Time-dependent changes in insulin requirement for maternal glycemic control during antenatal corticosteroid therapy in women with gestational diabetes: a retrospective study

Abstract

Abstract. Though recommended for pregnant women at risk of preterm birth to improve perinatal outcomes, antenatal corticosteroid (ACS) treatment can cause maternal hyperglycemia, especially in cases of glucose intolerance. A standardized protocol for preventing hyperglycemia during ACS treatment remains to be established. We herein retrospectively investigated the time-dependent changes in insulin dose required for maternal glycemic control during ACS treatment in gestational diabetes (GDM). Twelve singleton pregnant women with GDM who received 12 mg of betamethasone intramuscularly twice 24 hours apart were included in this analysis. Of those, eight also received ritodrine hydrochloride for preterm labor. The blood glucose levels were maintained at 70-120 mg/dL with continuous intravenous infusion of insulin and nothing by mouth for 48 hours after the first betamethasone administration. After the first dose of betamethasone, the insulin dosage needed for glycemic control gradually increased and reached a maximum (6.6 ± 5.8 units/hr) at 10 hours, then, decreased to 4.1 ± 1.5 units/hr at 24 hours. Similar changes in the insulin requirement were found after the second betamethasone dose (the maximum insulin dosage: 5.5 ± 1.6 units/hr at 9 hours following the second administration). Women treated with ritodrine hydrochloride needed more insulin, than those without ritodrine hydrochloride treatment (130.8 ± 15.0 vs. 76.8 ± 15.2 units/day, respectively, p < 0.05). Our data indicated that the requirement for insulin is highest 9-10 hours after each dose of betamethasone. When GDM is treated with ACS, levels of blood glucose should be carefully monitored, especially in patients treated with ritodrine hydrochloride.

An intravenous insulin protocol designed for pregnancy reduces neonatal hypoglycaemia following betamethasone administration in women with gestational diabetes

“…Marked between-trial heterogeneity in setting (early vs. late gestation) and steroid (prednisolone, dexamethasone or betamethasone), and small numbers, preclude significant analysis of efficacy, with no reported data on neonatal hypoglycaemia. Itoh and colleagues [27] demonstrated that intravenous insulin (IVI) infusions can be highly effective for controlling maternal glycaemia following betamethasone (on-IVI glucose 3.9-8.3 mmol/l in 12 women with gestational diabetes), although infusion rates were adjusted individually by attending physicians and no protocol was published. The Joint British Diabetes Societies for Inpatient Care (JBDS-IP) recent guideline proposes a variable rate IVI infusion for the management of glycaemic excursions following betamethasone, and although audit parameters are provided, audit data are not yet available [19].…”

Glycemia after Betamethasone in Pregnant Women without Diabetes—Impact of Marginal Values in the 75-g OGTT

“…The diabetogenic potential of BM is known, and combined with placental insulin resistance in pregnancy, leads to a transient increase in the blood glucose levels of pregnant women [7,8]. Few small studies in the literature exist regarding the action of BM on glucose homeostasis in pregnant women.…”

“…Great attention is paid to the group of pregnant women who have either pre-existing diabetes or gestational diabetes, and especially those under insulin therapy. In this case, it is recommended, by limited bibliographic data, to up-titrate the insulin dose by 30%-40% in order to prevent very high blood glucose levels, which may exacerbate an already at-risk pregnancy (hydramnios) [7][8][9][10][11][12][13][14][15][16]. Furthermore, hyperglycemia can lead to severe neonatal hypoglycemia in the case of preterm delivery [7,9,12].…”

“…In this case, it is recommended, by limited bibliographic data, to up-titrate the insulin dose by 30%-40% in order to prevent very high blood glucose levels, which may exacerbate an already at-risk pregnancy (hydramnios) [7][8][9][10][11][12][13][14][15][16]. Furthermore, hyperglycemia can lead to severe neonatal hypoglycemia in the case of preterm delivery [7,9,12]. More recent studies, also with a relatively small number of subjects, showed that this increase in insulin dose may be inadequate [7,8,10,12,16].…”

“…Furthermore, hyperglycemia can lead to severe neonatal hypoglycemia in the case of preterm delivery [7,9,12]. More recent studies, also with a relatively small number of subjects, showed that this increase in insulin dose may be inadequate [7,8,10,12,16]. Additionally, there has been growing emphasis in the literature on women with gestational diabetes under medical nutrition therapy or, in some cases, with apparent normal glucose metabolism, where-nevertheless-hyperglycemia may occur, necessitating the initiation of transient insulin therapy [8,10,17].…”