With the prevalence of type 2 diabetes (T2D) during pregnancy increasing over the past 10 years from 1.8 to 7.3 per 1000 deliveries, multidisciplinary teams must apply available resources to address the metabolic complexity of T2D to optimize glycemia and promote a healthier intrauterine environment, write authors of a JAMA Insights/Women’s Health article. “Patients with T2D have many metabolic, nutritional, social, and structural determinants of health and psychological factors that need to be screened and addressed, ideally before conception as well as throughout pregnancy, to reduce adverse perinatal and neonatal outcomes,” the authors conclude. “The expertise of multidisciplinary teams and resources can support the overall goal to improve perinatal and lifelong health and well-being for both the pregnant person and their offspring.”
“Insulin is the preferred agent at any gestational age for the glycemic management of T2D in pregnancy,” the article explains. “Metformin has been used as an adjunct to insulin, but should be considered with caution. The MiTy trial of pregnant persons with T2D found that metformin therapy added to insulin demonstrated a significantly higher rate of small-for-gestational-age neonates, lower gestational weight gain, and lower overall insulin dose requirements compared with those who received insulin plus placebo.” ACE inhibitors, statins, ARBs, and phentermine should ideally be discontinued before pregnancy. Other agents — including sodium-glucose cotransporter type 2 inhibitors and glucagon-like peptide-1 agonists — lack sufficient evidence of safety during pregnancy.
“Frequent glycemic monitoring is recommended to achieve pregnancy glucose targets,” write the authors. “Although there is only a paucity of literature on continuous glucose monitoring (CGM) systems among pregnancies complicated by T2D, CGM technology has been shown to be safe and improve hyperglycemia and neonatal outcomes in patients with type 1 diabetes. Currently, CGM use in pregnancy is not to be substituted for capillary blood glucose self-monitoring, but used in addition to optimize glycemia until further studies on accuracy and useful CGM metrics during pregnancy are determined among persons with T2D. Initiation of low-dose aspirin prophylaxis in the first trimester (optimally before 16 weeks) is recommended due to the increased risk for hypertensive spectrum disorders and indicated preterm births.”