Management of Preexisting Diabetes in Pregnancy: A Review
Preexisting diabetes complicates 0.9% of pregnancies in the US and increases the risk of adverse maternal and neonatal outcomes, specifically linked to preeclampsia, congenital anomalies, preterm delivery, and stillbirth. With type 1 and type 2 diabetes becoming more common, clinicians need to review planning and optimization of glycemic control with patients before pregnancy to mitigate the risk associated with diabetes. The researchers sought to update the management of preexisting diabetes in pregnancy with an evidence-based study. The researchers performed a review of the literature, searching for studies related to the management of preexisting diabetes in pregnancy from January 2000 to January 2019. Studies included in this review were randomized clinical trials, medical guidelines, meta-analyses, and observational studies. Within the studies, management varied depending on what stage the women studied were in: Preconception, pregnancy, or postpartum. Generally, the target for hemoglobin A1c should be less than 6.5% at conception and less than 6.0% during pregnancy (though this has to be balanced against causing significant hypoglycemia). Comorbid illnesses, such as retinopathy and nephropathy, should be screened for and managed, and for obese women, obstructive sleep apnea should be screened for as that goes undiagnosed often. Medications such as angiotensin-converting enzyme inhibitors and statins, known to be contraindicated during pregnancy, should be discontinued. For patients suffering from nephropathy, blood pressure goals must be reevaluated in this setting because of lower treatment thresholds. In type 1 diabetes patients, continuous glucose monitoring can improve glycemic control and neonatal outcomes. For all women diagnosed with diabetes before pregnancy, first-line therapy is insulin; injections and insulin pump therapy are effective administration routes. Glucagon should be available because of the increased rate of severe hypoglycemia. To minimize the preeclampsia risk, low-dose or medium-dose aspirin is recommended after 12 weeks' gestation. The researchers found the management of preexisting diabetes in pregnancy complex and linked to significantmaternal and neonatal risks. To minimize the effects of diabetes before, during, and after pregnancy, the literature recommend optimizing glycemic control, medication regimens, and paying attention to the comorbid conditions associated.
Alexopoulos, AS; Blair, R; Peters, AL
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