Related links: General management plan for the diabetic gravida

Ideally, the woman with insulin-requiring diabetes should attempt tight glucose control prior to conception, to reduce the chance of fetal anomalies.

Review the patient's blood glucose values and determine the degree of control.

Typical tight control values are

• Fasting: 60-90 mg/dl
• Pre-meals: 60-105 mg/dl
• 2 hour postprandial: less than 120 mg/dl
• Early AM (2AM to 6AM): >60 mg/dl

Usually, the initial step is to obtain fasting and pre and post meal blood glucose values. A common regimen in pregnancy is to administer

• Both an intermediate-acting insulin (NPH) and a short-acting insulin (regular or lispro) in the morning before breakfast
• Regular or lispro insulin before dinner
• Intermediate acting insulin before bedtime
• Two-thirds of the total daily dose is given in the morning, and one-third in the evening
• The ratio of intermediate to short-acting insulin in a dose is usually 2 : 1.
• The patient should report her dose and blood glucose values frequently and be given instructions about adjusting the doses according to meals and activity.

The total daily dose can initially be approximated as 0.7 units of insulin per kg of body weight, and then divided into AM and PM and intermediate-to-regular doses.

The oral hypoglycemic agent glyburide has been studied in women whose glucose was not controlled by diet.

• Glyburide-treated women in general achieved similar levels of control to those treated with insulin

• There was no detectable glyburide in the cord blood of the fetuses

• 4% to 20% of glyburide-treated women required initiation of insulin therapy due to persistent elevated blood glucose

• One study found an increased incidence of neonatal complications in glyburide-treated women.

• Further study is required before glyburide or other oral agents can be said to be equivalent in efficacy and safety to insulin