Diabetes, Steroids (Glucocorticoids) for Fetal Lung Maturation in Pregnancy (363)
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Background: in all women with diabetes in pregnancy (gestational or pre- gestational) use of antenatal glucocorticoids will result in resistance to insulin, a need for increased insulin doses and potentially onset of ketoacidosis unless diabetes is managed appropriately. All women should be checking blood glucose regularly as per local management plans and be able to test for ketones at home. Women on diet alone or metformin also require this monitoring and may require commencement of insulin.
Women should be advised:
1) Of plan for admission to hospital: depending on local management plans this will usually involve admission at time of, or 12-24 hours after, first glucocorticoid dose for monitoring of blood sugars, ketones and intravenous sliding scale as necessary
2) Of either:
- prospective increase subcutaneous insulin (see below) or
- planned commencement IV sliding scale
A.Prospective increase in insulin doses in women on insulin treatment for gestational, type 1 or type 2 diabetes
- After glucocorticoids insulin doses will need to be increased
- Medical staff may use the following algorithm to prescribe insulin depending on response on a day by day basis (i.e. no more than 24 hours in advance) if the patient is on 4 times daily insulin injections.
- For women using an insulin pump a similar increase in both basal and bolus doses will be planned with medical or nursing staff
Further adjustment in dose will be needed depending on response
Record baseline insulin doses
|
|
Betamethasone |
insulin dose (units) |
|
1 |
12mg im |
doses 8-24 hours later on same day increased 10% (short acting) or 25% (long acting) over baseline |
|
2 |
12 mg im |
all doses increased by 40% over baseline |
|
3 |
|
all doses increased by 40% over baseline |
|
4 |
|
all doses increased by 20% over baseline |
|
5 |
|
all doses increased by 10% over baseline |
|
6 + 7 |
|
reduce to baseline |
- If fingerstick blood glucose >12mmol/l OR urinary ketones >1+ OR blood ketones >0.3mmol/l consider sliding scale (see below).
B.Sliding Scale for Diabetes with Glucocorticoids
- site an i.v., start 1 litre of 5% dextrose with 20mmol of Potassium Chloride to be run over 10 hours i.e. 100mls/hr.
- start insulin via infusion pump using 50units soluble insulin in 50mls normal saline
- check blood sugars hourly and adjust via sliding scale.
- plasma potassium (U&E’s) should be monitored 6-12 hourly while on sliding scale. Venous bicarbonate every 24 hours. Unless directed, patient’s basal insulin ( eg Lantus, Levemir, Insulatard, Humulin I) should be continued whilst on sliding scale.
- Where a sliding scale is set up and the patient is still eating subcutaneous boluses of short acting insulin will still be necessary.
Sliding scale for Diabetes with Glucocorticoids
|
Capillary Blood glucose |
Insulin |
Revision of sliding scale if required |
Revision of sliding scale if required |
|
0.0-4.0 |
0- check for signs of hypoglycaemia |
|
|
|
4.1-7.0 |
1 |
|
|
|
7.1-10.0 |
2 |
|
|
|
10.1-14.0 |
3 |
|
|
|
> 14.0 |
6 |
|
|
|
|
Signed |
Signed |
Signed |
|
Date/ Time |
Date/ Time |
Date/ Time |
|
|
If Capillary Blood glucose > 14 mmol/l for 2 consecutive hours despite sliding scale contact diabetic/medical registrar for revision of sliding scale. Note typical revision Glucose TOO HIGH: check insulin being delivered 0.0-4.0, 0 units per hour; 4.1-7.0, 1.5 units per hour; |
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