Management of Diabetes in the Intrapartum and Postpartum Patient

Abstract

Achieving maternal euglycemia in women with pregestational and gestational diabetes mellitus is critical to decreasing the risk of neonatal hypoglycemia, as maternal blood glucose levels around the time of delivery are directly related to the risk of hypoglycemia in the neonate. Many institutions use continuous insulin and glucose infusions during the intrapartum period, although practices are widely variable. At Northwestern Memorial Hospital, the “Management of the Perinatal Patient with Diabetes” policy and protocol was developed to improve consistency of management while also allowing individualization appropriate for the patient's specific diabetic needs. This protocol introduced standardized algorithms based on maternal insulin requirements to drive real-time maternal glucose control during labor as well as provided guidelines for postpartum glycemic control. This manuscript describes the development and implementation of this protocol to encourage other institutions to adopt a standardized protocol that allows highly individualized intrapartum care to women with diabetes.

Keywords

diabetes - intrapartum - postpartum - neonatal hypoglycemia

• References

• 1 ACOG Committee on Practice Bulletins. ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists. Number 60, March 2005. Pregestational diabetes mellitus. Obstet Gynecol 2005; 105 (03) 675-685
• 2 Shand AW, Bell JC, McElduff A, Morris J, Roberts CL. Outcomes of pregnancies in women with pre-gestational diabetes mellitus and gestational diabetes mellitus; a population-based study in New South Wales, Australia, 1998-2002. Diabet Med 2008; 25 (06) 708-715
• 3 Crowther CA, Hiller JE, Moss JR, McPhee AJ, Jeffries WS, Robinson JS. ; Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS) Trial Group. Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. N Engl J Med 2005; 352 (24) 2477-2486
• 4 Sengupta S, Carrion V, Shelton J. , et al. Adverse neonatal outcomes associated with early-term birth. JAMA Pediatr 2013; 167 (11) 1053-1059
• 5 Burns CM, Rutherford MA, Boardman JP, Cowan FM. Patterns of cerebral injury and neurodevelopmental outcomes after symptomatic neonatal hypoglycemia. Pediatrics 2008; 122 (01) 65-74
• 6 Yamamoto JM, Benham J, Mohammad K, Donovan LE, Wood S. Intrapartum glycaemic control and neonatal hypoglycaemia in pregnancies complicated by diabetes: a systematic review. Diabet Med 2018; 35 (02) 173-183
• 7 Gabbe SG, Carpenter LB, Garrison EA. New strategies for glucose control in patients with type 1 and type 2 diabetes mellitus in pregnancy. Clin Obstet Gynecol 2007; 50 (04) 1014-1024
• 8 Rosenberg VA, Eglinton GS, Rauch ER, Skupski DW. Intrapartum maternal glycemic control in women with insulin requiring diabetes: a randomized clinical trial of rotating fluids versus insulin drip. Am J Obstet Gynecol 2006; 195 (04) 1095-1099
• 9 Coustan D. Delivery: timing, mode, and management. In: Reece EACD, Gabbe SG. , eds. Diabetes Mellitus in Women: Adolescence through Pregnancy and Menopause. 3rd ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2004
• 10 Curet LB, Izquierdo LA, Gilson GJ, Schneider JM, Perelman R, Converse J. Relative effects of antepartum and intrapartum maternal blood glucose levels on incidence of neonatal hypoglycemia. J Perinatol 1997; 17 (02) 113-115
• 11 Kitzmiller JL. , American Diabetes Association. Managing Preexisting Diabetes and Pregnancy: Technical Reviews and Consensus Recommendations for Care. Alexandria, VA: American Diabetes Association; 2008
• 12 American Diabetes Association. Standards of medical care in diabetes-2017. Diabetes Care 2017; 40 (Suppl. 01) S1-S135
• 13 Coustan DR. , American Diabetes Association. Medical Management of Pregnancy Complicated by Diabetes. 5th ed. Alexandria, VA: American Diabetes Association; 2013
• 14 Committee on Practice Bulletins—Obstetrics. Practice Bulletin No. 180: gestational diabetes mellitus. Obstet Gynecol 2017; 130 (01) e17-e37