glucose^59–61 while allowing sufficient energy intake to achieve recommended weight gain. The goal for women with preexisting diabetes mellitus is to achieve normal blood glucose values before conception (see the previous section, "Preconceptional Care") and sustain normal values throughout gestation to minimize the risk for fetal anomalies, fetal death, macrosomia, respiratory distress syndrome, maternal infection, and possibly preeclampsia.^62–65

The expertise of a dietitian is highly desirable when providing nutrition services for pregnant women with diabetes mellitus. According to the Third International Workshop-Conference on Gestational Diabetes Mellitus (GDM), "nutritional counseling is the cornerstone of the management of all women with GDM. . . ." (p. 200).⁶¹ Nutritional assessment, planning, and counseling are coordinated with medical management as a component of collaborative prenatal care.^17,66–69

At present, no consensus exists concerning the most favorable dietary recommendations for pregnant women with diabetes mellitus.^69–72 In all approaches, however, the proportion of fat and carbohydrate is controlled in some way, usually the proportion of simple sugars is decreased, and generous intake of food sources of fiber is encouraged. The distribution of food in meals and snacks is also controlled. If insulin is administered, a very careful balance must be struck between diet, physical activity, the insulin dosage, and sometimes other factors (such as infection) that influence metabolism. The self-monitoring of blood glucose with memory-based meters, usually on an outpatient basis, provides useful information for making decisions regarding diet and insulin for the day-to-day maintenance of normal blood glucose.

Hypertensive Disorders. In the past, nutritional interventions such as restriction of energy and sodium were recommended for the prevention of preeclampsia and the treatment of chronic hypertensive disease during pregnancy, but those interventions are no longer recommended. ^73,74 The effects of calcium supplementation for women at risk of developing preeclampsia are under study.^10,75,76

Because pregnancy increases the body's requirement for sodium, sodium restriction is ill-advised. Women who receive medication for hypertensive diseases are now encouraged to avoid excessive intake of salty foods but to salt foods to taste. Diuretics are seldom required except in the presence of cardiopulmonary failure or in the rare case of resistance to other forms of antihypertensive therapy.