Diabetes affects >8% of the 4 million live births annually
in the U.S.1 Three fourths of pregnant patients
with diabetes have either gestational diabetes or undiagnosed type
2 diabetes diagnosed through prenatal screening. Of the remaining
25%, 1% have preexisting type 1 diabetes and the
remaining are type 2 diabetics. Pregnant diabetic patients are at
increased risk for spontaneous abortion, particularly those patients
with poor glycemic control early in pregnancy, preexisting vascular
disease, and preeclampsia. Pregnant diabetics are also at increased
risk for several pregnancy complications, including pregnancy-induced hypertension,
preterm labor, spontaneous abortion, pyelonephritis, and diabetic
ketoacidosis (DKA). The goal of treatment during pregnancy is to
prevent spontaneous abortions, hyperglycemia-induced congenital
abnormalities and ketoacidosis, and hypoglycemia.
Diabetes in Pregnancy
Oral hypoglycemic agents, such as metformin and glyburide, are
occasionally used in select patients with gestational diabetes.2,3 Most
gestational diabetics are managed with diet alone if they can maintain
glycemic goals with frequent glucose monitoring.
Almost all pregnant patients with type 1 or type 2 diabetes require
multiple daily insulin injections to prevent hyperglycemic complications
during pregnancy and maintain euglycemia.
The American College of Obstetricians and Gynecologists
recommends the following goals for maintaining euglycemia in pregnant
diabetic patients: a fasting blood glucose concentration of ≤95
milligrams/dL and a 2-hour postprandial glucose concentration
≤120 milligrams/dL. Patients with gestational diabetes
who are managed by diet alone rarely develop acute hyperglycemic
complications because their glucose values rarely reach levels consistent
with DKA. Among patients with type 1 and type 2 diabetes, the need for
insulin increases throughout the course of pregnancy. In general,
during the first trimester, the initial insulin requirement is 0.7
units/kg/day. By late pregnancy, patients generally
require 1 unit/kg/day. Two thirds of the total
insulin dose is given in the morning and one third in the evening.
Two thirds of the morning dose consists of neutral protamine Hagedorn
(NPH) and one third of a short-acting, regular insulin. The evening
dose consists of half NPH and half regular insulin. Occasionally,
this regimen results in nocturnal hypoglycemia between 1 and 3 a.m.
Administration of the predinner NPH at bedtime may prevent this
The incidence of DKA in pregnancy decreases significantly with early
diagnosis and improved prenatal counseling.4 Poor
patient compliance, maternal emesis, and the use of β-sympathomimetic agents
used for tocolysis, such as terbutaline, increase the risk of DKA.
Patients who use continuous SC insulin infusions (the insulin pump)
are at higher risk of developing DKA than are pregnant diabetics
who use standard insulin therapy.
Ketosis occurs more rapidly and at lower glucose levels in pregnant
patients than in nonpregnant patients and is poorly tolerated by
Any pregnant diabetic presenting to the ED who is ill appearing and/or
with a ...