How should postpartum hypoglycemia be managed in a woman with pre‑existing or gestational diabetes who was receiving insulin or sulfonylureas during pregnancy?

Management of Postpartum Hypoglycemia in Women with Diabetes

Immediate Postpartum Insulin Adjustment

Insulin requirements drop dramatically—by approximately 34-50%—immediately after placental delivery, and doses must be reduced urgently to prevent severe hypoglycemia. 1

• Resume basal-bolus insulin at 50% of end-of-pregnancy doses or 80% of pre-pregnancy doses (whichever is documented) to minimize hypoglycemia risk while maintaining adequate glycemic control 2
• Insulin resistance decreases dramatically within minutes of placental delivery, as the diabetogenic placental hormones are removed from circulation 1
• Insulin sensitivity returns to pre-pregnancy baseline over the following 1-2 weeks, requiring ongoing dose adjustments 1

Specific Hypoglycemia Prevention Strategies

Particular attention must be directed to hypoglycemia prevention in the setting of breastfeeding and erratic sleep and eating schedules. 1

For Breastfeeding Mothers:

• Lactation increases the risk of overnight hypoglycemia due to high metabolic demands of milk production 1
• Women need extra caloric intake to maintain glucose levels during breastfeeding 3
• Insulin dosing requires further adjustment downward to account for glucose utilization during lactation 1
• More vigilant monitoring is required, especially in type 1 and type 2 diabetic mothers 3

Glycemic Targets Postpartum:

• After vaginal delivery, relax maternal glucose targets to 6-8.8 mmol/L (110-160 mg/dL) to reduce hypoglycemia risk 4, 2
• After 48 hours post-cesarean, targets can be liberalized to 100-180 mg/dL if wound healing progresses well 2
• These relaxed targets balance the need for adequate wound healing against the substantially increased hypoglycemia risk 2

Critical Safety Measures

Ensure patients receive regular meals and snacks once tolerating oral intake, and never give correction insulin without adequate carbohydrate intake. 2

• Implement a correction dose sliding scale based on pre-meal and bedtime blood glucose values 2
• Monitor for ketosis, especially in type 1 diabetes patients or those with prolonged fasting 2
• Check urine or serum ketones if blood glucose exceeds 200 mg/dL or if the patient is symptomatic 2

Considerations for Women on Sulfonylureas During Pregnancy

Women who were taking sulfonylureas (such as glyburide) during pregnancy face additional neonatal hypoglycemia risk due to potential drug transfer and prolonged neonatal effects 1

• Sulfonylurea concentrations in umbilical cord plasma can reach approximately 70% of maternal levels 1
• Glyburide was associated with higher rates of neonatal hypoglycemia compared to insulin or metformin 1
• Transition immediately to insulin postpartum at reduced doses rather than resuming sulfonylureas until breastfeeding patterns and glucose stability are established 1
• If sulfonylureas are resumed during lactation, infant monitoring for signs of hypoglycemia is mandatory, though exposure through breast milk is expected to be minimal 5

Neonatal Monitoring Requirements

Neonatal hypoglycemia occurs in 10-40% of infants born to mothers with diabetes due to fetal hyperinsulinemia persisting 24-48 hours postpartum while maternal glucose supply is abruptly discontinued 1, 2

• Mandatory pediatric assessment at delivery for neonatal hypoglycemia risk and respiratory distress 2
• Close neonatal glucose monitoring for the first 24-48 hours is essential 4
• Risk is highest with poor maternal glycemic control during pregnancy and labor, reflected by elevated HbA1c 1
• Consequences of untreated neonatal hypoglycemia are primarily neurological and related to duration and severity of episodes 1

Common Pitfalls to Avoid

• Do not continue pregnancy insulin doses postpartum—this is the most common cause of severe maternal hypoglycemia 1
• Do not delay dose reduction waiting for "stable" glucose readings—the physiologic change is immediate and predictable 1
• Do not forget that erratic sleep schedules with a newborn compound hypoglycemia risk independent of breastfeeding 1
• Do not use A1C for postpartum diabetes screening at 4-12 weeks, as it may be persistently lowered by pregnancy-related increased red blood cell turnover and delivery blood loss; use 75-g OGTT instead 1