Anesthesia and Metabolic Management Guidelines for Pregnant Patients with Euthyroid Hashimoto’s Thyroiditis and Insulin‑Controlled Gestational Diabetes

Regional Analgesia and Airway Management

Early initiation of epidural analgesia in labor provides effective pain relief, reduces maternal stress, avoids the airway risks of general anesthesia, and can be readily extended to surgical anesthesia for emergency cesarean delivery in pregnant women with GDM and euthyroid Hashimoto’s thyroiditis. 1
A needle‑through‑needle combined spinal‑epidural (CSE) technique yields more reliable analgesia than epidural alone, confirmed by free cerebrospinal fluid flow, and lowers the chance of inadequate block extension for cesarean surgery. 2
Baseline airway assessment (Mallampati, neck mobility, mouth opening, thyromental distance) should be documented because thyroid enlargement associated with Hashimoto’s may complicate airway management. 7
A backup plan for failed epidural extension—including videolaryngoscopy and skilled airway personnel—should be prepared, although the risk is minimized with proper epidural technique. 2
General anesthesia should be avoided unless absolutely necessary, given the increased difficulty of airway management, reduced safe apnea time, and higher aspiration risk in pregnancy. 2
Epidural placement should not be delayed; early insertion allows time to troubleshoot inadequate blocks and provides the option to extend to surgical anesthesia if urgent cesarean delivery becomes required. 2

Maternal capillary blood glucose should be maintained between 5–10 mmol/L (0.9–1.8 g/L) with hourly monitoring throughout active labor. [3][4]
Intravenous insulin therapy (IVES) should replace subcutaneous insulin during active labor and continue until transfer to the postpartum recovery unit. 4
A 10 % glucose infusion at 40 mL/h is recommended to prevent maternal hypoglycemia and ketosis during the energy‑demanding active phase of labor. 4
If capillary glucose exceeds 10 mmol/L (1.8 g/L), a corrective bolus of an ultra‑rapid insulin analogue should be administered. 3
Maternal glucose levels above 16.5 mmol/L (3 g/L) must trigger postponement of elective procedures and immediate corrective therapy. 3
Glucose infusion should not be discontinued prematurely in insulin‑treated patients, as continuous supply is essential to avoid hypoglycemia and ketosis during labor. 4

Maternal hyperglycemia during labor is a strong predictor of neonatal hypoglycemia; the prevalence of neonatal hypoglycemia in infants of mothers with GDM ranges from 10 % to 40 %. The neonatal team should be alerted in advance to provide close glucose monitoring for the first 24–48 hours postpartum. 5

Spontaneous labor should be allowed unless obstetric indications dictate cesarean delivery; metabolic disease alone is not an indication for operative delivery. 1
Gestational diabetes increases the risk of cesarean section by approximately 1.4‑fold compared with non‑diabetic pregnancies, underscoring the need for readiness to extend the epidural block to surgical anesthesia. 5
An increased number of analgesic boluses during labor predicts failure to adequately extend a labor epidural for cesarean delivery; vigilant monitoring is advised. 2
Specialized obstetric anesthesia coverage reduces rates of inadequate block extension compared with non‑specialized providers. 2

After vaginal delivery, maternal glucose targets should be relaxed to 6–8.8 mmol/L (1.10–1.60 g/L). 4
The basal‑bolus insulin regimen should be resumed with a 30‑50 % dose reduction from pregnancy levels, reflecting the rapid decline in insulin resistance postpartum. 4
Continuation of epidural analgesia postpartum for perineal repair or pain control is recommended to avoid systemic opioids that may interfere with breastfeeding initiation. 1