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Table 5 Evidence levels of the main recommendations and conclusions.

From: Dysglycemias in pregnancy: from diagnosis to treatment. Brazilian consensus statement

Recommendations and Conclusions Evidence
Level
• Diabetic patients must start pregnancy in ideal metabolic conditions (HbA1c < 6% or 1% above the maximum value used by the clinical analyses laboratory). B
• Advise patients to self monitor capillary blood glucose before and after meals, at bedtime and sporadically between 2:00 and 4:00 AM. C
• The amount of calories prescribed must be based on BMI. The total caloric amount recommended must be composed by: 40 to 45% carbohydrates, 15-20% proteins (minimum of 1, 1 mg/kg/day) and 30-40% fat. B
• Use of folic acid before pregnancy until neural tube closure is recommended for all women including those with diabetes. A
• Regular practice of physical activity will cause a wellbeing sensation, less weight gain, reduction in fetal adiposity, a better glycemic control and fewer problems during labor. Physical activity is contraindicated in case of: Pregnancy induced hypertension, premature membranes' rupture, preterm labor, persistent uterine bleeding after the second trimester, intrauterine growth restriction, nephrotic syndrome, pre and proliferative retinopathy, hypoglycemia unawareness, advanced peripheral neuropathy and dysautonomia A
• In most parts of the world the recommendation is to discontinue the use of antidiabetic oral agents and its substitution for insulin, before pregnancy or soon after its diagnosis. Recent trials have shown the safety of metformin during pregnancy and the use of glibenclamide in patients with GD after the second trimester. B
• Rapid acting insulin analogs such as insulin aspart and lispro are safe during gestation, lead to a better control of postprandial levels of glycemia and lower frequency of hypoglycemia. NPH human insulin is still the first choice among those intermediate acting insulins. There are some studies and short communications with the use of long acting insulin analogs detemir and glargine, but more consistent studies are warranted. A
• Discontinue the use of angiotensin converting enzyme inhibitors, of angiotensin II receptor agonists and statins before pregnancy or as soon as it is confirmed, due to its association with embriopathies and fetopathies A
• In order to simplify the diagnosis of GD, a fasting glycemia must be performed in the first antenatal visit. If glycemic level is ≥85 mg/dl and the patient shows risk factors for GD, a 75 g OGTT must be performed. If the test is normal, it must then be repeated between 24th and 28th gestation weeks. A
• Diagnosis of GD should not be done with a random glycemia, with a 50 g glucose challenge test and urine glucose testing.
Between 24-28th gestation weeks, a fetal echocardiography should be performed to evaluate the four fetal heart chambers, aiming to diagnose any kind of anatomic or functional dysfunction.
B
• Perform an OGTT six weeks after delivery, and then, at least a fasting glycemia annually. B