Ketones may also occur when there isn’t enough glucose in the bloodstream. These so-called starvation ketones may happen to women with preexisting diabetes as well as to those with gestational diabetes. If there is not enough food (glucose) in your system to meet your needs and those of your baby, the body will resort to using fat for energy and consequently produce ketones. In this case, your medical team may advise you to increase the amount of calories and carbohydrate in your meals and snacks.
Prompt troubleshooting. As mentioned earlier, if insulin delivery by an insulin pump is disrupted for any reason, high blood glucose can occur quickly. In this case, prompt action is needed. An injection of rapid- or short-acting insulin is usually needed to lower blood glucose until delivery of insulin with the pump is resumed. The insulin pump should never be disconnected for any significant length of time unless under specific direction from the physician. Frequent blood glucose monitoring is helpful to quickly detect any otherwise undetected interruption in insulin infusion.
Hypoglycemia also requires prompt treatment. Symptoms of hypoglycemia include weakness, shakiness, sweating, and dizziness. If these symptoms occur, ideally you should check your blood glucose level to verify that it is low. If hypoglycemia is not corrected promptly, the blood glucose level may continue to drop, preventing your brain from functioning efficiently and in some cases leading to seizures or unconsciousness.
Treatment for hypoglycemia is usually the consumption of 15 grams of carbohydrate, the amount in about three glucose tablets, one tube of glucose gel, or 4 ounces of fruit juice. A hormone called glucagon, which is given by injection, is available by prescription to treat severe hypoglycemia when a person is unable to eat or drink a carbohydrate source. Discuss proper indications and use of glucagon with your diabetes management team.
Infusion site considerations
Because the skin has a tendency toward dryness during pregnancy, you may be more likely to experience irritation at your infusion site, possibly as a result of the adhesive on the infusion set, the material the infusion set is made of, or simply leaving a set in too long. Because irritation can lead to infection, meticulous care of the infusion site is necessary. You should change your infusion set every 24–48 hours and use your set changes as an opportunity to observe your skin and infusion site. If skin irritation occurs in spite of frequent infusion set changes, work with your diabetes team to determine the cause and treatment. As your pregnancy progresses, you may want to try an insertion site other than your abdomen, or you may want to try an infusion set requiring a different angle of insertion from your usual set.
When the baby arrives
Ideally, you should discuss blood glucose control during labor and delivery—both target goals and method of insulin delivery—with your endocrinologist before you go into labor. Because blood glucose in excess of 120 mg/dl will stimulate the fetal pancreas to produce insulin, making hypoglycemia in the baby a possibility after he or she is born, it is important that your blood glucose level be kept in a lower range. To free you from the responsibility of managing your insulin pump during this time, your endocrinologist may recommend disconnecting your insulin pump and starting an intravenous insulin drip instead. Insulin delivery via an insulin drip can be modified based on blood glucose readings. Typically, insulin requirements decrease to 0 at the onset of active labor. An intravenous glucose infusion can be used to maintain caloric requirements.
Insulin requirements generally remain very low or decrease immediately after delivery. However, the amount of insulin needed immediately after delivery may depend on the type of delivery. Labor leading to a vaginal delivery is an intense, active process that can cause lowering of blood glucose level in the mother. A cesarean section, on the other hand, is a surgical procedure, which can be stressful to the body and may raise the blood glucose level. In either case, a substantial weight loss occurs at delivery, and the pregnancy hormones that have raised blood glucose levels are diminished, so insulin pump basal rates and bolus amounts must be recalculated at that time. Talk with your physician about this process so you know what to expect. Frequent blood glucose monitoring is recommended to assist with individualizing pump rates and to accommodate other factors such as breast-feeding following delivery.