New Joint Guidelines Reshape Diabetes Care Before and During Pregnancy
The Endocrine Society and European Society of Endocrinology release landmark joint guidelines targeting better outcomes for pregnant individuals with preexisting diabetes.
Summary
A major joint clinical practice guideline from the Endocrine Society and European Society of Endocrinology outlines updated recommendations for managing preexisting type 1 and type 2 diabetes before, during, and after pregnancy. Key guidance includes routine pregnancy-intent screening at all relevant clinical visits, use of contraception when pregnancy is not desired, discontinuing GLP-1 receptor agonists before conception, and avoiding routine metformin addition to insulin in T2DM pregnancies. The guideline supports hybrid closed-loop insulin pump use in T1DM, encourages early delivery based on risk assessment, and recommends postpartum endocrine follow-up. Evidence certainty was rated very low to low across most recommendations, underscoring an urgent need for higher-quality research in this population.
Detailed Summary
Preexisting diabetes mellitus (PDM) — encompassing both type 1 (T1DM) and type 2 (T2DM) — significantly elevates risks of maternal and perinatal mortality and morbidity. Despite strong evidence that preconception care (PCC) reduces congenital malformations and other adverse outcomes, only a minority of affected individuals receive it. This gap, combined with rising obesity rates complicating pregnancy management, motivated the development of this comprehensive joint guideline.
A multidisciplinary Guideline Development Panel identified 10 priority clinical questions spanning the full reproductive life cycle of individuals with diabetes. Systematic literature reviews were conducted, and recommendations were developed using GRADE methodology, incorporating patient representative perspectives and considerations of health equity, cost, and feasibility.
Key recommendations include screening for pregnancy intent at every reproductive, diabetes, and primary care visit; using contraception when pregnancy is not planned; and discontinuing GLP-1 receptor agonists before conception given limited but concerning safety data. For T2DM pregnancies already managed with insulin, the panel advises against routinely adding metformin due to risks of small-for-gestational-age infants and potential adverse childhood body composition outcomes.
For glucose monitoring, either CGM or self-monitoring of blood glucose is acceptable in T2DM pregnancies, while hybrid closed-loop insulin pumps are preferred over standard pump-plus-CGM approaches in T1DM. Standard multi-target glucose goals should not be replaced by a single 24-hour CGM threshold. Early delivery based on individualized risk assessment is preferred over expectant management beyond 38 weeks, and postpartum endocrine care is recommended for all individuals with PDM.
Critically, the evidence base for nearly all recommendations was rated very low to low certainty, highlighting a substantial research gap. The authors call for targeted RCTs, implementation science investment for PCC programs, and better data on nutrition, obesity management, and optimal delivery timing.
Key Findings
- Pregnancy intent should be screened at every reproductive, diabetes, and primary care visit for individuals with diabetes.
- GLP-1 receptor agonists should be discontinued before conception, not during the first trimester, due to limited safety data.
- Adding metformin to insulin in T2DM pregnancies is not recommended due to small-for-gestational-age infant risk.
- Hybrid closed-loop insulin pumps improve time-in-range and reduce hypoglycemia in pregnant T1DM individuals.
- All PDM recommendations carry very low to low evidence certainty, signaling urgent need for high-quality RCTs.
Methodology
The guideline was developed by a multidisciplinary panel using systematic literature reviews of RCTs and observational studies addressing 10 prioritized clinical questions. GRADE methodology was applied to assess evidence certainty and formulate recommendations. Patient representatives and health equity considerations were integrated into the process.
Study Limitations
The majority of recommendations are based on very low to low certainty evidence, limiting the strength of clinical directives. Much of the evidence is indirect, and RCT data specific to pregnant populations with PDM remain scarce. Nutritional recommendations and obesity management strategies during pregnancy lack sufficient high-quality data to support firm guidance.
Enjoyed this summary?
Get the latest longevity research delivered to your inbox every week.