Diabetes and Pregnancy

Ambulatory Medicine13rd Khon Kaen Annual Meeting, 2005.

Diabetes and Pregnancy

• Pregestational Diabetes

• Gestational Diabetes

Effect of Pregnancy to Diabetes

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

Maternal-Fetal Fuel and Hormone Exchange

Mother Placenta FetusGlucose Glucose : 28 wk

Insulin Insulin

Amino Acids AminoAcids:9-14wk

FFA FFAKetones Ketones

Maternal DM

Increase MaternalGlucose, ketones, Amino acids, lipids

Fetal hyperglycemia

Embryonic-fetalhyperalimentation

Fetal hyperinsulinemia

Fetal macrosomia

Congenitalanomalies

Fetal• hypoglycemia• RDS

Understanding GDMThe Role of Insulin Resistance

0

100

200

300

20 22 24 26 28 30 32 34 36

50

100

150

200

250

Weeks of Pregnancy

Glu

cose

Rel

ativ

e M

easu

reof

insu

lin /i

nsul

in a

ctio

n

Insulin Resistance

Insulin Level

Fasting Glucose

Post Meal Glucose

Human placental lactogenEstrogen

ProgesteroneCortisolProlactin

Effect of Diabetes to Pregnancy

• Mother1. Toxemia of pregnancy2. Pyelonephritis3. Hydraminos4. Cesarean Delivery5. Maternal Mortality

Effect of Diabetes to Pregnancy• Infant

1. Perinatal mortality2. Spontaneous abortion3. Congenital malformation4. Macrosomia5. IUGR6. Intrauterine fetal death

010

20

30

40

1926-45 1946-55 1956-65 1966-70 1971-75 1976-80 1981-85 1986-90

Perinatal mortality (%)

Year

Perinatal Mortality in Diabetic Pregnancies in the Period 1926-1990

0

50

100

50 100 150 200 250

Joslin (Pre – 1922)

Joslin (1924-1938)

Predersen (1969)

Kalsson (1972)

Joslin (1956-1975)Karlsson (1972)Essex (1973)Tyson (1979)

Fuhrmann (1980)

Martin (1979)

Tyson (1976)

DKA

Mean maternal blood glucose (mg/dl)

Infa

nt m

orta

lity

(%)

Effect of Diabetes to Pregnancy

• Infant 1. Perinatal mortality2. Spontaneous abortion3. Congenital malformation4. Macrosomia5. IUGR6. Intrauterine fetal death

Effect of Diabetes to Pregnancy

• Infant 7. Respiratory distress syndrome8. Hypoglycemia9. Hypocalcemia & Hypomagnesemia 10. Hyperviscosity 11. Hyperbilirubinemia 12. Cardiomyopathy

Effect of Diabetes to Pregnancy

• Infant13. Long term consequences : - Neuropsychological

development - Obesity - Diabetes Mellitus

Goals of Prepregnancy Planning Program

• Assessment of a woman’s fitness for pregnancy

• Obstetric evaluation• Intensive education of woman and family• Attainment of optimum diabetic control• Timing and planning of pregnancy

Potential Contraindication to Pregnancy

• Ischemic heart disease

• Untreated, active proliferative retinopathy

• Renal insuffinciency : CCr < 40 ml/min or serum creatinine > 2.5 - 3 mg/dl

• Severe gastroenteropathy : N/V, diarrhea

Gestational Diabetes

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

Risk and Screening

Risks Screening recommendation

High risk First ANCIf normal: GA 24-28 wks

Intermediate risk GA 24-28 wks

Low risk Not recommended

High risk

• Age >35 yr• Obesity (> 120 % Ideal BW)• Family history• Previous GDM• Urine sugar ++• History of poor obstetric outcome

Detection of Gestational Diabetes

• Screen all pregnant women Or

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

1. Age < 25 years2. Weight normal before pregnancy3. Member of an ethnic group with low GDM4. No known diabetes in first-degree relatives5. No history of abnormal glucose tolerance6. No history of poor obstetric outcome

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

> 140 mg/dl ( sensitive 80% )> 130 mg/dl ( sensitive 90% )

Diagnostic GDM with OGTT

1. 100 g OGTT “NDDG Criteria”2. 100 g OGTT “Carpenter & Coustan”3. 75 g OGTT “International Workshop

on GDM”4. 75 g OGTT “WHO”

Note: ADA 2005 recommend criteria 2 & 3

Comparison of OGTT Criteria

Glucose NDDG Car&Coust IWG WHO100g 100g 75g 75g

Fasting 105 95 95 <1261-hr 190 180 180 ----2-hr 165 155 155

>1403-hr 145 140 ---- ----

>/= 2

Classification

• Class A1: FPG < 105 mg/dL and 2 h PPG < 120 mg/dL

• Class A2: FPG ≥ 105 mg/dL and 2 h PPG ≥ 120 mg/dL

A1 : Diet control & OPDA2 : Insulin……Admit ?

White classification

• Class B: duration <10 yr or age onset ≥20 yr• Class C: duration 10-19 yr or age onset 10-19 yr• Class D: duration >20 yr or age onset <10 yr or

BDR• Class R: DM with PDR• Class F: DM with DN (proteinuria >500 mg/day)• Class H: DM with CHD• Class T: DM with renal transplantation

Treatment

• Diet control: A1/A2/Overt DMPregnancy Weight Status Kcal/Kg/day

Desirable body weight 30

120-150% Desirable BW 24

> 150% Desirable BW 12-18

< 90% Desirable BW 36-40

Desirable BW = (Ht in cm – 100) x 0.9

Recommended Calorie Distribution

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

INSULIN: A2/Overt DM

GA Dosage (unit/kg/day)

1st Trimester 0.72nd Trimester 0.83rd Trimester 0.9

Admit : 2-4 units q 2-3 daysOPD : 2-4 units q 7 days

Insulin Regimen

ครัง้ต่อวนั

ก่อนอาหารเชา้

ก่อนอาหารเท่ียง

ก่อนอาหารเยน็

ก่อนนอน

ผลการควบคุม

11224

NPHNPH+RINPHNPH+RIRI

RINPH+RIRI

NPH

NPH

PoorPoorPoorGoodVery good

Target

Glucose level (mg/dL)

Time4th international

workshop on GDM 1998

ADA 2004

FPG1 h PPG2 h PPG

≤ 105≤ 140≤ 120

< 105< 155< 130

Whole Blood Glucose Goals in Diabetic Pregnancy

• Fasting 60-90 mg/dl• Premeal 60-100 mg/dl• 1 hour postmeal < 120 mg/dl• 02.00-06.00 AM > 60 mg/dl

Note: Add 15% to convert numbers to plasma glucose

Labor

• Class A1: Normal labor• Class A2 / Overt DM

> 38 wkskeep 70-120 mg/dL

Insulin During Labor & Delivery

•Vaginal delivery: - NPO after 24.00 ก่อนวนักำ�หนดคลอดในกรณีนัดวนัคลอด- NPO ตัง้แต่ admit ในกรณีฉกุเฉิน- งดฉีด insulin วนักำ�หนดคลอดในกรณีนัดวนัคลอด

- ตรวจ FPG เช�้วนักำ�หนดคลอด - intrapartum insulin infusion ต�มระดับ

นำ้�ต�ล โดยเจ�ะทกุ 1-2 ชม.

Insulin During Labor & Delivery

With Elective Cesarean Delivery

- NPO after midnight ก่อนวนักำ�หนดผ่�ตัดคลอด

- พจิ�รณ�ผ่�ตัดคลอดชว่งเช�้- งดฉีด insulin มื้อเช�้ของวนัผ่�ตัดคลอด

- ตรวจ FPG เช�้วนัผ่�ตัดคลอด - intrapartum insulin infusion ต�มระดับ

นำ้�ต�ล โดยเจ�ะทกุ 1-2 ชม. - ผ่�ตัดคลอด

Insulin and Solution

Glucose level (mg/dL)

Insulin dosage(units/hr)

Solutions(drip 125 ml/hr)

< 100100-140141-180181-220

> 220

01

1.52

2.5

5%D, LRS5%D, LRS

Normal salineNormal salineNormal saline

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

Thank you for your attention