Managing hyperglycaemia during antenatal steroid administration, labour and birth in pregnant women with diabetes

Abstract

Optimal glycaemic control before and during pregnancy improves both maternal and fetal outcomes. This article summarizes the recently published guidelines on the management of glycaemic control in pregnant women with diabetes on obstetric wards and delivery units produced by the Joint British Diabetes Societies for Inpatient Care and available in full at www.diabetes.org.uk/joint-british-diabetes-society and https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group. Hyperglycaemia following steroid administration can be managed by variable rate intravenous insulin infusion (VRIII) or continuous subcutaneous insulin infusion (CSII) in women who are willing and able to safely self-manage insulin dose adjustment. All women with diabetes should have capillary blood glucose (CBG) measured hourly once they are in established labour. Those who are found to be higher than 7 mmol/l on two consecutive occasions should be started on VRIII. If general anaesthesia is used, CBG should be monitored every 30 min in the theatre. Both the VRIII and CSII rate should be reduced by at least 50% once the placenta is delivered. The insulin dose needed after delivery in insulin-treated Type 2 and Type 1 diabetes is usually 25% less than the doses needed at the end of first trimester. Additional snacks may be needed after delivery especially if breastfeeding. Stop all anti-diabetes medications after delivery in gestational diabetes. Continue to monitor CBG before and 1 h after meals for up to 24 h after delivery to pick up any pre-existing diabetes or new-onset diabetes in pregnancy. Women with Type 2 diabetes on oral treatment can continue to take metformin after birth.

Maternal glycaemic control and risk of neonatal hypoglycaemia in Type 1 diabetes pregnancy: a secondary analysis of the CONCEPTT trial

“…Theoretically, limiting maternal intrapartum hyperglycaemia reduces the risk of neonatal hypoglycaemia by preventing an acute rise in fetal insulin secretion before birth. The Joint British Diabetes Societies, National Institute for Health and Clinical Excellence and Canadian guidelines recommend tight intrapartum glucose targets (4.0–7.0 mmol/l) during labour and delivery . However, there are insufficient high quality data confirming an association between maternal intrapartum glucose control and neonatal hypoglycaemia.…”

Severe neonatal hypoglycaemia and intrapartum glycaemic control in pregnancies complicated by type 1, type 2 and gestational diabetes

“…Current guidelines recommend intensive intrapartum glycaemic control (4.0–7.0 mmol/l) to decrease the risk of neonatal hypoglycaemia by preventing a rise in foetal insulin in the hours prior to delivery . Tight glycaemic control is generally achieved through use of insulin therapy, administered subcutaneously or intravenously.…”

National guidelines have contributed to safer care for inpatients with diabetes

“…We do not believe that there is any convincing argument to change the target capillary blood glucose levels of 4.0-7.0 mmol/l for obstetric inpatients receiving steroids or during labour [4,5]. This has clinical support in the UK and is broadly in line with global opinion and current UK practice.…”

“…National Institute for Health and Care Excellence (NICE) guidance (2015) on the puerperal management of diabetes [4] is not a 'belief' but is based on evidence from some observational studies that a target capillary blood glucose of 4.0-7.0 mmol/l during labour may be associated with a lower incidence of neonatal hypoglycaemia. The NaDIA hypoglycaemia data are not relevant to peripartum women with diabetes [5] because obstetric data are not included in NaDIA [2]. Levy et al [1] state that in all studies cited by NICE supporting the range 4.0-7.0 mmol/l, maternal Correspondence to: Umesh Dashora.…”

“…We believe individualization of these targets is required based on clinical setting, frailty and comorbidity. We do not believe that there is any convincing argument to change the target capillary blood glucose levels of 4.0-7.0 mmol/l for obstetric inpatients receiving steroids or during labour [4,5]. An important early step in any population-based improvement strategy is to develop a consistency of approach, and to audit outcomes against this approach [12].…”