All recommendations have been updated and reorganized to clarify management considerations for women with pregestational or gestational diabetes in the prepregnancy period, during pregnancy, and in the intrapartum and postpartum periods. 1.All women of reproductive age with type 1 or type 2 diabetes should receive advice on reliable birth control, the importance of glycemic control prior to pregnancy, the impact of BMI on pregnancy outcomes, the need for folic acid and the need to stop potentially embryopathic drugs prior to pregnancy [Grade D, Level 4 (1)].
4.Women with type 2 diabetes who are planning a pregnancy should switch from noninsulin antihyperglycemic agents to insulin for glycemic control [Grade D, Consensus]. 6.Women should be screened for chronic kidney disease prior to pregnancy (see Chronic Kidney Disease chapter, p. 9.Detemir [Grade C, Level 2 (24)] or glargine [Grade C, Level 3 (25)] may be used in women with pregestational diabetes as an alternative to NPH. 11.Women should receive adequate glucose during labour in order to meet their high-energy requirements [Grade D, Consensus].
12.Women with pregestational diabetes should be carefully monitored postpartum as they have a high risk of hypoglycemia [Grade D, Consensus].
15.All women should be encouraged to breastfeed since this may reduce offspring obesity, especially in the setting of maternal obesity [Grade C, Level 3 (28)].
17.If there is a high risk of GDM based on multiple clinical factors, screening should be offered at any stage in the pregnancy [Grade D, Consensus].
21.Receive nutrition counselling from a registered dietitian during pregnancy [Grade C, Level 3 (37)] and postpartum [Grade D, Consensus]. 22.If women with GDM do not achieve glycemic targets within 2 weeks from nutritional therapy alone, insulin therapy should be initiated [Grade D, Consensus]. 23.Insulin therapy in the form of multiple injections should be used [Grade A, Level 1 (20)]. 24.Rapid-acting bolus analogue insulin may be used over regular insulin for postprandial glucose control, although perinatal outcomes are similar [Grade B, Level 2 (38,39)]. 27.Women should receive adequate glucose during labour in order to meet their high-energy requirements [Grade D, Consensus]. 29.Women should be screened with a 75 g OGTT between 6 weeks and 6 months postpartum to detect prediabetes and diabetes [Grade D, Consensus].
Women with pregestational diabetes who also have PCOS may continue metformin for ovulation induction [Grade D, Consensus]. S129) [Grade D, Level 4, for type 1 diabetes (17) ; Grade D, Consensus, for type 2 diabetes].
If the initial screening is performed before 24 weeks of gestation and is negative, rescreen between 24 and 28 weeks of gestation. Recommendations for weight gain during pregnancy should be based on pregravid BMI [Grade D, Consensus].

Use of oral agents in pregnancy is off-label and should be discussed with the patient [Grade D, Consensus].
Effectiveness of a regional prepregnancy care program in women with type 1 and type 2 diabetes: benefits beyond glycemic control. Preconception care for diabetic women for improving maternal and fetal outcomes: a systematic review and meta-analysis.
Preconception care and the risk of congenital anomalies in the offspring of women with diabetes mellitus: a meta-analysis. Poor glycated hemoglobin control and adverse pregnancy outcomes in type 1 and type 2 diabetes mellitus: systematic review of observational studies.
Glycemic control during early pregnancy and fetal malformations in women with type 1 diabetes mellitus.
Use of maternal GHb concentration to estimate the risk of congenital anomalies in the offspring of women with pre-pregnancy diabetes. Glycaemic control is associated with preeclampsia but not with pregnancy-induced hypertension in women with type 1 diabetes mellitus. Strategies for reducing the frequency of preeclampsia in pregnancies with insulin-dependent diabetes mellitus. Effect of pregnancy on microvascular complications in the Diabetes Control and Complications Trial.
Maternal exposure to angiotensin converting enzyme inhibitors in the first trimester and risk of malformations in offspring: a retrospective cohort study. Central nervous system and limb anomalies in case reports of first-trimester statin exposure.
Microalbuminuria, preeclampsia, and preterm delivery in pregnancy women with type 1 diabetes: results from a nationwide Danish study. Improved pregnancy outcome in type 1 diabetic women with microalbuminuria or diabetic nephropathy: effect of intensified antihypertensive therapy? Twice daily versus four times daily insulin dose regimens for diabetes in pregnancy: randomised controlled trial.
Maternal glycemic control and hypoglycemia in type 1 diabetic pregnancy: a randomized trial of insulin aspart versus human insulin in 322 pregnant women.
Glycemic control and perinatal outcomes of pregnancies complicated by type 1 diabetes: influence of continuous subcutaneous insulin and lispro insulin.
A comparison of lispro and regular insulin for the management of type 1 and type 2 diabetes in pregnancy. Maternal efficacy and safety outcomes in a randomized, controlled trial comparing insulin detemir with NPH insulin in 310 pregnant women with type 1 diabetes.

Metformin therapy throughout pregnancy reduces the development of gestational diabetes in women with polycystic ovary syndrome.
Breast-feeding and risk for childhood obesity: does maternal diabetes or obesity status matter? Fasting plasma glucose versus glucose challenge test: screening for gestational diabetes and cost effectiveness.
Impact of increasing carbohydrate intolerance on maternal-fetal outcomes in 3637 women without gestational diabetes. Postprandial versus preprandial blood glucose monitoring in women with gestational diabetes mellitus requiring insulin therapy. Recommendations for nutrition best practice in the management of gestational diabetes mellitus. Maternal metabolic control and perinatal outcome in women with gestational diabetes treated with regular or lispro insulin: comparison with non-diabetic pregnant women. Comparison of an insulin analog, insulin aspart, and regular human insulin with no insulin in gestational diabetes mellitus.
Prospective observational study to establish predictors of glyburide success in women with gestational diabetes mellitus. Comparative placental transport of oral hypoglycemic agents in humans: a model of human placental drug transfer. Comparison of glyburide and insulin for the management of gestational diabetes in a large managed care organization. Effects of early breastfeeding on neonatal glucose levels of term infants born to women with gestational diabetes. Association of breast-feeding and early childhood overweight in children from mothers with gestational diabetes mellitus. Lactation intensity and postpartum maternal glucose tolerance and insulin resistance in women with recent GDM: the SWIFT cohort. Women with microalbuminuria or overt nephropathy are at increased risk for development of hypertension and preeclampsia [Grade A, Level 1 (17,18)] and should be followed closely for these conditions [Grade D, Consensus].

Diabetes glucose testing frequency regulations
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