Q: My wife was diagnosed with gestational diabetes in her 30th week of pregnancy. She is strictly on diabetic diet, she goes for a one hour walk everyday and takes insulin twice (14, 14) daily. Doctor has told her to maintain post meal 1 hour sugar levels up to 140. Her readings generally comes in 135-145 range. I read somewhere that post meal 1 hour sugar levels for pregnant women should be less than 120/130. What level should she maintain?

A:During a healthy pregnancy, mean fasting blood sugar levels decline progressively to a remarkably low value of 74 ± 2.7 (standard deviation) mg/dL. On the other hand, peak postprandial blood sugar values rarely exceed 120 mg/dL. Meticulous replication of the normal glycaemic profile during pregnancy has been demonstrated to reduce the rate of macrosomia (large babies). Specifically, when 2-hour postprandial glucose levels are maintained at less than 120 mg/dL, approximately 20% of fetuses demonstrate macrosomia. Conversely, if postprandial levels range up to 160 mg/dL, macrosomia rates rise to 35%. The current recommendations are: Fasting whole blood glucose level less than 95 mg/dL (5.3 mmol/L) Two-hour postprandial whole blood glucose level less than 120 mg/dL (6.7 mmol/L) Dietary therapy Metabolic management of a patient is focused on dietary control, regular home glucose monitoring, and judicious use of insulin therapy. Most patients with gestational diabetes mellitus (GDM) diagnosed in the third trimester can maintain 1-hour postprandial blood glucose levels less than 130 mg/dL via diet manipulation alone (i.e., multiple, small, nonglycaemic meals and increased exercise). Glucose monitoring A home glucose monitor is essential to assist the patient in choosing the types and timing of food ingestion. For the first 1-2 weeks, the patient should perform capillary glucose checks upon awakening (fasting) and 1 hour after each major meal. Midmorning, mid afternoon, and bedtime snacks are essential to blunt the glucose surge occurring after meals. Once the patient has demonstrated success in controlling postprandial glucose with diet, the occurrence of abnormal fasting levels is exceedingly rare and the morning checks can be discontinued. Fasting checks are reinstituted if any postprandial glucose levels are abnormal. Insulin therapy Insulin therapy may be key in achieving a good outcome. Recent research from a study in which randomised subjects with GDM whose foetuses had abdominal circumferences above the 75th percentile either dieted or took twice-daily insulin therapy suggests that the earlier insulin therapy is started, the better the outcome. Although the gestational age at delivery was similar in insulin- and diet-treated groups, the prevalence of infants who were large for gestational age and neonatal skin-fold measurements at 3 sites were reduced in the insulin-treated group. The insulin regimen is determined based on the patients individual glucose profile. Typically, one to several postprandial glucose levels become consistently above target because the patients ability to compensate for rising insulin resistance with diet becomes inadequate. When more than 20% of postprandial blood sugar values exceed 130 mg/dL, administering rapid-acting insulin injections (4-8 U to start) before meals is usually successful in controlling glucose overshoots. If more than 10 U of short-acting insulin is needed prior to the noon meal, adding an 6-12 U dose of neutral protamine Hagedorn (NPH) insulin prior to breakfast helps achieve smoother control. When more than 10% of fasting glucose levels rise above 95 mg/dL, a starting dose of 6-8 U of NPH insulin at bedtime can be used. The doses are scaled up as necessary once or twice weekly to keep glucose levels on target.