© IDF (Europe) 1998

19 Pregnancy and contraception
20 Surgery and diabetes
21 Ketoacidosis

TYPE 1 DIABETES - 19 - PREGNANCY AND CONTRACEPTION

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19 PREGNANCY AND CONTRACEPTION

Enquire :

• as to need for contraceptive advice if pregnancy not intended

Advise :

• on barrier methods, or low-dose oral contraceptives if low arterial risk
• not to discontinue contraception until adequate metabolic control achieved

Enquire as part of Annual Review as to pregnancy intentions :

• emphasize repeatedly the need for pregnancy planning
• educate about diabetic pregnancy, including risks to fetus

Start folic acid 400 µg daily

Stop statins

Optimize blood glucose control ( Sections 9-13 ) :

• targets :

  pre-prandial	: 3.5-5.5 mmol/l ( 65-100 mg/dl )
  post-prandial	: 5.0-8.0 mmol/l ( 90-145 mg/dl )

• recommend highly purified human / pork insulin preparations

Assess and normalize blood pressure :

• replace ACE inhibitors with methyldopa / nifedipine / labetolol

Assess retina and treat as indicated

Review education and repeat as needed

Urge to stop smoking

19.3 Pregnancy care

Organize joint obstetric care in a designated centre :

• include a diabetologist, a diabetes teaching nurse, a dietician, an obstetrician, a midwife, and a neonatologist

Provide support for continuing good blood glucose control :

• frequent review ( every 1-2 weeks )
• appropriate educational support
• regular self-monitoring of blood glucose with reliable system
• target blood glucose as close to normal as possible, while avoiding hypoglycaemia

fasting blood glucose	: 3.5-5.5 mmol/l ( 65-100 mg/dl )
post-prandial blood glucose	: 5.0-8.0 mmol/l ( 90-145 mg/dl )
glycated haemoglobin close to the upper limit of normal

• multiple insulin injection regimen with highly purified human / pork insulin
• food intake
• adequate to maintain maternal and fetal nutrition
• frequent small meals may facilitate improved blood glucose control

Examine eyes each trimester

Provide regular obstetric care :

• ultrasound examination early and repeated for dates and fetal malformation
• fetal monitoring in later stages
• frequent antenatal review

Provide a normal safe delivery :

• deliver at term unless obstetric or diabetes risk
• deliver vaginally unless obstetric or diabetes risk
• provide optimal neonatal care :
• access to specialized neonatal intensive care
• neonatologists warned of expected delivery
• good blood glucose control during / after labour
• IV infusion of glucose and insulin with frequent blood glucose measurement
• rapid return to pre-pregnancy insulin requirements at delivery

Provide easily accessible advice for post-pregnancy blood glucose control

Caution about hypoglycaemia risk if breast feeding; may need further insulin dose reduction

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TYPE 1 DIABETES - 19 - PREGNANCY AND CONTRACEPTION

TYPE 1 DIABETES - 20 - SURGERY

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20 MANAGEMENT OF DIABETES DURING SURGERY

20.1 Organization

Prepare a local care protocol

Disseminate the protocol to relevant professionals

20.2 Management

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TYPE 1 DIABETES - 20 - SURGERY

TYPE 1 DIABETES - 21 - KETOACIDOSIS

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21 MANAGEMENT OF DIABETIC KETOACIDOSIS

21.1 Organization

Prepare a local care protocol

Disseminate the protocol to relevant professionals

21.2 Management

Fluid replacement :

• give 2 litres of isotonic saline ( 0.15 mol/l ) over the first 4 h
• give 2 litres over the next 8 h, then 1 litre every 8 h
• consider colloid if systolic blood pressure <100 mmHg after 2 h
• use hypotonic saline only very cautiously ( plasma Na⁺ >155 mmol/l, 1 litre over 8 h )
• monitor central venous pressure if cardiac disease
• be more cautious in the elderly

Insulin :

• infuse initially at 6 U/h ( alternatively 20 U IM followed by 6-10 U each hour )
• check pump and infusion lines and double dose if no response in 2 h

Potassium :

• give 20 mmol/h from the time of initiation of insulin infusion
• discontinue temporarily if laboratory K⁺ >6.0 mmol/l
• check every 2.0 h as a routine
• if potassium falls to <4.0 mmol/l, increase accordingly
• continuously monitor ECG

Bicarbonate :

• only use if pH is 6.9 or less
• if indicated, give 100 mmol with 20 mmol K⁺ over 30 min
• repeat blood gases and plasma K⁺ 30 min later

Infection :

• arrange urinalysis, chest X-ray, blood cultures
• do not rely on temperature and leucocytosis
• use antibiotics even if uncertain

General care

• when glucose <13.0 mmol/l (<230 mg/dl ) :
• start glucose-insulin-potassium regimen :

500 ml 10 % glucose ( dextrose ) + 24 U insulin + 20 mmol K⁺, at 80 ml/h
• aim for blood glucose 10.0-13.0 mmol/l ( 180-230 mg/dl ) by change of insulin dose
• start SC insulin therapy when able to eat
• insert a nasogastric tube if the patient is comatose
• insert a urinary catheter if no urine passed within 3 h
• heparinize if coma, hyperosmolar, other risk factors

Review cause to reduce risk of recurrence

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TYPE 1 DIABETES - 21 - KETOACIDOSIS

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