The latest Standards of Care in Diabetes—2026 published by the American Diabetes Association (ADA) provide a comprehensive and evidence-based framework for the management of diabetes in pregnancy. With a global rise in obesity and increased prevalence of type 1, type 2, and gestational diabetes mellitus (GDM) among reproductive-age individuals, the clinical management of diabetes during pregnancy has never been more critical. According to the ADA, diabetes in pregnancy significantly increases maternal and fetal risks—including spontaneous abortion, congenital anomalies, preeclampsia, fetal demise, macrosomia, neonatal hypoglycemia, and respiratory distress syndrome. Long-term, infants exposed to hyperglycemia in utero face increased risks of obesity, hypertension, and type 2 diabetes later in life

diabetes in pregnancy ada 2026

Preconception Counseling: A Critical Prevention Strategy

The ADA emphasizes integrating preconception counseling into routine diabetes care beginning at puberty and continuing throughout reproductive life. Individuals with diabetes should receive guidance on family planning, appropriate contraceptive use, and optimizing glycemic control—ideally achieving an A1C below 6.5% prior to conception to reduce the risk of congenital anomalies and complications

diabetes in pregnancy ada 2026

People with a history of gestational diabetes should undergo preconception screening for diabetes, as early detection and treatment of hyperglycemia help prevent congenital malformations and adverse outcomes. Observational studies confirm that optimized glycemia before conception is strongly associated with reduced risks of fetal malformations, preterm delivery, NICU admissions, and perinatal mortality.

Glycemic Targets and Monitoring During Pregnancy

The 2026 standards reaffirm that optimal glucose monitoring during pregnancy includes fasting, preprandial, and postprandial measurements. Recommended targets are:

• Fasting glucose: <95 mg/dL
• 1-hour postprandial: <140 mg/dL
• 2-hour postprandial: <120 mg/dL

Because A1C naturally trends lower during pregnancy due to increased red blood cell turnover, it should not serve as the sole measure of glucose control. A goal A1C below 6% is ideal if it can be achieved safely, although <7% may be acceptable to avoid hypoglycemia

diabetes in pregnancy ada 2026

Continuous glucose monitoring (CGM) is now strongly recommended for all pregnant individuals with type 1 diabetes. The CONCEPTT trial demonstrated that CGM improves time in range (TIR), reduces neonatal hypoglycemia, lowers rates of large-for-gestational-age infants, and decreases newborn hospitalization time.

Medical Nutrition Therapy and Lifestyle Interventions

Nutrition counseling is essential before and during pregnancy. ADA recommendations highlight eating patterns rich in:

• Fruits and vegetables
• Whole grains and legumes
• Lean proteins, fish, and healthy fats
• Nuts and seeds

Highly processed foods, added sugars, and excess saturated fats should be limited. In gestational diabetes, lifestyle modification alone can successfully manage glucose levels in up to 85% of cases.

The ADA also recommends at least 150 minutes of moderate-intensity exercise per week, which reduces risks of GDM, gestational hypertension, and preeclampsia.

Pharmacologic Treatment: Insulin First-Line

Insulin remains the preferred treatment for type 1 diabetes, type 2 diabetes in pregnancy, and GDM. Insulin requirements naturally change throughout pregnancy, often increasing in the second and third trimesters and rapidly decreasing postpartum.

The 2026 guidelines emphasize:

• Multiple daily injections or insulin pump therapy are appropriate.
• Automated Insulin Delivery (AID) systems with pregnancy-specific algorithms are recommended when available.
• AID systems without pregnancy-specific algorithms may be used selectively with expert guidance.

Oral agents—including metformin and glyburide—are not first-line therapies, as both cross the placenta and may not achieve adequate glycemic control for many individuals. Studies show that metformin use may lead to smaller neonates at birth but increased risk of higher BMI in childhood, raising concerns about long-term metabolic implications.

Special Clinical Considerations

Diabetic Ketoacidosis (DKA)

Pregnancy is a ketogenic state, increasing the risk of DKA—sometimes even at lower glucose levels than in nonpregnant individuals. Education on ketone monitoring and early recognition is crucial.

Retinopathy

Rapid improvement in glycemia can worsen diabetic retinopathy. The ADA recommends eye examinations:

• Before pregnancy
• Once per trimester
• For one year postpartum

Weight Gain

Recommended weight gain varies by pre-pregnancy BMI. Weight loss is not recommended during pregnancy due to risk of fetal growth restriction.

Preeclampsia Prevention

The ADA advises prescribing low-dose aspirin (100–150 mg/day) beginning at 12–16 weeks’ gestation for individuals with type 1 or type 2 diabetes. This reduces the risk of preeclampsia, a common and serious complication associated with diabetes in pregnancy.

Conclusion

The Standards of Care in Diabetes—2026 reinforce the importance of early planning, intensive glucose monitoring, personalized nutrition, lifestyle modifications, and insulin-centered treatment approaches to optimize outcomes for both mother and baby. As global rates of diabetes rise, ensuring that healthcare providers apply these evidence-based practices is vital to reducing maternal morbidity and improving long-term health outcomes for future generations.

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