a. Fifteen percent of women with gestational diabetes require insulin therapy because of elevated blood glucose concentrations despite dietary therapy. Insulin should be initiated when the fasting blood glucose is greater than 90 mg/dL and the one-hour postprandial blood glucose is greater than 120 mg/dL on two or more occasions within a two-week interval despite dietary therapy.

b. Preprandial blood glucose concentrations below 90 mg/dL and one-hour postprandial concentrations below 120 mg/dL minimize the incidence of macrosomia.

c. If insulin is required because the fasting blood glucose concentration is high, an intermediate-acting insulin, such as NPH insulin, is given before bedtime. The initial dose should be 0.15 U/kg body weight. If postprandial blood glucose concentrations are high, then regular insulin or insulin lispro should be given before meals in a dose calculated to be 1.5 U per 10 grams carbohydrate in the breakfast meal and 1.0 U per 10 grams carbohydrate in the lunch and dinner meals. If both preprandial and postprandial blood glucose concentrations are high, then a four-injection per day regimen should be initiated.

d. The total dose is 0.7 U/kg for weeks six to 18, 0.8 U/kg for weeks 19 to 26, 0.9 U/kg for weeks 27 to 36, and 1.0 U/kg for weeks 37 to term. The insulin should be divided about 45 percent as NPH insulin, 30 percent before breakfast and 15 percent before bedtime, and about 55 percent as preprandial regular insulin, 22 percent before breakfast, 16.5 percent before lunch, and 16.5 percent before dinner.

e. Adjustments in the insulin doses are based upon the results of self blood glucose monitoring. Insulin resistance increases as gestation proceeds, requiring an increase in insulin dose.

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