Inpatient management of pregnancy and type 1 diabetes

Inpatient management of pregnancy and type 1 diabetes
Inpatient management of pregnancy and type 1 diabetes

A patient, aged 33 years, with a history of type 1 diabetes for 10 years, presented to the hospital. She was admitted to the hospital for induction of labor at 38 weeks gestation.

The patient's pre-admission diabetes therapy was insulin pump with insulin aspart (Novalog).

Her insulin pump settings at time of admission were as follows:

Basal

  • Midnight: 0.625 units per hour
  • 3 AM: 0.825 units per hour
  • 7 AM: 0.675 units per hour
  • 7 PM: 0.850 units per hour
  • 10 PM: 0.600 units per hour

Bolus

  • 1 unit per 6 grams carbohydrate consumed (around the clock setting)
  • Sensitivity: 1 unit will drop glucose by 55 mg/dL
  • Blood glucose goal: 80 to 100 mg/dL
  • Active insulin time: 3 hours

The patient's hemoglobin A1C value taken 1 week prior to admission and was 5.6%.

Throughout her pregnancy, the patient worked closely with her outpatient endocrinology nurse practitioner for assistance with insulin dose adjustments.

Read the answer and explanation for Question 1.

There are some reports of lower insulin requirements during the latter part of the first trimester due to an increase in insulin sensitivity, rapid fetal growth, and reduction in oral intake associated with morning sickness.

After this period, insulin requirements often increase significantly with rising hormone levels and weight gain that leads to insulin resistance.

Read the answer and explanation for Question 2.

Following delivery, the patient planned on breastfeeding.

Read the answer and explanation for Question 3.


Question 1: What is known regarding insulin requirements throughout pregnancy?

Answer: D. Insulin requirements often rise significantly throughout pregnancy.

During pregnancy, patients will often experience a significant increase in>insulin requirements due to increases in hormone production and weight gain that lead to increased insulin resistance.

Immediately after delivery, insulin requirements can decrease significantly in patients with type 1 diabetes. Some patients will experience a honeymoon phase, requiring little to no insulin for a brief period of time. In the post-partum period, these patients require close blood glucose monitoring, especially if breastfeeding. There is increased glucose use during breastfeeding, contributing to decreased insulin needs.

Question 2: What are the current recommended glucose goals for the pregnant woman with preexisting type 1 diabetes, according to the American Diabetes Association?

Answer: D. All of the above.

The American Diabetes Association recommends pre-meal, bedtime and overnight glucose values between 60 to 99 mg/dL, post-prandial glucose values between 100 to 129 mg/dL and a hemoglobin A1c <6% without hypoglycemia.

Question 3: What is known regarding breastfeeding and insulin requirements?

Answer: B.

Immediately after delivery, insulin requirements can decrease significantly in patients with type 1 diabetes. Some patients will experience a honeymoon phase, requiring little to no insulin for a brief period of time. In the post-partum period, these patients require close blood glucose monitoring, especially if breastfeeding. There is increased glucose use during breastfeeding, contributing to decreased insulin needs.

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