Continuous infusion of both insulin and glucose has
been proven valuable to control maternal glucose
levels during labor and delivery.
In patients with well-controlled diabetes who are
scheduled for induction of labor or elective
cesarean delivery the usual dose of insulin is given at bedtime; and morning insulin is withheld in patients with
less than 20 U. Insulin can be discharged.
In Denmark we prefer to give the patient normal diet and insulin until she is in a state of induction and then keep fasting with iv. Glucose 60 ml/h and insulin on sliding scale every 4 hour as shown below. If Caesarean section 1/2 to 1/3 of morning insulin as insulin retard and then iv. glucose and sliding scale as above.
One unit of insulin decrease the glucose level by ~ 1 mmol/l.
The dose of insulin and the fluids:
Blood glucose (Mm/l) |
Insulin Dosage (u/hr) |
Fluids 125/hr |
5,5 |
0 |
Dextrose/Lactated Ringer |
5,5-7-7 |
1 |
Dextrose/Lactated Ringer |
7,8-10 |
1,5 |
Normal saline |
10-12 |
2 |
Normal saline |
>12 |
2,5 |
Normal saline |
Continuous electronic fetal heart rate monitoring
Avoid Foley catheter, if possible.
Postpartum Aspects * IV Maintenance
Continue intrapartum intravenous solution until next scheduled meal and other reason to maintain IV line (stopping IV without providing other carbohydrates source may result in hypoglycemia).
* Insulin
- Up to 80% of diabetics newly diagnosed in pregnancy will not need insulin postpartum. Many insulin dependent diabetics will have markedly reduced requirements after delivery.
- One-half of pre-pregnant long action insulin dose only when one can be certain patient is eating diet.
- When using the sliding scale - only give 5 - 10 units for 4+ urine glucose; no insulin for 3+ urine glucose. Unless acetone, then 5 - 10 units.
- Adjust until desired blood glucose control. a.FBS< 7 mmo/L b.2 hr PPBS in 8-11 mmol/L range
- Regular diet postpartum unless elevated plasma
glucose. For obese women, low caloric weight
reduction diets are initiated at 2 weeks postpartum
if not lactating.
- On at least 50% give 1/3 insulin as before delivery and after 1-3 month the insulin requirement is as before pregnancy. Keep the BS between 5-10 mmol fasting as well as before or after meals.
If Give antropid
BS > 12 2 IE
BS > 14 4 IE
BS > 16 6 IE
BS > 18 8 IE
BS > 20 10 IE
Breastfeeding is not contraindicated. Lactating women-add 200 kcal/day to antepartum calorie level.
- If not breastfeeding, decreases antepartum diet by 300
kcal/day. Further modification of calories for attaining
and/or maintaining desirable body weight is made at 2
weeks.
- Schedule FBS to do a formal GTT at postpartum check-up
(8 weeks)
VALUES FOR POSTPARTUM 75 G GLUCOSE TOLERANCE TEST
. |
Diabetes Mellitus |
Impaired Gluc. Tolerance (IGT) |
Impaired Fasting Glycaemia (IFG) |
Fasting plasma glucose (FPG) |
>6,9 mmol/L (126 mg/dL) |
>6,9 mmol/L (126 mg/dL) |
>6.0 mmol/L (110 mg/dL) |
|
or |
and |
<7.0mmol/L (126 mg/dL) |
2-hour 75 g value |
>11.1 mmol/L (200mg/dL) |
>7.8mmol/L (140 mg/dL) <11.1 mmol/L (200 mg/dL) |
>7.7mmol/L (140 mg/dL) |
Adapted from WHO Consultation: Definition, diagnosis and classification of diabetes mellitus and its complications
Remember Preconceptional Counseling
Annual fasting blood glucose postnatally to look for onset of NIDDM as 40 % develop NIDDM within 7 years and up to 60 % within 15 years and 10-30% would have established eye and/or renal disease at that time. Modification of lifestyle and diet may prevent or delay NIDDM.
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