World Health Organization Releases First Global Guidelines for Diabetes Management in Pregnancy

The global prevalence of diabetes increased from 630 million to nearly 830 million adults between 1990 and 2022, and diabetes is now considered one of the most widespread noncommunicable diseases worldwide.¹ This growing burden extends to pregnancy, where the American Diabetes Association and the World Health Organization (WHO) recognize diabetes as one of the most common noncommunicable diseases contributing to maternal and neonatal complications.^2,3

Approximately 23 million (19.7%) live births in 2024 were complicated by hyperglycemia in pregnancy.⁴ Hyperglycemia in pregnancy (HIP) can refer to preexisting diabetes (type 1, type 2, or rarer forms), diabetes first recognized during pregnancy, or gestational diabetes (GDM).⁴ HIP increases pregnancy-related complications such as preeclampsia and other hypertensive disorders, stillbirth or preterm birth, macrosomia, neonatal hypoglycemia, neonatal hyperbilirubinemia, birth injury, congenital anomalies, and neonatal distress syndrome.^3,5 A history of 1 or more pregnancies with GDM predisposes women to type 2 diabetes (T2D) development after childbirth.⁶ Children born to women with HIP are at increased risk of developing obesity, hypertension, cardiovascular disease, metabolic syndrome, fatty liver disease, and T2D.^3,5

Diabetes in pregnancy is addressed in 25 different guidelines. However, 18 were established in upper middle– or high-income countries.⁷ Recognizing the gap in guidance for low- and middle-income countries, the WHO developed the 2025 WHO Recommendations on Care for Women with Diabetes During Pregnancy.²

Monitoring

Glucose Monitoring

The WHO guidelines recommend different approaches to glucose monitoring depending on the type of diabetes. For individuals with T1D, either self-monitoring of blood glucose (SMBG) or a continuous glucose monitoring (CGM) system may be used. For those with T2D or gestational diabetes, SMBG is the standard recommendation.^2,3

Although CGM is not routinely advised because of resource and cost considerations, its use is not discouraged when it may meaningfully improve outcomes—for example, in pregnant patients who require insulin therapy.^2,3

Hemoglobin A_1C Monitoring

Individuals with T1D or T2D should have a hemoglobin A_1C (HbA_1C) test performed in the first trimester or at the start of antenatal care. For those with gestational diabetes, however, routine HbA_1C testing is not recommended.^2,3

Glycemic Targets

Finally, the WHO recommends a general HbA1C target of 7% for people with T1D, T2D, or gestational diabetes, recognizing that goals should be adjusted based on each patient’s risk of hypoglycemia.^2,3

The recommendations are informed by a systematic review conducted in women with T1D. When comparing very tight fasting plasma glucose (FPG) targets of 60 to 90 mg/dL with moderately tight targets of 95 to 115 mg/dL, the evidence showed no additional benefit and suggested a possible increase in maternal hypoglycemia and longer postnatal hospitalization, although the certainty of this evidence is low.³

Similarly, comparing tight targets (FPG < 101 mg/dL) with moderate targets (101-121 mg/dL) showed no clear benefit or harm, with overall certainty likely very low. In contrast, when moderate targets (101-121 mg/dL) were compared with looser targets (121-160 mg/dL), the review found a possible reduction in cesarean birth rates, macrosomia, and respiratory distress syndrome, again with low-certainty evidence and no indication of increased harm.³

For gestational diabetes, tight vs moderate glycemic targets did not differ in terms of induction of labor, birth weight, macrosomia, or the duration of maternal antenatal or maternal/neonatal postnatal hospitalization, with high-certainty evidence suggesting no added risk.³

Pharmacological Treatment

For T1D, the WHO recommends that patients continue using the same type of insulin and the same delivery method they relied on before pregnancy, unless there is a specific reason to adjust therapy. Evidence on adding metformin to insulin in T1D is limited, as no randomized controlled trials are available. When comparing insulin formulations, rapid-acting insulin may slightly reduce the risk of preterm birth before 37 weeks, although this conclusion is based on low-certainty evidence. Insulin detemir may carry a small increased risk of preeclampsia compared with neutral protamine Hagedorn (NPH) insulin, again with low-certainty evidence. Comparisons between insulin degludec and insulin detemir have not shown any clear benefits or harms.³

For T2D, the WHO advises beginning treatment with diet and physical activity. If additional therapy is needed, either metformin or insulin can be used as second-line options, and if glucose targets remain unmet with either agent alone, a combination of both may be considered. Women taking glucose-lowering therapies that pose safety concerns during pregnancy should transition to insulin and/or metformin before conception whenever possible. As with T1D, individuals should continue the type of insulin they used prior to pregnancy unless a change is warranted.³

The evidence indicates that metformin and insulin appear broadly comparable, with no clear advantages or disadvantages favoring either approach, although many women who start on metformin alone eventually require insulin. Using metformin alongside insulin, however, likely provides moderate benefits: It may lower the risk of cesarean birth and macrosomia and reduce gestational weight gain. Comparisons between insulin detemir and NPH suggest possible benefit with detemir—specifically, reduced gestational weight gain—although this comes with a small associated downside of slightly lower birth weight, and both findings are based on low-certainty data.³

Clinical Implications

The newly published WHO guidelines largely align with established recommendations while adding considerations for low- and middle-income settings. When using the guidelines, practitioners should consider resource availability and patient-specific factors that may influence the selection of pharmacotherapy or monitoring strategies.

REFERENCES

1. NCD Risk Factor Collaboration (NCD-RisC). Worldwide trends in diabetes prevalence and treatment from 1990 to 2022: a pooled analysis of 1108 population-representative studies with 141 million participants. Lancet. 2024;404(10467):2077-2093. doi:10.1016/S0140-6736(24)02317-1

2. WHO Recommendations on Care for Women with Diabetes During Pregnancy. World Health Organization; 2025. Accessed March 2, 2026. https://iris.who.int/server/api/core/bitstreams/232f6c49-7817-4d45-87ad-7e319baac3bb/content

3. American Diabetes Association Professional Practice Committee. 15. Management of diabetes in pregnancy: standards of care in diabetes—2025. Diabetes Care. 2025;48(1 suppl 1):S306-S320. doi:10.2337/dc25-S015

4. The Diabetes Atlas. International Diabetes Federation. Accessed March 2, 2026. https://diabetesatlas.org/

5. Bianco ME, Josefson JL. Hyperglycemia during pregnancy and long-term offspring outcomes. Curr Diab Rep. 2019;19(12):143. doi:10.1007/s11892-019-1267-6

6. Diaz-Santana MV, O’Brien KM, Park YMM, Sandler DP, Weinberg CR. Persistence of risk for type 2 diabetes after gestational diabetes mellitus. Diabetes Care. 2022;45(4):864-870. doi:10.2337/dc21-1430

7. Jung J, Karwal EK, McDonald S, Turner T, Chou D, Vogel JP. Prevention and control of non-communicable diseases in antenatal, intrapartum, and postnatal care: a systematic scoping review of clinical practice guidelines since 2011. BMC Med. 2022;20(1):305. doi:10.1186/s12916-022-02508-9