Choice of insulin

• The GDG acknowledged that the systematic review of evidence from randomized trials did not identify a clear difference in benefits and harms between different types of insulin during pregnancy (see Desirable and undesirable effects below). The choice of insulin for pregnant women with type 1 diabetes will be based on the woman’s experiences of insulin before becoming pregnant, her glycaemic control during pregnancy, and local availability and expertise. When treatments previously used are continued into pregnancy, it is important to monitor glycaemic control and modify the regimen promptly when it is not achieving optimal blood glucose control. Method of insulin delivery
• The GDG acknowledged that the availability of different methods for insulin delivery varies across countries and in various contexts and settings (e.g. twice daily injections, multiple daily injections, continuous subcutaneous insulin infusion, automated insulin delivery systems). Frequency of insulin injections
• Based on physiological evidence, insulin resistance increases during the second and third trimesters of pregnancy (47). The GDG acknowledged that, although the evidence on the frequency of insulin injections in pregnant women with type 1 diabetes is limited, increased frequency of insulin injections or continuous subcutaneous insulin infusion may be required. Indirect evidence from the systematic review of evidence conducted to inform this guideline suggests improved glycaemic control with four times compared to twice daily injections in women with GDM. Automated insulin delivery systems and/or hybrid closed loop therapy may also be a consideration, as available. Timing of insulin
• The GDG acknowledged that the study included in the systematic review that addressed this question did not provide evidence of a clear difference in benefits and harms between different timings of insulin during pregnancy (e.g. before or after meals). Indirect evidence (in non-pregnant type 1 diabetes populations) suggests that insulin before meals is advisable The GDG acknowledged that changes in the market mean that some medications may become unavailable and that new products may become available and trigger review of the guidelines as evidence emerges.