Diabetes, Steroids (Glucocorticoids) for Fetal Lung Maturation in Pregnancy (363)

Objectives

This guideline covers management of women with diabetes in pregnancy who require the use of antenatal glucocorticoids for fetal lung maturation. It aims to improve care and ensures quicker and more accurate diagnosis for any adverse outcomes that may arise and specify the most effective treatment.

Scope

GGC Maternity staff

This guidance is written for the benefit of all staff involved in caring for pregnant women with diabetes- who have been administered with Steroids (glucocorticoids) for fetal lung maturation, this includes obstetricians, midwives and any other members of the maternity multi-disciplinary team.

Audience

All midwives, obstetric staff and anyone else providing clinical care or guidance to women who have been administered with Steroids (glucocorticoids) for fetal lung maturation, should observe to the guidelines and ensure that local protocols and medical advice from specialist is sought.

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In all women with diabetes in pregnancy (gestational, type1 or type II) 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 levels 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.

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 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 when glucocorticoids used. Women on diet alone or metformin also require this monitoring and may require commencement of insulin after glucocorticoids.

Women should be advised:

Planned Steroids from Clinic;
Planned admission;
Emergency admission.

1. planned steroids from clinic with prospective increase in subcutaneous insulin

Prospective increase in insulin dose in women on insulin treatment for gestational, type1 or type2 diabetes

After glucocorticoids insulin dose 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 24hrs in advance) if the patient is on 4 times daily insulin.
For women using an insulin pump a similar increase in both basal and bolus doses will be planned with medical or nursing staff. Note that for women using a hybrid closed loop system the system will facilitate increased basal insulin but bolus ratios will need to be increased.

(Further adjustments in dose will be required depending on response)

Record baseline insulin dosage

Day	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

For example: with betamethasone at 12 noon on day 1 & 2
	Short acting (units) (pre b’fast, lunch, tea)	long acting (units) (bedtime/10pm)
Baseline	10, 10, 14	24
Day 1	10, 10, 14	30
Day 2	14, 14, 20	34
Day 3	14, 14, 20	34
Day 4	12, 12, 16	30
Day 5	12, 10, 16	26
Day 6&7	Back to baseline doses

2. Planned admission to hospital

Depending on local management plans this will usually involve admission at time, or 12-24 hours after, first glucocorticoids dose for monitoring of blood sugars, ketones and VRIII (Variable Rate Intravenous Insulin Infusion) as necessary.

3. Emergency admission to hospital

Post administration of Glucocorticoids, Capillary Blood Glucose monitoring should be commenced immediately, every 2hours with GGC equipment (do not use glucose readings from Freestyle Libre or continuous glucose monitoring (CGM) devices.

Capillary Blood Glucose Targets:

Outside labour CBG target 4 - 10mmol/L
During active labour CBG target 5 - 8mmol/L

If CBG >10mmol/L OR urinary ketones >1+ OR blood ketones >0.6mmol/L consider VRIII (see VRIII chart)

VRIII (formerly Sliding Scale)

Site IV cannula
Using an insulin syringe, draw up 50 units of soluble insulin (Actrapid® or Humulin S®) and add 49.5ml of 0.9% sodium chloride in a 50ml luer-lock syringe. Prepared concentration is 1 unit/ml
Secure a standard giving set to IV fluids (10mmol potassium chloride – 0.45% sodium chloride + 5% glucose + 0.15% potassium chloride) @100mls/hr
Obtain CBG (and thereafter every hour)
Commence both insulin pump with VRIII fluids at appropriate rate as below
U&E’s should be obtained 4 hours post commencement of VRIII and thereafter 6-12hrs (appropriate fluids to be prescribed as per potassium levels, see fluid chart below)
Women’s long-acting insulin should continue and if the women is well and remains eating, mealtime bolus of short-acting insulin should continue (unless advised otherwise) (premixed insulin should not be administered whilst on VRIII)

Capillary bloods Glucose (CBG) mmol/l	Insulin Infusion Rate (units/hour)
	Recommended initial rate	Alternative rate
<4 (see * below)	0 (if long acting insulin given) 0.5 (if long acting insulin not given)	(only to be used by specialist medical staff)
4-7	1
7.1 – 9	2
9.1 – 11	3
11.1 – 14	4 (check ketones if Type1)
14.1 – 17	5 (check ketones if Type1)
17.1 – 20	6 (check ketones if Type1)
>20	Seek senior medical advice (check ketones
*CBG <4.0 mmol/L: Treat as per Acute Hypo glycaemia Guideline (switch off VRIII)

Fluid chart

Plasma potassium	Prescribe a VRIII IV infusion bag with:	Examples of 500ml pre-prepared infusion bags
<3.5mmol/L	20mmol potassium chloride	0.45% sodium chloride + 5% glucose + 0.3% potassium chloride
3.5 – 5mmol/L	10mmol potassium chloride	0.45% sodium chloride + 5% glucose + 0.15% potassium chloride
5 mmol/L or women is anuric	Zero potassium	0.45% sodium chloride + 5% glucose +

Last reviewed: 28/08/2024

Next review date: 28/08/2027

Author(s): Robbie Lindsay.

Version: 4

Approved By: Maternity Clinical Governance Group

Document Id: 363