?????? Gestational Diabetes Mellitus

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?????? Gestational Diabetes Mellitus
Obstetrics department Liang Meiying
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GDM
Gestational Diabetes Mellitus (GDM) is defined
as Carbohydrate intolerance of varying severity
with the first recognition of onset occurring
during pregnancy
American Diabetes Association Clinical practice
Recommendations, Diabetes Care, 21, 1, S60, 1988
EMRC
3

• Prevalence
• Diabetes affects 2-4 of pregnancies overall
  in the U.S.
• 90 of cases are Gestational Diabetes
• 10 with pre-existing DM (65 type 2)
• Higher in African-American, Hispanic, Native-
• American and Asian women

1-5
Percent
EMRC
Epidemiology of glucose intolerance and GDM in
women of child bearing age, Diabetes Care, 21,
1998
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Etiology

• During pregnancy, the placenta is secreting
  diabetogenic hormones, which increase insulin
  production
• growth hormone
• corticotropin releasing hormone
• human placental lactogen
• progesterone

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?????????

• ??? ???
• ?????

?? ??DM
???????
??????
??????
???????
6
????????????????

• ???? ?? ??????
• B?????? 20? lt10?
• C? 1019? ? ?1019?
• D? lt10??20?????????????
• F???????
• R?????????,??????
• H?????????????
• T?????

A? ??????(A1 A2)
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? ?

• ????????
• ?????????
• ?????????????????
• ?????????
• ????????????
• ??????????

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? ????????(1)

• ?????
• ???????????
• ???????
• ????/???????
• ??????????,????????
• ???????,????/???????

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???????? (2)

• 3 ??????????
• ??????,????,????????
• ???????,??????,?????
  
• ??????
• 4 ?????????
• 1) human placental lactogen ????????,?
• ?????,???????,?????????
• 2) progesterone , E2
• ????????

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• 3)????????5-10?,??????
• 4)?????????????????????
• 5)??????? ???????????
• ?????????????
• ?4??????,???????????
• ???????gt??gt?????gt???gt????
• 
  

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??????????????

• ???????????????????
• ??????
• ??????????????????????????????????????????????
  ????

12
? ?????????

• ????? glycosuria??????????
• ???? hypoglycemia ???????4?
• ????? ketoacidosis
• ????? ????1/3,?????1/2-2/3

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? ?????????

• polyhydramnios 10,??20?
• PIH Preeclampsia???????3-5?
• ketoacidosis ??????
• infection ????? ???
• Birth trauma
• Fetal macrosomia Operative deliveries
• abnormal stage of labor

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?????????(1)

• ?? ketosis and hyperglycemia--
• Congenital malformations (4 fold)

?????
?????
??????
??????
???anencephalus
?????????
??????
??????
?????
???spina bifida
?????
????
?????
?????
?? Potters syndrome
????
???rectal atresia
???
????
???
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?????????(2)

• macrosomia, 25-42,
• hyperglycemia hyperinsulinemia??????

????????????
???????????? ?????????
??
????????????????? ???????????????? ???
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?????????(3)

• respiratory distress snydrome
• fetal demise and neonatal death, 10-30
• neonatal hypoglycermia?hypocalcium
• neonatal hyperbilirubinemia

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GDM??????

• ???????????????,?????????????,??????
• ???????????????????????--????????????????

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???????????

• Risk factors
• family history
• age gt30 years old
• previous history of large baby
• pre-pregnancy weight of 110 of ideal body
  weight
• previous unexplained perinatal loss or malformed
  child
• suspicious Macrosomia polyhydramnios
• ??????, ???14-50GDM

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GDM?????

• ???? Screening Test
• 50 gram oral glucose load 1973?OSullivan Mahan
• ?????24-28???50??,??????,??
• gt7.8mmol/L, ??? 85
• gt7.2mmol/L, Specialty 87
• Sensitivity 79
• ???????????,??1????
• ?????????????14,????????
• ????

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GDM???

• A 75gOGTT (oral glucose tolerance test)
• ??8-12??,???fasting?,??300????75????,???1?2?3???
  ?
• ?? 1?? 2?? 3??
• ?? 5.6 10.5 9.2 8.0
• ?? 5.5 10.2 8.2 6.6
• OGTT????,???GDM??????????????(GIGT)

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• 50g??11.1mmol/L(200 mg/dl),??
• 75gOGTT,?2?????
• B ??????5.8mmol/L(105mg/dl)???????11.1mmol/L(2
  00mg/dl),????5.8mmol/L(105mg/dl)?
• ??????????????2??????
• A1 ????lt5.8mmol/l,??2????
• lt6.7mmol/l,??????
• A2 ????5.8mmol/l,???2????
• 6.7mmol/l,????????

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GDM ????

• ????
• ????
• ????
• ????
• ????
• ?????

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??????

• ???? ???EKG????????
• ????????????????????3-6????????,
  ???????,???????8???????
• ?????? 28?? 2?28?? 1? ??????
• ????
• B ultrasound 20-24????????????????
• 28???4-6?????,??????????????
• ????????????????????
• Fetal monitoring 34? NST
• BPS biophysical
  profile score
• 
  
• fetal pulmonary maturity ????

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GDM????

• dietician?? (????????)
• ????33 kcal/kg
• ?????45-50???20-25??30
• ??????10,?30,?30,??10
• ?????5, 10, 5
• ???? ?? 5.6mmol/L
• ??? 3.35.8 mmol/l
• ??2?? 6.7 mmol/l

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GDM ????

• ??????????????
• ????,??,??,???
• ????
• ???????,??,??,???
• ?1200??/?
• ???Vit.DVit.B,C ??

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GDM ??

• ???? ????????,??????,??
• ???????
• ???????????,3?/?,20?/?
• ??,????,???
• ???????????, BP?140/90mmHg,
• ?????????(220-??)X70
• ?? ????? ???

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GDM ????

• ???????
• ?????????????????????
• ??????????,???????
• ???????????(12),????
• ????2/3,??1/3?
• ?????(???????)
• ??30???,2-4h??,???4h
• ???????4-5?,?????6-8u/h

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• ????? ??4-8h,??
• ?????????????????,
• ?????????????
• ????????,??????????????????????5.6mmol/L,?14????
  
• ???????24????????1/2, ?????1/3,
  ???????????????????????????????

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??????

• ??????(mg)(?????mg/dl-100)(???????)10????0.6(?
  ????)
• ?????55 kg,????14 mmol/l(250 mg/dl )
• ??????(mg)(250-100)10550.649500 mg 49.5
  g??2 g???1u?????,????24.5u,?????1/21/3
• RI????????????
• 2432? 0.8u / kg /d
• 3236? 0.9u / kg /d
  
• 3640? 1.0u / kg /d

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??????

• ?????????5.6mmol/L (3.3-5.6mmol/L)
• ???1?????7.8mmol/L
• ???2?????6.7mmol/L (4.4- 6.7mmol/L),
• HbA1c???4-6,????????7?

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GDM ????

• Must weigh maternal and fetal risks , With
  excellent glycemic control and normal fetal
  surveillance, can await spontaneous labor
• If antepartum testing is non-reassuring and
  lungs are mature - deliver patient, timing and
  mode of delivery
• labor inductionlt38 week
• or cesarean section,
• amniocentesis
• fetal pulmonary maturity

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• Time of Delivery
• Controlled DM between 38-40 weeks
• Uncontrolled Diabetes 37 38 weeks
• Poorly uncontrolled DM, severe pre-eclampsia
  36 weeks
• Earlier if fetal distress
• Mode of Delivery
• Vaginal delivery is expected in the
• average estimated weight of fetus lt 4000 gm
• Satisfactory fetal wellbeing
• Cephalic presentation
• satisfactory progress and descend during the
  first and second stage
• absence of Obstetric complications,

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? ? ? ?

• ??????????12???
• ?? ????????,(70-120mg/dl)
• 5????RI(13-6)??,????
• ????????????????
• ??????,????
• ???????
• ??????,????????????,
• ?????????
• ????????,????, RI???1/2

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GDM??????

• ?????gt10?
• ????
• ??????
• ???????

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• CESARIAN SECTION
• Macrosomic fetus (risk of shoulder dystocia) gt
  4000 gm
• Certain cases of IUGR or fetal distress
• Malpresentations
• Slow progress and descent during labour
• complications such as Hypertension
  polyhydromnios
• other obstetric indications such as placenta
  praevia
• Severe vaginal infections especially with
  primigravida
• Others Elderly primigravida, bad obstetric
  history

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GDM ?????

• ???????
• ??????
• ???????????gt40??/??
• ????,?HCTgt70,?????
• ????
• ????
• ????????
• ???????

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GDM ??????

• follow-up testing for Diabetes
• ??GDM?GIGT???????6?-12???75gOGTT?????????,?????
  DM,???????
• 50 chance of developing DM within the next 20
  years
• (normal 7)
• 2002 Kim????????6?-28?,??2.6-70GDM???2?????????GD
  M?????????????????
• ?20?????GDM?50gGCT 11.1mmol/L?FPG???????INS????10
  0U/??????????????????????FPG?

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GDM?DM??????

• ???????DM???????
• contraceptive choices??????
• ???????????????????,????????????

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Multicenter Survey of GDM (1993-1994)

• 2416 pregnant women
• Five hospital clinics of TUMS
• Universal Screening
• Carpenter Custan Criteria
• GCT ? 130 mg /dl (Positive)

Glucose Challenge Test
Iranian Journal of Endocrinology and Metabolism,
1999, Vol 1, No 2, 125-133 Journal of
Endocrinology, Abstract Supplement, 19th Joint
Meeting of the British Endocrine Societies, with
the European Federation of Endocrine Societies,
13-16 March 2000, p.124
EMRC
40
Multicenter Survey The prevalence of GDM 2416
Cases

• GDM 4.7
• IGT 7.6
• It is a moderate prevalence in the world

Iranian Journal of Endocrinology and Metabolism,
1999, Vol 1, No 2, 125-133 Journal of
Endocrinology, Abstract Supplement, 19th Joint
Meeting of the British Endocrine Societies, with
the European Federation of Endocrine Societies,
13-16 March 2000, p.124
EMRC
41
Conclusion
86 of all GDM patients can be diagnosed by
Screening based on historical risk factors.
Iranian Journal of Endocrinology and Metabolism,
1999, Vol 1, No 2, 125-133 Journal of
Endocrinology, Abstract Supplement, 19th Joint
Meeting of the British Endocrine Societies, with
the European Federation of Endocrine Societies,
13-16 March 2000, p.124
EMRC
42
The clinical recognition of GDM is important
because appropriate therapy can reduce fetal and
maternal morbidity
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Thank You