What is the insulin management for intrapartum (during labor) type 1 diabetes mellitus?

From the Guidelines

Intrapartum insulin management for type 1 diabetes requires continuous insulin infusion with frequent blood glucose monitoring to maintain target glucose levels between 0.8 and 1.4 g/L (4.4–8.25 mmol/L) 1.

Intrapartum Insulin Management

During labor, patients should be placed on an intravenous insulin infusion, typically using an electronic syringe, with concurrent glucose infusion to prevent hypoglycemia.

• Blood glucose should be checked frequently, adjusting the insulin rate according to the patient's response.
• The goal is to maintain blood sugar levels within the target range to prevent maternal and fetal complications.
• Subcutaneous insulin pumps may be continued during uncomplicated labor with close monitoring, but should be switched to IV insulin for cesarean deliveries or complicated labor.

Postpartum Management

After delivery, insulin requirements typically drop dramatically due to placental hormone removal, often requiring a decrease in pre-pregnancy insulin doses 1.

• Frequent monitoring is essential during this transition period to prevent hypoglycemia.
• For patients with type 1 diabetes, a basal-bolus insulin scheme should be restarted with decreased doses, typically 50% of the pre-pregnancy dose.
• It is crucial to individualize the insulin regimen based on the patient's specific needs and response to treatment, considering factors such as insulin type, dosing plan, and self-management capabilities 1.

From the FDA Drug Label

Careful glucose monitoring and management of patients with diabetes during labor and delivery are required. Insulin requirements may decrease during the first trimester, usually increase during the second and third trimesters, and rapidly decline after delivery. The insulin management of intrapartum type 1 diabetes involves careful glucose monitoring and management during labor and delivery. Insulin requirements may change during pregnancy, with a possible decrease in the first trimester and an increase in the second and third trimesters, followed by a rapid decline after delivery 2.

From the Research

Intrapartum Insulin Management for Type 1 Diabetes

• The optimal mode of intrapartum glycemic control for pregnant individuals with type 1 diabetes mellitus is not known, but insulin is required for all pregnant individuals with type 1 diabetes mellitus 3.
• Studies have compared the effect of intrapartum use of continuous subcutaneous insulin infusion with that of intravenous insulin infusion for glucose management among pregnant individuals with type 1 diabetes mellitus 3, 4, 5.
• One study found that there was no statistically significant difference in the first neonatal glucose measurement between the two groups, and patients should be given the option of both glycemic management strategies intrapartum 3.
• Another study found that continuous subcutaneous insulin infusion pump (CSIIP) was superior to achieving and maintaining intrapartum optimal metabolic control, reducing significantly the incidence of acute fetal distress, thus lowering the cesarean section rate and neonatal hypoglycemia 4.
• A retrospective cohort study found that there was no difference in maternal hypoglycemic events or severe hyperglycemia/development of diabetic ketoacidosis in labor between women who continued subcutaneous insulin and those who were transitioned to intravenous insulin infusion intrapartum 5.
• The management of diabetes in the intrapartum and postpartum patient involves achieving maternal euglycemia to decrease the risk of neonatal hypoglycemia, and many institutions use continuous insulin and glucose infusions during the intrapartum period 6.
• Current evidence suggests that subcutaneous insulin administration with multiple injections or insulin pump therapy is considered at least as safe and efficient as intravenous administration to obtain tight glycemic targets, and automated insulin delivery via insulin pump can be continued during labour and delivery 7.

Key Findings

• Intrapartum glucose management is critical to reducing neonatal hypoglycemia shortly after birth 3.
• Continuous subcutaneous insulin infusion and intravenous insulin infusion are two common strategies for intrapartum glycemic control in pregnant individuals with type 1 diabetes mellitus 3, 4, 5.
• The choice of intrapartum glycemic management strategy should be individualized and based on patient preferences and medical needs 3, 5.
• Diabetes management during labour and delivery involves intensive glucose monitoring, adequate insulin administration, and carbohydrate administration to support safe delivery and neonatal well-being 7.