Peripartum Management of Glycemia in Women With Type 1 Diabetes

Abstract

OBJECTIVEWe aimed to 1) describe the peripartum management of type 1 diabetes at an Australian teaching hospital and 2) discuss factors influencing the apparent transient insulin independence postpartum. RESEARCH DESIGN AND METHODSWe conducted a retrospective review of women with type 1 diabetes delivering singleton pregnancies from 2005 to 2010. Information was collected regarding demographics, medical history, peripartum management and outcome, and breast-feeding. To detect a difference in time to first postpartum blood glucose level (BGL) >8 mmol/L between women with an early (,4 h) and late (>12 h) requirement for insulin postpartum, with a power of 80% and a type 1 error of 0.05, at least 24 patients were required. RESULTSAn intravenous insulin infusion was commenced in almost 95% of women. Univariate analysis showed that increased BMI at term, lower creatinine at term, longer duration from last dose of long-or intermediate-acting insulin, and discontinuation of an insulin infusion postpartum were associated with a shorter time to first requirement of insulin postpartum (P = 0.005, 0.026, 0.026, and <0.001, respectively). There was a correlation between higher doses of insulin commenced postpartum and number of out-of-range BGLs (r[36] = 0.358, P = 0.030) and hypoglycemia (r[36] = 0.434, P = 0.007). Almost 60% had at least one BGL <3.5 mmol/L between delivery and discharge. CONCLUSIONSChanges in the pharmacodynamic profile of insulin may contribute to the transient insulin independence sometimes observed postpartum in type 1 diabetes. A dose of 50-60% of the prepregnancy insulin requirement resulted in the lowest rate of hypoglycemia and glucose excursions. These results require validation in a larger, prospective study.

Diabetes and Pregnancy

“…Diabetes management and insulin sensitivity immediately postpartum. In women with type 1 and type 2 diabetes, insulin requirements decrease rapidly immediately after the delivery of the placenta (175)(176)(177). This rapid increase in insulin sensitivity is related to the drop in circulating placental hormones (hPL, HGH) and, as a result, intravenous insulin infusion or CSII basal insulin should be immediately decreased by at least 50% after delivery to avoid hypoglycemia (175,178).…”

“…In the first days postpartum, insulin requirements are generally reduced by an average of 30% to 50% of the prepregnant insulin dosage in women with type 1 diabetes (175)(176)(177). In a recent study of 44 women with type 1 diabetes (73% on pumps, 27% on MDI), postpartum total daily insulin was 34% lower than preconception total needs (0.64 to 0.39 units/kg/day postpartum) independent of insulin administration mode or infant feeding.…”

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

“…24,25 In several studies maternal hypoglycaemia was a recognised complication when trying to keep CBG at 4-7 mmol/L. [26][27][28][29][30] In our group two women (22.2%) who used VRIII developed hypoglycaemia with CBG <4 mmol/L compared with none in those who did not require VRIII (p<0.02). This was appropriately treated.…”

Post-partum hypoglycaemia in lactating women with type 1 diabetes: a pilot study using continuous glucose monitoring

“…Unfortunately, little evidence is available on which to base advice on insulin dosage for these patients. [3][4][5][6][7] Unsurprisingly, qualitative evidence suggests that many women with type 1 diabetes find post-partum selfmanagement to be challenging, to which fear of hypoglycaemia may contribute. 8,9 The aim of the present study was to monitor glycaemic control in women with type 1 diabetes for 4 weeks post-partum, with a particular focus on the frequency of hypoglycaemia.…”

“…1 Strict glycaemic control after childbirth results in normal breast milk composition, but this may increase the risk of hypoglycaemia and this approach is often not emphasised in practice. [1][2][3] Barriers to optimal self-management include a fall in insulin requirement following delivery, maintenance of a regular diet and the need for frequent home blood glucose monitoring (HBGM) while caring for a neonate. Unfortunately, little evidence is available on which to base advice on insulin dosage for these patients.…”