• AACE Diabetes Mellitus Clinical Practice Guidelines Task Force. AACE diabetes mellitus guidelines. Diabetes and pregnancy. Endocr Pract 2007 May-Jun;13(Suppl 1):55-9. [19 references]

This is the current release of the guideline.

This guideline updates a previously published version: American Association of Clinical Endocrinologists, American College of Endocrinology. Medical guidelines for the management of diabetes mellitus: the AACE system of intensive diabetes self-management--2002 update. Endocr Pract 2002 Jan-Feb;8(Suppl 1):40-82.

The levels of evidence (1–4) and the recommendation grades (A–D) are defined at the end of the "Major Recommendations" field.

Diabetes and Pregnancy

Provide Prepregnancy Counseling

• Identify the possibility of pregnancy annually by directly questioning all fertile women of childbearing age with diabetes mellitus; provide contraceptive advice when appropriate (grade A).
• Offer prepregnancy counseling to all women with diabetes mellitus who are considering pregnancy (grade A); counseling should address:
  • Information and skills relevant to the management of pregnancy in a woman with diabetes mellitus (grade B)
  • The need for optimal control of the HbA_1c level (<6%), if safely achievable, (grade A) and blood glucose concentration between 60 mg/dL (fasting) and 120 mg/dL (1 hour after a meal) (grade A)
  • The need for optimal blood pressure control (<130/80 mm Hg) (grade A)
  • The importance of a healthy lifestyle, including advice on nutrition, exercise, smoking cessation, and alcohol use (grade B)
• Discontinue oral glucose-lowering drugs and start insulin if needed (grade A).
• Discontinue angiotensin-converting enzyme inhibitors and angiotensin receptor blockers; use methyldopa, hydralazine, nifedipine extended release, or labetalol (grade A).
• Discontinue statins and fibrates (grade A).
• Assess the patient for retinopathy, nephropathy, and thyroid function (grade A).
• Initiate folic acid supplementation to reduce the risk of neural tube defects (grade A).

Screen for Undiagnosed or New (Gestational) Diabetes During Pregnancy

• In all pregnant women, measure fasting glucose at the first prenatal visit (no later than week 20). Perform a 75-g oral glucose tolerance test if the fasting glucose concentration is greater than 85 mg/dL (grade A).
  • Initiate medical nutritional therapy immediately if the diagnosis of gestational diabetes is established (grade B).
  • Initiate insulin therapy if the patient is following an optimal diet but the self-monitored glucose levels reveal fasting glucose concentrations greater than 90 mg/dL and/or if postprandial glucose concentrations are greater than 120 mg/dL 1 hour after the first bite of food at each meal (grade A).

Diabetes Management Throughout Pregnancy

• Frequently assess the status of diabetes control, risk for and presence of diabetic complications, and the presence of other medical conditions (including weight gain) (grade B).
  • Strive for a HbA_1c level less than 6%; blood glucose concentrations should remain between 60 to 90 mg/dL (fasting) and less than 120 mg/dL (1 hour after the first bite of food at each meal) (grade A).
  • Monitor weight gain and blood pressure and advise and treat the patient accordingly; blood pressure should be maintained at less than 130/80 mm Hg, avoid using renin-angiotensin system blocking drugs (grade A).
• Persistently monitor and adjust insulin therapy to achieve all glucose targets (grade A).
  • Initiate a basal-bolus insulin regimen if a patient cannot maintain glucose targets with diet alone; this regimen may include either neutral protamine Hagedorn (NPH) insulin (basal) and rapid-acting insulin at meals or subcutaneous insulin infusion with an insulin pump (grade B).
  • Patients should intensively monitor blood glucose levels (grade A):
    • Diet only—instruct patients to assess blood glucose concentration 4 times daily, prebreakfast and 1 hour after the first bite of food at each meal (grade A)
    • Insulin therapy—instruct patients to assess blood glucose concentrations 6 times daily, before each meal to determine insulin dosage correction and 1 hour after the first bite of food at each meal (grade A)
  • Accurate timing of glucose testing at meals is critical to accurately assess glucose control (grade B).
  • Expect insulin requirements to rise as pregnancy progresses; insulin requirements may be decreased by hyperemesis; steroid therapy increases insulin requirements (grade B).
• Offer medical nutrition therapy and education; if the patient is overweight, advise a diet suitable for someone of optimal weight and encourage moderate exercise such as armchair exercises (grade A).
  • Management by a health care team is needed to assess and reinforce patient understanding of diabetes management including dietary needs and considerations, knowledge of glucose targets, current pharmacologic therapy, and use of self-monitoring of blood glucose (timing and interpretation of test results and appropriate response) (grade B).

Labor and Delivery

• Maternal hyperglycemia is the main cause of neonatal hypoglycemia; therefore, intrapartum maintenance of maternal euglycemia is essential (grade B).
• Insulin is still required before active labor and can be given subcutaneously or by intravenous infusion with a goal of maintaining blood glucose concentrations between 70 to 90 mg/dL (grade B).
• As the mother enters active labor, insulin resistance rapidly decreases because of the energy expenditure of labor as a form of strenuous exercise; as a result, insulin requirements drop to zero (see Table 9.1 and 9.2 below) present protocols for adjusting intrapartum intravenous solutions and insulin administration during labor and the postpartum period in women with insulin-requiring diabetes mellitus (Table 9.3 below lists sample glucose infusion rates in active labor) (grade B).
• To prevent hypoglycemia:
  • Infuse glucose at a rate of 2.5 mg/kg per min (grade C).
  • Measure the capillary blood glucose concentration hourly (grade C).
  • Double the glucose infusion for the next hour if the blood glucose value is less than 60 mg/dL (grade C).
  • Glucose values greater or equal to 120 mg/dL require the administration of regular insulin subcutaneously or intravenously until the blood glucose value falls to 70 to 90 mg/dL; now, the insulin dose is titrated to maintain normoglycemia while glucose is infused at a rate of 2.5 mg/kg per min (grade C).
  • Do not give bolus doses of glucose because they can raise maternal blood glucose concentrations and increase the risk of neonatal hypoglycemia, fetal hypoxia, and fetal or neonatal acidosis (grade A).
  • Anticipate changed insulin requirements, and thus the need for more frequent glucose monitoring, if the patient is continuing insulin therapy postpartum and during lactation (grade C).
• Provide appropriate care and facilities for the newborn (grade B).
• At 45 to 60 days after delivery, screen for diabetes in women who developed new diabetes in pregnancy; if there is no evidence of diabetes, advise the patient of the high risk of future diabetes and educate the patient about preventative lifestyle measures; advise the patient to be examined for diabetes annually because women with gestational diabetes mellitus (GDM) have a 50% risk of developing type 2 diabetes mellitus (T2DM) within 5 years (10% conversion per year) (grade A)

Table 9.1: Protocol for Adjusting Intrapartum Intravenous Solutions and Insulin Administration During Labor and the Postpartum Period in Women With Insulin-Requiring Diabetes Mellitus Treated With Insulin Pump Therapy^a

Abbreviation: TDIR, total daily insulin requirement.

^aBasal insulin infusion rate to be reduced in half. At term, the insulin requirement is 1.0 units/kg/d; thus, 3% of this dose would be 3 units in a woman weighing 100 kg at term.

^bD₁₀ normal saline is 10% dextrose in normal (isotonic saline).

^cD₅ normal saline is 5% dextrose in normal (isotonic) saline.

Table 9.2: Protocol for Adjusting Intrapartum Intravenous Solutions and Insulin Administration in Women With Insulin-Requiring Diabetes Mellitus Based on Hourly Blood Glucose Measurement^a

Abbreviation: TDIR, total daily insulin requirement.

^aDiscontinue neutral protamine Hagedorn (NPH) insulin administration.

^bGlucose infusion rate is 2.55 mg/kg of pregnant weight/min.

^cD₅ normal saline is 5% dextrose in normal (isotonic) saline.

Table 9.3: Sample Glucose Infusion Rates for Women With Insulin-Requiring Diabetes Mellitus in Active Labor^a

^aThe rate of infusion is equal to dextrose 2.55 mg/kg/min.

^bD₅ normal saline is 5% dextrose in normal (isotonic) saline.

Definitions:

Levels of Substantiation in Evidence-Based Medicine^a

^aAdapted from the American Association of Clinical Endocrinologists Protocol for the Standardized Production of Clinical Practice Guidelines.

^bLevel-of-evidence categories 1 through 3 indicate scientific substantiation or proof; level-of-evidence category 4 indicates unproven claims.

Recommendation Grades in Evidence-Based Medicine^a

^aAdapted from the American Association of Clinical Endocrinologists Protocol for the Standardized Production of Clinical Practice Guidelines.

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

• AACE Diabetes Mellitus Clinical Practice Guidelines Task Force. AACE diabetes mellitus guidelines. Diabetes and pregnancy. Endocr Pract 2007 May-Jun;13(Suppl 1):55-9. [19 references]

Not applicable: The guideline was not adapted from another source.

2000 Jan (revised 2007)

American Association of Clinical Endocrinologists - Medical Specialty Society
American College of Endocrinology - Medical Specialty Society

American Association of Clinical Endocrinologists (AACE)

American Association of Clinical Endocrinologists (AACE) Diabetes Mellitus Clinical Practice Guidelines Task Force

Task Force Members: Helena W. Rodbard, MD, FACP, MACE (Chairperson) Medical Director, Endocrine and Metabolic Consultants Past President, American Association of Clinical Endocrinologists Past President, American College of Endocrinology, Rockville, Maryland; Lawrence Blonde, MD, FACP, FACE, Director, Ochsner Diabetes Clinical Research Unit; Section on Endocrinology, Diabetes, and Metabolic Diseases Associate Residency Program Director, Department of Internal Medicine, New Orleans, Louisiana; Susan S. Braithwaite, MD, FACP, FACE, Clinical Professor of Medicine, University of North Carolina, Division of Endocrinology, Chapel Hill, NC; Elise M. Brett, MD, FACE, Assistant Clinical Professor of Medicine; Division of Endocrinology, Diabetes, and Bone Disease; Mount Sinai School of Medicine, New York, New York; Rhoda H. Cobin, MD, MACE, Clinical Professor of Medicine; Division of Endocrinology, Diabetes, and Bone Disease; Mount Sinai School of Medicine, Immediate Past President, American College of Endocrinology, Past President, American Association of Clinical Endocrinologists, New York, New York; Yehuda Handelsman, MD, FACP, FACE, Medical Director, Metabolic Institute of America, Senior Scientific Consultant, Metabolic Endocrine Education Foundation, Tarzana, California; Richard Hellman, MD, FACP, FACE, Clinical Professor of Medicine, University of Missouri-Kansas City School of Medicine, President, American Association of Clinical Endocrinologists, North Kansas City, Missouri; Paul S. Jellinger, MD, MACE, Professor of Medicine and Voluntary Faculty, University of Miami School of Medicine, Past President, American College of Endocrinology Past President, American Association of Clinical Endocrinologists, Hollywood, Florida; Lois G. Jovanovic, MD, FACE, CEO & Chief Scientific Officer, Sansum Diabetes Research Institute, Adjunct Professor Biomolecular Science and Engineering, University of California-Santa Barbara, Clinical Professor of Medicine, University of Southern California, Keck School of Medicine, Santa Barbara, CA; Philip Levy, MD, FACE, Clinical Professor of Medicine, University of Arizona College of Medicine, Past President, American College of Endocrinology, Phoenix, Arizona; Jeffrey I. Mechanick, MD, FACP, FACE, FACN, Associate Clinical Professor of Medicine and Director of Metabolic Support; Division of Endocrinology, Diabetes, and Bone Disease; Mount Sinai School of Medicine, New York, New York; Farhad Zangeneh, MD, FACP, FACE, Assistant Clinical Professor of Medicine, George Washington University School of Medicine, Washington, DC, Endocrine, Diabetes and Osteoporosis Clinic (EDOC), Sterling, Virginia

Medical Writer: Christopher G. Parkin, MS

Reviewers: Lewis E. Braverman, MD; Samuel Dagogo-Jack, MD, FACE; Vivian A. Fonseca, MD, FACE; Martin M. Grajower, MD, FACP, FACE; Virginia A. LiVolsi, MD; Fernando Ovalle, MD, FACE; Herbert I. Rettinger, MD, FACE; Talla P. Shankar, MD, FACE; Joseph J. Torre, MD, FACP, FACE; Dace L. Trence, MD, FACE

Dr. Lawrence Blonde reports that he has received grant/research support from Amylin Pharmaceuticals, Inc.; AstraZeneca LP; Bristol-Myers Squibb Company; Eli Lilly and Company; MannKind Corporation; Merck & Co., Inc.; Novo Nordisk Inc.; Novartis Corporation; Pfizer Inc.; and sanofi-aventis U.S. He has received speaker and consultant honoraria from Abbott Laboratories; Amylin Pharmaceuticals, Inc.; Eli Lilly and Company; GlaxoSmithKline; LifeScan, Inc.; Merck & Co., Inc.; Novartis, Novo Nordisk Inc.; Pfizer Inc.; and sanofi-aventis U.S. He has received consultant honoraria from Kos Pharmaceuticals, Inc. and U.S. Surgical. Dr. Blonde has also disclosed that his spouse is a stock shareholder of Amylin Pharmaceuticals, Inc. and Pfizer Inc., in an account that is not part of their community property.

Dr. Susan S. Braithwaite reports that she does not have any financial relationships with any commercial interests.

Dr. Elise M. Brett reports that her spouse is an employee of Novo Nordisk Inc.

Dr. Rhoda H. Cobin reports that she has received speaker honoraria from GlaxoSmithKline; Pfizer Inc.; sanofi-aventis U.S.; and Novartis and consultant honoraria from Abbott Laboratories.

Dr. Yehuda Handelsman reports that he has received speaker honoraria from Abbott Laboratories; Amylin Pharmaceuticals, Inc.; AstraZeneca LP; Bristol-Myers Squibb Company; GlaxoSmithKline; Merck & Co., Inc.; Novartis; and sanofi-aventis U.S. and consultant honoraria from Abbott Laboratories; Daiichi Sankyo, Inc.; Novartis; and sanofi-aventis U.S.

Dr. Richard Hellman reports that he has received speaker honoraria from Daiichi Sankyo, Inc. and Pfizer Inc. and research grants for his role as an independent contractor from Abbott Laboratories; Pfizer Inc.; and Medtronic, Inc.

Dr. Paul S. Jellinger reports that he has received speaker honoraria from Eli Lilly and Company; Merck & Co., Inc.; Novartis; Novo Nordisk Inc.; and Takeda Pharmaceuticals North America, Inc.

Dr. Lois G. Jovanovic reports that she has received research grants for her role as investigator from Eli Lilly and Company; DexCom Inc.; LifeScan, Inc.; Novo Nordisk Inc.; Pfizer Inc.; Roche Pharmaceuticals; sanofi-aventis U.S.; and Sensys Medical, Inc.

Dr. Philip Levy reports that he has received speaker honoraria from Abbott Laboratories; Amylin Pharmaceuticals, Inc.; GlaxoSmithKline; Eli Lilly and Company; Merck & Co., Inc.; Novo Nordisk Inc.; Novartis; Pfizer Inc.; and sanofi-aventis U.S. and research grants from Amylin Pharmaceuticals, Inc.; MannKind Corporation; Novo Nordisk Inc.; Pfizer Inc.; and sanofi-aventis U.S.

Dr. Jeffrey I. Mechanick reports that he does not have any financial relationships with any commercial interests.

Dr. Helena W. Rodbard reports that she has received consultant honoraria from Ortho-McNeil, Inc.; Pfizer Inc.; sanofi-aventis U.S.; and Takeda Pharmaceuticals North America, Inc.; speaker honoraria from Abbott; GlaxoSmithKline; Merck & Co., Inc.; Novo Nordisk; Pfizer Inc.; and sanofi-aventis U.S. and research support from Biodel, Inc. and sanofi-aventis U. S.

Dr. Farhad Zangeneh reports that he has received speaker honoraria from Eli Lilly and Company; GlaxoSmithKline; Novartis; Novo Nordisk Inc.; Pfizer Inc.; Roche Pharmaceuticals; sanofi-aventis U.S.; and Takeda Pharmaceuticals North America, Inc.

This is the current release of the guideline.

This guideline updates a previously published version: American Association of Clinical Endocrinologists, American College of Endocrinology. Medical guidelines for the management of diabetes mellitus: the AACE system of intensive diabetes self-management--2002 update. Endocr Pract 2002 Jan-Feb;8(Suppl 1):40-82.

None available

This NGC summary was completed by ECRI on March 1, 2000. The summary was verified by the guideline developer as of March 8, 2000. This summary was updated on April 16, 2002. The information was verified by the guideline developer on November 11, 2002. This summary was updated by ECRI Institute on September 27, 2007. The updated information was verified by the guideline developer on November 12, 2007.

All rights reserved. No part of these materials may be reproduced or retransmitted in any manner without the prior written permission of American Association of Clinical Endocrinologists (AACE)/American College of Endocrinology (ACE).