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Diabetes and Pregnancy Ambulatory Medicine 13 rd Khon Kaen Annual Meeting, 2005.

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

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Diabetes and Pregnancy Ambulatory Medicine 13 rd Khon Kaen Annual Meeting, 2005.

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  1. Diabetes and Pregnancy Ambulatory Medicine 13rd Khon Kaen Annual Meeting, 2005.

  2. Diabetes and Pregnancy • Pregestational Diabetes • Gestational Diabetes

  3. Effect of Pregnancy to Diabetes • Difficult to control diabetes • Effect to diabetic retinopathy • Effect to diabetic nephropathy • Effect on maternal and fetus

  4. Maternal-Fetal Fuel and Hormone Exchange MotherPlacentaFetus Glucose Glucose : 28 wk Insulin Insulin Amino Acids AminoAcids:9-14wk FFA FFA Ketones Ketones

  5. Maternal DM Increase Maternal Glucose, ketones, Amino acids, lipids Embryonic-fetal hyperalimentation Fetal hyperglycemia • Fetal • hypoglycemia • RDS Congenital anomalies Fetal hyperinsulinemia Fetal macrosomia

  6. Human placental lactogen Estrogen Progesterone Cortisol Prolactin Understanding GDMThe Role of Insulin Resistance Post Meal Glucose Glucose Fasting Glucose Insulin Resistance Relative Measure of insulin /insulin action Insulin Level Weeks of Pregnancy

  7. Effect of Diabetes to Pregnancy • Mother 1. Toxemia of pregnancy 2. Pyelonephritis 3. Hydraminos 4. Cesarean Delivery 5. Maternal Mortality

  8. Effect of Diabetes to Pregnancy • Infant 1. Perinatal mortality 2. Spontaneous abortion 3. Congenital malformation 4. Macrosomia 5. IUGR 6. Intrauterine fetal death

  9. 40 30 20 10 0 1926-45 1946-55 1956-65 1966-70 1971-75 1976-80 1981-85 1986-90 Perinatal Mortality in Diabetic Pregnancies in the Period 1926-1990 Perinatal mortality (%) Year

  10. 100 Joslin (Pre – 1922) Joslin (1924-1938) Infant mortality (%) 50 Predersen (1969) Kalsson (1972) Tyson (1976) Martin (1979) Joslin (1956-1975) Fuhrmann (1980) Karlsson (1972) Tyson (1979) Essex (1973) 0 DKA 50 100 150 200 250 Mean maternal blood glucose (mg/dl)

  11. Effect of Diabetes to Pregnancy • Infant 1. Perinatal mortality 2. Spontaneous abortion 3. Congenital malformation 4. Macrosomia 5. IUGR 6. Intrauterine fetal death

  12. Effect of Diabetes to Pregnancy • Infant 7. Respiratory distress syndrome 8. Hypoglycemia 9. Hypocalcemia & Hypomagnesemia 10. Hyperviscosity 11. Hyperbilirubinemia 12. Cardiomyopathy

  13. Effect of Diabetes to Pregnancy • Infant 13. Long term consequences : - Neuropsychological development - Obesity - Diabetes Mellitus

  14. 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

  15. 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

  16. Gestational Diabetes • Any degree of glucose intolerance with onset or first recognition during pregnancy

  17. Risk and Screening

  18. High risk • Age>35 yr • Obesity (> 120 % Ideal BW) • Family history • Previous GDM • Urine sugar ++ • History of poor obstetric outcome

  19. Detection of Gestational Diabetes • Screen all pregnant women Or • Screen all pregnant women except low risk patients that meet all of these criteria • Age < 25 years • Weight normal before pregnancy • Member of an ethnic group with low GDM • No known diabetes in first-degree relatives • No history of abnormal glucose tolerance • No history of poor obstetric outcome

  20. 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% )

  21. Diagnostic GDM with OGTT • 100 g OGTT “NDDG Criteria” • 100 g OGTT “Carpenter & Coustan” • 75 g OGTT “International Workshop on GDM” • 75 g OGTT “WHO” Note: ADA 2005 recommend criteria 2 & 3

  22. Comparison of OGTT Criteria Glucose NDDGCar&Coust IWG WHO 100g100g 75g 75g Fasting 105 95 95 <126 1-hr 190180 180 ---- 2-hr 165 155 155 >140 3-hr 145140 ---- ---- >/= 2

  23. 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 & OPD A2 : Insulin……Admit ?

  24. 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

  25. Treatment • Diet control: A1/A2/Overt DM Pregnancy Weight StatusKcal/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

  26. Recommended Calorie Distribution • 40-50% Carbohydrate • 20% Protein • 30-40% Fat

  27. INSULIN: A2/Overt DM GA Dosage (unit/kg/day) 1st Trimester 0.7 2nd Trimester 0.8 3rd Trimester 0.9 Admit : 2-4 units q 2-3 days OPD : 2-4 units q 7 days

  28. Insulin Regimen

  29. Target

  30. 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

  31. Labor • Class A1: Normal labor • Class A2 / Overt DM > 38 wks keep 70-120 mg/dL

  32. Insulin During Labor & Delivery • Vaginal delivery: - NPO after 24.00 ก่อนวันกำหนดคลอดในกรณีนัดวันคลอด - NPO ตั้งแต่ admit ในกรณีฉุกเฉิน - งดฉีด insulin วันกำหนดคลอดในกรณีนัดวันคลอด - ตรวจ FPG เช้าวันกำหนดคลอด - intrapartum insulin infusion ตามระดับน้ำตาล โดยเจาะทุก 1-2 ชม.

  33. Insulin During Labor & Delivery With Elective Cesarean Delivery - NPO after midnight ก่อนวันกำหนดผ่าตัดคลอด - พิจารณาผ่าตัดคลอดช่วงเช้า - งดฉีด insulin มื้อเช้าของวันผ่าตัดคลอด - ตรวจ FPG เช้าวันผ่าตัดคลอด - intrapartum insulin infusion ตามระดับน้ำตาล โดยเจาะทุก 1-2 ชม. - ผ่าตัดคลอด

  34. Insulin and Solution

  35. 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

  36. Thank you for your attention

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