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Intrapartum and postpartum management of insulin and blood glucose


In pregnancies complicated by diabetes mellitus, a key therapeutic goal during labor is to avoid maternal hyperglycemia, which increases the risk of fetal acidemia and neonatal hypoglycemia [1]. Glucose management postpartum is less critical, but remains a concern because of the potential for maternal hypoglycemia. Postdelivery glucose management is challenging because of the large and rapid changes in maternal hormone concentrations after delivery of the placenta.

Maternal glucose concentration in the intrapartum period is affected by the mother's type of diabetes (type 1, type 2, or gestational) and the phase of labor that she is in (latent versus active). Women with type 1 diabetes mellitus have no endogenous insulin production, whereas those with type 2 and gestational diabetes generally have sufficient basal insulin secretion to avoid diabetic ketosis. The latent phase of labor is characterized by slow cervical change over hours, but the length varies greatly. When labor is induced, the latent phase may extend beyond 24 hours. The latent phase causes minimal change in maternal metabolic demands. In contrast, active labor is a period of relatively rapid cervical dilatation with fetal descent and, ultimately, delivery of the infant. It occurs over a few hours and should be viewed as intense exercise, with increased energy expenditure and decreased insulin requirements.

In this topic review, we will assume that women with diabetes have entered labor with well-controlled glucose levels during the antecedent pregnancy. Women with poorly controlled pregestational diabetes entering labor may require larger doses of insulin. Their newborns are likely to have severe and prolonged hypoglycemia secondary to pancreatic hyperplasia and hyperinsulinemia, which are manifestations of diabetic fetopathy. Maternal normoglycemia during labor in these cases cannot prevent neonatal hypoglycemia once fetal pancreatic hyperplasia and excessive in utero insulin secretion have been established in response to a prolonged period of antenatal hyperglycemia.


Most protocols for intrapartum management of diabetes rely on a combination of glucose and insulin infusion to maintain target glucose ranges. Clinical evidence does not support one intrapartum management protocol over another. This evidence is largely retrospective and derived primarily from women with type 1 diabetes, or from groups of women with both pre- and gestational diabetes treated with the same protocol, thus not accounting for the probable differences between women with different underlying metabolic disorders. In the absence of high quality evidence from well designed randomized trials, we will present the components of intrapartum glycemic management and provide sample protocols.

Three protocols are presented (table 1); protocols 1 and 2 are recommended by the American Diabetes Association (ADA) Technical Reviews and Consensus Recommendations for Care [2]. Protocols 1 and 2 were designed for women with pregestational diabetes, but can be used in women with gestational diabetes. The third protocol ("Rotating fluids protocol") is from a randomized clinical trial demonstrating efficacy in women with primarily gestational diabetes (and a small number with type 2 diabetes), and should not be used in women with type 1 diabetes [3].


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Literature review current through: Jun 2014. | This topic last updated: Mar 4, 2014.
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  1. Mimouni F, Miodovnik M, Siddiqi TA, et al. Perinatal asphyxia in infants of insulin-dependent diabetic mothers. J Pediatr 1988; 113:345.
  2. Conway DL, Catalano PM. Management of delivery. In: Managing Preexisting Diabetes and Pregnancy. Technical Reviews and Consensus Recommendations for Care, Kitzmiller JL, Jovaniovic L, Brown F, Coustan D, Reader DM (Eds) (Eds), American Diabetes Association, Alexandria, VA 2008. p.584.
  3. 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; 195:1095.
  4. ACOG Committee on Practice Bulletins. ACOG Practice Bulletin. Clinical Management Guidelines for Obstetrician-Gynecologists. Number 60, March 2005. Pregestational diabetes mellitus. Obstet Gynecol 2005; 105:675.
  5. Garber AJ, Moghissi ES, Bransome ED Jr, et al. American College of Endocrinology position statement on inpatient diabetes and metabolic control. Endocr Pract 2004; 10 Suppl 2:4.
  6. Curet LB, Izquierdo LA, Gilson GJ, et al. Relative effects of antepartum and intrapartum maternal blood glucose levels on incidence of neonatal hypoglycemia. J Perinatol 1997; 17:113.
  7. Kline GA, Edwards A. Antepartum and intra-partum insulin management of type 1 and type 2 diabetic women: Impact on clinically significant neonatal hypoglycemia. Diabetes Res Clin Pract 2007; 77:223.
  8. Carron Brown S, Kyne-Grzebalski D, Mwangi B, Taylor R. Effect of management policy upon 120 Type 1 diabetic pregnancies: policy decisions in practice. Diabet Med 1999; 16:573.
  9. Barrett HL, Morris J, McElduff A. Watchful waiting: a management protocol for maternal glycaemia in the peripartum period. Aust N Z J Obstet Gynaecol 2009; 49:162.
  10. Jovanovic L, Peterson CM. Insulin and glucose requirements during the first stage of labor in insulin-dependent diabetic women. Am J Med 1983; 75:607.
  11. Jovanovic L. Glucose and insulin requirements during labor and delivery: the case for normoglycemia in pregnancies complicated by diabetes. Endocr Pract 2004; 10 Suppl 2:40.
  12. 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; 50:1014.
  13. Kitzmiller, JL, Gavin, L. Preexisting diabetes and pregnancy. In: Manual of Endocrinology and Metabolism, 3rd ed, Lavin, N (Ed), Lippincott Williams & Wilkins, Philadelphia 2002. p.660-665.
  14. Lepercq J, Abbou H, Agostini C, et al. A standardized protocol to achieve normoglycaemia during labour and delivery in women with type 1 diabetes. Diabetes Metab 2008; 34:33.
  15. Shrivastava VK, Garite TJ, Jenkins SM, et al. A randomized, double-blinded, controlled trial comparing parenteral normal saline with and without dextrose on the course of labor in nulliparas. Am J Obstet Gynecol 2009; 200:379.e1.
  16. American Diabetes Association. Standards of medical care in diabetes--2014. Diabetes Care 2014; 37 Suppl 1:S14.