Management of Type 1 Diabetes Mellitus* During Pregnancy Time Frame Before conception Prenatal Measures Diabetes iz controlled. Risk iz lowest if Hb Arclavele are 26% at conception.” Evaluation includes # 24-hurine collection (protein excration and creatinine clearance) to check for renal complications + Ophthalmologic examination to check for retinal complications ECG te check for cardiac complications Prenatal visits begin 22 soon 2 pregnancy iz recognized, Frequency of visits is determined by degree of glycemic control. Dist chould be individualized according te ADA guidelines and coordinated with | insulin | administration, Three meals and 3 snacks/day are recommended, with emphasis on consistent timing, Women are instructed in and should do plasma glucose ‘self monitoring. Women should be cautioned about the dangers of hypoglycemia during exercise and at night: Women and their family members should be instructed in glucagon administration, Hb Arc level should be checked every trimester. Fetal monitoring with the following should be done weekly from 32 wk to delivery (or eatlieriFindicated): * Nonstress tests * Biophysical profiles * Kick counts Amount and type of| insulin | should be individualized. In the an; 7/3 of total dose (60% NPH, 40% regular) is taken; in the mt; */3 (50% NPH, 50% regular) is taken.*During labor and delivery Yaginal delivery at arm is possible fwemen have documented jating criteria and good glycemic contral Amniocentesis is not done unless indicated for another problem or requested by the couple, (Cesarean delivery should be reserved for obstetrical indications or fetal macrosomia (=4300 9), which increnses rik of shoulder jstocia, Delivery should occur by 38-40 wk, During delivery, » constant low-dose insulin | infusion is usually preferred, and the usual sc administration of insulin | is stopped. IFinduction is planned, the usual PM NPH insulin doses given ‘on the day before induction. Postpartum and continuing diabetes care should be arranged. Postpartum | insulin] requirements may decrease by up to 50%. “Guidelines are only suggested; marked individual variations. require appropriate adjustments, tHormal-values may differ depending on laboratory methods used Some hospital programs recommend upto 4| sun | injections daly. Contnueus sc| insulin ‘infusion, which is labor-intensive, can sometimes be given in specialized diabetic research settings. ADA = American Diabetes Association; Hb A1g = glycosylated Hb; NPH = neutral protamine Hagedorn.Management of Type 2 Diabetes Mellitus* During Pregnancy Time Frame Before conception Prenatal During labor and delivery Hyperslycemia is controlled. Risk is lowest if Hb Aac levels are 38% at conception.” Weight loss is encouraged if BMI is >27 ke/m?. The diet should be low in fat, relatively high in complex carbohydrates, and high in fiber. Exercise is encouraged, For overweight women, diet and caloric intake are individualized and monitored to avoid weight gain of >9 kg; daytime snacks are discouraged. Moderate walling after meals is recommended, ‘Women are instructed in and should do plasma glucose ‘self-monitoring, ‘The 2-h postbreskfaet plasma glucoze level is checked weakly at clinic visits Hb Aiclevel should be checked every trimester. Fetal monitoring with the following should be done weekly from 32 wl to delivery (or earlier findicated): © Nonstress tests © Biophysical profiles ® Kick counts Amount and tyos of! insulin | is individualized. For obese women, regular insulin is taken before each meal, For women who are not obese, 7/3 of total dose (60% NPH, 40% regular) is taken in the sm; 473 (50% NPH, 50% regular) is taken in the mManagement of Gestational Diabetes During Pregnancy Time Frame Measures Before conception ‘Women who have had gestational diabetes in previous pregnancies should try to reach a normal weight and engage in modest exercise. ‘The diet should be low in fat, relatively high in complex carbohydrates, and high in fiber. Fasting plasms glucose and Hb Auclevels should be checked. Prenatal Diet and caloric intake are individualized and monitored to prevent sssight gain of 72 kg, Obese nomen are discouraged from daytime Moderate exercise after meals is recommended. Fetal monitoring with the following should be done weekly from 32 wk to delivery (or earlier if indicated): © Nonstress tests © ‘Biophysical profiles © Kick counts Insulin | therapy is reserved for persistent hyperalycemis (fasting plasma glucose >95 mg/dL or 2-h postprandial plasma glucose 2120 mg/dL) despite 2 trial of dietary therapy for 22 whe The amount and type of| insulin | should be individualized. For obese women, regular | insulin | is taken before each meal. For women who are not obese, 2/3 oftotal dose (60% NPH, 40% regular) is taleen in the ss; 4/3 (50% NPH, 50% regular) is taleen in the =. During labor anddelivery Vaginal delivery st term iz possible ifwemen have a well-documented delivery date and good diabetic control. Amniocentesis may not be required. (Cesarean delivery should be reserved for obstetric indications or fetal macrosoma (©4500 gh hich nereoses sake shoulder Delivery should occur by 38-40 wk, HD Ate= glycosylated Hb; NPH = neutral protamine Hagedorn,