Labor and Delivery

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Glycemic Control During Labor and
Delivery
1
Hormonal Changes During Labor
and Delivery in Healthy Nondiabetic Women
• PGE2 and oxytocin: substantial increase during
labor
– May be trigger for labor
• Estradiol, vasoactive intestinal peptide, gastric
inhibitory polypeptide (GIP): slight increase during
labor
• 17-hydroxyprogesterone: little or no change during
labor
• Prolactin: decrease during first stage of labor, then
increase during second to third stages and delivery
• Insulin (and glucose): increase during delivery
Jovanovic L. Endocr Pract. 2004;10:40-45.
2
Stages of Labor
• First stage:
– Commences when uterine contractions are of
sufficient frequency, intensity, and duration to bring
about effacement and dilation of the cervix
– Ends when the cervix is fully effaced
• Second stage:
– Commences when the cervix is fully effaced
– Ends when the infant is delivered
• Third stage:
– Commences when the infant is delivered
– Ends when the placenta is delivered
3
The Deleterious Effect of Hypertonic
Glucose Infusions During Labor
Year
Author
Subject
Glucose
Infused
Results
1966
Takeda
Dogs
25 g
Mothers >600 mg/dL
Pups >300mg/dL = 100% death
Pups <300 mg/dL = fewer dead pups
1966
Romney
Normal
humans
25 g
Fetuses >180 mg/dL
Bradycardia
Anderson
Normal
humans
25 g
No benefit
Fetal pH decreased
Uterine activity
Oakley
Humans with
gestational
diabetes
50 g
No benefit
Mothers >300 mg/dL
Fetal insulin increased >10-fold above normal,
leading to fetal hypoglycemia
1970
1972
Takeda Y, et al. Am J Obstet Gynecol. 1966;96:872-877.
Romney SL, et al. Am J Obstet Gynecol. 1966;96:698-709.
Anderson GG, et al. Obstet Gynecol. 1970;36:405-414.
Oakley NW, et al. BMJ. 1972;1:466-469.
4
The Magnitude of Neonatal Hypoglycemia
Inversely Related to Maternal
Hyperglycemia at Delivery
250
Type 1 DM
Type 2 DM
Gestational DM
200
150
100
50
0
Maternal Glucose
Jovanovic L, et al. Am J Med. 1983;75:607-612.
Neonatal Glucose
5
No Exogenous Insulin Administration
Superior to Any Insulin Infusion During
Labor and Delivery
Year
Author
Glucose Rate
Insulin Rate
Glycemia
1977
West
12 g/h
1-2 U/h
Hypoglycemia in 4 h
1978
Yeast
5 g/h
0.25-2 U/h
Hyperglycemia then
hypoglycemia
1982
Caplan
5 g/h
0.25-3 U/h
Severe hypoglycemia
1982
Golde
6 g/h
0
Normal
1983
Jovanovic
2.55 mg/kg/min =
10 g/h for 60 kg
0
Normal
West TE, et al. BMJ. 1977;1:1252-1254.
Yeast JD, et al. Am J Obstet Gynecol. 1978;131:861-864.
Caplan RH, et al. Diabetes Care. 1982;5:6-10.
Golde SH, et al. Am J Obstet Gynecol. 1982;144:556-559.
Jovanovic L, et al. Am J Med. 1983;75:607-612.
6
Glucose Infusion Rates for Diabetic
Women in Active Labor
Equal to Dextrose 2.55 mg/kg/h
D5NS
D10NS
Weight
kg
Glucose
mg/min
mL/min
mL/h
mL/min
mL/h
30
76.5
1.52
91.2
0.76
45.6
35
89.3
1.78
106.8
0.89
53.4
40
102.0
2.04
122.4
1.02
61.2
45
114.8
2.30
138.0
1.15
69.0
50
127.5
2.55
153.0
1.27
76.5
55
140.3
2.80
168.0
1.40
84.0
Jovanovic L, et al. Am J Med. 1983;75:607-6l2.
7
Glucose Infusion Rates for Diabetic
Women in Active Labor
Equal to Dextrose 2.55 mg/kg/h
D5NS
D10NS
Weight
kg
Glucose
mg/min
mL/min
mL/h
mL/min
mL/h
60
153.0
3.06
183.6
1.53
91.3
65
165.8
3.32
199.2
1.66
99.6
70
178.5
3.56
213.6
1.78
106.8
75
191.3
3.82
229.2
1.91
114.6
80
204.0
4.08
244.8
2.04
122.4
85
216.8
4.34
260.4
2.17
130.2
Jovanovic L, et al. Am J Med. 1983;75:607-6l2.
8
Glucose Infusion Rates for Diabetic
Women in Active Labor
Equal to Dextrose 2.55 mg/kg/h
D5NS
D10NS
Weight
kg
Glucose
mg/min
mL/min
mL/h
mL/min
mL/h
90
229.5
4.58
274.8
2.29
137.4
95
242.3
4.84
290.4
2.42
145.2
100
255.0
5.10
306.0
2.55
153.0
105
267.8
5.36
321.6
2.68
160.8
110
280.5
5.60
336.0
2.80
168.0
115
293.3
5.86
351.6
2.93
175.8
120
306.0
6.12
367.2
3.06
183.6
125
318.8
6.38
382.8
3.19
191.4
Jovanovic L, et al. Am J Med. 1983;75:607-6l2.
9
Protocol for Adjusting Intrapartum Intravenous
Solutions and Insulin Administration in Labor
and Postpartum
Glucose
Adjustments
≤70 mg/dL
D10NS for 10-15 minutes, rate 100 mL/h
71-100 mg/dL
D5NS/100 mL/h
101-120 mg/dL
NS/100 mL/h
>121 mg/dL
NS plus regular insulin IV or SC per hour as percent of “Big I”*
121-140 mg/dL
NS/100 mL/h plus 3% “Big I”
>141 mg/dL
NS/100 mL/h plus 6% “Big I”
“Big I” = Total daily insulin requirement.
* At term “Big I” is 1.0 U/kg per day. Thus, 3% of this dose would be 3 units in a 100-kg woman
at term.
D5, 5%dextrose; D10, 10% dextrose; NS, normal saline.
Jovanovic L. Endocr Pract. 2004;10:40-45.
10
Protocol for Adjusting Intrapartum Intravenous
Solutions and Insulin Administration in Labor and
Postpartum in Women with T1DM on Insulin Pumps
Glucose
Adjustments
≤70 mg/dL
D10NS for 10-15 minutes, rate 100 mL/h
71-100 mg/dL
D5NS/100 mL/h
101-120 mg/dL
NS/100 mL/h
>121 mg/dL
NS plus regular insulin IV or SC per hour as percent of “Big I”*
121-140 mg/dL
NS/100 mL/h plus 3% “Big I”
>141 mg/dL
NS/100 mL/h plus 6% “Big I”
“Big I” = Total daily insulin requirement.
* At term “Big I” is 1.0 U/kg per day. Thus, 3% of this dose would be 3 units in a 100-kg woman
at term.
D5, 5%dextrose; D10, 10% dextrose; NS, normal saline.
Jovanovic L. Endocr Pract. 2004;10:40-45.
11
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