One-hour postmeal less than or = 140 mg/dL (7.8 mmol/L) OR
Two-hour postmeal less than or = 120 mg/dL (6.7 mmol/L)
Target blood sugar ranges recommended during pregnancy by the California Diabetes and
Fasting blood sugar 60 to 89 mg/dl (3.3 to 4.9 mmol/L )
Premeal, bedtime,overnight 60 to 99 mg/dl ( 3.3 to 5 mmol/L)
Postprandial 1 hour from start of meals 100 to 129 mg/dl ( 5.6 to 7.2 mmol/L )
“Patients should check urine ketones when their glucose levels exceed 200 mg/dL and
immediately report positive results to their health care teams” 
The CDAPP recommends starting medical therapy when "greater than
20% of the blood glucose (BG) values in one week are out of range, or
BG values are repeatedly elevated at a specific time of day and meal
plan or activity cannot be modified to correct the elevated blood glucose
"  Insulin is considered the first-line treatment for diabetes in pregnancy by the ACOG and the ADA [1,44]
Insulin is an anabolic hormone with a molecular weight of 5808 Da. Maternal insulin
does not cross the placenta unless it is bound to IgG antibody .
Insulin is produced in the pancreas and is secreted in response to
increased blood glucose and amino acids following ingestion of a meal.
Insulin signals the cells (primarily skeletal muscle) to increase their
uptake of glucose, suppresses lipolysis, acts on the liver to store glucose
as glycogen, and inhibits glucagon secretion thereby preventing
glucagon from releasing glucose from the liver.
Synthetic "human" insulin is manufactured using recombinant DNA technology. Doses of
insulin are measured in units. U-100 insulin contains 100 units/mL. The most commonly used types of insulin during
pregnancy are regular insulin and NPH. Neutral Protamine Hagedorn , NPH, is named after one of its developers the
physician Hans Christian Hagedorn who discovered that combining a
suspension of crystalline zinc insulin with protamine could prolong the
duration of action of the insulin. Insulin aspart , insulin lispro, insulin detemir, and insulin glargine are human
insulin that have had their chemical composition slightly altered to
influence their onset and duration of action. Allergy to recombinant human
insulin preparations is uncommon , and more likely
due to components including zinc, protamine, and meta-cresol .
The graph below illustrates the differences in the onset and duration
of action for various types of insulin.
When compared to treatment with regular insulin, rapid-acting insulin
analogs,lispro and aspart
show better postprandial control, less hypoglycemia and a trend towards
reduction of preterm delivery. The California Diabetes and Pregnancy
Program recommends the rapid acting insulin analogs lispro and aspart, and NPH as
the preferred insulins for pregnancy. In addition, women on glargine
and detemir should consider switching to intermediate acting NPH or to a
continuous subcutaneous insulin pump before becoming pregnant .
In general, when a longer-acting insulin (e.g. NPH insulin isophane suspensions) is mixed with short-acting or
rapid acting-soluble insulin (e.g., regular), the short-acting or rapid
acting insulin should be drawn into the syringe first. Insulin glargine
must NOT be diluted or mixed with any other insulin or solution The
subcutaneous tissue of the abdomen is preferred site for injection because
absorption of the insulin is more consistent from this location than
subcutaneous tissues in other locations. 
Insulin Calculator and Intensive
Multiple Daily Injections (MDI)
Among the potential
clinical adverse effects associated with the use of all insulins are
hypoglycemia and hypokalemia.
Unopened insulin should be stored in a refrigerator between 2 and 8°C
(36 and 46°F); it should not be placed in a freezer. After initial use a
vial may be kept at temperatures below 30°C (86°F) for up to 28 days,
but should not be exposed to excessive heat or sunlight. Unused
insulin should be thrown away after the expiration date. Insulin in a pump
reservoir should be discarded after at least every 48 hours of use or after
exposure to temperatures that exceed 37°C (98.6°F).
Insulin syringes are available in three barrel sizes
1mL (100 units), ½ mL (50 units) and 3/10 mL (30 units). Needles also
come in different sizes
BD Micro-Fine™ IV Needle is a 28-gauge, 12.7mm (1/2") thin
BD Ultra-Fine™ Needle is a 30-gauge,
12.7mm (1/2") Thinner
BD Ultra-Fine™ Short Needle
31-gauge, 8mm (5/16") Thinnest needle
Insulin Pen Needle sizes
29 gauge, 31 gauge, or 32 gauge.
Insulin Pen Needle lengths
4, 5, 6, 8, or 12.7 mm
Example of a prescription for syringes :
Size: 1 cc, ½ cc, 1/3 cc, or 1/3 cc with half-unit scale
Ultra-Fine™ Short ;Needle 31-gauge, 8mm (5/16")
Sig: 4 of syringes used per day
Refills: 6 months
For information on safe disposal of needles, syringes,
and other sharps in the community contact:
Sharps Waste Disposal: Household Hazardous Waste - CalRecycle
Rapid-acting Insulins- Onset 15
Insulin aspart [rDNA origin] injection (NovoLog>®
Insulin lispro, [rDNA origin] injection (Humalog®
Insulin analogs. Onset 1 to 15 minutes , peak of
action 1 to 2 hours, duration 4 to 5 hours 
- Indicated in the treatment
of patients with diabetes mellitus for the control of hyperglycemia.
Give calculated dose subcutaneously 15 minutes before a meal.
The algorithm below may used, but may need to be modified according to the
patient population. 
|Preprandial or Bedtime Blood Glucose
average for at least 3 consecutive days (mg/dl)
||Adjust dose of aspart (Novolog)
(100 Units per mL in 10 mL vials, 3 mL cartridges, or 3 mL Pens)
Short-acting Insulins- Onset 30 to 60 minutes
Regular insulin human injection, USP (rDNA origin)
Humulin ® R, Novolin® R
Insulin. Onset 30 to 60 minutes, peak of action 2 to 3 hours, duration of action 5 to 8 hours .
(100 Units per mL in 10 mL vials)
Regular insulin human injection, USP (rDNA origin)
Humulin R (U-500) ®
Insulin. Onset 30 to 60 minutes , peak of action 2 to 4 hours, duration of action 6
to 8 hours
- Indicated in the treatment of diabetic patients with marked insulin resistance (daily requirements
more than 200 units
Give calculated dose subcutaneously 30
minutes before a meal.
(500 Units per mL in 20 mL vials)
Intermediate-acting, Basal Insulin
Neutral Protamine Hagedorn (NPH) Human Insulin (rDNA origin) Isophane Suspension
Humulin ®N , Novolin® N )
Zinc insulin combined with the polypeptide protamine. Onset 2 to 4 hours ,peak of action 4 to 10 hours, duration of action 10 to 16 hours
- Indicated in the treatment of patients with diabetes mellitus for the control of
Give calculated dose alone or mixed with short or rapid acting insulin subcutaneously.
(100 Units per mL in 10 mL vials)
Long-acting, Basal Insulin
Insulin detemir [rDNA origin] injection
Insulin .Onset 1 to 3 hours, peak of action 4 to 14 hours (no true
peak), duration of action 6 to 24 hours (dose dependent)
Indicated in the treatment of patients with diabetes mellitus for the control of
hyperglycemia. Not recommended for treating diabetic ketoacidosis.
Give calculated dose alone .Do not dilute or mix with any other insulin or solution. Do not
administer subcutaneously via an insulin pump, intramuscularly, or intravenously.
If converting from insulin glargine to LEVEMIR,
the change can be done on a unit-to-unit basis. If converting from NPH
insulin, the change can be done on a unit-to-unit basis. However, some
patients with type 2 diabetes may require more LEVEMIR than NPH
(100 Units per mL in 10 mL vials,3 mL LEVEMIR
FlexTouch ® )
Continuous subcutaneous insulin infusion (CSII) therapy- Insulin pump 
The American Association of Clinical Endocrinologists (AACE) considers suitable insulin pump candidates to have the following characteristics:
Women with type 1 Diabetes who do not reach glycemic goals despite adherence to
maximum multiple daily injections of insulin especially if they have very
labile diabetes , frequent severe hypoglycemia and/or hypoglycemia unawareness,
significant “dawn phenomenon,” extreme insulin sensitivity , and in special
populations (e.g. pregnant women , competitive athletes) or other patients
who, after investigation and careful consideration, feel that CSII would be
helpful in achieving and maintaining treatment targets
Women with insulin requiring type 2 Diabetes who satisfy any or all of the following: are C-peptide
positive, but with suboptimal control on a maximal program of basal/bolus
injections, have substantial “dawn phenomenon”, erratic lifestyle (e.g.,
unpredictable schedules), OR severe insulin resistance.
AACE also recommends "After delivery, the
insulin pump infusion should be stopped temporarily to avoid hypoglycemia;
once the blood glucose is >100 mg/dL, infusion should be resumed at the prepregnancy settings".
of Initial Insulin Pump settings (AACE)
of Initial Insulin Pump settings (Sweet Success)
Oral Hypoglycemic Agents (OHA)
If oral diabetes agents are used, patients should be clearly informed that these drugs cross the
placenta and may have unknown risks to the fetus.
Glyburide (Micronase® ). Used as an adjunct to diet to lower the blood glucose in patients withnon-insulin-dependent diabetes mellitus [1,7].
Oral blood-glucose-lowering drug of the sulfonyl- urea class . Glyburide stimulates release of of insulin from the pancreas .Glyburide crosses the placenta [26,27].
Starting dose 1.25 mg to 2.5 mg PO daily 60 minutes before meals to control postprandial sugar. Use lower
dose for women with weight less than 200 pounds.
May give at 10 to 11 PM to control fasting blood sugar.
May increase by 1.25 to 2.5 mg every 3 to 7days until blood sugar controlled
or a maximum daily dose of 20 mg.
Should not be used in patients who report a sulfa allergy .
Potential clinical adverse effects associated with the use of glyburide are
hypoglycemia and allergic reaction. Meta-analysis found when compared to
insulin, glyburide was associated with higher neonatal birth weight and
increased incidence of neonatal hypoglycemia [14,15]
(1.25, 2.5, and 5 mg tablets)
Use in Breastfeeding: Limited data indicate that the levels of glyburide in milk are negligible; Appears to be compatible with breast-feeding. However, the
baby should be monitored for signs of hypoglycemia [16,17].
Metformin (Glucophage ® )
Oral blood-glucose-lowering drug of the biguanide class. Metformin
decreases glucose production by the liver, decreases intestinal absorption
of glucose, and improves insulin sensitivity by increasing peripheral
glucose uptake and utilization . Metformin crosses the placenta[ 28]
- Used as an adjunct to diet to lower the blood
glucose in patients with non-insulin-dependent diabetes mellitus [14,15]. ACOG considers metformin a reasonable
second-line choice for women with GDM who decline insulin therapy or for those who may not be able to
safely administer insulin 
500 mg once or twice daily given with meals.
Usually given with breakfast and dinner. May increase in increments of 500
mg every 3 to 7 days up to a total of 2500
mg per day.
If a woman is taking metformin prior to her pregnancy or at the first
prenatal visit, the CDAPP Sweet Success Program recommends she continues to take metformin . Women taking metformin for polycystic ovarian
syndrome (PCOS) may benefit from continuing; to take metformin
throughout the pregnancy [19,20]
Lactic acidosis is a rare, but serious,
metabolic complication that can occur due to metformin accumulation during
treatment.; Metformin is contraindicated in renal disease or renal dysfunction (e.g., as suggested by serum creatinine
levels or abnormal creatinine clearance), which may also result from
conditions such as cardiovascular collapse (shock), acute myocardial
infarction, and septicemia Discontinue prior to major surgery, or
radiological studies involving contrast materials.
(500, 850, and 1000 mg tablets)
Use in Breastfeeding:
Metformin levels in milk are low and infants would receive less than 0.5%
of their mother's weight-adjusted dosage. Use with caution in premature
infants and infants with renal disease [22-25].
Reviewed by Mark A Curran, M.D.