10. Diabetes

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© Springer Nature Singapore Pte Ltd. 2020
A. Sharma (ed.)Labour Room Emergencieshttps://doi.org/10.1007/978-981-10-4953-8_10



10. Diabetes



K. Aparna Sharma1   and Gunjan Rai2


(1)
Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, India

(2)
Army Hospital (R&R), New Delhi, India

 



 

K. Aparna Sharma


10.1 Definition


Historically, gestational diabetes mellitus (GDM) is defined as any degree of glucose intolerance with onset or first recognition during pregnancy [1].


Increasingly, it has been seen that diabetes in pregnancy may either be a manifestation of pregnancy-induced resistance to insulin (GDM) or may result from the unmasking of the previously undiagnosed diabetes (overt diabetes or diabetes mellitus). It is vital to distinguish between the two entities as their effects on the maternal and fetal outcomes vary considerably. Table 10.1 shows the summary of the definitions currently being used to differentiate them.


Table 10.1

Defining diabetes in pregnancy



























































 

Fasting mg/dL

1 h mg/dL

2 h (75-g OGTT) mg/dL

HbA1C

Random

ADA [2, 3]


 DM/overt diabetes (any one criteria)

>126

  

200

>6.5%

200 mg/dL with symptoms of hyperglycemia


IADPSG (GDM)

 

92 mg/dL

180

153 mg/dL

    

WHO/IADPSG [4, 5]


 DM

≥126

  

≥200

≥6.5

  

 Impaired fasting

110–126

    

6.0–6.4

  

 Impaired glucose tolerance

    

≥140

6.0–6.4

  


ADA American Diabetes Association, DM diabetes mellitus, IADPSG International Association of Diabetes in Pregnancy Study Group, WHO World Health Organization, OGTT oral glucose tolerance test 75 g glucose load


10.2 Intrapartum Issues in Women with Diabetes


Good glycemic control remains important in the intrapartum period because maternal hyperglycemia during labor increases the risk of fetal acidemia and neonatal hypoglycemia. 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.


10.2.1 Key Targets


During labor and delivery, the goal is to maintain normoglycemia, that is, blood glucose level between 70 and 126 mg/dL to prevent neonatal hypoglycemia [6, 7]. Intrapartum euglycemia is also important for preventing fetal hyperglycemia. If intrapartum hyperglycemia occurs on a background of chronically poor maternal metabolic control (high glycated hemoglobin [A1C]), this is an increased risk of fetal hypoxemia and acidosis.


10.2.2 Glucose Monitoring


The frequency of intrapartum glucose monitoring would depend on the type of diabetes and the antenatal control of blood sugar. Table 10.2 gives the overview of glucose monitoring.


Table 10.2

Frequency of intrapartum blood sugar monitoring
















Gestational diabetes on diet/medical therapy

At admission; 4–6 h

  

Type 1 diabetes


Type 2 diabetes

Latent phase


2–4 h

Active phase


1–2 h


1 h if insulin infusion


10.2.3 Intrapartum Insulin Administration


Insulin can be administered as either subcutaneous intermittent rapid-acting insulin dosages or as intravenous infusion as shown in Table 10.3.


Table 10.3

Intrapartum insulin administration protocols






























































Maternal plasma glucose mg/dL

Subcutaneous insulin (units)

Insulin infusion (units/h)

Rotating fluids protocol (only in women with GDM and not type 1 or type 2 diabetes)
     

mg/dL

Fluid

     

<100

5%DNS


<120

0

0

100–140

RL/NS


121–140

1

1


141–160

2

2

>140

RL/NS with short or rapidacting insulin infusion to achieve a blood glucose of 100 mg/dL


161–180

3

3


181–200

4

4


>200

4 plus IV regular insulin

4 plus IV regular insulin


Glucose monitoring

2 hourly

1 hourly

    

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Mar 28, 2021 | Posted by in OBSTETRICS | Comments Off on 10. Diabetes

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