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Diabetes Mellitus In Pregnancy

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Title: Diabetes Mellitus In Pregnancy


1
Diabetes Mellitus In Pregnancy
  • ?????????????? ???????? ??????? ???????

2
Diabetes Mellitus In Pregnancy
  • Definition
  • Epidemiology
  • Pathogenesis
  • Classification
  • Screening
  • Diagnosis
  • Complications
  • Treatment

3
Diabetes Mellitus
  • ??????????????????????????????????????????????????
    ??????? (glucose intolerance)
  • - type 1 insulin dependent
  • - type 2 noninsulin dependent
  • The most common medical complication of pregnancy
  • Gestational diabetes (GDM) diagnosed during
    pregnancy
  • Pregestational diabetes (Overt DM) before
    pregnancy

4
Epidemiology
  • ?????? 2-3 ??????????????????????????????????????
  • ?????? 90 ???? GDM
  • Usually occur in 2nd trimester

5
Pathogenesis
  • ??????????????????????
  • Estrogen ??? Progesterone ????? ??????????????
    beta cell ?????????? ??????????????? insulin
    ????????? ????? FBS ????????????????????????????
  • ???????????????????????
  • ?????????? insulin ??????????????? HPL
    ???????????? ??????? prolactin, cortisol,
    glucagon ???????????????? insulin ?????????
    (diabetogenic effect) ?????????????????? insulin
    ???????????? ??????????????????

6
Classification
Class Onset Fasting Plasma Glucose 2-hr Postpandrial Glucose Therapy
A1 Gestation lt105 mg/dl And lt120 mg/dl Diet
A2 Gestation gt105 mg/dl And/or 120 mg/dl Insulin
Class Age of Onset Duration (yr) Vascular Disease Therapy
B gt 20 lt 10 None Insulin
C 10 19 10 19 None Insulin
D lt 10 20 Benign Retinopathy Insulin
F Any Any Nephropathy Insulin
R Any Any PDR Insulin
H Any Any Heart Insulin
7
Diabetes Mellitus In Pregnancy
  • Overt
  • Random plasma glucose gt 200 mg/dl ???????
    classical signs symptoms (polydipsia, polyuria
    unexplained wt. loss)
  • Fasting glucose 126 mg/dl

8
Diagnostic test
  • One-step approach 100 g OGTT
  • Two-step approach
  • - 50 g GCT 140 mg/dl (80),
  • 130 mg/dl (90)
  • - 100 g OGTT
  • Selective screening ????????????? high risk
    ????????
  • Universal screening ????????????????????????????
    ????

9
Risk Assessment for Detecting GDM
  • Low Risk blood glucose testing not routinely
    required
  • Age lt 25 yr
  • Member of an ethnic group with a low prevalence
    of GDM
  • No known diabetes in first-degree relatives
  • Weight normal before pregnancy
  • No history of abnormal glucose tolerance
  • No history of poor obstetric outcome

10
Risk Assessment for Detecting GDM
  • High Risk ????????????????????????????
    ??????????????????? ??????????????? GA 24-28 wks.
    ????????????????????GDM
  • Age gt 30 yr
  • Marked obesity (20 more than ideal weight)
  • First-degree relative with DM
  • Previous GDM
  • Previous large baby wt. gt 4,000 g
  • Previous still birth, or a child with a birth
    defect, PIH
  • Glucosuria
  • Polyhydramnios

11
Risk Assessment for Detecting GDM
  • Average Risk ????????????? GA 24-28 wks.
  • Not in High risk and Low risk categories

12
Diagnosis
  • Hx
  • - ????????????? ?????????? ???????????
    ???????????????????????????
  • - ???????????????????? ??????????????? gt 4,000
    g, ?????????????????? ????????????????????????????
    ??
  • PE
  • - ???????????
  • - ????????????????? ?????????????????
  • - ???????????????????????????? ? ??????????
    ???????????????????????????
  • Ix
  • - ????????????????????? ??????? glucosuria
    ????????????????????????????
  • - ????????????????????????????? ??????? OGTT

13
Oral glucose tolerance test
  • 100-gram OGTT (3hr)
  • ??????????????????????????????????????????????????
    ???? 2 ????????? ? GDM
  • ?????????? 1 ??? ?????????????????? 1 ????? ? pt.
    1/3 ?? GDM ????????????
  • 75-gram OGTT
  • ???????????????????????????? ?????????????????????
    ?????????????????

14
Diagnostic criteria
15
??????????????????????????????
  • ????????????????????????????
  • ?????????????????????????? ???????? diabetic
    ketoacidosis ???????
  • ???????????????????????????????? ????
    retinopathy, nephropathy
  • ???????? ?????????????????????????????????????

16
????????????????????????????????????????
  • ?????????
  • Neonatal hypoglycemia
  • ????????????????????????
  • ??????????????
  • ??????????????????
  • ????????? (macrosomia)
  • ???????????? RDS ???????
  • Neonatal hypocalcemia
  • Hyperbilirubinemia
  • Cardiomyopathy
  • Polycythemia
  • hydramnios

17
Congenital anomaly in overt DM
Anomaly Percent
Caudal regression 252
Situs inversus 84
Spina bifida, hydrocephaly, or other CNS defect 2
Anencephaly 3
Heart anomalies 4
Anal/rectal atresia 3
Renal anomalies -Agenesis -Cystic kidney -Duplex ureter 5 4 4 23
18
????????????????????????????????????????
  • ??????????
  • Abortion
  • Hypoglycemia
  • Hyperglycemia
  • Infection
  • PIH
  • Hydramnios
  • ??????????????????????????????????
  • PPH
  • death

19
MANAGEMENT
20
????????????
  • ????????????????????????????????????
  • ???????????????????????????
  • ???????????????????
  • ????????????????????????????????

21
Preconception
  • ??????????? ??????????????? ??????????????????????
    ???????????
  • ??????????????????? ????????????? ?? ??????????
    ???????????? ????????????????????????????????? ?
  • ??????????????????????????????????????????????????
    ? 3 ????????????????????? ( FPG 70-100 mg/dl ???
    postprandial 1sthr lt 140 mg/dl 2ndhr lt 120
    mg/dl )
  • ????? HbA1c ???????????????????????????????
  • ???????????????????????????????????
    ??????????????????????????????????????????????????
    ??????????????????????
  • Folic acid 400 ug/day ?? risk of neural-tube
    defect

22
???????????????????????????????????
  • DIET
  • EXERCISE
  • INSULIN
  • ORAL HYPOGLYCEMIC AGENT

23
DIET
  • Goals
  • provide necessary nutrients for mother and fetus
  • control glucose level
  • prevent starvation ketosis

24
Diet control
  • ?????? Ideal body weight (30-35 kcal/kg)
  • Average 1800-2000 Kcal/d
  • CHO Protein Lipid 55 20 25 ???????? 4
    ???? ????/??????/????/??????? ?????????
    25/30/30/15
  • ??????????????????/????? ???? ????????????????????
    ??????????????????????
  • Cardiovascular conditioning ???? aerobic
    exercise
  • ?????????????????????????????????????????????????
    ???????????????
  • (upper trunk exercise)

25
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26
Insulin
  • ????????????????????? ????????????????????????????
    ?, ???????????????, ???? hypoglycemia ???????
  • Used when FBS gt 105 mg/dl persist despite diet
    control
  • ???????? Dx overt DM ?????? admit ?????????????
    insulin ????????????????????????????
  • Overt DM ??? intermediate short-acting insulin
  • ?????? mix-split dose ??? NPH RI ????/????
    ??????? fluctuation
  • ???? NPHRI 21 (2/3 ??? total dose)
  • ???? NPHRI 11 (1/3 ??? total dose)
  • ??????????????? BS

27
Insulin
  • ??????? BS ?????????????????? 1 ?????
  • ?????????????????????????? hypoglycemia
    ????????????????????????? insulin
  • ??????????? insulin ??????????????????????????
  • Self injection and home monitoring

28
Goal ??????????? blood sugar
Goal ???????? BS mg/dl
FBS 60-90
Before lunch/dinner/snack 60-105
After meal 1 hr 140
After meal 2 hr 120
From 2-6 a.m. 60-90
29
Diabetic ketoacidosis
  • BS 200-250 mg/dl ?????????????? ???Na
  • Treatment
  • IV 2 lines ?????? 1 ????/??. ?? 2 ??.??? ??? BS lt
    250 mg/kg/hr ??????????? 5 D/W
  • Insulin IV bolus RI 10-20 U ??????? Insulin drop
    5-10 U/hr
  • Potassium
  • Within 2-4 hr ?????????????????
  • Not to drop gt 30-40 mEq/hr
  • Bicarbonate
  • Only in severe acidosis ( pHlt7.0)
  • Stop when pH 7.2

30
GDM
  • ??????????????????? GDM ??????????????????????????
    ? ??????????????????????? ???????????????????
  • ????????????? PIH

31
Overt DM ???????????????????????
  • 1st tri
  • Careful monitoring of glucose control is
    essential
  • ???????????????????????????????????????????????
    ???????? insulin ???????????????????????
  • ?????????????????????????????????????????????????
    ????????????????????????????
  • ?????? vascular complication
  • ??????????????????????? ultrasonography

32
Overt DM ???????????????????????
  • 2nd tri
  • ???? MSAFP ????? GA 16-20 wks. ?????????????????
  • ???? USG ???????????? ????? GA 18-20 wks.
    ?????????????????????????? neural tubes defect
  • ???? fetal echocardiogram ????? GA 20-22 wks.
    ??????????????????????????????

33
Overt DM ???????????????????????
  • 3 rd tri
  • ?????????? wk ????????????????????????????????????
    ???????????
  • ???????????????? preeclampsia ?????????????? ?
  • ?????????? USG ?????????????????????????????????
    ()
  • ??? pt. ?????????????????????? ?????????????????
    ?????? admit

34
??????????????????????????????
  • ????? GA 30-32 wk
  • Fetal movement count
  • GDM ???? NST 1 ?????/wk
  • Overt DM ???? NST 2 ?????/wk ????? nonreactive
    test ?????????????????? BPP
  • ?????????????? doppler ultrasound
    ???????????????????????????? vasculopathy

35
???????????????????????????
  • ??????????????????????? GA 38 wks. ??????????? GA
    ??????
  • ????????????? DM ?? lung maturity ???????????????
  • ?????????????
  • L/S ratio (Lecithin/sphingomyelin) gt2
  • Foam stability test or Shake test
  • PG level (phosphatidylglycerol level) gt3

36
???????
  • ??????????????????????????????????????????????????
    ?????????? ???????????? GA 38 wks
    (??????????????????????????)
  • ?????????????????????????????? ??????????????????
    ß-sympathomimetic (tocolytic)
    ?????????????????ketoacidosis ????????????????????
    ?????? MgSO4
  • ?????? corticosteroid ????????????????????????????
    ?????????????????
  • pt.??????????????????????? ???? severe
    preeclampsia ??????????????????????????????????

37
???????
  • Labor induction is attempted when fetus is not
    excessively large, and the cervix is considered
    favorable
  • C/S is common to avoid traumatic delivery of a
    large infant in class B or C and more advanced DM
    esp. with vascular disease (???? macrosomia,
    ??????????? gt 4500 g)

38
???????????????????
  • Regular insulin ????????????????????? 0.5-2 U/hr
    ??????? glucose ????????????????????? 5-10 g/hr
  • RI 8-10 U ?????? 5 D/NSS 100-120 ml/hr
  • DTX ??? ? 1-4 ??. ?????????? 70-120 mg/dl
  • ??????????????????????????? ins ?????? 5 D/NSS
  • ???????????????????????????????????. ?????????
    ??? ins subcutaneous
  • ?????????????? ins ???????????????????????????
    ??????????????????????????????????????
  • ?????????????????????????????????????????????

39
  • LOW-DOSE INSULIN INFUSION FOR THE INTRAPARTUM
    PERIOD

Blood glucose (mg/dl)
Insulin Dosage (U/hr)
Fluids (125ml/hr)
0 1.0 1.5 2.0 2.5
D5 lactated Ringer D5 lactated Ringer Normal
saline Normal saline Normal saline
lt 100 100 - 140 141 - 180 181 - 220 gt 220
From ACOG (1994)
40
???????????????????
  • ??????????????????????????????????????????????????
    ?
  • ?????????????
  • ?????????? RDS
  • ?????????????????????? ????? 1 ??.????????
    ???????????? 4 ??????? ???????? 24 ??. lt 40 mg/dl
    ??????????
  • ?????????????????????
  • ???????????????? ??????? ?????????????????
    glucose tolerance

41
????????????
  • ???????????????????????????????????????????????
    ????????????????????? ????????????????????????????
    ?
  • ?????????????????????????????????? ????????
    insulin ??????????????? (???????????????)
  • ????????????????????????????????????????????

42
????????????
  • ??????????????????? estrogen ?????????
  • ?????????????????????????????????????????
  • Progestin-only pill,Norplant ??????? carbohydrate
    metabolism ????
  • ?????????????? IUD ?????????????????
  • Barrier methods
  • ??????????????? ????????????????????????????

43
?????????????
  • ?????????????????????????????????????? DM (type
    2) ???????
  • GDM ??????????????????????????????????? 22-28 ??
    ????????? 50 ??????? 75 g OGTT 6-8 wk.
    ????????
  • ??????????????????????????

44
Table postpartum evaluation
  • 2-hour, 75-g oral glucose tolerance test plasma
    glucose(mg/dL)

Time tested No diabetes Impaired glucose tolerance Diabetes
Fasting lt 115 lt 140 140
½, 1, 1½ hr All lt 200 1 value 200 1 value 200
2 hr lt 140 140-199 200
45
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