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Page 1: Diabetes & pregnancy

Diabetes & Diabetes & pregnancypregnancy

Page 2: Diabetes & pregnancy

Insulin Insulin

Page 3: Diabetes & pregnancy

Diabetes & pregnancyDiabetes & pregnancy

• Impact of diabetes on Impact of diabetes on pregnancypregnancy

• Impact of pregnancy on Impact of pregnancy on diabetesdiabetes

Page 4: Diabetes & pregnancy

Diabetes & pregnancyDiabetes & pregnancy

• Gestational diabetes (GDM)Gestational diabetes (GDM)

• Pre-pregnancy diabetes (PGDM):Pre-pregnancy diabetes (PGDM):type 1 or type 2 diabetes or MODYtype 1 or type 2 diabetes or MODYSSynonymsynonyms: overt diabetes, chronic : overt diabetes, chronic diabetesdiabetes

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Diabetes Complicating Diabetes Complicating PregnancyPregnancy

Class Class Age of Age of onsetonset

DuratioDuration n

Vascular Vascular complicationscomplications

TherapTherapy y

G1G1 GestatioGestationn

-- NoneNone DD

G2G2 GestatioGestationn

-- NoneNone D + ID + I

BB > 20 > 20 < 10< 10 NoneNone D + ID + I

CC 10 – 1910 – 19 10 – 19 10 – 19 NoneNone D + ID + I

DD < 10< 10 > 20> 20 Benign retinopathyBenign retinopathy D + ID + I

FF AnyAny AnyAny NephropathyNephropathy D + ID + I

RR AnyAny AnyAny Proliferative Proliferative retinopathyretinopathy

D + ID + I

HH AnyAny AnyAny IHDIHD D + ID + I

NN AnyAny AnyAny Kidney Kidney transplantationtransplantation

D + ID + I

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Gestational Gestational diabetesdiabetes

CCarbohydrate intolerancearbohydrate intolerance

of of variablevariable severity severity

with onset or first recognitionwith onset or first recognition

during pregnancyduring pregnancy

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GDM:GDM: pathomechanism pathomechanism theoriestheories

• Exaggerated Exaggerated physiological changesphysiological changes in in glucose metabolism: induction of glucose metabolism: induction of hyperglycaemiahyperglycaemia

1st half of pregnancy: high insulin 1st half of pregnancy: high insulin sensitivitsensitivityy

2nd half of pregnancy: increase of insulin 2nd half of pregnancy: increase of insulin resistanceresistance

Postpartum drop of insulin resistancePostpartum drop of insulin resistance

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GDM:GDM: pathomechanism pathomechanism theoriestheories

• Preexisting Preexisting type 2 diabetestype 2 diabetes unmaskedunmasked

or firstor first discovered during discovered during pregnancypregnancy

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Detection of GDM: step 1 Detection of GDM: step 1 & 2& 2

• 1st 1st visitvisit:: fasting glucose level < 100 fasting glucose level < 100 mg/dlmg/dl

• Screening: Screening: universal or selective?universal or selective?• Method:Method: 50 g glucose Oral Challenge 50 g glucose Oral Challenge

Test (OCT)Test (OCT)• Timing:Timing: between 24th and 28th week between 24th and 28th week

of gestationof gestation• No regard to the time of day or of No regard to the time of day or of

last meallast meal

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GDM: screening resultsGDM: screening results

•< 140 mg/dl: < 140 mg/dl: negativenegative

•140 – 199 mg/dl:140 – 199 mg/dl: diagnostic testdiagnostic test

as as soon as possiblesoon as possible

•≥≥ 200 mg/dl:200 mg/dl: positivepositive•*140 mg/dl: identifies *140 mg/dl: identifies 80% of women with 80% of women with GDMGDM

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Detection of GDM: step 3 Detection of GDM: step 3

• Method:Method: 75 g load 2-hour Oral Glucose 75 g load 2-hour Oral Glucose Tolerance Test (OGTT) – according Tolerance Test (OGTT) – according

to WHO recommendationto WHO recommendation• 3 days before test:3 days before test: increase amount increase amount

of carbohydrates intake ( 150 g/dayof carbohydrates intake ( 150 g/day

at least)at least)• 1 day before test:1 day before test: last meal at 6.00 last meal at 6.00

a.m.a.m.• Overnight fastOvernight fast

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OGTT: thresholdsOGTT: thresholds

• Fasting: < 100 mg/dlFasting: < 100 mg/dl• 1-hour (optional): < 180 mg/dl1-hour (optional): < 180 mg/dl

• 2-hour: < 140 mg/dl2-hour: < 140 mg/dl

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Glucose tolerance Glucose tolerance curvescurves

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GDM detection GDM detection – no – no matters:matters:

Unrecognized glucose intolerance Unrecognized glucose intolerance having existed before the pregnancyhaving existed before the pregnancy

Glucose intolerance persistence or Glucose intolerance persistence or not after the pregnancynot after the pregnancy

Both conditions to be verifiedBoth conditions to be verified postpartum!postpartum!

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GDM functional GDM functional classificationclassification

• Depends on therapy Depends on therapy effectivenesseffectiveness

• G1 – diet onlyG1 – diet only• G2 – diet & insulin G2 – diet & insulin

administrationadministration

• Insulin analogues: Insulin analogues: acceptedaccepted

• Oral hypoglycaemic Oral hypoglycaemic agents: contraindicatedagents: contraindicated

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Fetal effects of GDMFetal effects of GDM

• Maternal hyperglycemiaMaternal hyperglycemia• Fetal hyperglycemiaFetal hyperglycemia• Fetal response: hyperinsulinemiaFetal response: hyperinsulinemia• Excessive fetal growth: macrosomiaExcessive fetal growth: macrosomia• Shoulder dystocia: birth traumaShoulder dystocia: birth trauma• Hydramnios (osmotic diuresis?)Hydramnios (osmotic diuresis?)• Intrauterine fetal death in last 4Intrauterine fetal death in last 4 –– 88

weeks of pregnancy (weeks of pregnancy (eexcessive xcessive oxygen oxygen consumptionconsumption? ? ffetal asphyxia?)etal asphyxia?)

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Neonatal effects of Neonatal effects of GDMGDM

• Excessive oxygen use in utero: Excessive oxygen use in utero: polycythemiapolycythemia

• HyperbilirubinemiaHyperbilirubinemia• Thrombosis Thrombosis • HypoglycemiaHypoglycemia• Respiratory distressRespiratory distress (Inhibition of lung (Inhibition of lung

maturation)maturation)• Longitudinal effects: obesity & diabetesLongitudinal effects: obesity & diabetes

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Neonatal macrosomia Neonatal macrosomia

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Maternal effects of Maternal effects of GDMGDM

• HypertensionHypertension• Cesarean deliveryCesarean delivery• Recurrence of GDM in subsequent Recurrence of GDM in subsequent

pregnancypregnancy• Overt diabetes developementOvert diabetes developement(over 50 – 70% of women with GDM(over 50 – 70% of women with GDM

in 20-years period)in 20-years period)• Metabolic syndrom developmentMetabolic syndrom development

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Maternal-fetal effectsMaternal-fetal effects

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GDM: managementGDM: management

• Diet:Diet:6 meals a day6 meals a dayCaloric restriction according to BMICaloric restriction according to BMIEliminate: monosaccharidesEliminate: monosaccharides• ExerciseExercise• Empirical insulin therapyEmpirical insulin therapy• Insulin: short-acting & long-actingInsulin: short-acting & long-acting• Never use combined insulin in Never use combined insulin in

pregnant woman!pregnant woman!

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GDM: plasma glucose GDM: plasma glucose controlcontrol

Goals:Goals:• Fasting 60 – 90 Fasting 60 – 90

mg/dlmg/dl• 1-hour postprandial1-hour postprandial

< 130 mg/dl < 130 mg/dl

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GDM: postpartum GDM: postpartum consequencesconsequences• 75-g 2-h OGTT 6 weeks 75-g 2-h OGTT 6 weeks

postpartum (poor compliance)postpartum (poor compliance)

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

• Weight control & adequate Weight control & adequate physical activity prevent physical activity prevent recurrence of GDMrecurrence of GDM

in subsequent pregnanciesin subsequent pregnancies

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PGDM & pregnancyPGDM & pregnancy

• 1st trimester: drop of insulin require1st trimester: drop of insulin require – reduce insulin doses!– reduce insulin doses!

• 2nd and 3rd trimester: insulin 2nd and 3rd trimester: insulin resistance gradual increaseresistance gradual increase

• Strict plasma glucose control Strict plasma glucose control necessary!necessary!

• Glycated hemoglobin rateGlycated hemoglobin rate

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Fetal effects of PGDMFetal effects of PGDM

• Abortion or preterm deliveryAbortion or preterm delivery• Congenital malformationsCongenital malformations• MacrosomiaMacrosomia• Unexplained fetal demise & stillbirthsUnexplained fetal demise & stillbirths

> 35 week of gestation (impaired > 35 week of gestation (impaired oxygene transport due to maternal oxygene transport due to maternal hyperglycemia?)hyperglycemia?)

• Placental insufficiency & IUGRPlacental insufficiency & IUGR• Hydramnios Hydramnios

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Neonatal effects of Neonatal effects of PGDMPGDM

• Respiratory distressRespiratory distress• HypoglycemiaHypoglycemia• HypocalcemiaHypocalcemia• HyperbilirubinemiaHyperbilirubinemia• Cardiac hypertrophyCardiac hypertrophy• Impaired long-term cognitive Impaired long-term cognitive

developmentdevelopment• Inheritance of diabetesInheritance of diabetes

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Maternal effects of Maternal effects of PGDMPGDM

• Diabetic nephropathyDiabetic nephropathy• Diabetic retinopathyDiabetic retinopathy• Diabetic neuropathyDiabetic neuropathy• PreeclampsiaPreeclampsia• KetoacidosisKetoacidosis• InfectionsInfections

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PGDM: management in PGDM: management in pregnancypregnancy

• Preconception counselling & educationPreconception counselling & education• Low glycated hemoglobin valuesLow glycated hemoglobin values• Multiple daily insulin injectionsMultiple daily insulin injections• Continous subcutaneous insulin infusion Continous subcutaneous insulin infusion • DietDiet• Fetal sonography: congenital anomalies, Fetal sonography: congenital anomalies,

excessive growth, excessive growth, hydramnios/oligohydramnioshydramnios/oligohydramnios

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Sequential vs continous Sequential vs continous insulin therapyinsulin therapy

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Delivery in diabetic Delivery in diabetic patientpatient

• GDM GDM per seper se is not an indication to is not an indication to caesarean section!caesarean section!

• Labor induction in GDM or Labor induction in GDM or B – C classB – C class PGDM, unless fetal macrosomia existsPGDM, unless fetal macrosomia exists

• Well-controlled Well-controlled B – C class B – C class PGDMPGDM: : according to other medical conditionsaccording to other medical conditions

• D – N class D – N class PGDMPGDM::no alternative to caesarean delivery!no alternative to caesarean delivery!

• Remember adequate hydration & plasma Remember adequate hydration & plasma glucose control during labor and delivery!glucose control during labor and delivery!

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