Diabetes and Pregnancy Ambulatory Medicine 13 rd 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 Fetus Glucose Glucose : 28 wk Insulin Amino Acids AminoAcids: 9-14wk FFA Ketones

Maternal DM Increase Maternal Glucose, ketones, Amino acids, lipids Fetal hyperglycemia Embryonic-fetal hyperalimentation Fetal hyperinsulinemia Fetal macrosomia Congenital anomalies Fetal hypoglycemia RDS

Understanding GDM The Role of Insulin Resistance Weeks of Pregnancy Glucose Relative Measure of insulin /insulin action Insulin Resistance Insulin Level Fasting Glucose Post Meal Glucose Human placental lactogen Estrogen Progesterone Cortisol Prolactin

Effect of Diabetes to Pregnancy Mother 1. Toxemia of pregnancy 2. Pyelonephritis 3. Hydraminos 4. Cesarean Delivery 5. Maternal Mortality

Effect of Diabetes to Pregnancy Infant 1. Perinatal mortality 2. Spontaneous abortion 3. Congenital malformation 4. Macrosomia 5. IUGR 6. Intrauterine fetal death

Perinatal mortality (%) Year Perinatal Mortality in Diabetic Pregnancies in the Period

Joslin (Pre – 1922) Joslin ( ) Predersen (1969) Kalsson (1972) Joslin ( ) Karlsson (1972) Essex (1973) Tyson (1979) Fuhrmann (1980) Martin (1979) Tyson (1976) DKA Mean maternal blood glucose (mg/dl) Infant mortality (%)

Effect of Diabetes to Pregnancy Infant 1. Perinatal mortality 2. Spontaneous abortion 3. Congenital malformation 4. Macrosomia 5. IUGR 6. Intrauterine fetal death

Effect of Diabetes to Pregnancy Infant 7. Respiratory distress syndrome 8. Hypoglycemia 9. Hypocalcemia & Hypomagnesemia 10. Hyperviscosity 11. Hyperbilirubinemia 12. Cardiomyopathy

Effect of Diabetes to Pregnancy Infant 13. 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 mg/dl Severe gastroenteropathy : N/V, diarrhea

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

Risk and Screening RisksScreening recommendation High riskFirst ANC If normal: GA wks Intermediate riskGA wks Low riskNot 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 years 2. Weight normal before pregnancy 3. Member of an ethnic group with low GDM 4. No known diabetes in first-degree relatives 5. No history of abnormal glucose tolerance 6. 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 g OGTT “NDDG Criteria” g OGTT “Carpenter & Coustan” g OGTT “International Workshop on GDM” g OGTT “WHO” Note: ADA 2005 recommend criteria 2 & 3

Comparison of OGTT Criteria Glucose NDDG Car&Coust IWG WHO 100g 100g75g 75g Fasting <126 1-hr hr >140 3-hr >/= 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 & OPD A2 : Insulin …… Admit ?

White classification Class B: duration <10 yr or age onset ≥20 yr Class C: duration yr or age onset 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 DM Pregnancy Weight Status Kcal/Kg/day Desirable body weight % Desirable BW24 > 150% Desirable BW < 90% Desirable BW 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) 1 st Trimester nd Trimester rd Trimester 0.9 Admit : 2-4 units q 2-3 days OPD : 2-4 units q 7 days

Insulin Regimen ครั้ง ต่อวัน ก่อน อาหาร เช้า ก่อน อาหาร เที่ยง ก่อน อาหาร เย็น ก่อน นอน ผล การ ควบคุ ม NPH NPH+ RI NPH NPH+ RI RI NPH+ RI RI NPH Poor Good Very good

Target Glucose level (mg/dL) Time 4 th international workshop on GDM 1998 ADA 2004 FPG 1 h PPG 2 h PPG ≤ 105 ≤ 140 ≤ 120 < 105 < 155 < 130

Whole Blood Glucose Goals in Diabetic Pregnancy Fasting60-90 mg/dl Premeal mg/dl 1 hour postmeal< 120 mg/dl AM > 60 mg/dl Note: Add 15% to convert numbers to plasma glucose

Labor Class A1: Normal labor Class A2 / Overt DM > 38 wks keep mg/dL

Insulin During Labor & Delivery Vaginal delivery: - NPO after ก่อนวันกำหนดคลอด ในกรณีนัดวันคลอด - NPO ตั้งแต่ admit ในกรณีฉุกเฉิน - งดฉีด insulin วันกำหนดคลอดในกรณี นัดวันคลอด - ตรวจ FPG เช้าวันกำหนดคลอด - intrapartum insulin infusion ตาม ระดับน้ำตาล โดยเจาะทุก 1-2 ชม.

Insulin During Labor & Delivery With Elective Cesarean Delivery - NPO after midnight ก่อนวันกำหนดผ่าตัด คลอด - พิจารณาผ่าตัดคลอดช่วงเช้า - งดฉีด insulin มื้อเช้าของวันผ่าตัดคลอด - ตรวจ FPG เช้าวันผ่าตัดคลอด - intrapartum insulin infusion ตามระดับ น้ำตาล โดยเจาะทุก 1-2 ชม. - ผ่าตัดคลอด

Insulin and Solution Glucose level (mg/dL) Insulin dosage (units/hr) Solutions (drip 125 ml/hr) < > %D, LRS Normal 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