Glucose control during labour in diabetic women

Division of Endocrinology and Metabolism, Department of Medicine, University of Alberta, Edmonton AB.
Journal of obstetrics and gynaecology Canada: JOGC = Journal d'obstetrique et gynecologie du Canada: JOGC 12/2012; 34(12):1149-57.
Source: PubMed


Glucose control during labour is important for mother and neonate, with high rates of neonatal hypoglycemia reported in offspring of women with pre-existing or gestational diabetes (48% and 19%, respectively). How glucose control can be achieved is rarely specified. We conducted a chart review of a standardized approach using an iterative intravenous insulin-glucose infusion.

We performed a retrospective review of the records of 274 diabetic women during labour. Fifty-five women had type 1 diabetes, 55 had type 2 diabetes, and 164 had gestational diabetes (GDM). The protocol used hourly capillary blood glucose determinations, each prompting changes in insulin-glucose infusion rates as required. Outcomes included maternal blood glucose levels three hours before delivery and neonatal hypoglycemia (blood glucose < 2 mmol/L).

The insulin-glucose infusion was used in 47% of women with type 1, type 2, and gestational diabetes requiring ≥ 0.5 units/kg/day of insulin during pregnancy and in 8% of women with GDM treated by diet or < 0.5 units/kg/day of insulin. The overall rate of maternal hypoglycemia was low (6.6% with blood glucose ≤ 3.5 mmol/L and 1.5% ≤ 3.0 mmol/L) pre-delivery; 13.9% of women had a blood glucose level ≥ 7.0 mmol/L. The neonatal hypoglycemia rate was 7.3% (4.9% in the offspring of women with GDM and 10.9% in the offspring of women with pre-existing diabetes). In women with type 1 and type 2 diabetes and high-dose insulin-requiring GDM, the rate of blood glucose values outside the range of 3.6 to 6.9 mmol/L was lower in those using the intravenous protocol (16.7%) than in those not using it (34.8%), but this reduction was not statistically significant.

Standardized management for diabetic women in labour using an intravenous insulin-glucose protocol was effective in achieving stable maternal blood glucose levels with low rates of neonatal hypoglycemia.

14 Reads
  • [Show abstract] [Hide abstract]
    ABSTRACT: Aims: To explore whether real-time continuous glucose monitoring during labour and delivery supplementary to hourly self-monitored plasma glucose in women with Type 1 diabetes reduces the prevalence of neonatal hypoglycaemia. Methods: Women with Type 1 diabetes participating in a randomized controlled trial on the effect of real-time continuous glucose monitoring in pregnancy were included in this study. Twenty-seven of 60 (45%) women in the intervention arm used real-time continuous glucose monitoring during labour and delivery, supplementary to hourly self-monitored plasma glucose. Real-time continuous glucose monitoring glucose data covering the last 8 h prior to delivery were retrospectively evaluated, and maternal hypo- and hyperglycaemia were defined as glucose values ≤ 3.9 mmol/l and > 7.0 mmol/l, respectively. Women in the control arm (n = 59) solely used self-monitored plasma glucose. Neonatal hypoglycaemia was defined as a 2-h plasma glucose < 2.5 mmol/l. Results: In infants of women using real-time continuous glucose monitoring during labour and delivery, 10 (37%) developed neonatal hypoglycaemia vs. 27 (46%) infants in the control arm (P = 0.45). Among 10 infants with and 17 infants without neonatal hypoglycaemia within the real-time continuous glucose monitoring arm, median maternal self-monitored plasma glucose was 6.2 (range 4.2-7.8) vs. 5.6 (3.3-8.5) mmol/l (P = 0.26) during labour and delivery, with maternal hyperglycaemia present in 17 (0-94) vs. 4 (0-46)% of the time (P = 0.02), and birthweight was 4040 (3102-4322) vs. 3500 (1829-4320) g (P = 0.04). Maternal hypoglycaemia up to delivery was relatively rare. Conclusions: The prevalence of neonatal hypoglycaemia was comparable between infants of women using real-time continuous glucose monitoring supplementary to self-monitored plasma glucose during labour and delivery and infants of women solely using self-monitored plasma glucose.
    Diabetic Medicine 06/2013; 30(11). DOI:10.1111/dme.12246 · 3.12 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: The prevalence of type 2 diabetes mellitus and the potential for perioperative dysglycaemia (hyperglycaemia, hypoglycaemia, stress-induced hyperglycaemia, or glucose variability) continue to increase dramatically. The majority of investigations on perioperative glycaemic control focused on critically ill patients and concentrated on goals of therapy, level of intensity of insulin infusion, feeding regimes, concerns over hypoglycaemia, and promulgation of recent guidelines calling for less strict glucose control. Areas of perioperative glycaemic control that deserve further investigation include preoperative identification of patients with undiagnosed type 2 diabetes and other forms of dysglycaemia, determination of appropriate intraoperative glucose goals, and establishment of the impact and natural history of perioperative abnormalities in glucose homeostasis. In the heterogeneous adult perioperative population, it is unlikely that one standard of perioperative glycaemic control is appropriate for all patients. This review presents recent evidence and expert guidance to aid preoperative assessment, intraoperative management, and postoperative care of the dysglycaemic adult patient. © 2013 © The Author [2013]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: [email protected] /* */
    BJA British Journal of Anaesthesia 12/2013; 111 Suppl 1(suppl 1):i18-i34. DOI:10.1093/bja/aet381 · 4.85 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Neonatal hypoglycemia is an important consequence for the infant of the mother with diabetes. We have reviewed 24 published papers of various protocols for control of glucose in pregnant diabetic women during labor and delivery including our own published work. A relationship of maternal glucose during labor and neonatal hypoglycemia was sought in 19 of these studies. A significant inverse relationship was found in 10 reports with 3 others showing a similar trend. In all but 1 of these 13 studies the participants had pregestational diabetes. Three of the 6 studies not reporting an inverse relationship involved women with GDM. From this review it appears that the maternal glucose should be maintained between 4.0 and 6.0-7.0 mmol/L during labor. Most women with gestational diabetes, especially if they require <1.0 units/kg/d of insulin, can simply be monitored without intravenous insulin. Our own results demonstrate that a target glucose of 4.0-6.0 mmol/L can be used safely and results in a low rate of neonatal hypoglycemia using an iterative glucose insulin infusion protocol for women with pregestational diabetes and when needed for women with gestational diabetes.
    Current Diabetes Reports 01/2014; 14(1):450. DOI:10.1007/s11892-013-0450-4 · 3.08 Impact Factor