Pregestational and gestational diabetes

2. Pregestational and gestational diabetes دکتر عادله بهار فوق تخصص غدد درون ریز و متابولیسم دانشگاه علوم پزشکی مازندران مرکز تحقیقات دیابت 95.12.5 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 minimalduring 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. Maternal energy demands can usually be met over the short-term by metabolism of stored hepatic glucose • 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

6. Women with Type 2 and GDM • 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 insulinto 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 2.5 mg/kg/min to maintain maternal glucose concentration at 70 - 90 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 5 % 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 140 - 180 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. 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 euglycemiaantenatally 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

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/dLincrease in glucose above 120 mg/dL

22. Intrapartumglycemic management of women with type 1 and type 2 diabetes

23. Check glucose every two hours in patients receiving insulin SC

24. 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

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

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  • 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 24 - 48 hours after delivery • Postoperative patients should receive a 5 % 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

45. All women with diabetes regardless of classification

46. After about 24 - 48 hours • Standard diabetes management can be resumed with calculated total daily dose of insulin at: 1. 0.6 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 predeliverylong-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/dLand • 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