New concepts and applications in the use of the insulin pump during pregnancy

Subcutaneous insulin infusion or insulin pump therapy has been advocated as an alternative to multiple dose insulin injections for nearly two decades. These devices provide insulin administration in a pattern which more closely resembles that of physiologic insulin release, a basal insulin infusion during the day and throughout the night with boluses given prior to meals. Because the number of patients using an insulin pump is increasing, it is likely the perinatologist will encounter women who are being treated with an insulin infusion pump or are considering this therapy. Insulin pump therapy requires that the patient be highly motivated and compliant. One of the most important criteria in selecting patients for this treatment is their willingness to test their capillary glucose levels 6 to 8 times each day. Interruption of the insulin infusion can produce hyperglycemia in any pump user. Should this occur in the pregnant patient, the likelihood of ketoacidosis developing is significantly greater. Ideally, insulin pump therapy should be initiated prior to pregnancy so that glucose control can be normalized, thereby reducing the risk for spontaneous abortion and fetal malformations. Gradually improving glucose control prior to pregnancy can reduce the likelihood of deterioration of retinopathy, which has been observed when poorly controlled pregnant patients rapidly become euglycemic. The published experience with the insulin pump has demonstrated that this therapy can achieve glucose control and perinatal outcomes comparable to that obtained with multiple-dose insulin injection therapy.