Intrapartum Care for People with Diabetes—Working towards Evidence-Based Management

Michal Fishel Bartal

doi:10.1055/a-2405-1846

American Journal of Perinatology, Inhaltsverzeichnis

Am J Perinatol 2025; 42(09): 1103-1108
DOI: 10.1055/a-2405-1846

Review Article

Intrapartum Care for People with Diabetes—Working towards Evidence-Based Management

Michal Fishel Bartal

¹Department of Obstetrics and Gynecology, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel

²Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas

› Institutsangaben

Abstract

The consensus in the literature supports the need for careful monitoring and management of maternal blood glucose during labor to optimize neonatal outcomes. Guidelines generally recommend strict control of maternal blood glucose during labor, involving frequent checks, and the use of dextrose and insulin as needed. However, recent evidence has not consistently shown a strong association between strict control of blood glucose and a reduction in the rate of neonatal hypoglycemia. This raises questions about the extent to which intrapartum blood glucose control impacts neonatal hypoglycemia. This review aims to explore the literature on intrapartum maternal blood glucose management in individuals with pregestational or gestational diabetes, utilizing peer-reviewed journals and datasets, including PubMed, Google Scholar, and clinical guidelines. Observational studies, small sample sizes, variability in definitions of maternal hyperglycemia and neonatal hypoglycemia, and differences in measurement methods such as timing and thresholds for intervention limit the literature on this topic. Additionally, many studies may not fully account for confounding factors such as maternal body mass index, diet, and other comorbidities affecting blood glucose levels. These limitations underscore the need for a cautious interpretation of current findings and highlight the necessity for future research in this area. This review elaborates on the available data and summarizes evidence on managing labor in pregnancies complicated by diabetes. We also emphasize the need for further research to clarify the relationship between maternal blood glucose during labor and neonatal blood glucose.

Key Points

The benefits of strict intrapartum blood glucose control are unclear.
The optimal maternal blood glucose range to prevent neonatal hypoglycemia remains undefined.
Additional research is necessary to understand the relationship between maternal and neonatal blood glucose.

Keywords

intrapartum - diabetes - neonatal hypoglycemia - insulin infusion - labor

Volltext

Referenzen

References
1 Centers for Disease Control and Prevention. QuickStats: Percentage of Mothers with Gestational Diabetes bMANVSS, United States, 2016 and 2021. MMWR Morb Mortal Wkly Rep 2023; 72: 16
2 Edwards T, Harding JE. Clinical aspects of neonatal hypoglycemia: a mini review. Front Pediatr 2021; 8: 562251
3 De Rose DU, Perri A, Maggio L. et al. Neonatal hypoglycemia and neurodevelopmental outcomes: yesterday, today, tomorrow. Eur J Pediatr 2024; 183 (03) 1113-1119
4 Meek CL, Stewart ZA, Feig DS. et al; CONCEPTT collaborative group. Metabolomic insights into maternal and neonatal complications in pregnancies affected by type 1 diabetes. Diabetologia 2023; 66 (11) 2101-2116
5 Collins K, Oehmen R, Mehta S. Effect of obesity on neonatal hypoglycaemia in mothers with gestational diabetes: a comparative study. Aust N Z J Obstet Gynaecol 2018; 58 (03) 291-297
6 Landon MB, Spong CY, Thom E. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. A multicenter, randomized trial of treatment for mild gestational diabetes. N Engl J Med 2009; 361 (14) 1339-1348
7 Rowan JA, Hague WM, Gao W, Battin MR, Moore MP. MiG Trial Investigators. Metformin versus insulin for the treatment of gestational diabetes. N Engl J Med 2008; 358 (19) 2003-2015
8 Yamamoto JM, Kallas-Koeman MM, Butalia S, Lodha AK, Donovan LE. Large-for-gestational-age (LGA) neonate predicts a 2.5-fold increased odds of neonatal hypoglycaemia in women with type 1 diabetes. Diabetes Metab Res Rev 2017; 33 (01)
9 Adamkin DH. Neonatal hypoglycemia. Semin Fetal Neonatal Med 2017; 22 (01) 36-41
10 Sengupta S, Carrion V, Shelton J. et al. Adverse neonatal outcomes associated with early-term birth. JAMA Pediatr 2013; 167 (11) 1053-1059
11 McKinlay CJD, Alsweiler JM, Anstice NS. et al; Children With Hypoglycemia and Their Later Development (CHYLD) Study Team. Association of neonatal glycemia with neurodevelopmental outcomes at 4.5 years. JAMA Pediatr 2017; 171 (10) 972-983
12 Kaiser JR, Bai S, Gibson N. et al. Association between transient newborn hypoglycemia and fourth-grade achievement test proficiency: a population-based study. JAMA Pediatr 2015; 169 (10) 913-921
13 Edwards T, Alsweiler JM, Gamble GD. et al. Neurocognitive outcomes at age 2 years after neonatal hypoglycemia in a cohort of participants from the hPOD randomized trial. JAMA Netw Open 2022; 5 (10) e2235989
14 Shah R, Harding J, Brown J, McKinlay C. Neonatal glycaemia and neurodevelopmental outcomes: a systematic review and meta-analysis. Neonatology 2019; 115 (02) 116-126
15 National Institute for Health and Care Excellence. Diabetes in pregnancy: management from preconception to the postnatal period. 2015 . Accessed November 11, 2021 at: https://www.nice.org.uk/guidance/ng3
16 Thompson D, Berger H, Feig D. et al; Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Diabetes and pregnancy. Can J Diabetes 2013; 37 (Suppl. 01) S168-S183
17 American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Obstetrics. ACOG Practice Bulletin No. 201: Pregestational diabetes mellitus. Obstet Gynecol 2018; 132 (06) e228-e248
18 Rudland VL, Price SAL, Hughes R. et al. ADIPS 2020 guideline for pre-existing diabetes and pregnancy. Aust N Z J Obstet Gynaecol 2020; 60 (06) E18-E52
19 Maheux PC, Bonin B, Dizazo A. et al. Glucose homeostasis during spontaneous labor in normal human pregnancy. J Clin Endocrinol Metab 1996; 81 (01) 209-215
20 Kashyap ML, Sivasamboo R, Sothy SP, Cheah JS, Gartside PS. Carbohydrate and lipid metabolism during human labor: free fatty acids, glucose, insulin, and lactic acid metabolism during normal and oxytocin-induced labor for postmaturity. Metabolism 1976; 25 (08) 865-875
21 Jovanovic L. Glucose and insulin requirements during labor and delivery: the case for normoglycemia in pregnancies complicated by diabetes. Endocr Pract 2004; 10 (Suppl. 02) 40-45
22 Jovanovic L, Peterson CM. Insulin and glucose requirements during the first stage of labor in insulin-dependent diabetic women. Am J Med 1983; 75 (04) 607-612
23 Pedersen J, Bojsen-Møller B, Poulsen H. Blood sugar in newborn infants of diabetic mothers. Acta Endocrinol (Copenh) 1954; 15 (01) 33-52
24 Light IJ, Keenan WJ, Sutherland JM. Maternal intravenous glucose administration as a cause of hypoglycemia in the infant of the diabetic mother. Am J Obstet Gynecol 1972; 113 (03) 345-350
25 West TE, Lowy C. Control of blood glucose during labour in diabetic women with combined glucose and low-dose insulin infusion. BMJ 1977; 1 (6071) 1252-1254
26 Alberti KG, Thomas DJ. The management of diabetes during surgery. Br J Anaesth 1979; 51 (07) 693-710
27 Nattrass M, Alberti KG, Dennis KJ, Gillibrand PN, Letchworth AT, Buckle AL. A glucose-controlled insulin infusion system for diabetic women during labour. BMJ 1978; 2 (6137) 599-601
28 Jovanovic L, Peterson CM. Optimal insulin delivery for the pregnant diabetic patient. Diabetes Care 1982; ;(5 suppl 1): 24-37
29 Caplan RH, Pagliara AS, Beguin EA. et al. Constant intravenous insulin infusion during labor and delivery in diabetes mellitus. Diabetes Care 1982; 5 (01) 6-10
30 Lean ME, Pearson DW, Sutherland HW. Insulin management during labour and delivery in mothers with diabetes. Diabet Med 1990; 7 (02) 162-164
31 Bowen DJ, Daykin AP, Nancekievill ML, Norman J. Insulin-dependent diabetic patients during surgery and labour. Use of continuous intravenous insulin-glucose-potassium infusions. Anaesthesia 1984; 39 (05) 407-411
32 Joshi T, Oldmeadow C, Attia J, Wynne K. The duration of intrapartum maternal hyperglycaemia predicts neonatal hypoglycaemia in women with pre-existing diabetes. Diabet Med 2017; 34 (05) 725-731
33 Yamamoto JM, Donovan LE, Mohammad K, Wood SL. Severe neonatal hypoglycaemia and intrapartum glycaemic control in pregnancies complicated by type 1, type 2 and gestational diabetes. Diabet Med 2020; 37 (01) 138-146
34 Dude AM, Niznik C, Peaceman AM, Yee LM. Evaluation of an intrapartum insulin regimen for women with diabetes. Obstet Gynecol 2020; 136 (02) 411-416
35 Hamel MS, Kanno LM, Has P, Beninati MJ, Rouse DJ, Werner EF. Intrapartum glucose management in women with gestational diabetes mellitus: a randomized controlled trial. Obstet Gynecol 2019; 133 (06) 1171-1177
36 Ulyatt CM, Roberts LF, Crowther CA, Harding JE, Lin L. Intrapartum maternal glycaemic control for the prevention of neonatal hypoglycaemia: a systematic review and meta-analysis. BMC Pregnancy Childbirth 2024; 24 (01) 423
37 Rosenberg VA, Eglinton GS, Rauch ER, Skupski DW. Intrapartum maternal glycemic control in women with insulin requiring diabetes: a randomized clinical trial of rotating fluids versus insulin drip. Am J Obstet Gynecol 2006; 195 (04) 1095-1099
38 Wilkie G, Orr L, Leung K, Leftwich H. Comparison of intrapartum glycemic management strategies in pregnant women with type 1 diabetes mellitus. J Matern Fetal Neonatal Med 2022; 35 (25) 8756-8760
39 Feldberg D, Dicker D, Samuel N, Peleg D, Karp M, Goldman JA. Intrapartum management of insulin-dependent diabetes mellitus (IDDM) gestants. A comparative study of constant intravenous insulin infusion and continuous subcutaneous insulin infusion pump (CSIIP). Acta Obstet Gynecol Scand 1988; 67 (04) 333-338
40 Bitar G, Bravo R, Pedroza C. et al. Permissive intrapartum glucose control: an equivalence randomized control trial (PERMIT). Am J Obstet Gynecol 2024; 231 (03) 355.e1-355.e11
41 Modi A, Levy N, Hall GM. Controversies in the peripartum management of diabetes. Anaesthesia 2016; 71 (07) 750-755
42 Stewart ZA, Thomson L, Murphy HR, Beardsall K. A feasibility study of paired continuous glucose monitoring intrapartum and in the newborn in pregnancies complicated by type 1 diabetes. Diabetes Technol Ther 2019; 21 (01) 20-27
43 Cordua S, Secher AL, Ringholm L, Damm P, Mathiesen ER. Real-time continuous glucose monitoring during labour and delivery in women with Type 1 diabetes - observations from a randomized controlled trial. Diabet Med 2013; 30 (11) 1374-1381
44 Stenninger E, Lindqvist A, Aman J, Ostlund I, Schvarcz E. Continuous Subcutaneous Glucose Monitoring System in diabetic mothers during labour and postnatal glucose adaptation of their infants. Diabet Med 2008; 25 (04) 450-454
45 American Diabetes Association Professional Practice Committee. 15. Management of diabetes in pregnancy: standards of care in diabetes-2024. Diabetes Care 2024; 47 (Suppl. 01) S282-S294
46 Drever E, Tomlinson G, Bai AD, Feig DS. Insulin pump use compared with intravenous insulin during labour and delivery: the INSPIRED observational cohort study. Diabet Med 2016; 33 (09) 1253-1259
47 Wilkie GL, Delpapa E, Leftwich HK. Intrapartum continuous subcutaneous insulin infusion vs intravenous insulin infusion among pregnant individuals with type 1 diabetes mellitus: a randomized controlled trial. Am J Obstet Gynecol 2023; 229 (06) 680.e1-680.e8
48 National Collaborating Centre for Women's and Children's Health; National Institute for Health and Care Excellence: Clinical Guidelines. Diabetes in Pregnancy: Management of Diabetes and Its Complications from Preconception to the Postnatal Period. National Institute for Health and Care Excellence (UK). Copyright © 2015 National Collaborating Centre for Women's and Children's Health. 2015