Changes in Postpartum Insulin Requirements for Patients with Well-Controlled Type 1 Diabetes

Abstract

Objective To compare postpartum with preconception insulin doses in well-controlled (HbA_1c ≤ 7.4%) type 1 diabetes mellitus (T1DM) and to characterize differences in postpartum insulin dosing based on infant feeding.

Study Design The primary outcome in this retrospective cohort was the change in total daily insulin (TDI) from preconception to postpartum. Insulin administration (continuous subcutaneous insulin infusion [CSII] vs. multiple daily injections [MDI]), HbA_1c, body mass index (BMI), and infant feeding were abstracted.

Results We identified 44 women with T1DM and HbA_1c ≤ 7.4%. Preconception mean BMI was 24.6 ± 3.6 kg/m² and median (interquartile range [IQR]) HbA_1c was 6.4 (6.0–6.9)%. Of these, 73% used CSII and 27% used MDI. Additionally, 80% of patients reported exclusive breastfeeding, 7% were exclusively formula feeding, and 13% used both breast milk and formula. Median (IQR) preconception TDI was 0.64 (0.49–0.69) U/kg/day, and postpartum: 0.39 (0.30–0.50) U/kg/day. Postpartum TDI was 34% lower than preconception TDI (p = 0.02). There was no difference in the postpartum TDI in patients who were breast versus formula feeding or when comparing CSII with MDI.

Conclusion There was a significant decrease in the TDI required postpartum when compared with preconception. Dosages do not seem to be impacted by administration route or breastfeeding. These findings warrant consideration when dosing postpartum insulin in patients with T1DM.

Keywords

insulin dosing - postpartum insulin requirements - type 1 diabetes - preconception insulin doses

• References

• 1 Maahs DM, West NA, Lawrence JM, Mayer-Davis EJ. Epidemiology of type 1 diabetes. Endocrinol Metab Clin North Am 2010; 39 (3) 481-497
• 2 Yoon JW, Jun HS. Autoimmune destruction of pancreatic beta cells. Am J Ther 2005; 12 (6) 580-591
• 3 Temple R, Aldridge V, Greenwood R, Heyburn P, Sampson M, Stanley K. Association between outcome of pregnancy and glycaemic control in early pregnancy in type 1 diabetes: population based study. BMJ 2002; 325 (7375) 1275-1276
• 4 Gonzalez-Gonzalez NL, Ramirez O, Mozas J , et al. Factors influencing pregnancy outcome in women with type 2 versus type 1 diabetes mellitus. Acta Obstet Gynecol Scand 2008; 87 (1) 43-49
• 5 ACOG Committee on Practice Bulletins. ACOG Practice Bulletin. Clinical Management Guidelines for Obstetrician-Gynecologists. Number 60, March 2005. Pregestational diabetes mellitus. Obstet Gynecol 2005; 105 (3) 675-685
• 6 Handwerger S, Freemark M. The roles of placental growth hormone and placental lactogen in the regulation of human fetal growth and development. J Pediatr Endocrinol Metab 2000; 13 (4) 343-356
• 7 Lønberg U, Damm P, Andersson AM , et al. Increase in maternal placental growth hormone during pregnancy and disappearance during parturition in normal and growth hormone-deficient pregnancies. Am J Obstet Gynecol 2003; 188 (1) 247-251
• 8 Ryan EA. Hormones and insulin resistance during pregnancy. Lancet 2003; 362 (9398) 1777-1778
• 9 Steel JM, Johnstone FD, Hume R, Mao JH. Insulin requirements during pregnancy in women with type I diabetes. Obstet Gynecol 1994; 83 (2) 253-258
• 10 Langer O, Anyaegbunam A, Brustman L, Guidetti D, Levy J, Mazze R. Pregestational diabetes: insulin requirements throughout pregnancy. Am J Obstet Gynecol 1988; 159 (3) 616-621
• 11 García-Patterson A, Gich I, Amini SB, Catalano PM, de Leiva A, Corcoy R. Insulin requirements throughout pregnancy in women with type 1 diabetes mellitus: three changes of direction. Diabetologia 2010; 53 (3) 446-451
• 12 Riviello C, Mello G, Jovanovic LG. Breastfeeding and the basal insulin requirement in type 1 diabetic women. Endocr Pract 2009; 15 (3) 187-193
• 13 Pregnancy outcomes in the Diabetes Control and Complications Trial. Am J Obstet Gynecol 1996; 174 (4) 1343-1353
• 14 Combs CA, Gunderson E, Kitzmiller JL, Gavin LA, Main EK. Relationship of fetal macrosomia to maternal postprandial glucose control during pregnancy. Diabetes Care 1992; 15 (10) 1251-1257
• 15 American Diabetes Association. Standards of medical care in diabetes—2014. Diabetes Care 2014; 37 (Suppl. 01) S14-S80
• 16 Moore T. Diabetes in Pregnancy. Creasy & Resnik's Maternal-Fetal Medicine Principles and Practice. 7th ed. Philadelphia, PA: Elsevier Saunders; 2014: 988-1021
• 17 Davies HA, Clark JD, Dalton KJ, Edwards OM. Insulin requirements of diabetic women who breast feed. BMJ 1989; 298 (6684) 1357-1358
• 18 Mintz DH, Stock R, Finster JL, Taylor AL. The effect of normal and diabetic pregnancies on growth hormone responses to hypoglycemia. Metabolism 1968; 17 (1) 54-61
• 19 Singer F, Horlick M, Poretsky L. Recovery of beta-cell function postpartum in a patient with insulin-dependent diabetes mellitus. N Y State J Med 1988; 88 (9) 496-498
• 20 Madsbad S, Krarup T, Reguer L, Faber OK, Binder C. Effect of strict blood glucose control on residual B-cell function in insulin-dependent diabetics. Diabetologia 1981; 20 (5) 530-534
• 21 Butler AE, Cao-Minh L, Galasso R , et al. Adaptive changes in pancreatic beta cell fractional area and beta cell turnover in human pregnancy. Diabetologia 2010; 53 (10) 2167-2176
• 22 Ilic S, Jovanovic L, Wollitzer AO. Is the paradoxical first trimester drop in insulin requirement due to an increase in C-peptide concentration in pregnant Type I diabetic women?. Diabetologia 2000; 43 (10) 1329-1330
• 23 Nielsen LR, Rehfeld JF, Pedersen-Bjergaard U, Damm P, Mathiesen ER. Pregnancy-induced rise in serum C-peptide concentrations in women with type 1 diabetes. Diabetes Care 2009; 32 (6) 1052-1057
• 24 Berg M, Erlandsson LK, Sparud-Lundin C. Breastfeeding and its impact on daily life in women with type 1 diabetes during the first six months after childbirth: a prospective cohort study. Int Breastfeed J 2012; 7 (1) 20
• 25 Kjos SL. Postpartum care of the woman with diabetes. Clin Obstet Gynecol 2000; 43 (1) 75-86