Preconception, Pregnancy, Postpartum & Gestational Diabetes

CDCES Certified Diabetes Care and Education Specialist

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1 Introduction & the CDCES Exam

About the CDCES Credential & Current Exam Facts The July 2024 Exam Content Outline & Domain Weights The ADCES7 Self-Care Behaviors Framework

2 Pathophysiology, Classification & Diagnosis

Normal Glucose Regulation and the Pathophysiology of T1DM and T2DM Classification and Diagnostic Criteria Risk Factors and Primary Prevention Treatment Goals and Glycemic Targets

3 Assessment: History, Physical & Data

Health History & Diabetes-Specific Physical Assessment Interpreting Diabetes Measures & Laboratory Data Social Determinants of Health & Psychosocial Wellbeing

4 Assessing Self-Management & Learning

Assessing Self-Management Behaviors & Knowledge Assessing Technology Use, Problem-Solving & Risk-Reduction Behaviors Assessing Learning: Goals, Readiness to Change & Literacy Learning Considerations & Barriers

5 Developing the Education & Care Plan

Developing the Individualized Education/Care Plan Instructional Methods & Person-Centered Teaching Strategies SMART Goals, Behavior-Change Theory & Motivational Interviewing

6 Nutrition Therapy

Nutrition Recommendations & Eating Patterns Carbohydrate Counting & Insulin-Food Timing Fats, Protein, Alcohol & Dietary Supplements Food Labels, Weight Management & Special Nutrition Considerations

7 Physical Activity

Physical Activity Recommendations, Benefits, Challenges & Safety Activity Planning with FITT and Adjusting for Planned & Unplanned Activity

8 Pharmacologic Therapy

Insulin — Types, Pharmacokinetics & Delivery Systems Non-Insulin Glucose-Lowering Agents Guideline-Based Medication Selection Medication Titration & Immunizations for People with Diabetes

9 Monitoring

Glucose Monitoring: SMBG, CGM & Time in Range A1C and Ketone Monitoring Cardiometabolic and Organ System Monitoring

10 Acute Complications

Hypoglycemia Hyperglycemia, DKA, and HHS

11 Chronic Complications

Screening Schedules and Microvascular Disease Macrovascular Disease and Lower-Extremity Foot Care Infections, Dental Disease, Sexual Dysfunction, and Other Comorbidities

12 Special Situations & Populations

Sick-Day Management, Surgery, Travel & Emergency Preparedness Special Populations Across the Lifespan Preconception, Pregnancy, Postpartum & Gestational Diabetes Daily Living, Psychosocial Wellbeing & Safety

13 Evaluation & Documentation

Evaluating Intervention Effectiveness & Outcomes Documentation, Plan Revision & Referral

14 Standards, Guidelines & Professional Practice

National Standards for DSMES and the National DPP Applying Evidence-Based Practice Guidelines Population Health, Health Equity & Advocacy

Preconception, Pregnancy, Postpartum & Gestational Diabetes

Key Takeaways Explain This Topic AI

Preconception A1C goal is <6.5%, since major fetal organogenesis occurs at 5-8 weeks of gestation, before pregnancy is often recognized.

ADA pregnancy glycemic targets are fasting <95 mg/dL, 1-hour postprandial <140 mg/dL, 2-hour postprandial <120 mg/dL, and A1C <6%.

Insulin is the preferred glucose-lowering agent in pregnancy; ACE inhibitors, ARBs, and statins must be stopped before or upon confirming pregnancy.

Insulin requirements drop by 50% or more immediately after delivery, creating a high risk of postpartum hypoglycemia.

GDM is screened at 24-28 weeks gestation, and a 75 g, 2-hour OGTT is used to screen for persistent diabetes at 4-12 weeks postpartum.

Last updated: July 2026

Preconception Care

Preconception planning is one of the highest-leverage interventions in diabetes care because major fetal organogenesis occurs at 5-8 weeks of gestation — often before a person knows they are pregnant. People with preexisting type 1 or type 2 diabetes who are planning pregnancy should work toward an A1C goal of <6.5% before conception, using only therapies approved for use in pregnancy; achieving this target before conception is associated with the lowest risk of congenital anomalies, preeclampsia, and preterm birth. ADA guidance also specifies preconception glucose goals to guide therapy adjustments in addition to the A1C target — the same numeric targets used during pregnancy itself (see table below). Counseling must explicitly address avoiding excessive hypoglycemia while working toward these tighter goals, since aggressive tightening without support can itself become unsafe.

Preconception care also includes:

Folic acid 400-800 mcg/day , started before conception to reduce neural tube defect risk

Contraception counseling for anyone not actively trying to conceive, continued until glycemic goals are met and pregnancy is planned

Discontinuing potentially teratogenic medications before conception (detailed below)

Reviewing existing complications before conception — a dilated eye exam is recommended before or early in pregnancy because retinopathy can progress rapidly with pregnancy's metabolic and hormonal changes, and kidney function should be assessed since nephropathy also affects pregnancy risk and management

Preconception counseling is ideally initiated well before a planned pregnancy so that glycemic goals, medication changes, and complication screening are complete rather than rushed once pregnancy is confirmed.

Pregnancy Glycemic Targets

The following ADA-recommended targets apply to all pregnant people with diabetes (preexisting or gestational) and must be taught precisely — these are frequently tested numbers:

Measure Target
Fasting plasma glucose <95 mg/dL
1-hour postprandial glucose <140 mg/dL
2-hour postprandial glucose <120 mg/dL
A1C <6% (a less stringent goal of <7% may be appropriate if needed to prevent hypoglycemia)
CGM time in range (63-140 mg/dL) >70%
CGM time below range (<63 mg/dL) <4% (<1% below 54 mg/dL)
CGM time above range (>140 mg/dL) <25%

A1C targets are lower in pregnancy than in the general adult population because increased red blood cell turnover shortens the interval A1C reflects.

Medication Safety in Pregnancy

Insulin is the preferred agent for glycemic control throughout pregnancy in type 1 diabetes, type 2 diabetes, and gestational diabetes requiring pharmacotherapy — it does not cross the placenta in clinically significant amounts and is the most titratable option. Oral agents carry documented tradeoffs: both metformin and glyburide cross the placenta, and glyburide is associated with higher rates of neonatal hypoglycemia and macrosomia compared with insulin, so it is not recommended as first-line therapy. Metformin is sometimes continued or initiated in select circumstances (for example, ongoing use for PCOS or type 2 diabetes, or shared decision-making around cost and access in gestational diabetes), but insulin remains the preferred agent overall, especially in type 1 diabetes.

Several medication classes must be stopped before or immediately upon confirming pregnancy because of teratogenic or fetal risk:

ACE inhibitors and ARBs — associated with fetal renal dysgenesis and other anomalies
Statins — discontinued in pregnancy

Most non-insulin glucose-lowering agents — GLP-1 receptor agonists, SGLT2 inhibitors, DPP-4 inhibitors, and (with the exceptions above) sulfonylureas and TZDs are switched to insulin

Low-dose aspirin for preeclampsia prophylaxis is typically continued or initiated in people with type 1 or type 2 diabetes, and thyroid replacement doses are monitored closely, since levothyroxine requirements often increase in pregnancy.

Postpartum Care

Insulin requirements drop sharply immediately after delivery — often by 50% or more from late-pregnancy doses — because the placenta was the source of the insulin-resistance-driving hormones. This creates a high-risk window for postpartum hypoglycemia, particularly in the first 24-48 hours and with breastfeeding, so doses must be reassessed rather than continued at prenatal levels. Breastfeeding is encouraged for its metabolic benefits to the parent and the infant, with attention to a pre-feeding snack to reduce hypoglycemia risk. Contraception counseling should occur before discharge, and postpartum depression screening is important given the elevated risk in people with diabetes.

Gestational Diabetes Mellitus (GDM)

Universal screening for GDM occurs at 24-28 weeks of gestation (earlier first-trimester testing is used only for those with risk factors, applying standard non-pregnant criteria to catch preexisting undiagnosed diabetes). Two screening approaches are used:

Approach Test Diagnostic Threshold

One-step 75 g OGTT GDM if any one value is met/exceeded: fasting ≥92 mg/dL, 1-hour ≥180 mg/dL, 2-hour ≥153 mg/dL

Two-step 50 g glucose challenge screen, then 100 g OGTT if positive (Carpenter-Coustan criteria) GDM if two or more values are met/exceeded: fasting ≥95, 1-hour ≥180, 2-hour ≥155, 3-hour ≥140 mg/dL

Medical nutrition therapy and physical activity are first-line management; insulin is added when glucose targets are not met with lifestyle measures alone, and insulin remains ADA's preferred pharmacologic agent when medication is needed. Because GDM signals substantially elevated future type 2 diabetes risk, ADA recommends postpartum screening with a 75 g, 2-hour OGTT at 4-12 weeks postpartum (more sensitive in the early postpartum period than fasting glucose or A1C alone), followed by ongoing screening at least every 1-3 years thereafter.