diabetes & pregnancy
DESCRIPTION
Diabetes & pregnancy. Insulin. Diabetes & pregnancy. Impact of diabetes on pregnancy Impact of pregnancy on diabetes. Diabetes & pregnancy. Gestational diabetes (GDM) Pre-pregnancy diabetes (PGDM): type 1 or type 2 diabetes or MODY S ynonyms : overt diabetes, chronic diabetes. - PowerPoint PPT PresentationTRANSCRIPT
Diabetes & Diabetes & pregnancypregnancy
Insulin Insulin
Diabetes & pregnancyDiabetes & pregnancy
• Impact of diabetes on Impact of diabetes on pregnancypregnancy
• Impact of pregnancy on Impact of pregnancy on diabetesdiabetes
Diabetes & pregnancyDiabetes & pregnancy
• Gestational diabetes (GDM)Gestational diabetes (GDM)
• Pre-pregnancy diabetes (PGDM):Pre-pregnancy diabetes (PGDM):type 1 or type 2 diabetes or MODYtype 1 or type 2 diabetes or MODYSSynonymsynonyms: overt diabetes, chronic : overt diabetes, chronic diabetesdiabetes
Diabetes Complicating Diabetes Complicating PregnancyPregnancy
Class Class Age of Age of onsetonset
DuratioDuration n
Vascular Vascular complicationscomplications
TherapTherapy y
G1G1 GestatioGestationn
-- NoneNone DD
G2G2 GestatioGestationn
-- NoneNone D + ID + I
BB > 20 > 20 < 10< 10 NoneNone D + ID + I
CC 10 – 1910 – 19 10 – 19 10 – 19 NoneNone D + ID + I
DD < 10< 10 > 20> 20 Benign retinopathyBenign retinopathy D + ID + I
FF AnyAny AnyAny NephropathyNephropathy D + ID + I
RR AnyAny AnyAny Proliferative Proliferative retinopathyretinopathy
D + ID + I
HH AnyAny AnyAny IHDIHD D + ID + I
NN AnyAny AnyAny Kidney Kidney transplantationtransplantation
D + ID + I
Gestational Gestational diabetesdiabetes
CCarbohydrate intolerancearbohydrate intolerance
of of variablevariable severity severity
with onset or first recognitionwith onset or first recognition
during pregnancyduring pregnancy
GDM:GDM: pathomechanism pathomechanism theoriestheories
• Exaggerated Exaggerated physiological changesphysiological changes in in glucose metabolism: induction of glucose metabolism: induction of hyperglycaemiahyperglycaemia
1st half of pregnancy: high insulin 1st half of pregnancy: high insulin sensitivitsensitivityy
2nd half of pregnancy: increase of insulin 2nd half of pregnancy: increase of insulin resistanceresistance
Postpartum drop of insulin resistancePostpartum drop of insulin resistance
GDM:GDM: pathomechanism pathomechanism theoriestheories
• Preexisting Preexisting type 2 diabetestype 2 diabetes unmaskedunmasked
or firstor first discovered during discovered during pregnancypregnancy
Detection of GDM: step 1 Detection of GDM: step 1 & 2& 2
• 1st 1st visitvisit:: fasting glucose level < 100 fasting glucose level < 100 mg/dlmg/dl
• Screening: Screening: universal or selective?universal or selective?• Method:Method: 50 g glucose Oral Challenge 50 g glucose Oral Challenge
Test (OCT)Test (OCT)• Timing:Timing: between 24th and 28th week between 24th and 28th week
of gestationof gestation• No regard to the time of day or of No regard to the time of day or of
last meallast meal
GDM: screening resultsGDM: screening results
•< 140 mg/dl: < 140 mg/dl: negativenegative
•140 – 199 mg/dl:140 – 199 mg/dl: diagnostic testdiagnostic test
as as soon as possiblesoon as possible
•≥≥ 200 mg/dl:200 mg/dl: positivepositive•*140 mg/dl: identifies *140 mg/dl: identifies 80% of women with 80% of women with GDMGDM
Detection of GDM: step 3 Detection of GDM: step 3
• Method:Method: 75 g load 2-hour Oral Glucose 75 g load 2-hour Oral Glucose Tolerance Test (OGTT) – according Tolerance Test (OGTT) – according
to WHO recommendationto WHO recommendation• 3 days before test:3 days before test: increase amount increase amount
of carbohydrates intake ( 150 g/dayof carbohydrates intake ( 150 g/day
at least)at least)• 1 day before test:1 day before test: last meal at 6.00 last meal at 6.00
a.m.a.m.• Overnight fastOvernight fast
OGTT: thresholdsOGTT: thresholds
• Fasting: < 100 mg/dlFasting: < 100 mg/dl• 1-hour (optional): < 180 mg/dl1-hour (optional): < 180 mg/dl
• 2-hour: < 140 mg/dl2-hour: < 140 mg/dl
Glucose tolerance Glucose tolerance curvescurves
GDM detection GDM detection – no – no matters:matters:
Unrecognized glucose intolerance Unrecognized glucose intolerance having existed before the pregnancyhaving existed before the pregnancy
Glucose intolerance persistence or Glucose intolerance persistence or not after the pregnancynot after the pregnancy
Both conditions to be verifiedBoth conditions to be verified postpartum!postpartum!
GDM functional GDM functional classificationclassification
• Depends on therapy Depends on therapy effectivenesseffectiveness
• G1 – diet onlyG1 – diet only• G2 – diet & insulin G2 – diet & insulin
administrationadministration
• Insulin analogues: Insulin analogues: acceptedaccepted
• Oral hypoglycaemic Oral hypoglycaemic agents: contraindicatedagents: contraindicated
Fetal effects of GDMFetal effects of GDM
• Maternal hyperglycemiaMaternal hyperglycemia• Fetal hyperglycemiaFetal hyperglycemia• Fetal response: hyperinsulinemiaFetal response: hyperinsulinemia• Excessive fetal growth: macrosomiaExcessive fetal growth: macrosomia• Shoulder dystocia: birth traumaShoulder dystocia: birth trauma• Hydramnios (osmotic diuresis?)Hydramnios (osmotic diuresis?)• Intrauterine fetal death in last 4Intrauterine fetal death in last 4 –– 88
weeks of pregnancy (weeks of pregnancy (eexcessive xcessive oxygen oxygen consumptionconsumption? ? ffetal asphyxia?)etal asphyxia?)
Neonatal effects of Neonatal effects of GDMGDM
• Excessive oxygen use in utero: Excessive oxygen use in utero: polycythemiapolycythemia
• HyperbilirubinemiaHyperbilirubinemia• Thrombosis Thrombosis • HypoglycemiaHypoglycemia• Respiratory distressRespiratory distress (Inhibition of lung (Inhibition of lung
maturation)maturation)• Longitudinal effects: obesity & diabetesLongitudinal effects: obesity & diabetes
Neonatal macrosomia Neonatal macrosomia
Maternal effects of Maternal effects of GDMGDM
• HypertensionHypertension• Cesarean deliveryCesarean delivery• Recurrence of GDM in subsequent Recurrence of GDM in subsequent
pregnancypregnancy• Overt diabetes developementOvert diabetes developement(over 50 – 70% of women with GDM(over 50 – 70% of women with GDM
in 20-years period)in 20-years period)• Metabolic syndrom developmentMetabolic syndrom development
Maternal-fetal effectsMaternal-fetal effects
GDM: managementGDM: management
• Diet:Diet:6 meals a day6 meals a dayCaloric restriction according to BMICaloric restriction according to BMIEliminate: monosaccharidesEliminate: monosaccharides• ExerciseExercise• Empirical insulin therapyEmpirical insulin therapy• Insulin: short-acting & long-actingInsulin: short-acting & long-acting• Never use combined insulin in Never use combined insulin in
pregnant woman!pregnant woman!
GDM: plasma glucose GDM: plasma glucose controlcontrol
Goals:Goals:• Fasting 60 – 90 Fasting 60 – 90
mg/dlmg/dl• 1-hour postprandial1-hour postprandial
< 130 mg/dl < 130 mg/dl
GDM: postpartum GDM: postpartum consequencesconsequences• 75-g 2-h OGTT 6 weeks 75-g 2-h OGTT 6 weeks
postpartum (poor compliance)postpartum (poor compliance)
• If normal: regular reassessment If normal: regular reassessment (OGTT) at minimum 3-year (OGTT) at minimum 3-year intervalsintervals
• Weight control & adequate Weight control & adequate physical activity prevent physical activity prevent recurrence of GDMrecurrence of GDM
in subsequent pregnanciesin subsequent pregnancies
PGDM & pregnancyPGDM & pregnancy
• 1st trimester: drop of insulin require1st trimester: drop of insulin require – reduce insulin doses!– reduce insulin doses!
• 2nd and 3rd trimester: insulin 2nd and 3rd trimester: insulin resistance gradual increaseresistance gradual increase
• Strict plasma glucose control Strict plasma glucose control necessary!necessary!
• Glycated hemoglobin rateGlycated hemoglobin rate
Fetal effects of PGDMFetal effects of PGDM
• Abortion or preterm deliveryAbortion or preterm delivery• Congenital malformationsCongenital malformations• MacrosomiaMacrosomia• Unexplained fetal demise & stillbirthsUnexplained fetal demise & stillbirths
> 35 week of gestation (impaired > 35 week of gestation (impaired oxygene transport due to maternal oxygene transport due to maternal hyperglycemia?)hyperglycemia?)
• Placental insufficiency & IUGRPlacental insufficiency & IUGR• Hydramnios Hydramnios
Neonatal effects of Neonatal effects of PGDMPGDM
• Respiratory distressRespiratory distress• HypoglycemiaHypoglycemia• HypocalcemiaHypocalcemia• HyperbilirubinemiaHyperbilirubinemia• Cardiac hypertrophyCardiac hypertrophy• Impaired long-term cognitive Impaired long-term cognitive
developmentdevelopment• Inheritance of diabetesInheritance of diabetes
Maternal effects of Maternal effects of PGDMPGDM
• Diabetic nephropathyDiabetic nephropathy• Diabetic retinopathyDiabetic retinopathy• Diabetic neuropathyDiabetic neuropathy• PreeclampsiaPreeclampsia• KetoacidosisKetoacidosis• InfectionsInfections
PGDM: management in PGDM: management in pregnancypregnancy
• Preconception counselling & educationPreconception counselling & education• Low glycated hemoglobin valuesLow glycated hemoglobin values• Multiple daily insulin injectionsMultiple daily insulin injections• Continous subcutaneous insulin infusion Continous subcutaneous insulin infusion • DietDiet• Fetal sonography: congenital anomalies, Fetal sonography: congenital anomalies,
excessive growth, excessive growth, hydramnios/oligohydramnioshydramnios/oligohydramnios
Sequential vs continous Sequential vs continous insulin therapyinsulin therapy
Delivery in diabetic Delivery in diabetic patientpatient
• GDM GDM per seper se is not an indication to is not an indication to caesarean section!caesarean section!
• Labor induction in GDM or Labor induction in GDM or B – C classB – C class PGDM, unless fetal macrosomia existsPGDM, unless fetal macrosomia exists
• Well-controlled Well-controlled B – C class B – C class PGDMPGDM: : according to other medical conditionsaccording to other medical conditions
• D – N class D – N class PGDMPGDM::no alternative to caesarean delivery!no alternative to caesarean delivery!
• Remember adequate hydration & plasma Remember adequate hydration & plasma glucose control during labor and delivery!glucose control during labor and delivery!