THE SECTION Gynecology and Obstetrics

MERCK MANUALS FOR HEALTHCARE

SUBJECT
TOPIC
Pregnancy Complicated by Disease
Diabetes Mellitus in Pregnancy
ONLINE MEDICAL LIBRARY PROFESSIONALS

MANAGEMENT OF DIABETES MELLITUS

DURING PREGNANCY

Care Before
Conception Prenatal Care Labor and Delivery

Type 1*
Diabetes is Prenatal visits begin as soon as Vaginal delivery at term is possible
controlled. pregnancy is recognized. if women have documented dat-
Risk is lowest if Frequency of visits is determined ing criteria and good glycemic
Hb A1c levels by degree of glycemic control. control.
are ≤ 8% at Diet should be individualized 2nd-trimester amniocentesis for
conception.† according to ADA guidelines and genetic testing is not done unless
Evaluation includes coordinated with insulin adminis- indicated for another problem or
a 24-h urine col- tration. requested by the couple.
lection (protein Three meals and 3 snacks/day are 3rd-trimester amniocentesis to
excretion and cre- recommended, with emphasis on determine fetal lung maturity
atinine clearance) consistent timing. may be done to help determine
to check for renal Women are instructed in and the optimal timing for elective
complications, should do plasma glucose self- delivery.
ophthalmologic monitoring. Cesarean delivery should be
examination to reserved for obstetric indications
check for retinal Hb A1c level should be checked
every trimester. or fetal macrosomia (> 4500 g),
complications, which increases risk of shoulder
and ECG to Women should be cautioned about dystocia.
check for cardiac the dangers of hypoglycemia dur-
complications. ing exercise and at night. Delivery should occur by
38–40 wk.
Women and their family members
should be instructed in glucagon During delivery, a constant low-
administration. dose insulin infusion is usually
preferred, and the usual sc
Amount and type of insulin should administration of insulin is
be individualized. In the AM, 2/3 stopped. If induction is planned,
of total dose (60% NPH, 40% the usual pm NPH insulin dose is
regular) is taken; in the PM, 1/3 given on the day before induc-
(50% NPH, 50% regular) is tion.
taken.‡
Postpartum and continuing diabetes
Fetal monitoring with nonstress care should be arranged.
tests, biophysical profiles, and Postpartum insulin requirements
kick counts should be done may decrease by up to 50%.
weekly from 32 wk to delivery
(or earlier if indicated).
Type 2*
Hyperglycemia is For overweight women, diet and Management is the same as for
controlled. caloric intake are individualized type 1.
Risk is lowest if and monitored to avoid weight
Hb A1c levels are gain of > 9 kg; daytime snacks
≤ 8% at concep- are discouraged.
tion.† Moderate walking after meals is
Weight loss is recommended.
encouraged Women are instructed in and
if BMI is > should do plasma glucose self-
27 kg/m2. monitoring.
The diet should The 2-h postbreakfast plasma glu-
be low in fat, cose level is checked weekly at
relatively high in clinic visits.
complex carbo- Hb A1c level should be checked
hydrates, and every trimester.
high in fiber.
The amount and type of insulin
Exercise is should be individualized. Regular
encouraged. insulin is taken before each meal:
2/3 of total dose (60% NPH, 40%
regular) is taken in the AM; 1/3
(50% NPH, 50% regular) is taken
in the PM.
Fetal monitoring with nonstress
tests, biophysical profiles, and
kick counts should be done
weekly from 32 wk to delivery
(or earlier if indicated).
 THE SECTION Gynecology and Obstetrics

MERCK MANUALS FOR HEALTHCARE

SUBJECT
TOPIC
Pregnancy Complicated by Disease
Diabetes Mellitus in Pregnancy
ONLINE MEDICAL LIBRARY PROFESSIONALS

MANAGEMENT OF DIABETES MELLITUS

DURING PREGNANCY—Continued

Care Before
Conception Prenatal Care Labor and Delivery

Gestational
Women who have Diet and caloric intake are individ- Vaginal delivery at term is possible
had gestational ualized and monitored to prevent if women have a well-document-
diabetes in previ- weight gain of > 9 kg. ed delivery date and good dia-
ous pregnancies Moderate exercise after meals is betic control.
should try to recommended. 2nd-trimester amniocentesis for
reach a normal genetic testing may not be
weight and Insulin therapy is reserved for per-
sistent hyperglycemia (fasting required. 3rd-trimester amnio-
engage in modest centesis to determine fetal lung
exercise. plasma glucose > 95 mg/dL or
2-h postprandial plasma glucose maturity may be done to help
The diet should be > 120 mg/dL) despite a trial of determine the optimal timing for
low in fat, rela- dietary therapy for ≥ 2 wk. elective delivery.
tively high in Cesarean delivery should be
complex carbohy- The amount and type of insulin
should be individualized. Regular reserved for obstetric indications
drates, and high or fetal macrosomia (> 4500 g),
in fiber. insulin is taken before each meal:
2
/3 of total dose (60% NPH, 40% which increases risk of shoulder
Fasting plasma glu- regular) is taken in the AM; 1/3 dystocia.
cose and Hb A1c (50% NPH, 50% regular) is taken Delivery should occur by 38–40
levels should be in the PM. wk.
checked.
Fetal monitoring with nonstress
tests, biophysical profiles, and
kick counts should be done
beginning at 32–34 wk (or earlier
if indicated) and continued until
delivery for women who require
insulin.

*Guidelines are only suggested; marked individual variations require appropriate adjustments.
†
Normal values may differ depending on laboratory methods used.
‡
Hospital programs may recommend up to 4 insulin injections daily. Continuous sc insulin infu-
sion, which is labor-intensive, can sometimes be given in specialized settings.
ADA = American Diabetes Association; BMI = body mass index; Hb A1c = glycosylated Hb;
NPH = neutral protamine Hagedorn.