2. Pregestational and gestational diabetes
دکتر عادله بهار
فوق تخصص غدد درون ریز و متابولیسم
دانشگاه علوم پزشکی مازندران
مرکز تحقیقات
دیابت
Intrapartum and postpartum
glycemic control

3. Intrapartum glucose and insulin requirements
Labor has a glucose-lowering effect
Most women have lower insulin requirements during labor
1. The mother's type of diabetes (type 1, type 2, or gestational)
2. whether she is in the latent or active phase of labor
Insulin requirements are affected by:

4. Latent phase
Maternal metabolic demands are minimal during the latent phase
If oral intake is permitted during latent phase
A reduced calorie diet
(eg, 50 % of daily caloric intake)
will meet energy demands

5. In women who have no or severely restricted oral intake
This will be inadequate if the latent phase is protracted
An IV glucose-containing solution will be needed, with or without half normal saline to minimize sodium load
Maternal energy demands can usually be met over the short-term by metabolism of stored hepatic glucose

6. Women with Type 2 and GDM Women with Type 1 DM
Generally produce sufficient endogenous insulin to maintain euglycemia during the latent phase without intrapartum supplemental exogenous insulin
Have no endogenous insulin production and therefore require intrapartum exogenous basal insulin to maintain euglycemia and prevent DKA
Women with Type 1 DM

7. Active phase

8. Active labor is an intense exercise with increased energy requirements
Most women, including those without DM, are given 5 % glucose IV because :
1. Glucose demands cannot be met by oral intake, which is usually limited or prohibited during the active phase &
2. Hepatic glycogen stores are rapidly depleted

9. Studies have shown that :
Glucose requirements increase to about mg/kg/min to maintain maternal glucose concentration at mg/dl
This is analogous to the requirement observed with sustained and vigorous exercise

10. Intrapartum administration of glucose may also be important for optimal myometrial function
In a randomized trial, administration of a % glucose-containing solution significantly shortened labor compared with normal saline infusion

11. Insulin requirements drop to almost zero in the active phase
women with type 2 DM and GDM (who produce some endogenous insulin) often do not need supplemental insulin during active labor
Women with type 1 DM (who do not produce endogenous insulin) have lower insulin requirements in active labor

12. Intrapartum glucose targets

13. A reasonable target range for intrapartum glucose levels is >70 and <126 mg/dL
This range has not been associated with clinically important neonatal hypoglycemia in insulin-requiring women
Intrapartum glucose levels above mg/dL are consistently associated with:
1. Neonatal hypoglycemia
2. Increased risk of maternal ketoacidosis

14. Intrapartum glucose monitoring

15. The optimum frequency of glucose monitoring required to maintain target glucose levels is
Glycemic control depends on:
1. Endogenous insulin secretion and
2 . Insulin resistance
Closer monitoring is required in women with pre-existing diabetes than in many women with GDM
unclear

16. Glucose levels are measured every two - four hours
During the
latent phase
In women with type 1 or type 2 diabetes, and women labeled “gestational diabetics” but who are likely to have undiagnosed type 2 diabetes during pregnancy
Glucose levels are measured every two - four hours

17. active phase
Glucose levels are measured every one - two hours during the active phase
every hour if insulin is being infused

18. Rarely develop intrapartum hyperglycemia
Women with GDM who have maintained euglycemia antenatally on diet, lifestyle, and/or medical therapy
Blood glucose levels can be measured :
On admission and
Every four - six hours
Monitoring frequency can be decreased in women with glucose values consistently within the target range
Rarely develop intrapartum hyperglycemia

19. overt hypoglycemia (<50 mg/dL) or hyperglycemia (>180mg/dL )detected in capillary blood should be treated promptly

20. Guidelines for insulin management
 Well-designed, sufficiently powered, RCT ,on intrapartum insulin management do not exist to guide recommendations for an optimal approach
Available evidence is largely retrospective or derived from groups of women with type 1, type 2, and GDM treated with the same protocol
Management must be individualized, considering the woman’s medical regimen prior to labor
The clinician must be experienced in euglycemic medical management to adjust regimens, which should be considered guidelines, not absolute protocols

21. Subcutaneous insulin regimen
For women with pregestational diabetes using multiple daily insulin injections for control of blood glucose, the author prefers to use a subcutaneous insulin regimen for glucose control during labor
Euglycemia is maintained by giving one unit of SC insulin for each 20 mg/dL increase in glucose above 120 mg/dL

22. Intrapartum glycemic management of women with type 1 and type 2 diabetes

23. Maternal plasma glucose mg/dL
Glucose management using SC rapid-acting insulin (units)*
Intravenous solution and comments
≤120
5% dextrose in 0.45% NSΔ
121 to 140
1.0
141 to 160
2.0
0.45% NSΔ
161 to 180
3.0
Check ketones
181 to 200*
4.0
≥200
4.0 units - SC plus a short acting or regular insulin by IV push starting at 2 units
Check ketones and intensive monitoring
Check glucose every two hours in patients receiving insulin SC

24. It decreases the need for insulin infusion
rotating fluids
A strategy of "rotating fluids" has been used in women with GDM
This approach should not be used in women with DM1 or DM 2 diabetes with limited insulin secretion as they may develop ketoacidosis
It decreases the need for insulin infusion

25. "Rotating fluids" For use in women with gestational diabetes

26. Maternal plasma glucose Intravenous insulin (units/hour)
Intravenous solution
≤100 mg/dL
Hold
D5NS at 125 mL/hour to achieve CBG of mg/dL
mg/dL
Lacted Ringers or NS at 125 mL/hour to achieve CBG of 100 mg/dL
>140 mg/dL
Short- or rapid-acting insulin infusion titrated to achieve CBG of mg/dL

27. Intravenous insulin infusion regimen
For women with pregestational diabetes using multiple daily insulin injections for control of blood glucose, infusion of intravenous insulin to maintain euglycemia during labor is a reasonable alternative to subcutaneous insulin
This approach has been associated with low maternal and neonatal complication rates in women with type 1 DM ,and can be used for women with type 2 or GDM requiring insulin
Insulin is held as long as the glucose level is ≤120 mg/dl
Above this level, insulin infusion (units/hour) is begun
Blood glucose are measured hourly during insulin infusion

28. Maternal plasma glucose mg/dL
Alternative approach to glucose management using IV regular
insulin(units/h)
Intravenous solution and comments
≤120
5% dextrose in 0.45% NSΔ
121 to 140
1.0
141 to 160
2.0
0.45% NSΔ
161 to 180
3.0
Check ketones
181 to 200*
4.0
≥200
4.0 units/h - IV plus a short acting or regular insulin IV push starting at 2 units
Check ketones and intensive monitoring

29. SPECIAL SITUATIONS
Cesarean delivery 

30. cesarean delivery 
When cesarean delivery is planned, especially in a woman with type 1 DM, the procedure should be scheduled Early in the morning

31. cesarean delivery 
A patient on insulin therapy should maintain her usual night time dose of:
Intermediate-acting insulin
Short- or rapid-acting insulin
Oral anti-diabetic medication until admission to the hospital
If she uses a long-acting insulin at night (detemir or glargine):
The dose is decreased 50% or
Switched to NPH insulin ( one-third of the long- acting nightly dose is given)

32. cesarean delivery 5 % dextrose infusion in order to avoid ketosis
The morning dose of insulin or oral anti- diabetic agent is held and the patient is given nothing by mouth
In women with type 1 or type 2 diabetes, if surgery occurs later in the day, basal insulin (about one-third of the morning dose of intermediate- or long-acting insulin) is given with
5 % dextrose infusion in order to avoid ketosis

33. cesarean delivery 
Glucose levels should be monitored frequently, every one - three hours
Glucose levels should be monitored with
more frequent measurements in:
1. Type 1 diabetes
2. If glucose levels are not in the target range

34. For intravenous pre hydration before operative anesthesia
NS is used rather than a dextrose solution to avoid administering a large glucose bolus, which reduces umbilical cord pH and can cause neonatal hypoglycemia

35. Glucose levels should be monitored during the cesarean delivery if the operation lasts over an hour
Hyperglycemia during surgery should be avoided to minimize the risk of:
Neonatal hypoglycemia
Maternal wound infection
Metabolic complications

36. Induction of labor 

37. Ideally, induction is scheduled for early morning
The patient should maintain her usual nighttime dose :
Intermediate-acting insulin
Short- or rapid-acting insulin
Oral anti-hyperglycemic medication
on the night before induction
If she uses a long-acting insulin at night
1. The dose needs to be decreased by 50 %
2. or switched to NPH insulin (one-third of the long-acting nightly dose)

38. The morning of induction
1. woman to eat a light breakfast (half of her usual breakfast intake) and
2. Reduce her insulin dose (NPH and short- or rapid-acting insulin) by 50 %

39. POSTPARTUM MANAGEMENT

40. Immediate postpartum period
 After delivery of the placenta
 The insulin resistant state that characterizes pregnancy ,
Insulin resistant Rapidly dissipates and Insulin requirements drop precipitously
Glucose targets can be relaxed to avoid hypoglycemia from over treatment 

41. Type 1 diabetes
Have markedly reduced insulin requirements for the first hours after delivery
Postoperative patients should receive a % dextrose (0.45 normal saline [NS]) solution until adequate oral intake is resumed

42. Glucose levels should be checked every four -six hours
Hyperglycemia treated with insulin prescribed using sliding scales
Insulin sensitivity increases with delivery
of the placenta
Insulin sensitivity returns to prepregnancy levels over the following 1–2weeks

43. Sliding insulin scale for postpartum management of glucose levels

44. All women with diabetes regardless of classification
Glucose (mg/dL)
All women with diabetes regardless of classification
<50
Give 25 mL of D 50% IV push x 1
Recheck BG in 15 minutes:
a. If repeat BG <50 mg/dL repeat step 1 & 2
b. If repeat BG is 50 to 69 mg/dL  go to next level below
50 -69
No insulin; if alert and tolerating oral fluids, give 4 oz juice; if unable to tolerate fluids, give 25 mL of D 50% IV push x 1
Recheck BG in 15 minutes
a. If repeat BG is <50 mg/dL : Follow step above for BG <50 mg/dL
b. If repeat BG is mg/dL :Repeat 1 above
c. If repeat BG is 70 to 100 mg/dL , follow step below for mg/dL
3.Reevaluate insulin dosage
No insulin; if this was bedtime BG, recheck CBG at 3:00 AM
Give snack if eating (half of a sandwich, three crackers, or 4 oz milk)
If NPO, increase rate of D5 solution, recheck BG in two hours
Reevaluate insulin dosage
oz =اونس= 31 گرم

45. All women with diabetes regardless of classification
Glucose (mg/dL)
Low dose (pre-pregnancy BMI<25; T1DM)
AC (before meal) or NPO
HS(hour of sleep)
100 to 150
No insulin
151 to 200
1 unit
201 to 250
2 units
251 to 300
3 units
301 to 350
4 units
351 to 400
5 units

46. After about hours
Standard diabetes management can be resumed with calculated total daily dose of insulin at:
units/kg postpartum weight or
2. About 50 %of the insulin dose prior to delivery
Marked hyperglycemia (eg, random glucose ≥180mg/dL ) should be avoided as hyperglycemia is associated with an increased risk of postoperative infection

47. Vaginal delivery
Women delivering vaginally generally resume normal oral intake after delivery
They can be restarted on their multiple daily dosing regimen but require :
One-third to one-half of their predelivery long-acting or intermediate-acting insulin dose
One-half to two-thirds of their predelivery short- or rapid-acting insulin premeal doses

48. The goal is to maintain relaxed glucose levels and avoid hypoglycemia
For most patients, reasonable glycemic targets while hospitalized postpartum are :
premeal glucose concentrations <140 mg/dL and
Random glucose concentrations <180 mg/dL

49. Type 2 diabetes
Glucose levels tend to be normal or modestly elevated in postpartum women with type 2 diabetes
Fasting, pre- and post-prandial glucose levels should be measured
Hyperglycemia is treated with insulin prescribed using a sliding scale

50. All women with diabetes regardless of classification
Glucose (mg/dL)
Intermediate dose (pre-pregnancy BMI 25 to 35, T2DM)
AC (before meal) or NPO
HS(hour of sleep)
100 to 150
No insulin
151 to 200
2 unit
201 to 250
4 units
1 unit
251 to 300
6 units
301 to 350
8 units
351 to 400
10 units

51. All women with diabetes regardless of classification
Glucose (mg/dL)
High dose (pre-pregnancy BMI >35, T2DM)
AC (before meal) or NPO
HS(hour of sleep)
100 to 150
No insulin
151 to 200
4 unit
2 unit
201 to 250
8 units
251 to 300
12 units
6 unit
301 to 350
16 units
351 to 400
20 units
10 units

52. Type 2 diabetes
After 24 to 48 hours, the effects of pregnancy on glucose and endogenous insulin levels dissipate and standard diabetes management with diet and pharmacologic therapy should be resumed, as needed
Metformin is the preferred first-line oral agent for type 2 diabetic patients and does not produce hypoglycemia
Intermediate-acting insulin in the AM and PM may also be needed
Early follow-up contact at two weeks postpartum to assess glucose control and insulin dose is helpful to adjust to the changing metabolic milieu during the puerperium
Puerperium=دوره نفاس

53. Gestational diabetes
Women with GDM should have fasting glucose levels monitored for hours after delivery to check for overt diabetes (fasting glucose >126 mg/dL)
Unless overt diabetes is diagnosed postpartum, women with prior GDM should be screened or tested for diabetes weeks after delivery to establish glucose status

54. Breast feeding

55. Breast feeding
Breastfeeding requires an additional kcal per day, which can be consumed :
100 g of carbohydrate and
20 g of protein
Blood glucose levels can drop rapidly during nursing due to the high metabolic demand

56. There is minimal information on milk levels and infant effects of many anti- hyperglycemic agents
Insulin, glyburide, and metformin enter milk in small amounts that are unlikely to cause hypoglycemia
The infant should be observed for signs of low glucose levels if the mother is taking these drugs

57. Postpartum Follow-up

58. The OGTT is recommended over A1C at
the time of the 4- to 12-week postpartum
visit because A1C may be persistently
impacted (lowered) by the:
1. Increased red blood cell turnover related to pregnancy or
2. blood loss at delivery
The OGTT is more sensitive at detecting glucose intolerance, including both pre- diabetes and diabetes

59. Because GDM is associated with increased maternal risk for diabetes:
women should also be tested every
1–3 years thereafter if the week
75 g OGTT is normal
Frequency of testing depending on other risk factors including:
Family history
Prepregnancy BMI
Need for insulin or oral glucose lowering
medication during pregnancy

60. Ongoing evaluation may be performed
with any recommended glycemic test:
Hemoglobin A1C
Fasting plasma glucose
75-g OGTT using non-pregnant thresholds
Ongoing= در دست اقدام