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Glycemic Control During Labor and Delivery: A Survey Of Academic Centers in the United States
Abstract Number: 193
Abstract Type: Original Research
Introduction: Significant controversy surrounds the management of blood glucose levels (BGL) during labor and delivery. The American College of Obstetrics and Gynecology (ACOG) has recommended “tight” blood glucose control (BGL <110 mg/dL). However, there is concern that tight control can increase the incidence of maternal hypoglycemia. Thus, there remains a lack of consensus regarding glycemic control during labor and delivery. To assess current intrapartum glycemic management, we surveyed obstetrical residency programs in the United States.
Methods: Questionnaires were distributed via email and if there was no response within 3 weeks, they were mailed to obstetrics/gynecology residency program directors.
Results: Of the 117 questionnaires distributed, 49 responses (41.9%) were received, but one was excluded, as it was incomplete. 75% of the responders have a moderate-to-large annual delivery volume (i.e., 1500-5000 deliveries/year). Obstetricians primarily manage BGL during labor and 85% have a written protocol for intrapartum glycemic management. However, in the OR, BGL are primarily managed by anesthesiologists, in collaboration with the obstetricians. 58% of responders instruct patients not to take oral hypoglycemic medications on the day of elective cesarean delivery and/or labor induction, while 67% instruct patients not to take long-acting insulin. 58% maintain BGL <110 mg/dL, while 29% maintain BGL between 110-150 mg/dL and the remaining 13% maintain BGL >200 mg/dL. 57% of responders routinely employ a continuous insulin infusion for maintenance of target BGL, 83% start insulin at a BGL between 100-120 mg/dL and 85% use glucose-containing solutions when starting insulin. 85% of management decisions aimed at maintaining “tight” intrapartum glycemic control were primarily based upon concerns for acute neonatal well-being. Of the 42% who maintain BGL >110 mg/dL, the primary reason (46%) is to avoid maternal hypoglycemia.
Discussion: The key finding of our survey is that there is significant variation in blood glucose management during labor and delivery. The ACOG recommendations were primarily based upon the position statement of the American College of Endocrinology (ACE) . However, ACE has recently recommended that the BGL in hospitalized patients be maintained between 140-180 mg/dL due to concerns of hypoglycemia and the lack of benefit from “tight” control . This explains the confusion amongst practitioners with regard to intrapartum target BGL.
Properly conducted trials are necessary to assess the optimal intrapartum target BGL, approaches to achieving this target BGL; and management of factors that would influence BGL such as management of antidiabetic meds (oral and/or insulin) preadmission and on admission, therapies during labor if applicable, fluid management, and optimal monitoring intervals.
References:  Obstet Gynecol 2005; 105: 675-85.  Diabetes Care 2009; 32: 1119-31.  Endocr Pract 2004