Subcutaneous insulin infusion by a calibrated pump does not yield better pregnancy outcomes compared with multiple daily injections. But, an infusion pump is a safe alternative in appropriately selected patients (Farrar, 2016; Sibai, 2014). With the advent of sensor-augmented insulin pumps and closed-loop insulin delivery systems, improved glycemic control with either manual or computer-generated insulin adjustments based on continuous glucose monitoring is now possible. One small randomized, crossover study of 16 pregnant women compared these two technologies (Stewart, 2016). Those with automatic closed-loop systems had glucose values within target range for a higher percentage of time and had lower daily median glucose values. Moreover, their rates of hypoglycemic episodes were not increased. Roeder and colleagues (2012) noted with insulin pump use in women with type 1 diabetes that total daily insulin doses declined in the first trimester but later rose more than threefold. Postprandial glucose elevations prompted most of the required daily-dose increases. If a continuous-infusion insulin pump is elected, it is best started before pregnancy to avoid the hypoglycemia and ketoacidosis risk associated with the learning curve (Sibai, 2014).
Monitoring. Self-monitoring of capillary glucose levels using a glucometer is recommended because this involves the woman in her own care. he ADA (2017b) recommends fasting and postprandial glucose monitoring. Glucose goals recommended during pregnancy are shown in Table 57-9. Advances in noninvasive glucose monitoring will undoubtedly render intermittent capillary glucose monitoring obsolete. Subcutaneous continuous glucose monitoring devices have shown that pregnant women with diabetes experience signiicant periods of daytime hyperglycemia and nocturnal hypoglycemia that are undetected by traditional monitoring (Combs, 2012). Such glucose monitoring systems, coupled with a continuous insulin pump, ofer the potential of an "artificial pancreas" to avoid undetected hypo-or hyperglycemia during pregnancy.
Diet. Nutritional planning includes appropriate weight gain through carbohydrate and caloric modiications based on height, weight, and degree of glucose intolerance (merican Diabetes Association, 2017b; Bantle, 2008). he mix of carbohydrate, protein, and fat is adjusted to meet the metabolic goals and individual patient preferences. A minimum of 175 g/d of carbohydrates ideally is provided. In one analysis of more than 200 obese pregnant women with glucose intolerance, a lower carbohydrate intake, particularly late in pregnancy, was
TABLE 57-9. Self-Monitored Capillary Blood Glucose Goals
Fasting :;95 Premeal :;100 1-hr postprandial :;140 2-hr postprandial :;120
Hemoglobin Ale :;6% associated with lower fat mass in ofspring at birth (Renault, 2015). Allotted carbohydrates are distributed throughout the day in three small-to moderate-sized meals and two to four snacks. Weight loss is not recommended, but modest caloric restriction may be appropriate for overweight or obese women. An ideal dietary composition is 55 percent carbohydrate, 20 percent protein, and 25 percent fat, of which < 10 percent is saturated fat.