First trimester

1. First prenatal visit. At the first prenatal visit, the severity of diabetes can be categorized according to the White classification.

Modified White's Classification of Diabetes in Pregnancy




Abnormal GTT at any age or of any duration treated only by diet therapy


Onset at age 20 years or older and duration of less than 10 years


Onset at age 10-19 years or duration of 10-19 years


Onset before 10 years of age, duration over 20 years, benign retinopathy, or hypertension ( not preeclampsia)


Onset before age 10 years


Duration over 20 years


Calcification of vessels of the leg (macrovascular disease)


Hypertension (not preeclampsia)


Proliferative retinopathy or vitreous hemorrhage


Nephropathy with over 500 mg/day proteinuria




Criteria for both classes R and F


Many pregnancy failures


Evidence of arteriosclerotic heart disease


Prior renal transplantation

Classes B through T require insulin treatment

Gestational diabetics


Diet-controlled gestational diabetes


Insulin-treated gestational diabetes

2. Routine prenatal laboratory evaluation is performed. In addition to the standard prenatal laboratory panel, tests in diabetic gravida include:

a. Early morning urine test for microalbuminuria is the earliest clinical sign of diabetic nephropathy. A urine albumin concentration is >20 to 30 mg/L indicates microalbuminuria.

b. Glycosylated hemoglobin concentration is obtained.

c. Thyrotropin (TSH) and free thyroxine should be measured.

d. Baseline electrocardiogram should be obtained if not performed within the preceding year.

e. Dilated and comprehensive eye examination by an ophthalmologist should be performed during the first trimester, then at least every three months until parturition.

Frequency of Testing During Pregnancy in Women with Type I Diabetes



Hemoglobin A1c

Every 4-6 weeks

Blood glucose

Home measurements 4-8 times daily; during weekly/biweekly visits in physician's office

Urine ketones

During period of illness; when any blood glucose value is >200 mg/dL


Weekly/biweekly office visits

Serum creatinine

Each trimester

Thyroid function tests

Baseline measurements of serumfree T4 and TSH

Eye examination

Baseline and then every 3 months

3. Women who are in very poor metabolic control after the first visit may require admission to the hospital. Admission is also required for diabetic ketoacidosis.

B. Glucose monitoring. Measurements of blood glucose in women with type 1 diabetes should occur at 7:30 AM, 10 AM, 1 PM, 4:30 PM, and 6:30 PM. If the first morning blood glucose value is high, testing should also be performed at bedtime and in middle of the night. Bedtime and middle-of-the-night tests are important to discover, treat, and prevent nocturnal hypoglycemia.

C. Urinary ketones should be measured periodically, especially when the woman is ill or when any blood glucose value is over 200 mg/dL.

D. Target blood glucose values in pregnant diabetic woman:

1. A fasting capillary blood glucose concentration of 55 to 65 mg/dL.

2. One-hour postprandial blood glucose concentration less than 120 mg/dL.

3. Diet recommendations a. Approximately 30 kcal/kg per day if the woman is at ideal body weight.

b. 24 kcal/kg per day if 20 to 50 percent above ideal body weight.

c. 12 to 18 kcal/kg per day if more than 50 percent above ideal body weight.

d. 36 to 40 kcal/day if more than 10 percent below ideal body weight.

e. The recommended distribution of calories is 40 to 50 percent carbohydrate, 20 percent protein, and 30 to 40 percent fat.

f. Three meals and three snacks per day are recommended. An acceptable calorie distri bution would be 10 percent of calories at breakfast, 30 percent at both lunch and dinner, and 30 percent as snacks. A daily supplement of ferrous sulfate (30 mg) and folate (400 pg) is also recommended.

4. Insulin regimen. Most women with type 1 diabetes require at least three injections of insulin per day.

a. The average insulin requirement in pregnant women with type 1 diabetes is 0.7 units/kg in the first trimester, often increasing to 0.8 U/kg for weeks 18 to 26, 0.9 U/kg for weeks 27 to 36, and 1.0 U/kg for weeks 37 to term.

b. Women with type 2 diabetes also should be treated with insulin for blood glucose control, preferably started during the preconception period. During the first trimester, insulin requirements are similar in women with type 1 and type 2 diabetes. However, as the pregnancy proceeds into the third trimester, insulin requirements increase proportionately more in women with type 2 than type 1 diabetes; in one study, for example, the respective insulin doses are 1.6 and 1.2 U/kg per day.

c. Administer a combination of regular insulin and intermediate-acting insulin (such as NPH insulin). The insulin is initially distributed as follows:

(1) Approximately 45 percent of the total daily dose is given as NPH insulin and 22 percent as regular insulin before breakfast.

(2) Approximately 17 percent of the total daily dose is given as both NPH and regular insulin before dinner.

(3) The premeal dose of regular insulin (including lunch) is given on a sliding scale according to the blood glucose value.

Insulin Adjustment Based upon Self-Measured Blood Glucose (BG) Concentrations

Ti m e

Insulin dose being analyzed

Adjustment recommendations


Bedtime NPH insulin

If BG is >90 mg/dL, check at bedtime and 3:00 AM BG. If bedtime value is high, increase dinner regular insulin or decrease evening snack. If bedtime value normal but 3:00 A< value is above 100 mg/dL, then raise bedtime NPH insulin by 2 units. If 3:00 am value is below 60 mg/dL, reduce bedtime NPH by 2 units.

10 AM

Morning regular insulin

If 1 hour postprandial value is above 140 mg/dL, increase next morning regular insulin by 2 units. If the value is <110 mg/dL, decrease next morning AM regular by 2 units.


Morning NPH insulin

If 1 hour postprandial value is above 140 mg/dL, increase next day's lunch regular insulin by 2 units. If the value is below 110 mg/dL, decrease next day's lunch regular insulin by 2 units.


Morning NPH insulin

If BG is above 90 mg/dL, then increase morning NPH insulin by 2 units. If BG is below 60 mg/dL, then decrease morning NPH by 2 units.


Dinner regular insulin

If 1 hour postprandial value is above 140 mg/dL, increase dinner regular insulin by 2 units. If 1 hour value is below 110 mg/dL, decrease dinner regular insulin by 2 units.

5. Second prenatal visit is scheduled one week after the first. Self-monitored blood glucose values and results from the ophthalmologic and laboratory examination are reviewed.

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