From the Adult Diabetes and Clinical Research sections, Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts
Objective: The Joslin Guideline for Detection and Management of Diabetes in Pregnancy is designed to assist internal medicine specialists, endocrinologists, and obstetricians in individualizing the care of and setting goals for women with preexisting diabetes who are pregnant or planning pregnancy. It is also a guide for managing women who are at risk for or who develop gestational diabetes mellitus (GDM). This guideline is not intended to replace sound medical judgment or clinical decision making. Clinical judgment determines the need for adaptation in all patient care situations; more or less stringent interventions may be necessary.
3.2.1 Glucose goals prior to conception:
The objective of the Joslin Guideline for Detection and Management of Diabetes in Pregnancy is to support clinical practice and to influence clinical behaviors in order to improve clinical outcomes and assure that patient expecta- tions are reasonable and informed. This guideline was approved November 13, 2016, and updated February 12, 2018.FIGURE. See at end of Chapter 3 (download PDF at end of chapter).
3.2.3 Medical assessment:
3.2.4 Diabetes medications:
3.2.5 Other medications:
3.2.5a Hypertension and/or albuminuria management:
3.2.5b Diabetic nephropathy/chronic kidney disease management:
3.2.5c Lipid management:
3.3.1 Self-monitoring of blood glucose and urine ketones: preexisting diabetes and GDM:
3.3.2 Treatment goals:
3.3.2a Preexisting diabetes:
3.3.2b Gestational diabetes mellitus (GDM):
TABLE 1. Diagnosing GDM
3.3.3 Diabetes monitoring and visits:
3.3.3a Preexisting diabetes:
3.3.3b Gestational diabetes mellitus:
For preexisting diabetes the only diabetes medication currently used throughout pregnancy is insulin (see Preconception Care). Insulin does not cross the placenta. Oral agents are often insuf- ficient and ineffective in both T1D and T2D.[1B]
Recommendations are the same for preexisting diabetes and GDM except where noted.
3.6.1 Counseling and education:
Guide to Calculating Energy Needs
Estimated Energy Requirements (EER) for pregnancy: EER in pregnancy = EER pre-pregnancy (see below) + additional energy expended during pregnancy + energy dispostion, as follows:
First trimester: EER prepregnancy + 0
Second trimester: EER prepregnancy + 340 singleton
Third trimester: EER prepregnancy + 452 singleton
Calculate EER prepregnancy, for women aged 19 years and older, as follows:
EER = 354 — (6.91 x age [years] + PA x [(9.36 x weight in kg + 726 x height in m), where PA is physical activity coefficient (see below).
PA = 1.0 for sedentary (physical activity level [PAL] is >1.0 but <1.4)
PA = 1.12 for low activity (PAL is ≥ 1.4 but < 1.6)
PA = 1.27 for active (PAL is ≥1.6 but < 1.9) PA = 1.45 for very active (PAL is ≥1.9)
3.6.2a Distribution of calories:
TABLE 3. Calorie Distribution
Other Dietary Guidelines for Pregnancy
Nutritive and nonnutritive sweeteners. The safety of nonnutritive sweeteners has not been established.
Vitamin and mineral supplements. Prenatal multivitamin and mineral supplements should include: (1) iron, 30 mg/ day; (2) potassium iodide 150 mcgs (3) folic acid, 400 mcg to supplement 400 mcg from daily dietary intake. Start the prenatal vitamin preconception, ideally, to boost folic acid to decrease the risk of neural tube defects; (4) added calcium to reach 1000 mg/day, or 1300 mg/day if aged 18 years or less; (5) vitamin D, 600 IUs/day, with tolerable upper intake of 4000 IU/day for 12 weeks.
Caffeine/Fluids. Limit caffeine to <200 mg/day (equivalent of 1 cup of coffee or 4 cups of black tea). Excess caffeine consump- tion during pregnancy may increase the risk of miscarriage. Three liters of water per day for adequate hydration, or about 10 cups per day, in total beverage intake is recommended.Regular physical activity is recommended after a provider gives clearance.
Benefits of exercise include reducing insulin resistance postprandial hyperglycemia, and excessive weight gain. Activity after meals can reduce postprandial hyperglycemia.Breastfeeding is encouraged in patients with preexisting or gestational diabetes.
Enalapril and captopril may be used to treat hypertension and albuminuria in nursing mothers of full-term infants.
Appointments with the following specialists should be completed 6 to 8 weeks postpartum: ophthalmology, RD or registered nurse, and endocrinology.
For women who developed GDM