How should I manage a 39‑year‑old gravida 2 para 1 woman with a 7‑week early pregnancy loss, advanced maternal age, insulin‑requiring type II diabetes mellitus, class II obesity, prior low‑transverse cesarean delivery, and prior bariatric surgery who is scheduled for dilation and curettage (D&C) tonight?

Perioperative Management for D&C in a High-Risk Diabetic Patient

For this 39-year-old woman with insulin-requiring type 2 diabetes undergoing D&C tonight, immediately transition to intravenous insulin infusion with concurrent 10% glucose administration, targeting blood glucose 110–160 mg/dL intraoperatively, then reduce insulin to 50% of current doses immediately after the procedure to prevent severe postpartum hypoglycemia. 1

Pre-Procedure Insulin Management

Transition to IV Insulin Protocol

• Switch from subcutaneous insulin to continuous IV insulin infusion for the D&C procedure, using her current basal insulin rate as the starting point for the infusion 1
• Administer 10% glucose infusion concurrently with the insulin to prevent maternal hypoglycemia and ketosis during the fasting state required for the procedure 2, 3
• Never interrupt insulin therapy in insulin-requiring diabetic patients, as this creates high risk for ketoacidosis even at moderately elevated glucose levels 2, 3

Intraoperative Glycemic Targets

• Maintain blood glucose 110–160 mg/dL (6.1–8.9 mmol/L) during the procedure to optimize wound healing and prevent both hyperglycemia (infection risk) and hypoglycemia (maternal safety concern) 1
• Perform frequent glucose monitoring every 30–60 minutes during the procedure 2

Critical Post-Procedure Management

Immediate Insulin Dose Reduction

• Insulin requirements drop precipitously immediately after pregnancy tissue removal due to the abrupt loss of placental diabetogenic hormones 1
• Resume subcutaneous insulin at 50% of end-of-pregnancy doses or 80% of pre-pregnancy doses (whichever is documented) as soon as the patient is tolerating oral intake 1, 2
• This dramatic reduction is non-negotiable—continuing pregnancy-dose insulin is the leading cause of severe maternal hypoglycemia and represents a critical safety hazard 1

Post-Procedure Monitoring Protocol

• Target blood glucose 110–160 mg/dL for the first 48 hours to support optimal wound healing 1
• Perform blood glucose checks before meals and 2 hours postprandially for at least 48 hours 2
• Never administer correction insulin without adequate carbohydrate intake—ensure regular meals and snacks once tolerating oral intake 1

Special Considerations for This Patient's Risk Profile

Bariatric Surgery History

• Her prior bariatric surgery increases risk of micronutrient deficiencies (thiamine, B12, vitamin D, iron, folate) that may impair wound healing 2
• Post-bariatric patients have altered glucose absorption patterns that can make glycemic control unpredictable 2
• Consider checking thiamine levels if she has had prolonged nausea/vomiting, as deficiency can occur rapidly and cause serious complications 2

Class II Obesity & Prior Cesarean

• Her obesity (BMI 35–39.9 kg/m²) combined with prior uterine surgery increases risk of postoperative wound complications and infection 4, 5
• Meticulous glycemic control in the 110–160 mg/dL range is essential to minimize infection risk 1

Advanced Maternal Age

• At 39 years, she has higher baseline risk for complications including hypertensive disorders and metabolic decompensation 6

Ketosis Monitoring

When to Check Ketones

• Check urine or serum ketones if blood glucose exceeds 200 mg/dL or if she develops nausea, vomiting, or abdominal pain 1
• Type 2 diabetic patients on insulin can develop ketoacidosis at lower glucose thresholds than typically expected, especially in the pregnancy/early post-pregnancy state 2

Common Pitfalls to Avoid

The Hypoglycemia Trap

• Do not wait for "stable" glucose readings before reducing insulin—the physiologic drop in insulin need after pregnancy tissue removal is immediate and predictable 1
• Delaying dose reduction is unsafe and will result in severe hypoglycemia 1

The Infection Risk

• Hyperglycemia >160 mg/dL increases surgical site infection risk, but overly aggressive correction causes hypoglycemia 1
• Balance is achieved through the 110–160 mg/dL target range 1

Anesthesia Considerations

• Regional anesthesia is preferred over general anesthesia to reduce hyperglycemic stress response 1
• Coordinate with anesthesia regarding the IV insulin-glucose protocol 1

Discharge Planning

Outpatient Insulin Regimen

• Provide explicit written instructions for reduced insulin doses (50% of pregnancy doses) 1
• Schedule urgent endocrinology follow-up within 1 week for dose titration 1
• Educate on hypoglycemia recognition and treatment, as irregular sleep and eating patterns post-procedure increase risk 1

Diabetes Screening

• She will require 75-gram oral glucose tolerance test at 4–12 weeks post-procedure to assess for persistent diabetes (do not use A1C, as pregnancy-related changes make it unreliable) 1

Happy Sunday po, and please ensure the night team is aware of the critical need for immediate insulin dose reduction post-procedure to prevent severe hypoglycemia. 1