gestational diabetes mellitus

Gestational Diabetes Mellitus (1) 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 (2) 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 had 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 (3) Pregnancy creates a metabolic stress that simply pushes a woman with compensated type DM or type 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 DM, or has β cell secretory reserve insufficient to meet the demands of pregnancy because of early type 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 DM More than 90% of women in whom DM develops after a history of GDM have classic type DM Pathophysiologic observations of GDM are similar to those of type DM Gestational Diabetes Mellitus (4) 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 weeks, with 30% 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 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 Screening Schedule for Gestational Diabetes 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 ) ↓ 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 ↓ ↓ ≧ 5.5 mM ＜ 5.5 mM ↓ ↓ 　　　　　　　　　　　　　 75g oGTT 　　 75g oGTT at 32 weeks 　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　 Diagnostic Criteria for Gestational Diabetes Plasma glucose level : (different from those for non-gestational subjects) fasting level : 　　　　　　　　　　　≧ 100 mg/dl ( = 5.5 mM ) hour after 75g glucose load : ≧ 180 mg/dl ( = 10 mM ) hours after 75g glucose load : ≧ 150 mg/dl ( = 8.3 mM ) diagnose to have gestational diabetes, when one fulfills more than 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 hours after glucose load ≧11.1 mM ) should test 75g oGTT after to 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 to months, and those with normal oGTT pattern should be checked every year because of high frequency of developing DM Impact of Pregnancy on Diabetes Mellitus and Its Management 1) Aggravation of diabetic retinopathy especially, in patients with long standing retinopathy (more than 10 years), 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 Diabetes Mellitus on Pregnancy 1) Impact on fetus in the early gestational stage : the initial weeks after conception (for 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 Management of Pregnancy in Patients with Diabetes Mellitus Planned pregnancy is the principle for diabetic woman 1) Evaluation of complications 1) patients with nephropathy : permit when Ccr ≧70 ml/min, without HT not permit when proteinuria ≧3 g/day, or serum creatinine ≧1.5 mg/dl desirable during normal to microalbuminuric stage of nephropathy 2) patients with retinopathy : permit while simple retinopathy 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 month before conception and 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 to times in each day A mild exercise might prevent hyperglycemia Target for Diabetic Pregnants (including GDM) before and during Pregnancy Blood glucose control : fasting plasma glucose 70 - 100 mg/dl ( = 3.9 – 5.5 mM ) hours postprandial ＜ 120 mg/dl ( = 6.7 mM ) HbA1c ＜ 5.8 % SMBG : times a day (before, 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 not exercise when complications exist Blood pressure control : salt restriction when syst BP ≧140 or diast BP ≧90 anti-hypertensive drugs (hydrarazine, αmethyldopa) when control is insufficient Management during pre- and postconception and during Pregnancy (1) 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 kg before delivery Management during pre- and postconception and during Pregnancy (2) b insulin treatment 1) When blood glucose control is insufficient with diet therapy alone, 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 hours after each meal, sometimes 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 postconception and during Pregnancy (3) 2) laboratory tests during pregnancy FPG HbA1c urine ketone BP, BW urine protein, renal function fundus finding retinopathy (-) retinopathy (+) fetal echographyic examination non-stress test 32 ～ 35 weeks 36 weeks ～ once per month once per month once per month once per month once per month once per months once per month once per week ～ once per month once per week twice per week determination to delivery Determine when to deliver by the fetal development When complications not exist, 38 ～ 40 weeks are appropriate Management during pre- and postconception 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 units of regular insulin per 500 ml solution at the speed of 100 ml / hr before delivery In case of unstable type 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 ～ 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 Diabetic Mother he newborn delivered from diabetic mother is strongly influenced by trauterine hyperglycemia and resultant hyperinsulinemia, and present veral neonatal complications close cooperation between physician, obstetrician, pediatrician, phthalmologist, nutritian, and nurse is required eonatal complications from diabetic mother and its provision neonatal complication provision neonatal hypoglycemia blood glucose control before delivery glucose infusion deformity blood glucose control starting pre-conception giant baby intensive blood glucose control neonatal acute respiratory blood glucose control and evaluation of distress syndrome pulmonary tissue maturation hypocalcemia iv administration of calcium gluconate hyperbilirubinemia photo therapy polycythemia exchange transfusion to get Ht level ＜ 55% ... to have gestational diabetes, when one fulfills more than of the above criteria diagnose to have diabetes mellitus, when one fulfills diagnostic criteria for diabetes mellitus by Japan Diabetes. . .Gestational Diabetes Mellitus (2) Gestational diabetes mellitus (GDM) may be viewed as, 1) An unidentified preexisting disease,... DM Gestational Diabetes Mellitus (4) Most subjects with GDM revert to normal carbohydrate tolerance postpartum However, depending on the ethnic group, conversion rates postpartum to nongestational