Diabetes managemen

임신 때 당뇨병 관리

김 성 훈

관동의대 제일병원 내과

Contents

• Epidemiology of diabetes in preg-nancy

• Risks to the mother and the baby• Preconception counselling and

prepregnancy care • Management of hyperglycemia in

pregnancy• Diagnosis and management of GDM

증 례 1• 37 세 , 임신 9 주 (gravida 3, para 2)• 둘째 아이 : 4 세 , 출생 체중 (4500 g) Hx of neonatal jaundice and hypoglycemia• Random glucose; 325 mg/dl, A1C: 8.9%• 지난 임신때 당뇨 진단 받지 않았고 , 이번 임신에서

prepregnancy care 받지 않았음• 신장 161 cm, 체중 79 kg, BMI 30.5 kg/m2

• 망막검사 : mild NPDR

Classification of diabetes in pregnancy

• Type 1 diabetes (results from β-cell destruction, usually leading to absolute insulin deficiency)

• Type 2 diabetes (results from a progressive insulin secretory defect on the background of insulin resistance)

• Other specific types of diabetes due to other causes, e.g., genetic defects in β-cell function, genetic defects in insulin action, diseases of the exocrine pancreas (such as cystic fi-brosis), and drug- or chemical-induced (such as in the treatment of HIV/AIDS or after organ transplantation)

• Gestational diabetes mellitus (GDM) (diabetes diagnosed during pregnancy that is not clearly overt diabetes)

한국모자보건학회지 14: 170-80, 2010

임신중당뇨병 임부의 유병률 및 의료이용 추이

Issues

• Epidemics of obesity and T2DM -> numbers of women with T2DM be-come pregnant ↑

• Frequently undiagnosed T2DM before pregnancy

• Lack of preconception care• ↑Cx of pregnancy due to the coexis-

tence of obesity and T2DM

Risks of diabetes in pregnancy (I)

• Fetal macrosomia

• Birth trauma (to mother and baby)

• Induction of labor or cesarean sec-tion

Accelerated fetal growth

Risks of diabetes in pregnancy (II)

• Miscarriage

• Congenital malformation

• Stillbirth

Glucose control and risk of malformation

Guerin A. Diabetes Care 30:1920, 2007

Glucose control and risk of malformation

Guerin A. Diabetes Care 30:1920, 2007

For every 1% de-

crease in A1c,

there is approxi-

mately 50% rela-

tive risk reduction

for a congenital

anomaly

Risks of diabetes in pregnancy (III)

• Transient neonatal morbidity - hypoglycemia, hypocalcemia, hypomagne-

semia, hyperbilirubinemia, erythremia, hyper-trophic cardiomyopathy, respiratory distress syndrome

• Neonatal death

• Obesity and/or diabetes developing later in the baby’s life

Maternal complications in dia-betic pregnancy

• Hypoglycemia, ketoacidosis• Pregnancy induced hypertension• Pyelonephritis, other infections• Polyhydramnios• Preterm labor• Worsening of chronic complications-

retinopathy, nephropahty, neuropa-thy, cardiac disease

Risks of pregnancy for the mother with diabetes

• Pregnancy may affect pre-existing micro- and macrovascular disease but does not usually have any long-term detrimental effect on either retinopathy or nephropathy

• Risk of women with established car-diovascular disease

Diabetic Retinopathy– Diabetic retinopathy may accelerate during preg-

nancy

– Risk can be reduced by • Gradual attainment of good metabolic control before

conception • Preconceptual laser photocoagulation

– Baseline dilated comprehensive eye examination and follow-up

; necessary before conception and during pregnancy

– Pre-existing diabetes should be counseled on the risk of development and progression of diabetic retinopa-thy

Kitzmiller JL et al:Diabetes Care 2008;31:1060-1079

Diabetic nephropathy

Cardiovascular disease

– Untreated CAD : a high mortality during preg-nancy

– Successful pregnancies after coronary revascu-larization in women with diabetes

– Exercise tolerance should be normal : to tolerate the increased cardiovascular de-

mands of gestation

The Pre-Preganacy Clinic

• Pregnancy planning/Contraceptive advice

• Optimize control and explain glycemic goals during pregnancy.

• Switch Type 2 diabetics to insulin. Review educational needs.

• Genetic counselling.

• Congenital malformations.

• Perinatal complications.

• Assessment of diabetic complications.

• Review smoking, alcohol, medications, folic acid.

Laboratory and special exam of pregnant women with preexisting dia-betes


Management of hyperglycemia in preg-nancy

Optimal glycemic goals

• premeal, bedtime, and overnight glucose: 60–99

mg/dl

• peak postprandial glucose: 100–129 mg/dl

• mean daily glucose: <110 mg/dl

• A1C <6.0 %


Recommended targets for capil-lary glucose during pregnancy

Source Fast-ing

1 h Peak 2 h Pre-meal

ADA GDM 95 140 - 120 -

ADA preexisting 60-99 - 100-129 - 60-99

IDF 99 - 144 - -

NICE 63-106 140 - - -

ADIPS 99 144 126 126 -

Mathiesen 72-110 140 72-144 - 72-110

Assessment of metabolic control

• SMBG: daily and fingerstick

• Postprandial capillary glucose 1hr after begin-

ning the meal: postmeal peak glucose

• CGM: T1D, esp, hypoglycemia unawareness

• Urine ketone: ill or persistent hyperglycemia

(>200 mg/dl)

• A1C:monthly

Medical Nutrition Therapy (MNT)

• Individualized MNT

• Basic plan: dietary recommendations for all preg-nant women, adjusted to the individual needs

• CHO and caloric contents: modified based on the woman’s height, weight, and degree of glucose intolerance

• Carbohydrate-restricted diet; small frequent meals and high-fiber and low GI foods

Goals for weight gain (1)

Prepregnancy BMI Total wt.gain (kg) Rate of wt.gain(2&3Tri.)kg/wk

Underweight (<18.5) 12.5 - 18 0.51 (0.44-0.58) Normal weight (18.5-24.9) 11.5 - 16 0.42 (0.35-0.50) Overweight (25-29.9) 7 - 11.5 0.28 (0.23-0.33) Obese (≥30) 5 - 9 0.22 (0.17-0.27)

Institute of Medicine, 2009

Goals for weight gain (2)

• Less weight gain is safe and has a beneficial effect on perinatal out-comes in obese women: a weight gain of 0-7 pounds was associated with the least macrosomia

Cheng YW et al. Gestational weight gain and gestational dia-betes mellitus: perinatal outcomes. Obstet Gynecol 112:1015-1022, 2008

Exercise/Physical activity

• Educate women with diabetes as to benefits of appropriate daily physcial activity (reduce blood glucose, weight gain and insulin require-ments)

• Encourage regular exercise, at least 30 min/day

Insulin therapy during preg-nancy

• Basal–bolus insulin regimens (MDI) or CSII are recommended for optimal glycaemic control in pregnancy in women with pre-existing diabetes

• Oral antidiabetic drugs in women with type 2 diabetes should be discontinued and in-sulin initiated and titrated to achieve the recommended glycaemic control prior to conception

Pharmacokinetics of human insulin and insulin analogs

Type of insulin Onset of action Peak plasma values

Duration of action

Regular human insulin

30-60 min 1-3 h 5-7 h

NPH insulin 60-90 min 8-12 h 18-24 h

Insulin lispro 15-60 min 0.5-1 h 2-4 h

Insulin aspart 10-20 min 1-3 h 3-5 h

Insulin glulisine 10-20 min 1-2 h 3-5 h

Glargine 4-5 h No peak >24 h

Detemir 4-6 h No peak 20 h

증 례 2• 임신 28 주의 32 세 여성• 임신 27 주에 50g OCT:1 시간 혈당이 174

mg/dL

• 100g OGTT: fasting-97 mg/dL, 1 hour-189 mg/dL, 2 hour-166mg/dL, 3 hour-140mg/dL

• 신장 164cm, 체중은 75kg ( 임신전 68kg)

• 혈압 110/70mmHg, 신체 검사 , 소변검사나 다른 검사 소견은 정상

임신성 당뇨병의 진단기준

당뇨병 진료지침 2013, 대한당뇨병학회

Management of GDM

Summary of antepartum care

• Medical Nutritional therapy• Regular exercise• Maternal SMBG or fetal AC for intensi-

fied Tx• Insulin remains the mainstay of Tx • glyburide and metformin may be of-

fered as an alternative

Management of women with prior GDM

Buchanan TA et al. Nat. Rev Endocrinol 8: 639, 2012

Summary1. Preconception detection and management of

T2DM may become a critical public health issue 2. Women with diabetes who are reproductive age

need preconception counselling and prepreg-nancy care in the 6-12 months before preg-nancy

3. The key to improving outcome of pregnancy in women with diabetes is strict glycemic control

4. Diagnosing and treating GDM can reduce peri-natal complications and postpartum follow up and prevention of DM is important

Health & Medicine

Diabetes managemen