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MS WordPerinatologist Corner - C.E.U/C.M.E. Modules
Diabetes In Pregnancy Series
Sponsored by The Indian Health Service Clinical Support Center
PART 2: Management, delivery, and postpartum
4. Insulin Therapy
Case continued
Ms Kanulie returns the following week and presents this glucose log (ranges reported for simplicity):
Day |
FBS |
breakfast 2-hr PPG |
lunch 2-hr PPG |
dinner 2-hr PPG |
8-15 |
98-121 |
131-203 |
103-129 |
92-118 |
Insulin Therapy
Despite two weeks of MNT, the fasting and the post breakfast glucose values remain out of range, but the other post-prandial sugars are good. On the basis of the elevated fasting sugars one might again suspect that she may actually be a pre-gestational diabetic (“class B”). (See White Classification) Nevertheless, the interventions are essentially the same at this point.
You decide to start Ms Kanulie on split dose insulin. She is now classified as “GDM, class A-2”, no longer diet-controlled. How should you decide on an insulin dose for her? There are several ways to do this, and most will be successful in individuals who are not type I diabetics.
One way would be to administer a small dose of short acting (regular or lispro) insulin before each meal to control the post-prandial sugars, and a small dose of longer acting insulin (usually NPH) at bedtime to control the fasting glucose.
Another way would be to give NPH and regular insulin together twice a day, before breakfast and again before dinner. A third way would be to give lispro three times a day at each meal and give NPH twice a day, on arising and at bedtime.
Type I diabetics often need Ultralente insulin or one of the newer analogs, in order to provide them 24-hour basal insulinization. The short acting insulin should control the glucose excursions after eating, and the NPH should both smooth out the daytime control, and work during the night to result in a target range FBS.
The advantage of lispro is that it is conveniently given as the patient sits down to eat, not 30 minutes before the meal, as is appropriate for regular insulin. There can be some difficulty mixing Lispro and insulins from other manufacturers, but it is OK to mix Lispro with other insulins made by the same manufacturer.
