By Gerard N. Burrow, M.D., Thomas P. Duffy, M.D., and Joshua A. Copel, M.D. (Eds.)
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Despite this, however, no permanent maternal sequelae were seen, and fetal outcomes were favorable, with no perinatal mortality or congenital anomalies. 66 The best predictive value was a blood glucose level below 108 mg/dL at 2300 hours, which resulted in a risk of nocturnal hypoglycemia of 71%, whereas the chance of avoiding nocturnal hypoglycemia was 83% if the before-bedtime blood glucose level was 108 mg/dL or higher. 67 The tendency toward ketosis that is observed in normal pregnancy is also accentuated in the diabetic patient.
Their pharmacokinetic profile appears to make them ideal for use during pregnancy, in view of the marked insulin resistance that occurs and leads to significant postprandial hyperglycemia; however, neither insulin lispro nor insulin aspart90 is yet approved for use during pregnancy in North America. Continuous subcutaneous insulin infusion via an insulin pump offers the type 1 diabetic patient the opportunity for the most intensive glycemic control. 91 The computerized pump provides a continuous basal rate of insulin, which may change according to the hour of the day, meeting the basal metabolic demands of the body.
Proactive insulin adjustments, based on the expected level of activity before the next meal, allow for flexibility in mealtimes and food choices in addition to enhancing control. Patients may additionally modulate their dose on the basis of their caloric intake (carbohydrate counting), as well as taking into account their anticipated postprandial activity level. In most cases, an adjustment of ±2 to ±4 U of the short- or rapid-acting insulin is required. Postprandial glycemic excursions may be particularly difficult to control in pregnancy; therefore, significant increases in short- or rapid-acting insulin, beyond the usual proportions that are more in keeping with successful regimens outside pregnancy, are often required.