Pregestational and gestational diabetes: Intrapartum and postpartum glycemic control
- Siri L Kjos, MD
Siri L Kjos, MD
- Director of Perinatalogy
- WellHealth Quality Care
- Section Editors
- Michael F Greene, MD
Michael F Greene, MD
- Section Editor — Diabetes in Pregnancy
- Professor of Obstetrics and Gynecology
- Harvard Medical School
- David M Nathan, MD
David M Nathan, MD
- Editor-in-Chief — Endocrinology
- Section Editor — Diabetes Mellitus
- Professor of Medicine
- Harvard Medical School
In pregnancies complicated by diabetes mellitus, a key therapeutic goal across gestation is avoidance of maternal hyperglycemia, which increases the risk of several pregnancy-specific adverse events. (See "Pregestational diabetes: Preconception counseling, evaluation, and management".)
Good glycemic control remains important intrapartum because maternal hyperglycemia during labor increases the risk of fetal acidemia and neonatal hypoglycemia . Avoidance of hyperglycemia is less critical postpartum, but concern about maternal hypoglycemia increases because of large, rapid changes in maternal hormone concentrations after delivery of the placenta.
It should be noted that intrapartum maternal normoglycemia will not reduce the risk of neonatal hypoglycemia in women with poor antepartum glycemic control, since fetal pancreatic hyperplasia and excessive in utero insulin secretion have been established in response to prolonged exposure to hyperglycemia. These neonates are at risk of developing severe and prolonged hypoglycemia. (See "Pathogenesis, screening, and diagnosis of neonatal hypoglycemia", section on 'Increased glucose utilization'.)
This topic will discuss intrapartum and postpartum glycemic control of women with pregestational and gestational diabetes. Other important issues in the management of these women are reviewed separately:
- Mimouni F, Miodovnik M, Siddiqi TA, et al. Perinatal asphyxia in infants of insulin-dependent diabetic mothers. J Pediatr 1988; 113:345.
- 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.
- 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.
- 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.
- Jovanovic L, Peterson CM. Management of the pregnant, insulin-dependent diabetic woman. Diabetes Care 1980; 3:63.
- 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.
- 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.
- Blumer I, Hadar E, Hadden DR, et al. Diabetes and pregnancy: an endocrine society clinical practice guideline. J Clin Endocrinol Metab 2013; 98:4227.
- 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.
- 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.
- Taylor R, Lee C, Kyne-Grzebalski D, et al. Clinical outcomes of pregnancy in women with type 1 diabetes(1). Obstet Gynecol 2002; 99:537.
- Madsen H, Ditzel J. Changes in red blood cell oxygen transport in diabetic pregnancy. Am J Obstet Gynecol 1982; 143:421.
- American Diabetes Association. Standards of medical care in diabetes--2014. Diabetes Care 2014; 37 Suppl 1:S14.
- 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.
- Coustan DR. Delivery: Timing, mode, and management. In: Diabetes in women: adolescent, pregnancy and menopause, Reese EA, Coustan DR, Gabbe SG. (Eds), Lippincott Williams & Wilkins, 2004.
- Kitzmiller JL, Gavin L. Preexisting diabetes and pregnancy. In: Manual of Endocrinology and Metabolism, Lavin N. (Ed), Lippincott Williams & Wilkins, 2002.
- 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.
- 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.
- 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.
- Fresa R, Visalli N, Di Blasi V, et al. Experiences of continuous subcutaneous insulin infusion in pregnant women with type 1 diabetes during delivery from four Italian centers: a retrospective observational study. Diabetes Technol Ther 2013; 15:328.
- Grylack LJ, Chu SS, Scanlon JW. Use of intravenous fluids before cesarean section: effects on perinatal glucose, insulin, and sodium homeostasis. Obstet Gynecol 1984; 63:654.
- Kenepp NB, Kumar S, Shelley WC, et al. Fetal and neonatal hazards of maternal hydration with 5% dextrose before caesarean section. Lancet 1982; 1:1150.
- Ramos M, Khalpey Z, Lipsitz S, et al. Relationship of perioperative hyperglycemia and postoperative infections in patients who undergo general and vascular surgery. Ann Surg 2008; 248:585.
- Hanazaki K, Maeda H, Okabayashi T. Relationship between perioperative glycemic control and postoperative infections. World J Gastroenterol 2009; 15:4122.
- INTRAPARTUM ISSUES
- Intrapartum glucose and insulin requirements
- Glucose targets and monitoring
- - Intrapartum glucose targets
- - Intrapartum glucose monitoring
- Guidelines for insulin management
- - Subcutaneous insulin regimen
- - Intravenous insulin infusion regimen
- - Women on a continuous subcutaneous insulin infusion (CSII) antepartum
- SPECIAL SITUATIONS
- Scheduled cesarean delivery
- Induction of labor
- POSTPARTUM MANAGEMENT
- Immediate postpartum period
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS