Diabetes Mellitus

Diabetes Mellitus Liu Wei Department of Ob & Gy Ren Ji hospital

General Consideration • Diabetes mellitus complicating pregnancy Diabetes mellitus is diagnosed before this pregnancy • Gestational diabetes mellitus (GDM) Carbohydrate intolerance of varying degree of severity with onset or first recognition during pregnancy. • Incidence 1%-2% (our country); 1%-10% (other countries)

The impact of pregnancy on DM • The first half of pregnancy • Relative insulin sensitivity: insulin requirement↓ • Morning sickness: hypoglycemia • The latter half of pregnancy • Increased insulin resistance: placental hormones↑ • Intake↓intrapartum: hypoglycemia • Postpartum: placental hormones↓→hypoglycemia

Effects on mother and fetus • Effects on monther • Spontaneous abortion • Preeclampsia • Infection: urinary infection • Polyhydramnios (羊水过多) • Fetal macrosomia(巨大儿), dystocia(难产) • Ketoacidosis (酮症酸中毒)

Effects on mother and fetus • Effects on fetus • Fetal macrosomia • Fetal growth restriction • Premature labor • Fetal malformation • Effects on infant • RDS • Hypoglycemia

Diagnosis • Diabetes mellitus complicating pregnancy Already diagnosed or easy to be diagnosed • GDM • History Family history of DM, urine glucose repeatedly (+), recurrent abortion or fetal death, candidal vaginitis(假丝酵母菌阴道炎)

Diagnosis • Lab examination • fasting plasma glucose(空腹血糖): ≥5.8mmol/L twice or more • glucose screening test 糖筛查 (50g glucose) 1 hr postchallenge ≥7.8mmol/L→ oral glucose tolerance test, OGTT糖耐量

Diagnosis • OGTT (75g glucose) Any two or more plasma glucose values exceed the following thresholds→ GDM 1 hr postchallenge: 5.6 mmol/L 2 hr postchallenge: 10.5 mmol/L 3 hr postchallenge: 9.2 mmol/L 4 hr postchallenge: 8.0 mmol/L One value exceed the threshold→ abnormal glucose tolerance

Classification • White’s classification of DM in pregnancy A1: gestational diabetes not requiring insulin A2: gestational diabetes requiring insulin B: onset at ≥20 years of age or duration of <10 years C: onset at 10 to 19 years of age or duration of ≥20 years or any onset or duration but with background retinopathy视网膜病or hypertension only F: nephropathy 肾病(>500mg proteinuria per day at <20 weeks of pregnancy) H: arteriosclerotic动脉粥样硬化heart disease, clinically evident R: proliferative diabetic retinopathy or vitreous hemorrhage玻璃体出血 T: history of renal transplant

Treatment • Conception should be prevented in the patients with class D or F or R DM • Diet management • Meal plans: individualized • Calories: 30 to 35 cal/kg (ideal body weight, IBW) per day. carbohydrates 40%-45%, protein 20%-30%, fat 30% • Concentrated sweets: forbidden • Six meals per day, 2 to 3 hr apart • The adequacy of calories intake may be assessed by using daily fasting urinary ketone levels

Treatment • Medication (insulin) • 2g glucose → 1 u insulin • Early pregnancy: insulin↓ • Late pregnancy: insulin ↑50%-100%, peaking at 32 to 33 weeks • Postpartum: insulin↓1/3-1/2 • Ketoacidosis: low-dose insulin, 0.1U/kg.h

Treatment • Maternal antepartum care: plasma glucose, renal function, blood pressure • Fetal surveillance: development of fetus, placental function, maturity of fetus • Termination of pregnancy • With other obstetric problems → CS • Keeping electrolytical balance • Intrapartum: preventing hypoglycemia • Postpartum: reducing the dose of insulin, preventing infection

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Diabetes Mellitus