Diabetes & pregnancy

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Diabetes & pregnancy. Insulin. Diabetes & pregnancy. Impact of diabetes on pregnancy Impact of pregnancy on diabetes. Diabetes & pregnancy. Gestational diabetes (GDM) Pre-pregnancy diabetes (PGDM): type 1 or type 2 diabetes or MODY S ynonyms : overt diabetes, chronic diabetes. - PowerPoint PPT Presentation

Transcript of Diabetes & pregnancy

  • Diabetes & pregnancy

  • Insulin

  • Diabetes & pregnancyImpact of diabetes on pregnancy

    Impact of pregnancy on diabetes

  • Diabetes & pregnancy

    Gestational diabetes (GDM)

    Pre-pregnancy diabetes (PGDM):type 1 or type 2 diabetes or MODYSynonyms: overt diabetes, chronic diabetes

  • Diabetes Complicating Pregnancy

  • Gestational diabetes

    Carbohydrate intoleranceof variable severitywith onset or first recognitionduring pregnancy

  • GDM: pathomechanism theoriesExaggerated physiological changes in glucose metabolism: induction of hyperglycaemia

    1st half of pregnancy: high insulin sensitivity

    2nd half of pregnancy: increase of insulin resistance

    Postpartum drop of insulin resistance

  • GDM: pathomechanism theoriesPreexisting type 2 diabetes unmaskedor first discovered during pregnancy

  • Detection of GDM: step 1 & 21st visit: fasting glucose level < 100 mg/dlScreening: universal or selective?Method: 50 g glucose Oral Challenge Test (OCT)Timing: between 24th and 28th weekof gestationNo regard to the time of day or of last meal

  • GDM: screening results< 140 mg/dl: negative

    140 199 mg/dl: diagnostic testas soon as possible

    200 mg/dl: positive*140 mg/dl: identifies 80% of women with GDM

  • Detection of GDM: step 3 Method: 75 g load 2-hour Oral Glucose Tolerance Test (OGTT) according to WHO recommendation3 days before test: increase amountof carbohydrates intake ( 150 g/dayat least)1 day before test: last meal at 6.00 a.m.Overnight fast

  • OGTT: thresholdsFasting: < 100 mg/dl1-hour (optional): < 180 mg/dl2-hour: < 140 mg/dl

  • Glucose tolerance curves

  • GDM detection no matters:Unrecognized glucose intolerance having existed beforethe pregnancy

    Glucose intolerance persistence or not after the pregnancy

    Both conditions to be verified postpartum!

  • GDM functional classificationDepends on therapy effectivenessG1 diet onlyG2 diet & insulin administration

    Insulin analogues: acceptedOral hypoglycaemic agents: contraindicated

  • Fetal effects of GDMMaternal hyperglycemiaFetal hyperglycemiaFetal response: hyperinsulinemiaExcessive fetal growth: macrosomiaShoulder dystocia: birth traumaHydramnios (osmotic diuresis?)Intrauterine fetal death in last 4 8 weeks of pregnancy (excessive oxygen consumption? fetal asphyxia?)

  • Neonatal effects of GDMExcessive oxygen use in utero: polycythemiaHyperbilirubinemiaThrombosis HypoglycemiaRespiratory distress (Inhibition of lung maturation)Longitudinal effects: obesity & diabetes

  • Neonatal macrosomia

  • Maternal effects of GDMHypertensionCesarean deliveryRecurrence of GDM in subsequent pregnancyOvert diabetes developement(over 50 70% of women with GDMin 20-years period)Metabolic syndrom development

  • Maternal-fetal effects

  • GDM: managementDiet:6 meals a dayCaloric restriction according to BMIEliminate: monosaccharidesExerciseEmpirical insulin therapyInsulin: short-acting & long-actingNever use combined insulin in pregnant woman!

  • GDM: plasma glucose controlGoals:Fasting 60 90 mg/dl1-hour postprandial< 130 mg/dl

  • GDM: postpartum consequences75-g 2-h OGTT 6 weeks postpartum (poor compliance)

    If normal: regular reassessment (OGTT) at minimum 3-year intervals

    Weight control & adequate physical activity prevent recurrence of GDMin subsequent pregnancies

  • PGDM & pregnancy1st trimester: drop of insulin require reduce insulin doses!2nd and 3rd trimester: insulin resistance gradual increase

    Strict plasma glucose control necessary!Glycated hemoglobin rate

  • Fetal effects of PGDMAbortion or preterm deliveryCongenital malformationsMacrosomiaUnexplained fetal demise & stillbirths> 35 week of gestation (impaired oxygene transport due to maternal hyperglycemia?)Placental insufficiency & IUGRHydramnios

  • Neonatal effects of PGDMRespiratory distressHypoglycemiaHypocalcemiaHyperbilirubinemiaCardiac hypertrophyImpaired long-term cognitive developmentInheritance of diabetes

  • Maternal effects of PGDMDiabetic nephropathyDiabetic retinopathyDiabetic neuropathyPreeclampsiaKetoacidosisInfections

  • PGDM: management in pregnancyPreconception counselling & educationLow glycated hemoglobin valuesMultiple daily insulin injectionsContinous subcutaneous insulin infusion DietFetal sonography: congenital anomalies, excessive growth, hydramnios/oligohydramnios

  • Sequential vs continous insulin therapy

  • Delivery in diabetic patientGDM per se is not an indication to caesarean section!Labor induction in GDM or B C class PGDM, unless fetal macrosomia existsWell-controlled B C class PGDM: according to other medical conditions D N class PGDM:no alternative to caesarean delivery!Remember adequate hydration & plasma glucose control during labor and delivery!