gestational diabetes mellitus

1→continue or strengthen the management of her diabetes mellitus 2 →in spite of normal glucose tolerance, threshold for glucose excretion become lower during pregnancy due to increase

When glucosuria is found in a pregnant woman,

it means that

1) she has been diabetic since previously.

2) she has renal glucosuria.

3) she has gestational diabetes mellitus.

1)→continue or strengthen the management of her diabetes mellitus

2) →in spite of normal glucose tolerance, threshold for

glucose excretion become lower during pregnancy

due to increased glomerular filtration rate and

decreased tubular reabsorption of glucose

3) →definition: woman who altered to be abnormal in

glucose tolerance during pregnancy, and/or woman found to be abnormal in glucose tolerance for the first time during pregnancy

Gestational Diabetes Mellitus

(1)

Gestational diabetes mellitus (GDM) may be viewed as,

1) An unidentified preexisting disease, or

2) The unmasking of a compensated metabolic abnormality

by the added stress of pregnancy, or

3) A direct consequence of the altered maternal metabolism

resulting from the changing hormonal milieu rsulting in milder

abnormality in glucose tolerance than diabetic glucose tolerance

pattern.

Those diagnosed with GDM before 24 weeks’ gestation were significantly

older and had a twofold greater incidence of requiring insulin therapy than did women diagnosed after 24 weeks’ gestation.

A substantial subset of women diagnosed with GDM, particularly those diagnosed early in pregnancy, may have had preexisting disease that ha

d

gone undiagnosed.

Therefore, it is necessay to assess fasting glucose concentrations at the beginning of pregnancy in order to diagnose preexisting carbohydrate intolerance.

Gestational Diabetes Mellitus (2)

Pregnancy creates a metabolic stress that simply pushes a woman with

compensated type 1 DM or type 2 DM into a decompensated state.

Insulin requirements increase substantially (1.5 – 2.5 times) during normal pregnancy.

If a woman has a limited β cell response secondary to autoimmune β cell destruction, as seen in type 1 DM, or has β cell secretory reserve

insufficient to meet the demands of pregnancy because of early type 2 DM, she may decompensate from a normoglycemic state in the nonpregnant situation to a hyperglycemic state during pregnancy.

It is reported that

a twofold increase in the frequency of HLA DR3 or DR4 in women with GDM, or

islet cell antibodies (ICA) in as many as 31% of women in whom GDM

developed, however others reported fewer than 10% frequency.

It is far more likely that GDM results from decompensation of prediabetes

or an early stage of type 2 DM.

More than 90% of women in whom DM develops after a history of GDM have classic type 2 DM.

Pathophysiologic observations of GDM are similar to those of type 2 DM.

Gestational Diabetes Mellitus (3)

Most subjects with GDM revert to normal carbohydrate tolerance

postpartum.

However, depending on the ethnic group, conversion rates postpartum to nongestational DM may be as high as 9% within the first 6 weeks, with 3 0%

in the first year.

A 50% prevalence of DM after 28 years of follow-up in those in whom

pregnancy was complicated by GDM.

The prevalence of GDM parallels the prevalence of type 2 DM in high-risk ethnic and racial groups.

The diagnosis of GDM is necessary to protect the fetus, both in utero and long term.

All pregnant women should be screened for GDM.

Gestational Diabetes Mellitus (4)

pregnant woman → history taking, urine glucose check, and

plasma glucose check at the time of diagnosis of pregnancy

　　　　　　 ↓

　　　 when obese or having diabetes mellitus among first-degree relatives

or past history of giant baby or intrauterine fetal death

or mandatory plasma glucose level ≧ 100 mg/dl ( = 5.5 mM ) 100 mg/dl ( = 5.5 mM )

↓

75g oGTT at earlier weeks

↓ ↓

abnormal normal

↓ ↓

manage as DM (GDM) because of postprandial (mandatory) plasma glucose high possibility diabetes has been level at 24 – 28 weeks of pregnancy

existed before pregnancy ↓ ↓

≧ 100 mg/dl ( = 5.5 mM ) 5.5 mM ＜ 5.5 mM

↓ ↓

　　　　　　　 75g oGTT 　　 75g oGTT at

　　　　　 of pregnancy

Screening Schedule for Gestational Diabetes

Plasma glucose level : (different from those for non-gestational subjects)

fasting level : ≧ 100 mg/dl ( = 5.5 mM )

1 hour after 75g glucose load : 180 mg/dl ( = 10 mM ) ≧ 100 mg/dl ( = 5.5 mM )

2 hours after 75g glucose load : 150 mg/dl ( = 8.3 mM ) ≧ 100 mg/dl ( = 5.5 mM )

diagnose to have gestational diabetes, when one fulfills more than 2

of the above criteria

diagnose to have diabetes mellitus, when one fulfills diagnostic criteria for diabetes mellitus by Japan Diabetes Society

( fasting level 7.0 mM and/or 2 hours after glucose load 11.1 mM ) ≧ 100 mg/dl ( = 5.5 mM ) ≧ 100 mg/dl ( = 5.5 mM )

should test 75g oGTT after 1 to 3 months post-delivery to see whether glucose tolerance is normalized or continue to be abnormal

Cases with IGT pattern in postpartum oGTT should be checked

every 3 to 6 months, and those with normal oGTT pattern should

be checked every 1 year because of high frequency of developing DM

Diagnostic Criteria for Gestational Diabetes

1) Aggravation of diabetic retinopathy

especially, in patients with long standing retinopathy (more than 10 year

s),

or in patients with pre-proliferative or proliferative retinopathy

Management : photocoagulation should be done before conception

regular examination of fundus

2) Aggravation of diabetic nephropathy

increase in GFR and decrease in protein reabsorption in tubules

may aggravate diabetic nephropathy

toxemia and pyeronephritis also worsen renal function

may lead to increased proteinuria and decrease in Ccr

Management : control glucose and BP extensively,

and treat urinary infection

start dialysis, if Ccr become less than 25 ml/min during pregnancy

3) Increase in insulin requiement

extensive blood glucose control is required during pregnancy

ketoacidosis due to insulin deficiency lead to fetus death

insulin requirement is increased during pregnancy

Management : intensive insulin treatment is necessary

Impact of Pregnancy on Diabetes Mellitus and Its Management

1) Impact on fetus

in the early gestational stage : the initial 7 weeks after conception

(for 9 weeks from the last menstration) is important for organ

formation, which is labile to blood glucose level in mothers

in the middle and late gestational stage : hyperglycemia, ketoacidosis,

hypoglycemic attack, and toxemia lead to intrauterine fetal death

at delivery : perinatal death, giant baby, hypoglycemia, respiratory

failure, hypokalemia, hyperbilirubinemia when mother is hyperglycemic

2) Impact on mother

ketoacidosis or hypoglycemic coma induce abortion

urinary tract infection is common in diabetic pregnant woman

Impact of Diabetes Mellitus on Pregnancy

Planned pregnancy is the principle for diabetic woman.

1) Evaluation of complications

1) patients with nephropathy : permit when Ccr 70 ml/min, without HT ≧ 100 mg/dl ( = 5.5 mM )

do not permit when proteinuria 3 g/day, or ≧ 100 mg/dl ( = 5.5 mM )

serum creatinine 1.5 mg/dl ≧ 100 mg/dl ( = 5.5 mM )

desirable during normal to microalbuminuric stage of nephropathy 2) patients with retinopathy : permit while simple retinopathy

do not permit when untreated proliferative retinopathy exist

permit when proliferative retinopathy was photocoagulated and stable extensive regular ophthalmic examination is necessary

2) Management and Guide before Pregnant

Blood glucose control during 1 month before conception and 7 weeks after conception should be the most rigid Even a short time of hyperglycemia in

a day might induce malformation in fetus Meal could be divided into 4 to 6 times in each day A mild exercise might prevent hyperglycemia.

Management of Pregnancy in Patients with

Diabetes Mellitus

Blood glucose control : fasting plasma glucose 70 - 100 mg/dl ( = 3.9 – 5.5 mM )

2 hours postprandial ＜ 120 mg/dl ( = 6.7 mM )

HbA1c ＜ 5.8 %

SMBG : 6 times a day (before, 2 hours after meal)

Education of insulin therapy

1) CSII (continuous subcutaneous insulin infusion)

2) change to insulin therapy when oral hypoglycemic drugs were administered

Exercise : less than 15 minutes during pregnancy

less than 140 times/min of heart beats

do not exercise when complications exist

Blood pressure control : salt restriction when syst BP 140 or diast BP 90 ≧ 100 mg/dl ( = 5.5 mM ) ≧ 100 mg/dl ( = 5.5 mM )

anti-hypertensive drugs (hydrarazine, αmethyldopa)methyldopa) when control is insufficient

Target for Diabetic Pregnants (including GDM)

before and during Pregnancy

Management during pre- and post-concepti

on and during Pregnancy (1)

a diet therapy

1) energy intake

during first half periods of pregnancy : 30 kcal x IBW + 100 ～ 150 kcal

during second half periods of pregnancy : 30 kcal x IBW + 350 ～ 400 kcal

during nursing after delivery : 30 kcal x IBW + 800 kcal

2) nutrients

Since carbohydrate is necessary at least 50 g everyday for fetal

development, and pregnant woman easily shows ketosis, therefore,

more than 200 g of carbohydrate should be taken everyday during

pregnancy.

Protein to be taken is 1.5 ～ 2.0 g / kg IBW.

3) body weight

Body weight increase should not exceed 8 kg before delivery.

Management during pre- and

post-conception and during Pregnancy (2)

b insulin treatment

1) When blood glucose control is insufficient with diet therapy alone,

do not postpone starting the insulin therapy to prevent adverse effect

of hyperglycemia to fetus.

2) Intensive insulin treatment should be introduced to maintain good

blood glucose control since pre-conception period.

3) SMBG should be continued (before and 2 hours after each meal,

sometimes 1 hour after each meal) In order to get good control,

sliding scale for insulin doses could be utilized.

4) Doses of insulin required for good control increased in response to

progress in pregnancy, and will reach to 1.5 ～ 2.0 times of

non-pregnant periods.

c laboratory tests

1) Frequency : During first half of pregnancy, regular checkup once per month is necessary, however, during second half of pregnancy regular checkup once per week become necessary for prevent complications.

Management during pre- and post-concepti

on and during Pregnancy (3)

2) laboratory tests during pregnancy

FPG once per month

HbA1c once per month

urine ketone once per month

BP, BW once per month

urine protein, renal function once per month

fundus finding

retinopathy (-) once per 2 months

retinopathy (+) once per month

fetal echographyic examination once per week ～ once per month

non-stress test 32 ～ 35 weeks once per week

36 weeks ～ twice per week

d determination to delivery

Determine when to deliver by the fetal development

When complications do not exist, 38 ～ 40 weeks are appropriate.

Management during pre- and post-concepti

on and during Pregnancy (4)

e delivery

1) Vaginal delivery is performed generally.

In case with proliferative retinopathy, or with giant baby having more than

4,500 g, cesarean section is indicated.

2) Since eating is prohibited pre- and post-delivery, start 5% glucose infusion

with 4 units of regular insulin per 500 ml solution at the speed of 100 ml / hr

before delivery.

In case of unstable type 1 diabetes mellitus, insulin administration using sliding scale should be added to the above infusion.

The target range of plasma glucose concentration is around 100 mg/dl (5.5 mM)

to prevent fetal hypoglycemia.

Check capillary glucose level every 1 ～ 2 hours.

3) Insulin requirement decrease when placenta is delivered.

Therefore, insulin administration should be decreased at just after delivery.

A half of previous insulin dose will be adequate when it is injected subcutaneously However, when sliding scale or continuous insulin infusion is adopted using SMBG,

the same dose will be continued.

Problems in Newborn delivered from Diabe

tic Mother

The newborn delivered from diabetic mother is strongly influenced by

intrauterine hyperglycemia and resultant hyperinsulinemia, and present

several neonatal complications.

A close cooperation between physician, obstetrician, pediatrician,

ophthalmologist, nutritian, and nurse is required.

Neonatal complications from diabetic mother and its provision

neonatal complication provision

1 neonatal hypoglycemia blood glucose control before delivery

glucose infusion

2 deformity blood glucose control starting pre-conception

3 giant baby intensive blood glucose control

4 neonatal acute respiratory blood glucose control and evaluation of

distress syndrome pulmonary tissue maturation

5 hypocalcemia iv administration of calcium gluconate

6 hyperbilirubinemia photo therapy

7 polycythemia exchange transfusion to get Ht level ＜ 55%