Glucose and Insulin Requirements During Labor And Delivery: The Case for Normoglycemia in Pregnancies Complicated by Diabetes

Jovanovič, Lois

doi:10.4158/ep.10.s2.40

Cited by 65 publications

(26 citation statements)

References 21 publications

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“…However, it was clear that the exercise of a contracting uterus decreased the maternal glucose concentration. The insulin requirement during labor and delivery was decreased, whereas the glucose in fusion rate needed to be increased to 2.55mg/kg per hour; equal to the glucose need of a trained marathon runner [17].…”

Section: /2mentioning

confidence: 99%

The Quest to Conquer the Maternal Postprandial Glucose Concentration

Jovanovič¹

2018

IOD

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OpinionOnce upon a time, I had the task of analyzing the glucose diaries of 322 type 1 diabetic women who performed 8-10 self-monitored blood glucose tests a day for at least 14 days before conception and throughout pregnancy including labor and delivery and a month postpartum [1]. I always thought that maternal hyperglycemia was the villain that caused malformations and macrosomia, but there was no concrete evidence that glucose was the main culprit [2]. I spent hours poring over the data and all of a sudden the answer appeared: the highest blood glucose of the day, not the average or the pre-prandial glucose, related to macrosomia. I asked the statistician to confirm my crude observation and thus the landmark paper was published in 1991 and validated my observation [3].The twist to the results was that the highest blood glucose of the day was one hour (not two hours) after the start of the meal. This observation was contrary to the ADA's guidelines for care stated that the postprandial glucose was to be measure at the two hour postprandial time point [4]. The experts on this statement were concerned about hypoglycemia from the pre-prandially injected insulin .this group of experts defined the word postprandialas the plasma glucose concentrations after eating but stated that many factors determine the postprandial glucose profile. They reported that in non-diabetic individuals, fasting plasma glucose concentrations (i.e., following an overnight 8-to 10-h fast) generally range from 70 to 110mg/dl. Glucose concentrations begin to raise ∼10min after the start of a meal as a result of the absorption of dietary carbohydrates. They concluded that the postprandial profile is determined by carbohydrate absorption, insulin and glucagon secretion, and their coordinated effects on glucose metabolism in the liver and peripheral tissues.They also stated that the magnitude and time of the peak plasma glucose concentration depend on a variety of factors, including the timing, quantity, and composition of the meal. In non-diabetic individuals, plasma glucose concentrations peak ∼60min after the start of a meal, rarely exceed 140mg/dl, and return to preprandial levels within 2-3h. Even though glucose concentrations have returned to preprandial levels by 3h, absorption of the ingested carbohydrate continues for at least 5-6h after a meal. Because the absorption of food persists for 5-6h after a meal in both diabetic and non-diabetic individuals, they concluded that the optimal time to measure the postprandial glucose concentration is two hours after the start of a meal. Thus the highest blood glucose of the day (the one hour postprandial) would not be detected. Many times I have been told by clinicians that they have patients who had "normoglycemia" throughout pregnancy but had a macrosomic infant anyway. Obviously they did not know that their patients had postprandial hyperglycemia.The only means to maintaining the one hour postprandial glucose in the normal range (less than 120mg/dl) is to decrease the carbohydrate content of ...

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Section: /2mentioning

confidence: 99%

The Quest to Conquer the Maternal Postprandial Glucose Concentration

Jovanovič¹

2018

IOD

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“…With onset of labor pains blood sugars may increase because of increased release of cortisol and epinephrine, as the labor progresses there may be hypoglycemia and with pain relief with Neuraxial blockade significant decrease in catecholamine levels may prevent raise in blood glucose [7][8][9].…”

Section: Discussionmentioning

confidence: 99%

“…The neurogenic symptoms develop at a higher threshold {at a plasma glucose concentration of approximately 58 mg/ dL(3.2 mmol/l)} while neuroglycopenic symptoms and decline in cognitive function tests develop at significantly lower plasma glucose thresholds, approximately 51 and 49 mg/dL (2.8 and 2.7 mmol/l), respectively [3]. Hypoglycemia is treated by intravenous glucose (25g) followed by a glucose infusion guided by serial plasma glucose measurements [4].In one study by GH Movaseghi, 150 parturients were studied with Lidocaine spinal anaesthesia and serum Glucose levels showed a decrease in values compared to preoperative recordings [5].One case report by Crites J showed hypoglycaemia in a parturient with pre-existing type-2 diabetes mellitus after induction of a combined spinal-epidural (CSE) technique for labour analgesia [6].With onset of labor pains blood sugars may increase because of increased release of cortisol and epinephrine, as the labor progresses there may be hypoglycemia and with pain relief with Neuraxial blockade significant decrease in catecholamine levels may prevent raise in blood glucose [7][8][9].In our patient as she was not a known Diabetic and symptoms could have been masked by High spinal, we thought about hypoglycemia later as our primary concern was treating the effects of High spinal. …”

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Incidental Hypoglycemia with Suspected High Spinal in a Case for Emergency Caesarian

Shahid

Madhusudhana

Raichurkar

2015

JCDR

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A 25-year-old primigravida with 39 wk gestation of height 152 cms weighing 55 kgs was posted for LSCS in view of Cephalo pelvic disproportion (CPD). She was nil by mouth for 10 h. On physical examination patient was moderately built and nourished, pale with alopecia and buck tooth. Patient gives history of fever in childhood at the age of 10 y with loss of hair. Examination of respiratory, cardiovascular and central nervous system revealed no abnormalities, including Investigations (Her blood sugars were normal).After taking informed consent, Spinal anaesthesia was planned for this patient. Monitors were connected and baseline vitals recorded. Spinal anaesthesia was induced with 2ml (10 mg) hyperbaric bupivacaine 0.5% with a 25 G spinal needle in L2-L3 interspace in sitting position. A wedge was given to right buttock and 10 degree head up was given. Sensory and motor block was adequate for surgery. Within 5 min patient became drowsy not responding to oral commands associated with sweating. As the patient was not responding, high spinal was suspected. Oxygen was administered with assisted ventilation. As it was an emergency LSCS surgery was continued with 100% oxygen throughout the surgical period. Baby extracted after 9 mins cried immediately after birth. Surgery was uneventful with no intraoperative hypotension or bradycardia. Patient was still drowsy, not responding to oral commands after closure of abdomen, after 50 min of Spinal anaesthesia and the level could not be assessed. As the patient had a episode of preoperative hypoglycemia, blood glucose level was checked and it was found to be 50mg/dl. Fifty ml of 25% Dextrose was infused after which the patient started responding to oral commands. There were no further episodes of hypoglycemia postoperatively. DisCussionHigh or complete spinal block is a known complication of spinal anesthesia. Pregnant women demonstrate increased sensitivity to both regional and general anesthetics. From early stages when neuraxial anesthesia is administered, pregnant women require less local anesthetic than non-pregnant women do to reach a given dermatomal sensory level [1].As high spinal is common in parturients, when the patient became unresponsive she was managed as a case of high spinal with 100% aBstRaCt Spinal anaesthesia is a suitable choice for emergency LSCS (lower segment caesarian section). High spinal is common in parturients. We report a case of 25-year-old primigravida with cephalo pelvic disproportion coming for emergency LSCS with no comorbidities. The patient became unresponsive after 5 min of Sub Arachnoid Block (SAB), managed as a case of high spinal. Still the patient remained unresponsive at the end of surgery, 50 min after SAB. Patient started responding to oral commands after correction of hypoglycemia with 25% dextrose infusion.Keywords: Anaesthesia, High sub arachnoid block, Low blood sugars, Pregnancy oxygen supplementation with assisted ventilation. As she remained unresponsive after the end of surgery other reasons were sought for her unresponsiven...

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“…[2][3][4][5] It has been hypothesised that the last 18 hours in utero is important to prevent neonatal complications, even in women with good glycaemic control during pregnancy. 6 The National Institute for Health and Care Excellence (NICE) has suggested maintaining maternal blood glucose at 4-7 mmol/L to reduce neonatal hypoglycaemia. 1 The use of a combined insulin and glucose infusion during labour to maintain maternal blood glucose in a narrow range (4-7 mmol/L) is a common and clinically efficient practice.…”

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confidence: 99%

The feasibility and impact of implementing NICE guidance on diabetes control during delivery

et al. 2017

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Aims: The aim of this study was to report on the practicality, feasibility and impact of implementing the National Institute for Health and Care Excellence (NICE) guidelines for the control of diabetes in women during labour and birth. Methods: We analysed case records of pregnant women with diabetes who delivered in the period between July 2014 and June 2015. The data were collected in relation to the availability of a plan in the notes, capillary blood glucose (CBG) monitoring, use of variable rate intravenous insulin infusion (VRIII), maintenance of CBG targets within 4-7 mmol/L, maternal hypoglycaemia during labour and neonatal hypoglycaemia. Results: Fifty-one women with diabetes delivered during this period. Only 45% of women were monitored by complete hourly CBGs until delivery. 27.4% of women had CBG ≥7 mmol/L but only 17.6% were started on VRIII. The VRIII group had a 22.2% incidence of minor maternal hypoglycaemia. Neonatal hypoglycaemia occurred in 47% of the babies. Conclusion: A CBG target of 4-7 mmol/L during labour and initiation of VRIII when levels are above this target in pregnant women with diabetes is difficult to achieve and is associated with some maternal hypoglycaemia. Repeat CBG measurements within half an hour and strict adherence to clear guidelines and protocols supported by more education and adequate staffing may improve results.Br J Diabetes 2017;17:ONLINE AHEAD OF PUBLICATION

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Glucose and Insulin Requirements During Labor And Delivery: The Case for Normoglycemia in Pregnancies Complicated by Diabetes

Cited by 65 publications

References 21 publications

The Quest to Conquer the Maternal Postprandial Glucose Concentration

The Quest to Conquer the Maternal Postprandial Glucose Concentration

Incidental Hypoglycemia with Suspected High Spinal in a Case for Emergency Caesarian

The feasibility and impact of implementing NICE guidance on diabetes control during delivery

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