2025 Guidelines for the holistic management of diabetes in pregnancy
Introduction: Global Challenges and Responses to Gestational Diabetes Mellitus
Gestational diabetes mellitus (GDM) is the most common metabolic disease in pregnant women worldwide, with a prevalence of about 7%-15%. Without standardized management, the mother and fetus are at risk of macrosomia, preterm delivery, and preeclampsia. Recent studies have shown that scientific interventions can bring 90% of pregnant women with GDM into glycemic compliance, significantly improving maternal and infant outcomes. This article integrates international guidelines and clinical practice to explain the core strategies for GDM management.
I. Diagnosis and screening: accurate identification of high-risk groups
- International diagnostic standards
Diagnosis is confirmed when the 75g oral glucose tolerance test (OGTT) is performed and any of the following values are met:
Fasting blood glucose: ≥5.1 mmol/L
1-hour glucose: ≥10.0 mmol/L
2-hour glucose: ≥8.5 mmol/L
Timing of screening:
Routine screening: 24-28 weeks of pregnancy
High-risk groups (obesity, family history of diabetes, previous history of GDM): early screening at the first delivery visit
- Typing and management goals
Type A1: Medical Nutrition Therapy (MNT) and exercise only.
Type A2: need to combine insulin or oral hypoglycemic drugs.
II.The five pillars of pregnancy management
- Medical Nutrition Therapy (MNT): personalized diet design
| pre-pregnancy BMI（kg/m²） | Total weight gain range（kg） | Weekly weight gain in mid to late pregnancy（kg） |
|---|---|---|
| <18.5（low weight） | 11.0-16.0 | 0.37-0.56 |
| 18.5-24.0（normalcy） | 8.0-14.0 | 0.26-0.48 |
| 24.0-28.0（overweight） | 7.0-11.0 | 0.22-0.37 |
| ≥28.0（obese） | 5.0-9.0 | 0.15-0.30 |
Dietary Principles
Carbohydrates (50%-60%): choose low glycemic index (GI) foods such as quinoa (GI=35), oatmeal (GI=55).
Protein (15%-20%): Prioritize fish (e.g. salmon), skinless poultry, beans.
Fat (25%-30%): prioritize olive oil, nuts, avoid trans fatty acids.
Meal portioning strategy
3 main meals + 2-3 additional meals: 2-3 hours between each meal, e.g. Greek yogurt + blueberries for additional meal after breakfast.
Sugar control contraindication: forbid sugary drinks, refined pastries, but need to ensure at least 180g of carbohydrates per day to prevent ketosis.
Case in point:
Emma (pre-pregnancy BMI 26), through a daily intake of 1,800 calories (breakfast: whole wheat bread + eggs; lunch: grilled chicken breast + brown rice; dinner: steamed fish + broccoli), blood glucose to reach the standard and gained 9kg during pregnancy.
- Exercise intervention: the key to activate metabolism
Recommended Program
Frequency: ≥5 days per week, 30 minutes each time
Type: moderate-intensity aerobic exercise (e.g. brisk walking, swimming, Pilates for pregnant women)
Optimal timing: start 1 hour after meal, can reduce postprandial blood glucose peak by 20%-30%
Contraindications and Adjustments
Avoid high-risk exercises: e.g. sit-ups, strenuous jumping
For cervical insufficiency: change to upper body resistance training or seated yoga
- Glucose monitoring: the core of dynamic treatment adjustment
Target values
Fasting blood glucose: <5.3 mmol/L
1 hour after meal: <7.8 mmol/L
2 hours after meal: <6.7 mmol/L
Nocturnal blood glucose: ≥3.3 mmol/L
Monitoring strategy
Initial stage: 7 times a day (before and after 3 meals + bedtime)
After stabilization: all-day monitoring 1-2 days per week, combined with continuous glucose monitoring (CGM)
- Medication: balancing safety and efficacy
Insulin application
Starting dose: 0.7-1.0 U/kg/day in 3-4 injections
Adjustment basis: 10%-20% dose adjustment every 3 days according to blood glucose logs
Oral hypoglycemic agents
Metformin: for those who refuse injections, dose 500-2000 mg/day, but may increase risk of preterm labor (informed consent required)
Glibenclamide: effectiveness is more controversial, and has been phased out in European and American guidelines
- Fetal health monitoring: key to preventing complications
Ultrasound assessment
Every 4 weeks after 28 weeks of gestation: measure fetal abdominal circumference (AC), femur length (FL), if AC>75th percentile suggests risk of macrosomia
Amniotic fluid index (AFI) >25 cm to screen for poor glycemic control
Fetal heartbeat monitoring (NST)
Twice weekly after 32 weeks of gestation, especially in those with fluctuating blood glucose
Abnormal pattern (e.g., variant decelerations) suggests placental insufficiency
III.Decision-making in labor: timing and mode of delivery science
- Timing of delivery
Ideally: natural onset at 39-40 weeks to minimize neonatal respiratory distress.
Indications for early labor: poor glycemic control, preeclampsia, fetal growth restriction.
- Mode of delivery
Vaginal delivery: preferred in the absence of obstetric contraindications, blood glucose should be maintained at 5.0-8.0 mmol/L during labor.
Cesarean section: estimated fetal weight ≥4500g or history of obstructed labor.
Perioperative management
Discontinue subcutaneous insulin preoperatively and switch to intravenous drip (0.5-2.0 U/h)
Postoperatively monitor blood glucose every 2 hours until resumption of diet
IV. Postpartum management: blocking intergenerational metabolic risk
- Newborn care
Test blood glucose within 1 hour after birth, feed immediately if <2.6 mmol/L
Breastfeeding reduces the risk of long-term infant obesity by 30%.
- Maternal follow-up
Short-term: 75g OGTT at 6 weeks postpartum, same diagnostic criteria as non-pregnancy
Long term: screening for diabetes every 3 years, lifestyle interventions reduce risk of progression by 50%.
Case:
Linda (history of GDM), no progression to type 2 diabetes in 5 years by postnatal daily 30 minutes brisk walking + Mediterranean diet.
V. Psychological support and family involvement
- Psychological intervention
Cognitive Behavioral Therapy (CBT): to alleviate anxiety and improve treatment adherence.
Online support community: e.g. “GDM Moms Forum” provides recipe sharing and emotional counseling.
- Family Role
Spousal involvement: joint nutrition classes, supervised exercise programs
Culturally adapted: low GI traditional recipes (e.g. quinoa salad instead of tortillas) for Latino families.
VI. Global Practices and Innovative Technologies
- Ambulatory glucose monitoring (CGM)
Advantage: Identify hidden hyperglycemia (e.g., nocturnal spikes) and adjust insulin dose more accurately
Research data: 18% reduction in the incidence of macrosomia in pregnant women with GDM using CGM
- Telemedicine
Solution: weekly video consultation + blood glucose data synchronization in the cloud
Results: Glucose compliance rate of pregnant women in remote areas increased to 85%.
Conclusion: Multidisciplinary collaboration for a healthy future
The management of gestational diabetes requires the integration of obstetrics, nutrition, endocrinology and psychology. Through personalized diets, precise medications, and technological innovations, the vast majority of patients will have safe deliveries and improved long-term health. Remember, GDM is not only a challenge during pregnancy, but also a golden window to prevent intergenerational metabolic disease.
