1、Piyawadee Wuttikonsammakit,M.D.Prevalence of diagnosed diabetes has increased:14.5(1991)47.9 cases/1000(2003)Increasing prevalence of type 2 diabetes in younger peopleMaternal hyperglycemia leads to fetal hyperinsulinemia,obesity&insulin resistance in childhoodDefined as carbohydrate intolerance of
2、variable severity with onset or first recognition during pregnancySome women with GDM have previously unrecognized overt diabetesFasting hyperglycemia early in pregnancy almost invariably represents overt diabetesNo consensus regarding the optimal approachUniversal or selective screeningPlasma gluco
3、se after 50 g glucose test(50 gm glucose challenge test GCT)is the best to identify women at risk for GDMOne-step approach or two-step approachLow risk:blood glucose testing not routinely required if all the following are present:Member of an ethnic group with a low prevalence of GDMNo known diabete
4、s in first-degree relativesAge=126 mg/d oror=200 mg/dlImpaired glucose tolerance(IGT)=140 and 200 mg/dlImpaired fasting glucose(IFG)110-125 mg/dl andand140Fasting plasmaFasting plasma glucoseglucose2 hr 2 hr postprandialpostprandialGDM A1105 mg/dl and=105 mg/dl or=120 mg/dlFetal anomalies are not in
5、creasedRisk of fetal death is not apparent for those who have diet-treated postprandial hyperglycemiaElevated fasting glucose levels have increased rates of unexplained stillbirths during the last 4-8 weeks of gestationIncreased frequency of hypertension and cesarean deliveryACOG 2000:birthweight ex
6、ceeds 4500 gAnthropometrically different from other LGA infants:excessive fat deposition on the shoulders and trunkPredisposes to shoulder dystocia or cesarean deliveryMaternal hyperglycemia prompts fetal hyperinsulinemia during second half of gestation,which in turn stimulates excessive somatic gro
7、wthNeonatal hyperinsulinemia may provoke hypoglycemia(30 kg/m2Monitored with weekly tests for ketonuriaMaternal ketonemia linked with impair psychomotor development in offspringExercise improved cardiorespiratory fitnessPhysical activity reduced risk of GDMResistance exercise diminished the need for
8、 insulin therapy in overweight women with GDMPrepregnancy BMIPrepregnancy BMITotal weight Total weight gain(kg)gain(kg)Rates of weight Rates of weight gain 2gain 2ndnd and 3 and 3rdrd trimester(kg/wk)trimester(kg/wk)Underweight(=30.0 kg/m2)5-90.22(0.17-0.27)Rasmussen KM,Yaktine Al.Weight gain during
9、 pregnancy:reexamining the guildelines.Washington:Committee to Reexamine IOM Pregnancy Weight Guidelines;Institute of Medicine;National Research Council 2009:254AimFasting plasma glucose 95 mg/dl1 hr postprandial 140 mg/dl2 hr postprandial 105 mg/dlTotal dose of 20-30 units dailyBefore breakfast is
10、commonly used to initiate therapySplit-dose insulin(twice daily):divided into 2/3 intermediate-acting and a third short-acting insulinACOG 2001 has suggested that CS delivery should be considered in women with a sonographically EFW=4500Elective induction to prevent shoulder dystocia in women with so
11、nographically diagnosed fetal macrosomia is controversialSonographic suspicion of macrosomia was too inaccurate to recommend induction or primary CS delivery without a trial of laborNo consensus regarding whether antepartum fetal testing is necessary,and if so,when to begin such testing in women wit
12、hout severe hyperglycemiaThose women who require insulin therapy for fasting hyperglycemia,typically undergo fetal testing and are managed as if they had overt diabetesLabor evaluationElectronic fetal monitoringDTX q 1-2 hrInsulin iv dripOff insulin after deliveryNewborn evaluation:birthweight,APGAR
13、 score,hypoglycemiaBlood glucose Blood glucose(mg/dl)(mg/dl)Insulin dosage Insulin dosage(unit/hour)(unit/hour)Fluids Fluids(125ml/hr)(125ml/hr)2202.5Normal salineAmerican College of Obstetricians and Gynecologists.Pregestational diabetes Mellitus.ACOG Practice Bulletin 60.Washington,DC;ACOG;2005Tim
14、eTimeTestTestPurpose Purpose Postdelivery(1-3d)Fasting or random PG Detect presistent,overt diabetesEarly postpartum(6-12wk)75 g 2-h OGTTPostpartum classification of glucose metabolism1 yr postpartum75 g 2-h OGTTAssess glucose metabolismannuallyFPGAssess glucose metabolismTri-annually75 g 2-h OGTTAs
15、sess glucose metabolismPrepregnancy75 g 2-h OGTTClassify glucose metabolismNormalNormalImpaired Impaired fasting fasting glucose or glucose or impaired impaired glucose glucose tolerancetoleranceDiabetes Diabetes mellitusmellitusFasting=126 mg/dl2hr=140-199 mg/dl2hr=200 mg/dl33-37%underwent postpart
16、um screening testsRecommendations for postpartum follow-up are based on the 50%likelihood of women with GDM developing overt diabetes within 20 yearsIf fasting hyperglycemia develops during pregnancy,then diabetes is more likely to persist postpartumInsulin therapy during pregnancy,and especially be
17、fore 24 weeks,is a powerful predictor of persistent diabetesWomen with Hx of GDM are also at risk for cardiovascular complications associated with dyslipidemia,hypertension,abdominal obesity the metabolic syndromeRecurrence of GDM in subsequent pregnancies was documented in 40%Obese women were more
18、likely to have impaired glucose toleranceLifestyle behavioral changes:weight control and exerciseLow-dose hormonal contraceptives may be used safely by women with recent GDMClassClassAge of onsetAge of onsetDurationDurationVascular Vascular diaseasediaseaseBOver 20 20Benign retinopathyFAnyAnyNephrop
19、athyRAnyAnyProliferative retinopathyHAnyAnyHeartAmerican Diabetes Association 2011Pregestational-or overt-diabetes has a significant impact on pregnancy outcomeRelated to degree of glycemic control,degree of underlying cardiovascular or renal diseaseFactorFactorDiabetic(%)Diabetic(%)NondiabeticNondi
20、abetic (%)(%)P valueP valueGestational hypertension2890.001Preterm birth2850.001Macrosomia 45130.001Fetal growth restriction510 12%,persistent preprandial 120 mg/dl)Increased preterm delivery(both spontaneous&indicated)Macrosomia and hydramniosIUGR(advanced vascular disease or congenital malformatio
21、ns)Stillbirths without identifiable causes are a phenomenon relatively unique to pregnancies complicated by overt diabetes.No obvious placental insufficiency,abruption,FGR,or oligohydramniosTypically large-for-gestational age and die before labor,usually at 35 weeks or laterHyperglycemia-mediated ch
22、ronic abberations in transport of oxygen and fetal metabolitesRespiratory distress syndrome:fetal lung maturation was delayed in diabetic pregnanciesHypoglycemiaHypocalcemiaHyperbilirubinemiaPolycythemiaHypertrophic cardiomyopathyLong-term cognitive developmentInheritance of diabetesException of dia
23、betic retinopathy,the long-term course of diabetes is not affected by pregnancyMaternal death is uncommon,rates are still increased tenfoldDeaths most often result from ketoacidosis,hypertension,preeclampsia,pyelonephritis,ischemic heart disease3 stages1.microalbuminuria 30 to 300 mg of albumin/24h:
24、manifest as early as 5 years after onset of diabetes2.overt proteinuria 300 mg/24hr(may develop hypertension):develop after another 5 to 10 years3.end-stage renal disease-rising creatinine,decreased GFR:develop in next 5 to 10 yearsPGDM class F significantly increased preeclampsia and indicated pret
25、erm deliveryThe first and most common visible lesions are small microaneurysms followed by blot hemorrhages,hard exudates benign or nonproliferative retinopathyAbnormal vessels on background eye disease become occluded,leading to retinal ischemia and infarctions“cotton wool exudate”preproliferative
26、retinopathyNeovascularization(in response to ischemia)on retinal surface and out into vitreous cavity and hemorrhage proliferative retinopathyThe effects of pregnancy on proliferative retinopathy are controversialLaser photocoagulation and good glycemic control during pregnancy minimize the potentia
27、l for deleterious effects of pregnancyPeripheral symmetrical sensorimotor diabetic neuropathy is uncommonDiabetic gastropathy,is trouble some in pregnancy causes N/V,nutritional problems,and difficulty with glucose controlTreatment:metoclopradmide and H2 receptor antagonistsRisk factors for preeclam
28、psia include any vascular complications and preexisting proteinuria,with or without chronic hypertensionRisk of preeclampsia 11-12%in Class B,21-22%in class C,21-23%in class D,36-54%in class F-ROnly 1%Most serious complicationMay develop with hyperemesis gravidarum,B-mimetic drugs given for tocolysi
29、s,infection and corticosteroidsFetal loss is about 20%Pregnant women usually have ketoacidosis with lower blood glucose levels than when nonpregnant(293 mg/dl VS 495 mg/dl)ABG,serum ketone,electrolyte,blood glucose q 1-2 hrInsulin IV infusion:loading 0.2-0.4 u/kg,maintenance 2-10 U/hFluids:NSS 1 L i
30、n first hour,500-1000ml/h for 2-4 h,250 ml/h until 80%replacedBegin 5%D/NSS when glucose plasma level reaches 250 mg/dlCorrect electrolyte:K,bicarbonateAll types of infections:candida vulvovaginitis,urinary infection,respiratory tract infection,puerperal pelvic infection,wound infectionRenal infecti
31、on was associated with increased preterm deliveryOptimal preconceptional glucose control using insulinPreprandial 70-100 mg/dl,1hr postprandial 140 mg/dl,2 hr 120 mg/dlHb A1c within or near the upper limit of normal(10%Periconceptional folic acid 400 ug/dOHD are not recommended for overt diabetesGly
32、cemic control usually achieve with multiple daily insulin injections and adjustment of dietary intakeSelf-monitoring of capillary glucose levels using a glucometer is recommendedA caloric intake of 30-35 kcal/kg/d(for normal weight women)Three meals and three snacks dailyUnderweight women:40 kcal/kg
33、/dFor those 120%above ideal weight:24 kcal/d55%carbohydrate:20%protein:25%fatAccurate datingSecond trimester:targeted sonographic 18-20 weeks to detect NTD and other anomaliesThird trimester:follow growth&fetal surveillanceCaution:detection of fetal anomalies in obese women is more difficultAvoid hy
34、poglycemia and hyperglycemiaIncreased insulin requirement after approximately 24 weeksIncrease CS delivery rateDelete the dose of long-acting insulin given on the day of deliveryInsulin requirements typically drop markedly after deliveryInsulin calibrated pump is most satisfactoryIt is not unusual t
35、o require no insulin for the first 24 hours or so postpartum and then fluctuate during the next few daysNo single contraceptive method appropriate for all women with diabetesRisk of vascular disease in hormonal contraceptives may be problematicIUD increased risk of pelvic infectionElect sterilization is an option
