Management of insulin treatment in type 1 diabetes mellitus in prospect for and during pregnancy: Means and objectives.

Clinical data in the 1980s showed a close relationship between the concepti onal glycated hemoglobin and the occurrence of spontaneous early abortions and fetal malformations. Blood glucose level during pregnancy was similarly correlated with the risk of fetal macrosomia, due to significant links bet ween birthweight. fetal hyperinsulinemia and mean maternal blood glucose. T ight blood glucose control from conception to term was shown to be able to lower the risk of fetal malformations and perinatal mortality to that of th e offspring of a non diabetic mother. Prerequisites include: 1) contracepti on until tight blood glucose control, 2) close partnership between diabetol ogist and obstetrician, 3) assessment of diabetic complications. Seldom, co ronary heart disease or advanced nephropathy contraindicate pregnancy. Unco ntrolled proliferative or pre-proliferative retinopathy, or macular edema, are temporary contraindications to pregnancy. Laser plotocoagulation must t hen be performed before tightening blood glucose control. A complete review of diabetes management is associated with therapeutic intensification. Blo od glucose objectives allow as limits: 70 to 100 mg/dl before meals, up to 140 mg/dl one hour and 120 mg/dl two hours after meals. HbA1c allowing conc eption is close to 7%. Blood glucose monitoring requires 6-7 measurements p er day. The most efficient insulin regimens include 3 to 4 shots per day. T he distribution between regular and NPH or lente insulins is adapted indivi dually. Lispro insulin, now appearing as safe, may be used to improve post- meal blood glucose control. Insulin pumps may be useful in case of late-nig ht poor control or frequent hypoglycemic events. Patient acceptance of this option is unavoidable to obtain a benefit. Preconceptional insulin therapy must be maintained until pregnancy term. Follow-up must be intensified aft er twenty fourth week. Labor and delivery, cesarean section, fetal maturati on by corticosteroids and use of IV betamimetic drugs require continuous IV insulin delivery. The continuation of intensive insulin management in post -partum is encouraged.