Guidance offered on handling pregnancy in patients with pre-existing diabetes

A new joint clinical guideline from the Endocrine Society and the European Society of Endocrinology offers advice on handling the possibility of pregnancy in patients with diabetes.

The guideline was developed by a multidisciplinary panel of experts after systematic reviews of the literature, and it included perspectives from two patient representatives, also taking patient values, costs and resources, acceptability and feasibility, and impact on health equity into account. It was published July 13 by the Journal of Clinical Endocrinology & Metabolism.

The guideline suggests that clinicians ask patients with diabetes who can become pregnant a screening question about pregnancy intent at every reproductive, diabetes, and primary care visit, as well at urgent care and ED visits when clinically appropriate. When pregnancy is not desired, the guideline suggests use of contraception.

Glucagon-like peptide-1 (GLP-1) receptor agonists should be discontinued before conception rather than between the start of pregnancy and the end of the first trimester, the guideline suggests, since there are limited data on the effects of exposure to GLP-1 receptor agonists during pregnancy. The guideline noted that sudden discontinuation of GLP-1 receptor agonists may cause hyperglycemia and weight gain, which increase the risk for congenital malformations and spontaneous abortion, and it said that the timing of discontinuation before pregnancy should be individualized.

In pregnant patients with type 2 diabetes who are already taking insulin, the guideline suggests against routine addition of metformin. The guideline suggests a carbohydrate-restricted diet (<175 g/d) or usual diet (>175 g/d) during pregnancy in those with pre-existing diabetes, noting that while there is no clear evidence determining the optimal amount of carbohydrate intake during pregnancy, indirect evidence indicates that lower and higher extremes are harmful.

The guideline suggests that pregnant patients with type 2 diabetes use a continuous glucose monitor (CGM) or self-monitor their blood glucose levels, since there is a lack of indirect evidence supporting CGM over self-monitoring in this population. In those with pre-existing diabetes who are using a CGM, the guideline suggests against the use of a single 24-hour CGM target below 140 mg/dL (<7.8 mmol/L) in place of standard-of-care pregnancy glucose targets of fasting levels less than 95 mg/dL (<5.3 mmol/L), one-hour postprandial levels below 140 mg/dL (<7.8 mmol/L), and two-hour postprandial levels below 120 mg/dL (<6.7 mmol/L), due to indirect evidence that adverse pregnancy outcomes are associated with a fasting glucose level above 126 mg/dL (>7 mmol/L).

Use of a hybrid closed-loop pump that adjusts automatically based on CGM is suggested in pregnant patients with type 1 diabetes, rather than an insulin pump with CGM without an algorithm or multiple daily insulin injections with CGM, the guideline said.

The guideline suggests early delivery based on risk assessment rather than expectant management in patients with pre-existing diabetes. All patients with pre-existing diabetes, including those with pregnancy loss or termination, should receive postpartum endocrine care in addition to usual obstetric care, the guideline suggests.

The guideline panel noted that the data supporting the recommendations were of very low to low certainty and called for more research and investment in the implementation and delivery of preconception care. “Randomized controlled trials … to further define glycemic targets in pregnancy and refinement of emerging technology to achieve those targets can lead to significant reduction of harm and in the burden of diabetes care,” they wrote. “Data on optimal nutrition and obesity management in pregnancy are lacking, so clinical studies in this context are necessary.”