes.

References

• Endocrine Society and European Society of Endocrinology Clinical Practice Guidelines for Preexisting Diabetes in Pregnancy