Diabetes mellitus, a disease of elevated blood glucose secondary to insulin resistance or insulin deficiency, is a common complication of pregnancy, leading to significant maternal and fetal complications if inadequately treated. Diabetes is estimated to affect up to 7% of pregnant women, with 86% of those cases representing gestational diabetes.[1] Women with diabetes have a higher risk of cesarean delivery and preeclampsia. Mothers with gestational diabetes are also more likely to develop type 2 diabetes and cardiac disease later in life.[1] Infants born to mothers with diabetes are at higher risk for macrosomia, neonatal hypoglycemia, hyperbilirubinemia, shoulder dystocia, birth trauma, and stillbirth.[1] Pregestational diabetes also carries the additional risks of diabetic retinopathy and diabetic ketoacidosis (DKA) in the mother and major congenital abnormalities in the fetus.[2] OB/GYN hospitalists are uniquely positioned to diagnose DKA in patients presenting to the Obstetric ED or Obstetric Triage Unit, maintain a high index of suspicion for symptoms of euglycemic and hyperglycemic DKA and hyperosmolar hyperglycemia, and changes in the fetal heart rate patterns suggesting DKA. OB/GYN hospitalists can use evidence-based approaches to optimize glucose control during labor, as well as during the antepartum and postpartum periods. OB/GYN hospitalists can lead multidisciplinary teams to develop institutional guidelines and protocols for the management of diabetes in labor, including intravenous insulin infusion, glucose monitoring, and hypoglycemia management that will optimize maternal and fetal outcomes.

Knowledge

OB/GYN hospitalists should be able to:

• Define gestational diabetes and pregestational diabetes and list the prevalence of and risk factors for each disorder.
• Explain the maternal and fetal complications associated with both gestational and pregestational diabetes.
• Describe the pathophysiology of diabetes (differentiating type 1, type 2, and gestational) and explain the alterations in carbohydrate metabolism that occur during pregnancy.
• Explain the antenatal screening and diagnostic criteria recommended by the American College of Obstetricians and Gynecologists for both gestational and pregestational diabetes.
• List the types of insulin and insulin delivery systems available to pregnant women and state their dosing intervals and adverse effects.
• List the indications for oral hypoglycemic agents, including both glyburide and metformin, and describe the mechanism of action, dosing intervals, and adverse effects of these medications.
• Summarize the current evidence regarding the use of insulin vs oral hypoglycemic agents and the rationale for choosing one over the other.
• Understand the goals for fasting and postprandial blood glucose levels during pregnancy to enhance patient treatment and education.
• Delineate the treatment of hypoglycemia.
• Describe the management of diabetic ketoacidosis and hyperosmolar hyperglycemic states in pregnancy including laboratory assessment; use of intravenous fluids; and administration of insulin, potassium, and bicarbonate.
• Discuss the expected impact of diabetic ketoacidosis and hyperosmolar hyperglycemia on the fetal heart rate tracing, as well as the recommendation to correct maternal metabolic status to achieve fetal intrauterine resuscitation.
• Describe the management of blood glucose during labor and delivery, including the optimal interval for blood glucose checks and the amount and type of intravenous insulin to be administered.
• Describe the recommendations for antenatal surveillance in pregnancies complicated by gestational and pregestational diabetes.
• Discuss the recommended timing of delivery for pregnant women with diabetes.
• Discuss the special delivery considerations for pregnancies complicated by gestational or pregestational diabetes.
• Discuss the risks of wound infection at the time of cesarean delivery and describe the benefits of euglycemia at the time of surgery.
• Describe the postpartum management of women with diabetes during pregnancy, including follow-up for women with class A1 vs A2 gestational diabetes, in the postpartum admission and after discharge.
• Describe the beneficial effect of breastfeeding for women with a history of gestational diabetes.

Skills

OB/GYN hospitalists should be able to:

• Elicit a thorough and relevant medical history with emphasis on the diagnosis of diabetes (when and how), the presence or absence of diabetes-associated medical conditions, any prescribed diabetes medications, and fasting and postprandial blood glucose control.
• Demonstrate how to calculate a starting insulin dosage and how to titrate insulin during pregnancy.
• Assess patients who present emergently with diabetic ketoacidosis and hyperosmolar hyperglycemia and manage these patients with the primary OB/GYN provider, maternal-fetal medicine physician, and internal medicine or critical care physician.
• Assess patients who present for inpatient management of glucose control and manage or comanage these patients with the primary OB/GYN provider or maternal-fetal medicine physician to calculate and titrate the optimal insulin dosage.
• Assess patients with diabetes who present in labor and manage or comanage these patients with their primary OB/GYN provider or maternal-fetal medicine physician to guide insulin use during labor.
• Communicate with patients and families regarding the plan of care, appropriate diet, medication adverse effects, management of hypoglycemia, and when to notify their physicians.
• Diagnose and manage hypoglycemia.
• Diagnose and manage diabetic ketoacidosis and hyperosmolar hyperglycemia, with special vigilance regarding the possibility of diabetic ketoacidosis with euglycemia in pregnancy.
• Communicate with ancillary staff such as dieticians, nutrition personnel, and pharmacists.
• Critically evaluate a patient with diabetes who may require emergent delivery, describe her candidacy for operative vaginal delivery, and discuss the risk of shoulder dystocia.
• Engage the patient in a discussion regarding her long-term health, subsequent pregnancies, risk of non-gestational diabetes and its sequelae, and the benefits of exercise and weight control.
• Assess patient understanding of the risks of uncontrolled diabetes to herself and to her fetus and document accordingly.
• In the medical record, appropriately document the medical history, physical examination findings, relevant test results, and discussion with the patient regarding the diagnosis, care options, and management plan.

Self-Awareness and Collaborative Attitudes

OB/GYN hospitalists should be able to:

• Provide evidence-based, patient-centered, cost-effective care to patients with diabetes.
• Collaborate and communicate effectively within a multidisciplinary team, including the patient, those who support the patient, nursing staff, anesthesiologists, operating room personnel, maternal-fetal medicine specialists, diabetes educators, nutritionists, and primary OB/GYN provider, to optimize outcomes and the patient experience.
• Follow evidence-based recommendations in the management of patients with diabetes, including management of glucose, antenatal surveillance, and timing and route of delivery.
• Demonstrate awareness of and ability to address patient concerns regarding glucose management, risk of hypoglycemia, and maternal-fetal risks of hyperglycemia.
• Respect the patient’s desires, values, and autonomy.

System Organization and Improvement

OB/GYN hospitalists should be able to:

• Lead, coordinate, and/or participate in efforts to create standard guidelines for the management of diabetes in labor.
• Lead, coordinate, and/or participate in efforts to establish guidelines for timing of delivery for patients with gestational and pregestational diabetes.
• Lead, coordinate, and/or participate in efforts to ensure that patients have the tools to manage diabetes upon discharge and are aware of the signs and symptoms of hypoglycemia.
• Lead, coordinate, and/or participate in educational efforts focused on issues related to diabetes, such as management of severe hypoglycemia, diabetic ketoacidosis and hyperosmolar hyperglycemia.
• Implement quality initiatives related to diabetes and track outcomes of perinatal patients with diabetes.

References