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Epidemiology

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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.

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Management of Diabetes in Pregnancy

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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.

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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.

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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 problem.

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Diabetic Ketoacidosis

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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.

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Ketosis occurs more rapidly and at lower glucose levels in pregnant patients than in nonpregnant patients and is poorly tolerated by the fetus.

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ED Evaluation and Treatment

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Any pregnant diabetic presenting to the ED who is ill appearing and/or with a ...

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