for optimal glycemic control (Frayne, 2016). This was defined Insulin Treatment as HbA}c <6.5 percent in women with pregestational diabetes.
The overtly diabetic gravida is best treated with insulin. While Unfortunately, nearly half of pregnancies in the United States oral hypoglycemic agents have been used successfully for gesare unplanned, and diabetic women frequently begin pregnancy tational diabetes (p. 11r12), these agents are not currently recwith suboptimal glucose control (Finer, 2016; Kim, 2005).
ommended for overt diabetes, although this is controversial The ADA (20 17b) has also deined optimal preconcep(American College of 0bstetricians and Gynecologists, 20 16b).
tional glucose control using insulin. Relective values are selfMaternal glycemic control can usually be achieved with mulmonitored preprandial glucose levels of70 to 100 mg/dL, peak tiple daily insulin injections and adjustment of dietary intake.
2-hour postprandial values of 100 to 120 mg/dL, and mean he action proiles of commonly used short-and long-termdaily glucose concentrations < 110 mg/dL. In one prospective insulins are shown in Table 57-8.
population-based study of 933 pregnant women with type 1 diabetes, the risk of congenital malformations was not demonstrably higher with HbA}c levels <6.9 percent compared with the risk in more than 70,000 nondiabetic controls Qensen, 2010). These investigators also found a substantial fourfold greater risk for malformations at levels > 10 percent.
If indicated, evaluation and treatment for diabetic complica
TABLE 57-8. Action Profiles of Commonly Used Insulins Insulin Type Onset Peak (hr) Duration (hr)
Lispro <15nmin 0.5-1n.5
Glulisine <15 min 0.5-1.5 3-4 tuted before pregnancy. Finally, folate, 400 jLg/d orally, is given periconceptionally and during early pregnancy to decrease the risk of neural-tube defects.
Aspart <15 min 0.5-1n.5
Careful monitoring of glucose control is essential. For this reason, many clinicians hospitalize overtly diabetic women during early pregnancy to initiate an individualized glucose control program and provide education. This also provides an opportunity to assess the extent of diabetic vascular complications and precisely establish gestational age.
aMinimal peak activity.
NPH = neutral protamine Hagedorn; SC = subcutaneous. Data from Powers, 201 2.