Labor and Delivery of the Patient with Diabetes
The goal is for the patient with
diabetes to deliver a healthy child vaginally. The adequacy of glucose control,
the well-being of the infant, estimated fetal weight by ultrasound, presence of
hypertension or other complications of preg-nancy, gestational age,
presentation of the fetus, and status of the cervix are all factors involved in
decisions re-garding delivery. In the
well-controlled patient with diabeteswho has no complications, induction at
term (38 to 39 weeks) is often undertaken. For women with GDM or
pregesta-tional diabetes and an estimated fetal weight of 4500 g or more, caesarean
delivery may be considered. If an earlier delivery is deemed necessary for
either fetal or maternal indications, fetal maturity studies may be performed
on amniotic fluid obtained by amniocentesis. If antepartum steroids for fetal
lung maturity become necessary (e.g., for patients with preterm labor),
frequent glucose monitoring and, at times, increased doses of insulin are
necessary to counter the hyperglycemic effects of corticosteroids.
Whether
the patient’s labor begins spontaneously or is in-duced, the goal of
intrapartum insulin therapy is strict glucose con-trol. Once
active labor begins or glucose levels decrease to70 mg/dL, a constant glucose
infusion of a 5% dextrose solution delivered at a rate of 100 to 150 mL/hr is
adminis-tered to maintain a glucose level of 100 mg/dL. The plasma glucose
level should be assessed every 1 to 2 hours. Short-acting insulin may be
administered, usually by constant intravenous infusion, if glucose levels
exceed 100 mg/dL.
With delivery of the placenta,
the source of the “anti-insulin” factors, most notably hPL, is removed. With
its short half-life, the effect on plasma glucose is evident within hours. Many
patients do not require any insulin for a few days postpartum. Routine
management generally consists of frequent glucose assessments and a sliding
scale approach with minimal insulin injections. The goals for optimal glu-cose
values are less stringent in the puerperium than dur-ing pregnancy. For
patients with gestational diabetes, no further insulin is required postpartum.
In patients with pregestational diabetes, insulin is generally resumed at 50%
of the pre-pregnant dose once a patient is consum-ing a normal diet.
Thereafter, insulin can be adjusted over the ensuing weeks, with requirements
usually reaching the pre-pregnancy level.
More than 95% of mothers with
gestational diabetes return to a completely normal glucose status immediately
postpartum; however, approximately 50% of these women go on to develop type 2
diabetes later in life and need to be educated about the importance of
maintaining a healthy diet and regular exercise program. Glucose tolerance screen-ing is advocated 2 to 4 months postpartum to
detect the 3% to 5% who remain diabetic and require treatment. Typically,such
screening involves a 75-g glucose load, followed by plasma glucose
determination 2 hours later. A value above 140 mg/dL requires follow-up.
For contraception, barrier
methods or intrauterine contraceptives are often chosen; patients who choose
oral contraceptives should monitor their glucose values to iden-tify an
increase that is sometimes seen with this method.
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