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ACOG Guidelines: Pregestational Diabetes Mellitus

Obstet Gynecol; ePub 2018 Dec; ACOG, et al

Prepregnancy counseling for women with pregestational diabetes mellitus is beneficial and cost effective and should be encouraged, according to a practice bulletin from the American College of Obstetricians and Gynecologists (ACOG). The updated document includes summary information to counsel and manage women with pregestational diabetes before and during pregnancy and suggests management guidelines during pregnancy. Among the ACOG’s recommendations (Level B):

  • Maternal glucose control should be maintained near physiologic levels before and throughout pregnancy to decrease the likelihood of complications of hyperglycemia, including spontaneous abortion, fetal malformation, fetal macrosomia, fetal death, and neonatal morbidity.
  • The dietary approach to glycemic control is focused on careful carbohydrate counting and allocation of appropriate ratios of carbohydrates to meals and snacks.
  • Patients and their families should be taught how to respond quickly and appropriately to hypoglycemia.
  • Because pregestational diabetes is considered a high-risk factor for the development of preeclampsia, the ACOG recommends that low-dose aspirin (81 mg/day) prophylaxis should be initiated between 12 weeks and 28 weeks of gestation (optimally before 16 weeks of gestation) and continued until delivery.
  • The use of all oral hypoglycemic agents for control of pregestational type 2 diabetes mellitus during pregnancy should be limited and individualized until data regarding the safety and efficacy of these drugs become available.
  • Insulin is the preferred treatment for pregestational diabetes in pregnancy not controlled by diet and exercise.
  • Antepartum fetal monitoring, including the nonstress test, the biophysical profile, or the modified biophysical profile when performed at appropriate intervals (usually once or twice per week), is a valuable approach and can be used to monitor the pregnancies of women with pregestational diabetes mellitus.


Pregestational diabetes mellitus. ACOG Practice Bulletin No. 201. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2018;132:e228-48.