Diabetes Dialogue: 2025 Guideline Updates for Diabetes & Pregnancy

Welcome back to Diabetes Dialogue: Technology, Therapeutics, and Real-World Perspectives!

In this episode of Diabetes Dialogue, cohosts Diana Isaacs, PharmD, an endocrine clinical pharmacist, director of Education and Training in Diabetes Technology, and co-director of Endocrine Disorders in Pregnancy at the Cleveland Clinic, and Natalie Bellini, DNP, program director of Diabetes Technology at University Hospitals Diabetes and Metabolic Care Center, discuss the newly released Preexisting Diabetes in Pregnancy guidelines from The Journal of Clinical Endocrinology & Metabolism, which offer 10 key recommendations to improve outcomes in pregnant individuals with type 1 or type 2 diabetes.

1–2. Reproductive Counseling and Contraceptive Use

The first 2 recommendations call for routine pregnancy intention discussions between patients and their clinicians as well as contraceptive counseling. Despite their simplicity, these are often overlooked and underutilized in clinical practice. The hosts stress that preventing unplanned pregnancies in poorly controlled diabetes is crucial to reducing risks of congenital anomalies.

3. Discontinuation of GLP-1 RAs Prior to Conception

The third recommendation advises discontinuation of GLP-1 RAs before conception, rather than waiting until pregnancy is confirmed. This includes agents like semaglutide, liraglutide, and tirzepatide.

While observational data suggest no clear signal for increased congenital anomalies with GLP-1 RA exposure, the guideline prioritizes caution due to the absence of randomized controlled trial data.

Isaacs and Bellini highlight the real-world tension clinicians face: stopping GLP-1s can lead to glycemic deterioration and weight gain, both of which are detrimental in early pregnancy. The discussion emphasizes the importance of careful insulin titration prior to conception and underscores the need for individualized care planning, especially given the long half-life of agents like semaglutide.

4. Metformin Use in Pregnant Individuals with Type 2 Diabetes

Recommendation 4 advises that metformin should not be routinely added to insulin regimens during pregnancy for individuals with pre-existing type 2 diabetes due to concerns about fetal outcomes like small-for-gestational-age infants and potential long-term metabolic risks.

Isaacs and Bellini explain that while metformin’s convenience is appealing—especially in gestational diabetes—it may not offer added benefit in insulin-requiring patients and may introduce unnecessary fetal exposure. The evidence supports a primary reliance on insulin for managing dysglycemia in this population.

5. Individualized Carbohydrate Targets in Pregnancy

The guideline recommends that pregnant individuals with diabetes follow either a carbohydrate-restricted (<175g/day) or standard carbohydrate diet (≥175g/day), depending on clinical context.

Isaacs and Bellini commend the move away from rigid carb targets toward individualized nutrition, while cautioning against overly restrictive diets (<100g/day) linked to neural tube defects.

6–7. Use of CGM and Glucose Targets

The sixth and seventh recommendations relate to glucose monitoring technologies and glycemic targets, deeming CGM and BGM as appropriate tools for self-monitoring in pregnancy with type 2 diabetes. Standard pregnancy glucose targets remain preferred over CGM time-in-range (TIR) metrics.

The hosts underscore that while CGM use is expanding and shows promise, especially for reducing glycemic variability, current data are stronger in type 1 than in type 2 diabetes. They also stress that focusing on individual glucose points remains crucial, as a high average glucose could still fall within an acceptable TIR range, potentially masking hyperglycemia.

8. Use of Hybrid Closed-Loop Systems

Recommendation eight suggests hybrid closed-loop insulin delivery systems should be used over standard pumps with CGM or MDI + CGM when feasible. When feasible, hybrid closed-loop insulin systems are preferred over standard pump or MDI therapy. However, FDA-approved systems for pregnancy are lacking in the U.S. Isaacs and Bellini discuss adapting care using available technologies and centering patient choice.

The evidence supports improved overnight glycemia and reduced burden, but the hosts point out a significant challenge: while systems like the MiniMed 780G and CamAPS FX have pregnancy indications in Europe, no systems are formally approved for this indication in the US. To work within these limitations, the hosts suggest transitioning patients to more pregnancy-compatible technologies and emphasizing patient choice.

9. Timing of Delivery Based on Risk Stratification

The ninth recommendation supports delivery by 38 weeks or earlier when clinically indicated based on individual risk assessment.

Given the elevated stillbirth risk in diabetes—especially with obesity or comorbidities—the hosts say clinicians must balance proactive delivery against patient preferences for full-term birth.

10. Postpartum Endocrine Follow-Up

The final recommendation emphasizes postpartum follow-up with an endocrinology team, alongside standard obstetric care. This is essential for managing glycemia, selecting lactation-safe medications, and planning future pregnancies. The hosts highlight the need for better transitions of care and system-level strategies to ensure follow-up, particularly in newly diagnosed type 2 diabetes.

Isaacs and Bellini close by emphasizing the importance of these guidelines in standardizing care for a high-risk population. While many recommendations are expert consensus-based, they represent meaningful progress. They call for increased uptake of preconception counseling, more research on nutrition and technology in pregnancy, and investment in team-based, longitudinal care.