Diabetes and Pregnancy

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

• Pregestational Diabetes
• Gestational Diabetes

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Effect of Pregnancy to Diabetes

• Difficult to control diabetes
• Effect to diabetic retinopathy
• Effect to diabetic nephropathy
• Effect on maternal and fetus

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Maternal-Fetal Fuel and Hormone Exchange

• Mother Placenta Fetus
• Glucose Glucose 28 wk
• Insulin Insulin
• Amino Acids AminoAcids9-14wk
• FFA FFA
• Ketones Ketones

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Maternal DM
Increase Maternal
Glucose, ketones, Amino acids, lipids
Embryonic-fetal hyperalimentation
Fetal hyperglycemia

• Fetal
• hypoglycemia
• RDS

Congenital anomalies
Fetal hyperinsulinemia
Fetal macrosomia
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Understanding GDMThe Role of Insulin Resistance
Human placental lactogen Estrogen Progesterone Cor
tisol Prolactin
Post Meal Glucose
Glucose
Fasting Glucose
Insulin Resistance
Relative Measure of insulin /insulin action
Insulin Level
Weeks of Pregnancy
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Effect of Diabetes to Pregnancy

• Mother
• 1. Toxemia of pregnancy
• 2. Pyelonephritis
• 3. Hydraminos
• 4. Cesarean Delivery
• 5. Maternal Mortality

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Effect of Diabetes to Pregnancy

• Infant
• 1. Perinatal mortality
• 2. Spontaneous abortion
• 3. Congenital malformation
• 4. Macrosomia
• 5. IUGR
• 6. Intrauterine fetal death

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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)
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Effect of Diabetes to Pregnancy

• Infant
• 1. Perinatal mortality
• 2. Spontaneous abortion
• 3. Congenital malformation
• 4. Macrosomia
• 5. IUGR
• 6. Intrauterine fetal death

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Effect of Diabetes to Pregnancy

• Infant
• 7. Respiratory distress syndrome
• 8. Hypoglycemia
• 9. Hypocalcemia Hypomagnesemia
• 10. Hyperviscosity
• 11. Hyperbilirubinemia
• 12. Cardiomyopathy

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Effect of Diabetes to Pregnancy

• Infant
• 13. Long term consequences
• - Neuropsychological
  development
• - Obesity
• - Diabetes Mellitus

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Goals of Prepregnancy Planning Program

• Assessment of a womans fitness for pregnancy
• Obstetric evaluation
• Intensive education of woman and family
• Attainment of optimum diabetic control
• Timing and planning of pregnancy

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Potential Contraindication to Pregnancy

• Ischemic heart disease
• Untreated, active proliferative retinopathy
• Renal insuffinciency CCr lt 40 ml/min or serum
  creatinine gt 2.5 - 3 mg/dl
• Severe gastroenteropathy N/V, diarrhea

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Gestational Diabetes

• Any degree of glucose intolerance with onset or
  first recognition during pregnancy

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Risk and Screening
Risks Screening recommendation
High risk First ANC If normal GA 24-28 wks
Intermediate risk GA 24-28 wks
Low risk Not recommended
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High risk

• Age gt35 yr
• Obesity (gt 120 Ideal BW)
• Family history
• Previous GDM
• Urine sugar
• History of poor obstetric outcome

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Detection of Gestational Diabetes

• Screen all pregnant women
• Or
• Screen all pregnant women except low risk
  patients that meet all of these criteria
• Age lt 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

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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
• gt 140 mg/dl ( sensitive 80 )
• gt 130 mg/dl ( sensitive 90 )

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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

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Comparison of OGTT Criteria

• Glucose NDDG CarCoust IWG WHO
• 100g 100g 75g 75g
• Fasting 105 95 95 lt126
• 1-hr 190 180 180 ----
• 2-hr 165 155 155 gt140
• 3-hr 145 140 ---- ----

gt/ 2
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Classification

• Class A1 FPG lt 105 mg/dL and
• 2 h PPG lt 120 mg/dL
• Class A2 FPG 105 mg/dL and
• 2 h PPG 120 mg/dL

A1 Diet control OPD A2 InsulinAdmit ?
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White classification

• Class B duration lt10 yr or age onset 20 yr
• Class C duration 10-19 yr or age onset 10-19 yr
• Class D duration gt20 yr or age onset lt10 yr or
  BDR
• Class R DM with PDR
• Class F DM with DN (proteinuria gt500 mg/day)
• Class H DM with CHD
• Class T DM with renal transplantation

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Treatment

• Diet control A1/A2/Overt DM

Pregnancy Weight Status Kcal/Kg/day Desirable
body weight 30 120-150 Desirable BW 24 gt
150 Desirable BW 12-18 lt 90 Desirable BW
36-40
Desirable BW (Ht in cm 100) x 0.9
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Recommended Calorie Distribution

• 40-50 Carbohydrate
• 20 Protein
• 30-40 Fat

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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
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Insulin Regimen
??????????? ????????? ???? ????????? ?????? ????????? ???? ??????? ???????????
1 1 2 2 4 NPH NPHRI NPH NPHRI RI RI NPHRI RI NPH NPH Poor Poor Poor Good Very good
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Target
Glucose level (mg/dL) Glucose level (mg/dL)
Time 4th international workshop on GDM 1998 ADA 2004
FPG 1 h PPG 2 h PPG 105 140 120 lt 105 lt 155 lt 130
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Whole Blood Glucose Goals in Diabetic Pregnancy

• Fasting 60-90 mg/dl
• Premeal 60-100 mg/dl
• 1 hour postmeal lt 120 mg/dl
• 02.00-06.00 AM gt 60 mg/dl
• Note Add 15 to convert numbers to plasma glucose

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Labor

• Class A1 Normal labor
• Class A2 / Overt DM
• gt 38 wks
• keep 70-120 mg/dL

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Insulin During Labor Delivery

• Vaginal delivery
• - NPO after 24.00 ???????????????????????????????
  ?
• - NPO ??????? admit ?????????????
• - ????? insulin ????????????????????????????
• - ???? FPG ????????????????
• - intrapartum insulin infusion
  ?????????????? ?????????? 1-2 ??.

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Insulin During Labor Delivery

• With Elective Cesarean Delivery
• - NPO after midnight ??????????????????????
• - ?????????????????????????
• - ????? insulin ????????????????????????
• - ???? FPG ?????????????????
• - intrapartum insulin infusion
  ?????????????? ?????????? 1-2 ??.
• - ??????????

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Insulin and Solution
Glucose level (mg/dL) Insulin dosage (units/hr) Solutions (drip 125 ml/hr)
lt 100 100-140 141-180 181-220 gt 220 0 1 1.5 2 2.5 5D, LRS 5D, LRS Normal saline Normal saline Normal saline
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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

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Thank you for your attention