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December 21, 2001

Family Planning

Question from Pennsylvania, USA:

My two children were born healthy, and I had normal A1cs during my pregnancies, but the pressure to achieve perfect blood sugars with different insulins did more harm than good. With the way insulin peaks (even Humalog) and food is absorbed, isn't it impossible to achieve a one-hour post meal blood sugar of less than 130 mg/dl [7.2 mmol/L] without subsequent hypoglycemia? (Use of The Continuous Glucose Monitoring System should show this.) By making it seem like this is an achievable goal for pregnant women with type 1 diabetes, aren't you setting them up to feel totally responsible for any birth defects, especially since their insulin requirements are changing throughout the pregnancy? Wouldn't a normal A1c be a more realistic goal?

Answer:

The blood glucose parameters are guidelines. Not every pregnant woman can achieve these consistently. I always tell my patients this. However, the effort should be made to try and maintain blood glucose values as close to normal as possible, particularly prior to conception and during the first trimester. This is when the developing embryo is most sensitive to hyperglycemia.

In general though, the occasional elevation in blood glucose is acceptable, but be aware that It does not take much of a persistent increase in maternal blood sugars to cause a large baby. This carries the risk of shoulder dystocia and neonatal hypoglycemia.

If a woman is having frequent hypoglycemic events, then I will tolerate higher blood glucose values to prevent complications for the mother. While a normal hemoglobin A1c is good, this does not reflect day to day changes in glucose and resulting insulin requirements.

OWJ