Comparison of IV insulin infusion vs CSII in managing intrapartum glycemia

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A recent study found no significant difference in neonatal hypoglycemia risk between intravenous insulin infusion and continuous subcutaneous insulin infusion for intrapartum glycemic control in pregnant individuals with type 1 diabetes mellitus.

Comparison of IV insulin infusion vs CSII in managing intrapartum glycemia | Image Credit: © Davizro Photography - © Davizro Photography - stock.adobe.com.

Comparison of IV insulin infusion vs CSII in managing intrapartum glycemia | Image Credit: © Davizro Photography - © Davizro Photography - stock.adobe.com.

Neonatal hypoglycemia risk does not differ between the use of intravenous (IV) insulin infusion or continued use of continuous subcutaneous insulin infusion (CSII) for intrapartum insulin in pregnant individuals with type 1 diabetes mellitus (T1DM), according to a recent study published in the American Journal of Obstetrics & Gynecology.

Takeaways

  1. Pregnant individuals with Type 1 Diabetes Mellitus (T1DM) are at increased risk for various adverse perinatal outcomes, including neonatal hypoglycemia, retinopathy, diabetic ketoacidosis, stillbirth, and more.
  2. A recent randomized clinical trial compared neonatal blood glucose levels in pregnant patients with T1DM receiving either continuous subcutaneous insulin infusion (CSII) or intravenous (IV) insulin infusion for intrapartum glucose management.
  3. The study involved 70 pregnant individuals using CSII. Results showed that the first neonatal blood glucose measurement after birth did not differ significantly between those on CSII and those on IV infusion. Moreover, the odds of neonatal hypoglycemia were similar regardless of the method of insulin administration.
  4. No adverse safety events were reported in either the CSII or IV infusion group. A data safety and monitoring board oversaw participant safety, recommending IV insulin infusion for those developing persistent hyperglycemia, hypoglycemia, diabetic ketoacidosis, or neonatal hypoglycemia.
  5. The study suggests that continuing with CSII for intrapartum glycemic management is as effective and viable as transitioning to IV insulin infusion for pregnant patients with T1DM. As such, clinicians are advised to consider continued CSII intrapartum for these patients when it's feasible.

One percent to 2% of pregnancies are impacted by pregestational diabetes. During pregnancy, the quality of glycemic control is impacted because of placental hormone expression.

Adverse perinatal outcomes such as hypoglycemia, retinopathy and nephropathy, diabetic ketoacidosis, congenital anomalies, stillbirth, macrosomia, cesarean delivery, polyhydramnios, and hypertensive disorders of pregnancy are especially more likely in patients with T1DM and poor glycemic control. The risk of neonatal hypoglycemia is also increased in these patients.

Intrapartum glucose management is critical to decrease neonatal hypoglycemia after birth. However, it is unclear which mode and range of intrapartum glycemic control are optimal, and the preference for continued use of CSII or transition to IV insulin infusion varies between providers.

To compare neonatal blood glucose levels after birth in pregnant patients with T1DM receiving continued CSII for glucose management vs IV insulin infusion, investigators conducted a randomized clinical trial from March 2021 to April 2023.

Participants included pregnant individuals aged 18 years and older diagnosed with T1DM and managed with CSII.After admission, participants were randomized to receive intrapartum CSII or IV insulin infusion.

Exclusion criteria included being aged under 18 years, having multiple gestations, having an altered state of consciousness intrapartum, needing intensive care unit admission for critical illness, at risk of suicide, being unable to partake in care, and having diabetic ketoacidosis on admission for delivery, an intrauterine fetal demise before labor, or fetal anomalies.

A data safety and monitoring board evaluated participant safety, identifying persistent hyperglycemia, hypoglycemia, diabetic ketoacidosis development, and neonatal hypoglycemia. Patients developing these conditions were recommended to transition to IV insulin infusion.

The first neonatal blood glucose level after birth was measured as the primary outcome of the analysis. Blood glucose level measurements under 40 mg/dL were used to identify neonatal hypoglycemia.

Secondary outcomes included mean neonatal glucose in the first 24 hours of life, neonatal hypoglycemia oral or IV treatments, 5-minute Apgar score below 7, neonatal intensive care unit admission, neonatal birthweight, large for gestational age, and additional adverse neonatal outcomes. Maternal demographic and clinical characteristics were obtained from medical records.

There were 70 pregnant individuals using CSII included in the final analysis, with similar age, race and ethnicity, nulliparity, third-trimester hemoglobin A1c, pregravid body mass index, and gestational age at delivery observed between groups. Public insurance was reported in 62.9% of the IV insulin infusion group vs 31.4% of the CSII group.

Intrapartum CSII was associated with a history of cesarean delivery, having a previous large for gestational age infant, and a longer duration of T1DM, with rates of 45.7%, 34.3%, 19.7±6.5 years, respectively. In the IV insulin infusion group, these rates were 17.1%, 8.6%, and 14.1±8.5 years, respectively. No adverse safety events were reported in either group.

The first neonatal glucose measurement did not significantly differ between the 2 groups. Oral, IV, or both treatments for hypoglycemia were necessary in 57.1% of neonates in the CSII group vs 51.4% in the IV infusion group. 

Necessary IV treatment for hypoglycemia was reported in 28.6% of neonates in both groups. The odds of developing neonatal hypoglycemia did not differ based on intrapartum insulin administration method.

These results indicated continuation of CSII for intrapartum glycemic management is viable compared to switching to IV insulin infusion for pregnant patients with T1DM. Investigators concluded that clinicians should consider offering continued CSII intrapartum to pregnant patients with T1DM when feasible.

Reference

Wilkie GL, Delpapa E, Leftwich HK. Intrapartum continuous subcutaneous insulin infusion vs intravenous insulin infusion among pregnant individuals with type 1 diabetes mellitus: a randomized controlled trial. Am J Obstet Gynecol. 2023;229:680.e1-8. doi:10.1016/j.ajog.2023.07.003

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