Management of Hypoglycemia in Emergency LSCS After Betamethasone Administration
Immediately administer IV glucose to correct the hypoglycemia (blood sugar 69 mg/dL), then proceed with emergency LSCS while maintaining continuous IV insulin infusion with hourly glucose monitoring to manage the anticipated betamethasone-induced hyperglycemia. 1
Immediate Hypoglycemia Management
Administer IV glucose immediately since the blood sugar of 69 mg/dL (3.8 mmol/L) meets the threshold for glucose administration in the perioperative setting, particularly given the patient cannot take oral glucose due to the emergency surgical situation. 1
- IV glucose is mandatory for any patient who is unconscious, unable to swallow, or NPO for surgery, even if hypoglycemia symptoms are absent. 1
- The guideline threshold is clear: glucose should be administered for blood sugar levels between 0.7 and 1 g/L (3.8-5.5 mmol/L) if the patient reports signs of hypoglycemia, or immediately if <3.3 mmol/L (0.6 g/L) regardless of symptoms. 1
Anticipate Betamethasone-Induced Hyperglycemia
Prepare for significant hyperglycemia following the 12 mg betamethasone dose, as corticosteroids are well-known to cause blood glucose elevation and increase insulin requirements. 2
- Recent evidence shows betamethasone causes more hyperglycemic episodes and higher median blood glucose levels compared to dexamethasone in gestational diabetes patients, with effects lasting 3 days post-administration. 3
- Betamethasone-treated patients had median blood glucose of 6.7 mmol/L (120 mg/dL) on Day 1 and 2, with 5 hyperglycemic episodes per day versus 4 with dexamethasone. 3
Intraoperative Management
Initiate continuous IV insulin infusion once hypoglycemia is corrected and maintain throughout the emergency LSCS procedure. 4, 5
- Target blood glucose range of 100-180 mg/dL (5.6-10.0 mmol/L) during the perioperative period. 4
- Monitor blood glucose hourly during surgery to maintain glycemic targets and reduce surgical complications. 4
- Starting insulin infusion rate typically 0.5-1 unit/hour, adjusted to maintain glucose 140-180 mg/dL. 5
Postoperative Management
Continue IV insulin infusion until blood glucose is stable ≤180 mg/dL (10 mmol/L) and the patient resumes oral feeding. 1, 5
- Do not abruptly discontinue IV insulin as this leads to rebound hyperglycemia and potential ketoacidosis, especially critical given the betamethasone on board. 5
- Maintain the IV insulin until stable blood sugar levels are obtained <1.80 g/L (10 mmol/L). 1
Transition to Subcutaneous Insulin
Calculate subcutaneous insulin doses based on total 24-hour IV insulin requirements when transitioning off IV therapy. 1, 5
- Half of the total 24-hour IV insulin dose becomes the basal (long-acting) insulin given once in the evening. 1
- The other half is divided by 3 for ultra-rapid analogue doses at each meal. 1
- Give first subcutaneous basal insulin 1-2 hours before stopping IV infusion to ensure adequate overlap and prevent rebound hyperglycemia. 5
Critical Monitoring Requirements
Check blood glucose every 1-2 hours while NPO and during IV insulin infusion. 4, 5
- Monitor serum potassium closely to avoid hypokalemia during insulin therapy. 5
- Scale up regular blood glucose monitoring given the dual risk of hypoglycemia from surgery/NPO status and hyperglycemia from betamethasone. 1
Key Pitfalls to Avoid
- Never delay surgery to "optimize" the blood sugar—correct the hypoglycemia with IV glucose and proceed with the emergency LSCS. 1
- Do not use sliding-scale insulin alone without a basal insulin component, as this is ineffective for perioperative glycemic control. 6
- Watch for hyperosmolarity in the postoperative period given the betamethasone-induced hyperglycemia, which presents with dehydration and confusion. 5
- Ensure adequate hydration alongside insulin therapy, as betamethasone-induced hyperglycemia may cause osmotic diuresis. 5