Management of 2 cm Cervical Dilation in a Pregnant Patient with Type 1 Diabetes and Hypertension
For this 20-year-old at 9 months gestation with 2 cm cervical dilation, continue her current insulin regimen with the same tight glycemic targets used throughout pregnancy (fasting <95 mg/dL, 1-hour postprandial <140 mg/dL or 2-hour postprandial <120 mg/dL), switch to intravenous insulin-glucose infusion once active labor begins, maintain strict blood pressure control <140/90 mmHg, and prepare for potential complications including shoulder dystocia, cesarean delivery, and neonatal hypoglycemia. 1, 2
Immediate Glycemic Management During Early Labor (Cervical Dilation Phase)
Continue her current diabetes treatment regimen unchanged during the cervical dilation phase, maintaining the same glycemic targets used throughout pregnancy. 1, 2
Monitor blood glucose levels frequently (every 1-2 hours minimum) to maintain fasting glucose <5.2 mmol/L (95 mg/dL) and postprandial <6.6 mmol/L (120 mg/dL). 1
Never interrupt insulin therapy in Type 1 diabetes patients, even if glucose levels appear controlled, due to extremely high risk of ketoacidosis that can occur even with only moderately elevated blood glucose levels (<11 mmol/L or 200 mg/dL). 1, 2
Screen for ketosis if any clinical signs appear, even with blood glucose <11 mmol/L, as Type 1 diabetes patients have heightened risk of ketoacidosis during labor with potential for fetal death if untreated. 1
Transition to Active Labor Protocol
Switch from subcutaneous insulin to intravenous insulin-glucose infusion once active labor is established (typically at 3-4 cm dilation with regular contractions). 1, 2
If she is using an insulin pump, it is preferable to transition to IV insulin, though pump continuation is possible with a personalized protocol for adjusting pump output during labor. 1, 2
Administer 10% glucose infusion alongside the insulin infusion to prevent maternal hypoglycemia and ketosis due to the fasting state and increased energy demands of active labor. 1, 2
Target maternal glucose between 4.0-7.0 mmol/L (72-126 mg/dL) during active labor and second stage to prevent neonatal hypoglycemia while avoiding maternal hypoglycemia. 2
Hypertension Management During Labor
Maintain blood pressure <140/90 mmHg but not below 80 mmHg diastolic to balance maternal cardiovascular protection with adequate uteroplacental perfusion. 3
Continue her current pregnancy-safe antihypertensive medications (extended-release nifedipine, labetalol, or methyldopa) throughout labor. 3
Monitor blood pressure every 30-60 minutes during early labor, increasing to every 15-30 minutes during active labor, as women with both diabetes and hypertension face 25% risk of developing superimposed preeclampsia. 3, 4
Watch for signs of preeclampsia or eclampsia (headache, visual changes, right upper quadrant pain, sudden blood pressure elevation), as her risk is increased 4.0-6.6 fold compared to non-diabetic patients. 1
Obstetric Complications to Anticipate
Prepare for potential cesarean delivery, as Type 1 diabetes increases cesarean risk 4.3-fold compared to non-diabetic patients. 1
Assess estimated fetal weight carefully—if >4500g, strongly consider cesarean delivery due to significantly increased risk of shoulder dystocia in diabetic pregnancies. 2
Have experienced personnel available for delivery, as macrosomia risk is increased 7.7-fold in Type 1 diabetes, raising shoulder dystocia risk substantially. 1
Intensify fetal surveillance with continuous electronic fetal monitoring once in active labor, as perinatal mortality is increased 3.6-fold in Type 1 diabetes. 1, 2
Neonatal Hypoglycemia Prevention
Meticulous avoidance of maternal hyperglycemia during labor is critical to prevent neonatal hypoglycemia, which occurs in 10-40% of infants born to mothers with Type 1 diabetes. 1, 5
Maternal hyperglycemia during labor induces fetal hyperinsulinism, which persists 24-48 hours postpartum while maternal glucose supply stops immediately at birth, causing severe neonatal hypoglycemia with potential neurological consequences. 1
Maintain maternal glucose 4.0-7.0 mmol/L (72-126 mg/dL) throughout labor, as neonatal hypoglycemia is directly related to maternal hyperglycemia during labor and delivery. 2, 6
Alert the neonatal team that this infant is at high risk for hypoglycemia, respiratory distress (2.1-fold increased risk), and will require immediate glucose monitoring after birth. 1
Immediate Postpartum Management Plan
Reduce insulin dosage dramatically immediately after placental delivery to either 80% of pre-pregnancy doses or 50% of end-pregnancy doses to prevent severe maternal hypoglycemia. 2
Never discontinue basal insulin in Type 1 diabetes patients postpartum due to high risk of ketoacidosis. 2
Target postpartum blood glucose 6-8.8 mmol/L (110-160 mg/dL) after vaginal delivery, with slightly lower targets if cesarean delivery occurs to support wound healing. 2
Continue IV insulin-glucose infusion through delivery and for 1-2 hours postpartum before transitioning to subcutaneous basal-bolus regimen. 2
Critical Pitfalls to Avoid
Interrupting insulin therapy at any point is the most dangerous error—Type 1 diabetes patients can develop ketoacidosis rapidly, even with moderately elevated glucose levels. 1, 2
Failing to switch to IV insulin-glucose infusion during active labor leads to inadequate glucose control and increased risk of both maternal ketosis and neonatal hypoglycemia. 1, 2
Administering excessive insulin postpartum causes severe hypoglycemia, as insulin requirements drop by 50-80% immediately after placental delivery. 2
Inadequate glucose infusion during labor (labor is a form of exercise requiring an eightfold increase in glucose substrate) leads to maternal hypoglycemia and ketosis despite reduced insulin needs. 6
Poor blood pressure control during labor increases risk of eclampsia (6.6-fold increased risk in Type 1 diabetes) and placental abruption. 1, 4