1、15. Management of Diabetes inPregnancy:Standards of MedicalCare in Diabetes2022Diabetes Care 2022;45(Suppl. 1):S232S243 | https:/doi.org/10.2337/dc22-S015American Diabetes AssociationProfessional Practice Committee*The American Diabetes Association (ADA) “Standards of Medical Care in Dia-betes” incl
2、udes the ADAs current clinical practice recommendations and isintended to provide the components of diabetes care, general treatment goalsand guidelines, and tools to evaluate quality of care. Members of the ADA Profes-sional Practice Committee, a multidisciplinary expert committee (https:/doi.org/1
3、0.2337/dc22-SPPC), are responsible for updating the Standards of Careannually, or more frequently as warranted. For a detailed description of ADAstandards, statements, and reports, as well as the evidence-grading system forADAs clinical practice recommendations, please refer to the Standards ofCare
4、Introduction (https:/doi.org/10.2337/dc22-SINT). Readers who wish tocomment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.DIABETES IN PREGNANCYThe prevalence of diabetes in pregnancy has been increasing in the U.S. in parallelwith the worldwide epidemic of obesity. N
5、ot only is the prevalence of type 1 diabe-tes and type 2 diabetes increasing in women of reproductive age, but there is alsoa dramatic increase in the reported rates of gestational diabetes mellitus (GDM).Diabetes confers significantly greater maternal and fetal risk largely related to thedegree of
6、hyperglycemia but also related to chronic complications and comorbid-ities of diabetes. In general, specific risks of diabetes in pregnancy include sponta-neous abortion, fetal anomalies, preeclampsia, fetal demise, macrosomia, neonatalhypoglycemia, hyperbilirubinemia, and neonatal respiratory distr
7、ess syndrome,among others. In addition, diabetes in pregnancy may increase the risk of obesity,hypertension, and type 2 diabetes in offspring later in life (1,2).PRECONCEPTION COUNSELINGRecommendations15.1Starting at puberty and continuing in all women with diabetes andreproductive potential, precon
8、ception counseling should be incorpo-rated into routine diabetes care. A15.2Family planning should be discussed, and effective contraception (withconsideration of long-acting, reversible contraception) should be pre-scribed and used until a womans treatment regimen and A1C are opti-mized for pregnan
9、cy. A15.3Preconception counseling should address the importance of achievingglucose levels as close to normal as is safely possible, ideally A1C 6.5%*A complete list of members of the AmericanDiabetes Association Professional Practice Com-mittee can be found at https:/doi.org/10.2337/dc22-SPPC.Sugge
10、sted citation: American Diabetes Asso-ciation Professional Practice Committee. 15.Management of diabetes in pregnancy: Stan-dardsofMedicalCareinDiabetes2022.Diabetes Care 2022;45(Suppl. 1):S232S243 2021 by the American Diabetes Association.Readers may use this article as long as thework is properly
11、cited, the use is educationaland not for profit, and the work is not altered.Moreinformationisavailableathttps:/diabetesjournals.org/journals/pages/license.15. MANAGEMENT OF DIABETES IN PREGNANCYS232Diabetes Care Volume 45, January 2022Downloaded from http:/diabetesjournals.org/care/article-pdf/45/S
12、upplement_1/S232/636911/dc22s015.pdf by guest on 10 July 2022(48 mmol/mol), to reduce therisk of congenital anomalies,preeclampsia, macrosomia, pre-term birth, and other complica-tions. AAll women of childbearing age with dia-betes should be informed about theimportance of achieving and maintaininga
13、s near euglycemia as safely possibleprior to conception and throughout preg-nancy. Observational studies show anincreased risk of diabetic embryopathy,especiallyanencephaly,microcephaly,congenital heart disease, renal anomalies,and caudal regression, directly propor-tional to elevations in A1C durin
14、g the first10 weeks of pregnancy (3). Althoughobservational studies are confounded bythe association between elevated peri-conceptional A1C and other poor self-care behavior, the quantity and consis-tency of data are convincing and supportthe recommendation to optimize glyce-mia prior to conception,
15、 given thatorganogenesis occurs primarily at 58weeks of gestation, with an A1C 6.5%(48 mmol/mol) being associated with thelowest risk of congenital anomalies, pre-eclampsia, and preterm birth (37). Asystematic review and meta-analysis ofobservational studies of preconceptioncare for women with preex
16、isting diabetesdemonstrated lower A1C and reducedrisk of birth defects, preterm delivery,perinatal mortality, small-for-gestational-age births, and neonatal intensive careunit admission (8).There are opportunities to educateall women and adolescents of reproduc-tive age with diabetes about the risks
17、 ofunplannedpregnanciesandaboutimproved maternal and fetal outcomeswith pregnancy planning (9). Effectivepreconception counseling could avertsubstantial health and associated costburdens in offspring (10). Family plan-ning should be discussed, including thebenefits of long-acting, reversible con-tra
18、ception, and effective contraceptionshould be prescribed and used until awomanispreparedandreadytobecome pregnant (1115).To minimize the occurrence of compli-cations, beginning at the onset of pubertyor at diagnosis, all girls and women withdiabetes of childbearing potential shouldreceive education
19、about 1) the risks ofmalformations associated with unplannedpregnancies and even mild hyperglycemiaand 2) the use of effective contraceptionat all times when preventing a pregnancy.Preconception counseling using develop-mentally appropriate educational toolsenables adolescent girls to make well-info
20、rmed decisions (9). Preconceptioncounseling resources tailored for adoles-cents are available at no cost through theAmericanDiabetesAssociation(ADA)(16).Preconception CareRecommendations15.4Women with preexisting dia-beteswhoareplanningapregnancy should ideally bemanaged beginning in precon-ception
21、in a multidisciplinaryclinic including an endocrino-logist, maternal-fetal medicinespecialist, registered dietitiannutritionist, and diabetes careand education specialist, whenavailable. B15.5In addition to focused atten-tion on achieving glycemic tar-gets A, standard preconceptioncare should be aug
22、mented withextra focus on nutrition, diabeteseducation, and screening for dia-betes comorbidities and compli-cations. E15.6Women with preexisting type1 or type 2 diabetes who areplanning pregnancy or whohave become pregnant shouldbe counseled on the risk ofdevelopment and/or progres-sion of diabetic
23、 retinopathy.Dilated eye examinations shouldoccur ideally before pregnancyor in the first trimester, andthen patients should be moni-tored every trimester and for 1year postpartum as indicatedby the degree of retinopathyand as recommended by theeye care provider. BThe importance of preconception car
24、efor all women is highlighted by the Amer-ican College of Obstetricians and Gyne-cologists(ACOG)CommitteeOpinion762, “Prepregnancy Counseling” (17). Akey point is the need to incorporate aquestion about a womans plans forpregnancy into routine primary and gyne-cologic care. The preconception care of
25、women with diabetes should include thestandard screenings and care recom-mended for all women planning preg-nancy(17).Prescriptionofprenatalvitamins (with at least 400 mg of folicacid and 150 mg of potassium iodide18) is recommended prior to concep-tion. Review and counseling on the useof nicotine p
26、roducts, alcohol, and recrea-tionaldrugs,includingmarijuana,isimportant. Standard care includes screen-ing for sexually transmitted diseases andthyroid disease, recommended vaccina-tions, routine genetic screening, a carefulreview of all prescription and nonpre-scription medications and supplementsu
27、sed, and a review of travel history andplans with special attention to areasknown to have Zika virus, as outlined byACOG. See Table 15.1 for additionaldetails on elements of preconceptioncare (17,19). Counseling on the specificrisks of obesity in pregnancy and lifestyleinterventions to prevent and t
28、reat obe-sity, including referral to a registereddietitian nutritionist (RD/RDN), is recom-mended when indicated.Diabetes-specificcounselingshouldinclude an explanation of the risks tomother and fetus related to pregnancyand the ways to reduce risk, includingglycemic goal setting, lifestyle and beha
29、v-ioral management, and medical nutritiontherapy. The most important diabetes-specific component of preconceptioncare is the attainment of glycemic goalsprior to conception. Diabetes-specifictesting should include A1C, creatinine,and urinary albumin-to-creatinine ratio.Special attention should be pa
30、id to thereview of the medication list for poten-tially harmful drugs (i.e., ACE inhibitors20,21, angiotensin receptor blockers20, and statins 22,23). A referral for acomprehensive eye exam is recommended.Women with preexisting diabetic retino-pathy will need close monitoring duringpregnancy to asse
31、ss for progression of reti-nopathy and provide treatment if indicated(24).Several studies have shown improveddiabetesandpregnancyoutcomeswhen care has been delivered from pre-conception through pregnancy by amultidisciplinarygroupfocusedonimproved glycemic control (2528). Onestudy showed that care o
32、f preexistingdiabetes in clinics that included diabetescare.diabetesjournals.orgManagement of Diabetes in PregnancyS233Downloaded from http:/diabetesjournals.org/care/article-pdf/45/Supplement_1/S232/636911/dc22s015.pdf by guest on 10 July 2022and obstetric specialists improved care(28). However, th
33、ere is no consensus onthe structure of multidisciplinary teamcare for diabetes and pregnancy, andthere is a lack of evidence on theimpact on outcomes of various methodsof health care delivery (29).GLYCEMIC TARGETS INPREGNANCYRecommendations15.7Fasting and postprandial self-monitoring of blood glucos
34、eare recommended in bothgestational diabetes mellitusand preexisting diabetes inpregnancy to achieve optimalglucose levels. Glucose tar-gets are fasting plasma glu-cose 95 mg/dL (5.3 mmol/L) and either 1-h postprandialglucose140mg/dL(7.8mmol/L) or 2-h postprandialglucose120mg/dL(6.7mmol/L). Some wom
35、en withpreexistingdiabetesshouldalso test blood glucose pre-prandially. B15.8Due to increased red bloodcell turnover, A1C is slightlylower in normal pregnancythan in normal nonpregnantwomen. Ideally, the A1C tar-get in pregnancy is 6% (42mmol/mol)ifthiscanbeachieved without significanthypoglycemia,
36、but the targetmay be relaxed to 7% (53mmol/mol) if necessary toprevent hypoglycemia. B15.9When used in addition topre- and postprandial bloodglucose monitoring, continu-ous glucose monitoring canhelp to achieve A1C targetsin diabetes and pregnancy. B15.10 When used in addition toblood glucose monito
37、ring tar-geting traditional pre- andpostprandial targets, real-timecontinuous glucose monitoringcan reduce macrosomia andneonatal hypoglycemia in preg-nancy complicated by type 1diabetes. B15.11 Continuous glucose monitor-ing metrics may be used inaddition to but should not beusedasasubstituteforTab
38、le 15.1Checklist for preconception care for women with diabetes (17,19)Preconception education should include:wComprehensive nutrition assessment and recommendations for:? Overweight/obesity or underweight? Meal planning? Correction of dietary nutritional deficiencies? Caffeine intake? Safe food pre
39、paration techniquewLifestyle recommendations for:? Regular moderate exercise? Avoidance of hyperthermia (hot tubs)? Adequate sleepwComprehensive diabetes self-management educationwCounseling on diabetes in pregnancy per current standards, including: natural history ofinsulin resistance in pregnancy
40、and postpartum; preconception glycemic targets; avoidanceof DKA/severe hyperglycemia; avoidance of severe hypoglycemia; progression ofretinopathy; PCOS (if applicable); fertility in patients with diabetes; genetics of diabetes;risks to pregnancy including miscarriage, still birth, congenital malform
41、ations, macrosomia,preterm labor and delivery, hypertensive disorders in pregnancy, etc.wSupplementation? Folic acid supplement (400 mg routine)? Appropriate use of over-the-counter medications and supplementsMedical assessment and plan should include:wGeneral evaluation of overall healthwEvaluation
42、 of diabetes and its comorbidities and complications, including: DKA/severehyperglycemia; severe hypoglycemia/hypoglycemia unawareness; barriers to care;comorbidities such as hyperlipidemia, hypertension, NAFLD, PCOS, and thyroiddysfunction; complications such as macrovascular disease, nephropathy,
43、neuropathy(including autonomic bowel and bladder dysfunction), and retinopathywEvaluation of obstetric/gynecologic history, including history of: cesarean section,congenital malformations or fetal loss, current methods of contraception, hypertensivedisorders of pregnancy, postpartum hemorrhage, pret
44、erm delivery, previousmacrosomia, Rh incompatibility, and thrombotic events (DVT/PE)wReview of current medications and appropriateness during pregnancyScreening should include:wDiabetes complications and comorbidities, including: comprehensive foot exam;comprehensive ophthalmologic exam; ECG in wome
45、n starting at age 35 years who havecardiac signs/symptoms or risk factors and, if abnormal, further evaluation; lipid panel;serum creatinine; TSH; and urine protein-to-creatinine ratiowAnemiawGenetic carrier status (based on history):? Cystic fibrosis? Sickle cell anemia? Tay-Sachs disease? Thalasse
46、mia? Others if indicatedwInfectious disease? Neisseria gonorrhea/Chlamydia trachomatis? Hepatitis C? HIV? Pap smear? SyphilisImmunizations should include:wRubellawVaricellawHepatitis BwInfluenzawOthers if indicatedPreconception plan should include:wNutrition and medication plan to achieve glycemic t
47、argets prior to conception, includingappropriate implementation of monitoring, continuous glucose monitoring, and pump technologywContraceptive plan to prevent pregnancy until glycemic targets are achievedwManagement plan for general health, gynecologic concerns, comorbid conditions, orcomplications
48、, if present, including: hypertension, nephropathy, retinopathy; Rhincompatibility; and thyroid dysfunctionDKA, diabetic ketoacidosis; DVT/PE, deep vein thrombosis/pulmonary embolism; ECG, elec-trocardiogram; NAFLD, nonalcoholic fatty liver disease; PCOS, polycystic ovary syndrome;TSH, thyroid-stimu
49、lating hormone.S234Management of Diabetes in PregnancyDiabetes Care Volume 45, Supplement 1, January 2022Downloaded from http:/diabetesjournals.org/care/article-pdf/45/Supplement_1/S232/636911/dc22s015.pdf by guest on 10 July 2022self-monitoringofbloodglucose to achieve optimalpre- and postprandial
50、glyce-mic targets. E15.12 CommonlyusedestimatedA1C and glucose managementindicatorcalculationsshouldnot be used in pregnancy asestimates of A1C. CPregnancy in women with normal glu-cose metabolism is characterized byfasting levels of blood glucose that arelower than in the nonpregnant state,duetoins
