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March 27, 2002

Family Planning, Type 2

Question from Ephrata, Pennsylvania, USA:

I am 38 weeks pregnant with my third child. I had gestational diabetes during my first two pregnancies, and I developed type 2 diabetes little over two years ago. Neither of our first two children had problems at birth, even though my sugars ran higher than they are with this pregnancy. My fasting sugars are ranging from 85-120 mg/dl [4.7-6.7 mmol/L], my two-hour post-meal sugars are running about 130-168 mg/dl [7.2-9.3 mmol/L], and my hemoglobin A1c two months ago was 5.8%. I am also on Synthroid [a brand of thyroid replacement hormone], which has been increased to 0.1 mg during this pregnancy. I am frustrated at this point because one of my doctors wanted me to start insulin "as a precautionary measure" about three weeks ago, but the other doctor (whom I've seen much longer) didn't see the need, so I did not start it. They are now recommending because of those two levels that I start 5 units of the 24-hour insulin at night, and I am concerned with this because I only had two highs this past week, and I am afraid the introduction of insulin may cause low sugars. I have just two weeks left to this pregnancy, and I have been feeling great, with only occasional low sugar symptoms. I understand their concern for the baby (something about lung development), but again I never had this tight control during either of my prior pregnancies so I'm not sure why all the fuss. We have had a horrendous time trying to locate health insurance for me and my family, due to my diet-controlled type 2 diabetes so it seems to me this will only make that matter even more difficult. We want to do what is necessary, but should we be seeking another opinion?


The glucose goals I recommend in my patients are fasting 60-90 mg/dl [3.3-5 mmol/L], pre-meal 80-90 mg/dl [4.5-5 mmol/L] and post-meal of 130 mg/dl [7.2 mmol/L] at one hour or 120 mg/dl [6.7 mmol/L] at two hours. These are strict guidelines and cannot always be realistically achieved.

The ranges you report exceed these recommendations, therefore I think it is reasonable to start insulin even if it is for a short period of time. You may do fine on one injection a day. At this point in pregnancy the main benefit will be to prevent neonatal hypoglycemia.