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Diabetes and Pregnancy Ambulatory Medicine 13 rd Khon Kaen Annual Meeting, 2005. Diabetes and Pregnancy. Pregestational Diabetes Gestational Diabetes. Effect of Pregnancy to Diabetes. Difficult to control diabetes Effect to diabetic retinopathy Effect to diabetic nephropathy - PowerPoint PPT Presentation
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Diabetes and Pregnancy
Ambulatory Medicine13rd Khon Kaen Annual Meeting, 2005.
Diabetes and Pregnancy
• Pregestational Diabetes
• Gestational Diabetes
Effect of Pregnancy to Diabetes
• Difficult to control diabetes• Effect to diabetic retinopathy• Effect to diabetic nephropathy• Effect on maternal and fetus
Maternal-Fetal Fuel and Hormone Exchange
Mother Placenta FetusGlucose Glucose : 28 wk
Insulin Insulin
Amino Acids AminoAcids:9-14wk
FFA FFAKetones Ketones
Maternal DM
Increase MaternalGlucose, ketones, Amino acids, lipids
Fetal hyperglycemia
Embryonic-fetalhyperalimentation
Fetal hyperinsulinemia
Fetal macrosomia
Congenitalanomalies
Fetal• hypoglycemia• RDS
Understanding GDMThe Role of Insulin Resistance
0
100
200
300
20 22 24 26 28 30 32 34 36
50
100
150
200
250
Weeks of Pregnancy
Glu
cose
Rel
ativ
e M
easu
reof
insu
lin /i
nsul
in a
ctio
n
Insulin Resistance
Insulin Level
Fasting Glucose
Post Meal Glucose
Human placental lactogenEstrogen
ProgesteroneCortisolProlactin
Effect of Diabetes to Pregnancy
• Mother1. Toxemia of pregnancy2. Pyelonephritis3. Hydraminos4. Cesarean Delivery5. Maternal Mortality
Effect of Diabetes to Pregnancy• Infant
1. Perinatal mortality2. Spontaneous abortion3. Congenital malformation4. Macrosomia5. IUGR6. Intrauterine fetal death
010
20
30
40
1926-45 1946-55 1956-65 1966-70 1971-75 1976-80 1981-85 1986-90
Perinatal mortality (%)
Year
Perinatal Mortality in Diabetic Pregnancies in the Period 1926-1990
0
50
100
50 100 150 200 250
Joslin (Pre – 1922)
Joslin (1924-1938)
Predersen (1969)
Kalsson (1972)
Joslin (1956-1975)Karlsson (1972)Essex (1973)Tyson (1979)
Fuhrmann (1980)
Martin (1979)
Tyson (1976)
DKA
Mean maternal blood glucose (mg/dl)
Infa
nt m
orta
lity
(%)
Effect of Diabetes to Pregnancy
• Infant 1. Perinatal mortality2. Spontaneous abortion3. Congenital malformation4. Macrosomia5. IUGR6. Intrauterine fetal death
Effect of Diabetes to Pregnancy
• Infant 7. Respiratory distress syndrome8. Hypoglycemia9. Hypocalcemia & Hypomagnesemia 10. Hyperviscosity 11. Hyperbilirubinemia 12. Cardiomyopathy
Effect of Diabetes to Pregnancy
• Infant13. Long term consequences : - Neuropsychological
development - Obesity - Diabetes Mellitus
Goals of Prepregnancy Planning Program
• Assessment of a woman’s fitness for pregnancy
• Obstetric evaluation• Intensive education of woman and family• Attainment of optimum diabetic control• Timing and planning of pregnancy
Potential Contraindication to Pregnancy
• Ischemic heart disease
• Untreated, active proliferative retinopathy
• Renal insuffinciency : CCr < 40 ml/min or serum creatinine > 2.5 - 3 mg/dl
• Severe gastroenteropathy : N/V, diarrhea
Gestational Diabetes
• Any degree of glucose intolerance with onset or first recognition during pregnancy
Risk and Screening
Risks Screening recommendation
High risk First ANCIf normal: GA 24-28 wks
Intermediate risk GA 24-28 wks
Low risk Not recommended
High risk
• Age >35 yr• Obesity (> 120 % Ideal BW)• Family history• Previous GDM• Urine sugar ++• History of poor obstetric outcome
Detection of Gestational Diabetes
• Screen all pregnant women Or
• Screen all pregnant women except low risk patients that meet all of these criteria
1. Age < 25 years2. Weight normal before pregnancy3. Member of an ethnic group with low GDM4. No known diabetes in first-degree relatives5. No history of abnormal glucose tolerance6. No history of poor obstetric outcome
Screening GDM
• One step approach Perform OGTT without screening may be cost effective in high risk pts.
• Two step approach Initial screening by measuring 1 hr plasma glucose after a 50 g-glucose load and perform OGTT only patients who screen abnormal
> 140 mg/dl ( sensitive 80% )> 130 mg/dl ( sensitive 90% )
Diagnostic GDM with OGTT
1. 100 g OGTT “NDDG Criteria”2. 100 g OGTT “Carpenter & Coustan”3. 75 g OGTT “International Workshop
on GDM”4. 75 g OGTT “WHO”
Note: ADA 2005 recommend criteria 2 & 3
Comparison of OGTT Criteria
Glucose NDDG Car&Coust IWG WHO100g 100g 75g 75g
Fasting 105 95 95 <1261-hr 190 180 180 ----2-hr 165 155 155
>1403-hr 145 140 ---- ----
>/= 2
Classification
• Class A1: FPG < 105 mg/dL and 2 h PPG < 120 mg/dL
• Class A2: FPG ≥ 105 mg/dL and 2 h PPG ≥ 120 mg/dL
A1 : Diet control & OPDA2 : Insulin……Admit ?
White classification
• Class B: duration <10 yr or age onset ≥20 yr• Class C: duration 10-19 yr or age onset 10-19 yr• Class D: duration >20 yr or age onset <10 yr or
BDR• Class R: DM with PDR• Class F: DM with DN (proteinuria >500 mg/day)• Class H: DM with CHD• Class T: DM with renal transplantation
Treatment
• Diet control: A1/A2/Overt DMPregnancy Weight Status Kcal/Kg/day
Desirable body weight 30
120-150% Desirable BW 24
> 150% Desirable BW 12-18
< 90% Desirable BW 36-40
Desirable BW = (Ht in cm – 100) x 0.9
Recommended Calorie Distribution
• 40-50% Carbohydrate• 20% Protein• 30-40% Fat
INSULIN: A2/Overt DM
GA Dosage (unit/kg/day)
1st Trimester 0.72nd Trimester 0.83rd Trimester 0.9
Admit : 2-4 units q 2-3 daysOPD : 2-4 units q 7 days
Insulin Regimen
ครัง้ต่อวนั
ก่อนอาหารเชา้
ก่อนอาหารเท่ียง
ก่อนอาหารเยน็
ก่อนนอน
ผลการควบคุม
11224
NPHNPH+RINPHNPH+RIRI
RINPH+RIRI
NPH
NPH
PoorPoorPoorGoodVery good
Target
Glucose level (mg/dL)
Time4th international
workshop on GDM 1998
ADA 2004
FPG1 h PPG2 h PPG
≤ 105≤ 140≤ 120
< 105< 155< 130
Whole Blood Glucose Goals in Diabetic Pregnancy
• Fasting 60-90 mg/dl• Premeal 60-100 mg/dl• 1 hour postmeal < 120 mg/dl• 02.00-06.00 AM > 60 mg/dl
Note: Add 15% to convert numbers to plasma glucose
Labor
• Class A1: Normal labor• Class A2 / Overt DM
> 38 wkskeep 70-120 mg/dL
Insulin During Labor & Delivery
•Vaginal delivery: - NPO after 24.00 ก่อนวนักำ�หนดคลอดในกรณีนัดวนัคลอด- NPO ตัง้แต่ admit ในกรณีฉกุเฉิน- งดฉีด insulin วนักำ�หนดคลอดในกรณีนัดวนัคลอด
- ตรวจ FPG เช�้วนักำ�หนดคลอด - intrapartum insulin infusion ต�มระดับ
นำ้�ต�ล โดยเจ�ะทกุ 1-2 ชม.
Insulin During Labor & Delivery
With Elective Cesarean Delivery
- NPO after midnight ก่อนวนักำ�หนดผ่�ตัดคลอด
- พจิ�รณ�ผ่�ตัดคลอดชว่งเช�้- งดฉีด insulin มื้อเช�้ของวนัผ่�ตัดคลอด
- ตรวจ FPG เช�้วนัผ่�ตัดคลอด - intrapartum insulin infusion ต�มระดับ
นำ้�ต�ล โดยเจ�ะทกุ 1-2 ชม. - ผ่�ตัดคลอด
Insulin and Solution
Glucose level (mg/dL)
Insulin dosage(units/hr)
Solutions(drip 125 ml/hr)
< 100100-140141-180181-220
> 220
01
1.52
2.5
5%D, LRS5%D, LRS
Normal salineNormal salineNormal saline
Post-partum period
• 98% normal after delivery• 75 OGTT: recommend for diabetic
screening in all GDM• Breast feeding• Type 2 DM: 10% in 10 yr
45% in 20 yr
Thank you for your attention