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<마더리스크라운드>Type 2 diabetes in pregnancy


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김성훈 관동대학교 의과대학 내과 교수

김성훈 관동대학교 의과대학 내과 교수

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  • 1. Type 2 diabetes in pregnancy 김성훈 관동의대 제일병원 내과
  • 2. Contents• Case• Risks of diabetes in pregnancy• Risks of pregnancy for the mother with diabetes• Risk factors for poor outcome in T2DM• Prepregnancy care• Management of hyperglycemia in pregnancy
  • 3. 증례• 37세, 임신 9주 (gravida 3, para 2)• 둘째 아이: 4세, 출생 체중(4500 g) Hx of neonatal jaundice and hypoglycemia• Random glucose; 325 mg/dl, A1C: 8.9%• 지난 임신때 당뇨 진단 받지 않았고, 이번 임 신에서 prepregnancy care 받지 않았음• 신장 161 cm, 체중 79 kg, BMI 30.5 kg/m2• 망막검사: mild NPDR
  • 4. Classification of diabetes in pregnancy• Type 1 diabetes (β-cell destruction) - Autoimmune - idiopathic• Type 2 diabetes (insulin resistance with insulin secretory defect)• Other specific types (e.g. genetic defects of β-cell function)• Gestational diabetes
  • 5. Issues of concern• Epidemics of obesity and T2DM -> increase in No of women with T2DM• Frequently undiagnosed T2DM before pregnancy• Lack of preconception care• Increase in Cx of pregnancy due to the coexistence of obesity and T2DM
  • 6. Risks of diabetes in pregnancy (I)• Fetal macrosomia• Birth trauma (to mother and baby)• Induction of labor or cesarean section
  • 7. Accelerated fetal growth
  • 8. Risks of diabetes in pregnancy (II)• Miscarriage• Congenital malformation• Stillbirth
  • 9. Glucose control and risk of malformation Guerin A. Diabetes Care 30:1920, 2007
  • 10. Risks of diabetes in pregnancy (III) • Transient neonatal morbidity - hypoglycemia, hypocalcemia, hypomagnesemia, hyperbilirubinemia, erythremia, hypertrophic cardiomyopathy, respiratory distress syndrome • Neonatal death • Obesity and/or diabetes developing later in the baby’s life
  • 11. Maternal complications in diabetic pregnancy• Hypoglycemia, ketoacidosis• Pregnancy induced hypertension• Pyelonephritis, other infections• Polyhydramnios• Preterm labor• Worsening of chronic complications- retinopathy, nephropahty, neuropathy, cardiac disease
  • 12. Risks of pregnancy for the mother with diabetes• Pregnancy may affect pre-existing micro- and macrovascular disease but does not usually have any long-term detrimental effect on either retinopathy or nephropathy• Risk of women with established cardiovascular disease
  • 13. Diabetic Retinopathy– Diabetic retinopathy may accelerate during pregnancy– Risk can be reduced by • Gradual attainment of good metabolic control before conception • Preconceptual laser photocoagulation– Baseline dilated comprehensive eye examination and follow-up ; necessary before conception and during pregnancy– Pre-existing diabetes should be counseled on the risk of development and progression of diabetic retinopathy
  • 14. Diabetic nephropathy Kitzmiller JL et al:Diabetes Care 2008;31:1060-1079
  • 15. Cardiovascular disease– Untreated CAD is associated with a high mortality rate during pregnancy– Successful pregnancies have been undertaken after coronary revascularization in women with diabetes– Exercise tolerance should be normal to maximize the probability that the patient will tolerate the increased cardiovascular demands of gestation
  • 16. Potential contraindications to pregnancy • Ischemic heart disease • Active proliferative retinopathy, untreated • Renal insufficiency: Ccr <50 ml/min or serum Cr >2 mg/dl or heavy proteinuria (> 2g/24 h) or hypertension (BP >130/80 mmHg despite treatment) • Severe gastroenteropathy :nausea/vomiting, diarrhea
  • 17. Remaining Problems• A high prevalence of congenital anomalies and spontaneous abortions in infant of diabetic mothers (IDMs)• Care of the woman with severe complications of diabetes• Care of the ―difficult patient‖ who often presents late for antenatal care and/or nonadherent
  • 18. Comparison of pregnancyoutcomes in T1 and T2DM J clin Endocrinol Metab 94:4284-91, 2009
  • 19. Risk factors for poor outcome in T2DM• Obesity - congenital malformations: NTDs (esp. spinal bifida), omphalocele, and heart defects - perinatal mortality - delivery by cesarean section - macrosomia - hypertensive disorders• Ethnicity: Asian > Caucasian• Poor pregnancy preparation
  • 20. Paradigm shift• Detection/diagnosis of diabetes in early pregnacy• To consider recommendations for preconception screening to identify patients with abnormal glucose tolerance before conception
  • 21. Women at very high risk for DM1) prior history of GDM or delivery of LGA infant2) Strong family history of T2DM3) Diagnosis of PCOS4) severe obesity (or BMI ≥ 30)
  • 22. Screen for undiagnosed T2DM at the first prenatal visit inthose with risk factors, using standard diagnostic criteria (B) ADA: Standards of Medical Care in Diabetes—2011. Diabetes Care 34:S11-S61, 2011
  • 23. 임신성 당뇨병의 진단기준 당뇨병 진료지침 2011, 대한당뇨병학회
  • 24. The Pre-Preganacy Clinic• Pregnancy planning/Contraceptive advice• Optimize control and explain glycemic goals during pregnancy.• Switch Type 2 diabetics to insulin. Review educational needs.• Genetic counselling.• Congenital malformations.• Perinatal complications.• Assessment of diabetic complications.• Review smoking, alcohol, medications, folic acid.
  • 25. Laboratory and special exam of pregnant women with preexisting diabetes
  • 26. Management of hyperglycemia in pregnancy
  • 27. Glycemic control and perinatal outcome (I) • Before pregnancy, in order to prevent excess spontaneous abortions and major congenital malformations, target A1C is as close to normal as possible without significant hypoglycemia. (B) • Ensure effective contraception until stable and acceptable glycemia is achieved. (E) • Excellent glycemic control in the first trimester continued throughout pregnancy is associated with the lowest frequency of maternal, fetal, and neonatal complications. (B) Kitzmiller JL et al:Diabetes Care 2008;31:1060-1079
  • 28. Glycemic control and perinatal outcome (II)• Throughout pregnancy, optimal glycemic goals: - premeal, bedtime, and overnight glucose 60–99 mg/dl - peak postprandial glucose 100–129 mg/dl - mean daily glucose <110 mg/dl - A1C <6.0. (B)• Higher glucose targets may be used in patients with hypoglycemia unawareness or the inability to cope with intensified management. (E)
  • 29. Assessment of metabolic control• SMBG: daily and fingerstick• Postprandial capillary glucose 1hr after beginning the meal: postmeal peak glucose• CGM: T1D, esp, hypoglycemia unawareness• Urine ketone: ill or persistent hyperglycemia (>200 mg/dl)• A1C:monthly
  • 30. Medical Nutrition Therapy (MNT)• Individualized MNT• Basic plan: dietary recommendations for all pregnant women, adjusted to the individual needs of the patient• CHO and caloric contents: modified based on the woman’s height, weight, and degree of glucose intolerance• Carbohydrate-restricted diet; small frequent meals and high-fiber and low GI foods
  • 31. Goals for weight gain (1)Prepregnancy BMI Total wt.gain (kg) Rate of wt.gain(2&3Tri.)kg/wk Underweight (<18.5) 12.5 - 18 0.51 (0.44-0.58) Normal weight (18.5-24.9) 11.5 - 16 0.42 (0.35-0.50) Overweight (25-29.9) 7 - 11.5 0.28 (0.23-0.33) Obese (≥30) 5 - 9 0.22 (0.17-0.27) Institute of Medicine, 2009
  • 32. Goals for weight gain (2)• Less weight gain is safe and has a beneficial effect on perinatal outcomes in obese women: a weight gain of 0-7 pounds was associated with the least macrosomia Cheng YW et al. Gestational weight gain and gestational diabetes mellitus: perinatal outcomes. Obstet Gynecol 112:1015-1022, 2008
  • 33. Gynecol Endocrinol. 2010 Dec 29. [Epub ahead of print]
  • 34. Exercise/Physical activity• Educate women with diabetes as to benefits of appropriate daily physcial activity (reduce blood glucose, weight gain and insulin requirements)• Encourage regular exercise, at least 30 min/day
  • 35. Insulin therapy• Intensive regimen of multiple injections in a basal-bolus fashion (MDI) or an insulin pump (CSII)
  • 36. Insulin profiles as used in pregnancy
  • 37. Insulin profiles as used in pregnancy
  • 38. Insulin Analogues in DM Pregnancy• Rapidly acting analogues (aspart and lispro): safe• Basal analogues not proven safe, but datemir safe in recent trial. We still used NPH insulin• But during organogenesis, the risk to the fetus from hyperglycemia is greater than any theoretical risk from analogue insulin. Thus ? Continue analogue till 8-10 wks.
  • 39. Summary and Conclusions1. Preconception detection and management of T2DM is a critical public health issue: universal preconception screening for diabetes, with a minimun of a fasting glucose, adding an OGTT in high risk individuals2. Women with type 2 diabetes, who are reproductive age are given preconception counselling and prepregnancy care in the 6-12 months before pregnancy3. The key to improving outcome of pregnancy in women with diabetes is strict glycemic control