What is the best management plan for a 37-year-old female, Gravida 3, Para 2, at 37 3/7 weeks gestation, with overt Diabetes Mellitus (DM) on insulin, undergoing a stat repeat Cesarean Section (CS)?

Management Plan for G3P2 at 37 3/7 Weeks with Overt DM on Insulin for Stat Repeat Cesarean Section

Receiving Notes

For a pregnant patient with overt diabetes on insulin undergoing cesarean section, transition to intravenous insulin infusion (IVES) is the standard approach during the procedure, with glucose infusion to prevent maternal hypoglycemia and ketosis. 1

Key Documentation Points:

• Obstetric History: G3P2 at 37 3/7 weeks by LMP, scheduled for stat repeat cesarean section 1
• Diabetes Status: Overt diabetes mellitus on insulin therapy (document current insulin regimen, total daily dose, and basal-bolus breakdown) 1
• Risk Assessment: High risk for surgical site infection, wound complications, and postoperative metabolic derangements requiring strict glycemic control 1
• Neonatal Risk: Neonate at risk for severe hypoglycemia, respiratory distress syndrome, macrosomia, and potential need for NICU admission 2

Perioperative Management Plan

Intraoperative Insulin Management

Switch from subcutaneous insulin to intravenous insulin infusion (IVES) for the cesarean section, starting at least 30 minutes before discontinuing subcutaneous insulin. 1

• Insulin Infusion Rate: Use patient's current basal insulin rate as starting point (e.g., if basal rate is 0.5 units/hour subcutaneously, start 0.5 units/hour IV) 1
• Glucose Infusion: Administer 10% dextrose infusion concurrently to prevent maternal hypoglycemia and ketosis during fasting state 1
• Regional Anesthesia Preferred: Regional technique (spinal/epidural) significantly reduces hyperglycemic stress response compared to general anesthesia 1

Intraoperative Glycemic Targets

Target blood glucose range during cesarean section: 110-160 mg/dL (6.1-8.8 mmol/L) to support optimal wound healing. 1, 3

• This range is slightly tighter than vaginal delivery targets due to wound healing requirements 1
• Avoid both hyperglycemia (increases infection risk) and hypoglycemia (maternal safety concern) 1

CBG Monitoring Protocol

Intraoperative Monitoring

Check capillary blood glucose (CBG) every 30-60 minutes during the procedure and immediate postoperative period. 1

• More frequent monitoring (every 30 minutes) if patient has Type 1 diabetes or history of brittle glucose control 1
• Continue hourly monitoring in PACU until stable and transitioned back to subcutaneous regimen 1

Postpartum Monitoring Protocol

For overt diabetes (not gestational): Continue CBG monitoring before meals and 2 hours postprandially for at least 48 hours. 1, 3

• Critical distinction: Unlike gestational diabetes where insulin is stopped immediately, overt diabetes requires continued insulin therapy postpartum 1, 3
• Monitor for hypoglycemia risk, especially during breastfeeding 1

Postpartum Insulin Management (RISS Plan)

Immediate Post-Delivery (First 2 Hours)

After placental delivery, insulin requirements drop precipitously—reduce insulin infusion rate by 50% immediately and monitor closely for hypoglycemia. 1

• Continue IV insulin infusion until patient is fully awake, tolerating oral intake, and ready to transition to subcutaneous regimen 1
• Check CBG 30-60 minutes after delivery to assess immediate postpartum insulin needs 1

Transition to Subcutaneous Insulin

Resume basal-bolus insulin regimen at 50% of end-of-pregnancy doses OR 80% of pre-pregnancy doses, whichever is documented. 1

• Timing: Start subcutaneous basal insulin at least 2 hours before discontinuing IV insulin infusion to establish subcutaneous depot 1
• Never stop basal insulin in Type 1 diabetes—high risk of ketoacidosis even with modest hyperglycemia 1
• If patient was on insulin pump pre-operatively, can restart pump 2 hours before stopping IV infusion 1

Regular Insulin Sliding Scale (RISS)

Implement correction dose sliding scale based on pre-meal and bedtime CBG values:

Blood Glucose (mg/dL)	Regular Insulin Dose (subcutaneous)
150-200	2 units
201-250	4 units
251-300	6 units
301-350	8 units
>350	10 units + notify physician

1

• Adjust scale based on patient's insulin sensitivity and total daily dose requirements 1
• Hold correction doses if CBG <100 mg/dL 1

Postpartum Glycemic Targets

Target range: 110-160 mg/dL (6.1-8.8 mmol/L) for first 48 hours post-cesarean to optimize wound healing. 1, 3

• Less strict than intrapartum targets but tighter than routine postpartum management 1
• After 48 hours, can liberalize to 100-180 mg/dL if wound healing progressing well 1

Critical Safety Considerations

Hypoglycemia Prevention

Ensure patient receives regular meals and snacks once tolerating oral intake—never give correction insulin without adequate carbohydrate intake. 1

• Breastfeeding increases hypoglycemia risk; may need additional snacks before nursing 1
• Have 50% dextrose available at bedside for severe hypoglycemia (<50 mg/dL) 1

Ketosis Screening

For Type 1 diabetes or prolonged fasting, check urine or serum ketones if CBG >200 mg/dL or patient symptomatic, even with modest hyperglycemia. 1

• Pregnant/postpartum women with Type 1 diabetes develop ketoacidosis at lower glucose thresholds 1
• Risk of fetal demise in utero if ketoacidosis develops pre-delivery 1

Wound Infection Prevention

Strict glycemic control (maintaining CBG 110-160 mg/dL) reduces surgical site infection risk, which is significantly elevated in diabetic patients. 1

• Hyperglycemia directly impairs wound healing and immune function 1
• Monitor incision site closely for signs of infection (erythema, drainage, dehiscence) 1

Neonatal Considerations

Mandatory pediatric assessment at delivery for neonatal hypoglycemia risk (prevalence 10-40% in infants of diabetic mothers) and respiratory distress. 2

• Neonatal hypoglycemia occurs due to fetal hyperinsulinemia persisting 24-48 hours postpartum 2
• Risk of permanent neurological injury if neonatal hypoglycemia not promptly treated 2
• Increased respiratory distress syndrome risk even at term due to impaired surfactant production 2
• Consider NICU admission for close glucose and respiratory monitoring 1, 2

Multidisciplinary Coordination

Ensure endocrinology/internal medicine consultation within 24 hours for insulin regimen optimization and discharge planning. 1

• Document clear plan for outpatient diabetes management and follow-up 1
• Patient will require lifelong diabetes care, unlike gestational diabetes 3
• Encourage breastfeeding (reduces future diabetes risk in mother and infant) but monitor for hypoglycemia 3, 4