Management of diabetes
So Young Park, M.D.
• 임신성 당뇨병 (gestational diabetes, GDM) :
기존에 당뇨병이 없는 상태에서 임신 기간중에
• 임신전 당뇨병 (preexisting diabetes, PGDM) :
임신전에 당뇨병이 진단되어 있는 경우
• 임신과 관련한 위험
- 태아의 고인슐린혈증
- 임신중 고혈압
- 분만후 당뇨병의 위험
• 당뇨병 종류
- 제 1 형 당뇨병
- 제 2 형 당뇨병
• 임신과 관련한 위험
- 임신초기 ; 선천성 기형 ,
- 임신후기 ; 고인슐린혈증
, 거대아 , 사산 , 호흡곤란
• In 1939, ‘‘benign glycosurics are more likely to give birth
to larger babies than do normal women’’
• In 1952, a link between higher maternal glucose during
pregnancy and neonatal hypoglycemia hypothesizing the
involvement of fetal hyperinsulinemia
• In 1957, ‘‘gestational diabetes’’ by Carrington
• O’Sullivan focused on the long-term risk of diabetes
developing in high risk women and using the pregnancy
OGTT proposed using an upper cutoff of 2SD above the
O’Sullivan criteria for diagnosing GDM
with subsequently derived values
Pathophysiology of GDM
Gestational Diabetes: Caring for Yourself and Your Baby, IDC Publishing
Diagnosis of GDM
• Two step approach
- Perform screen using 50 g oral glucose load
and check blood glucose at 1 hour
Diagnosis of GDM
* Two or more values meeting or exceeding the cut points are
required for diagnosis.
• An observational study
• 23,316 pregnant women
• A 75 g OGTT with sampling at 0, 1, and 2 hours
• Primary outcomes : large for gestational age (LGA), clinical
neonatal hypoglycemia, cord blood C-peptide > the 90th percentile,
primary cesarean section delivery rate
Frequency of primary outcomes across
the glucose categories (HAPO study)
N Engl J Med 2008;358:1991-2002
International Association of Diabetes in
Pregnancy Study Groups (IADPSG)
Diabetes Care 2010;33:676–81
Screening for and diagnosis of GDM
Diabetes Care. 2013;36 (suppl 1):S67–S74.
vs. IADPSG/ADA position
→ 100g 3-hour OGTT
Based on the likelihood that a
woman would develop DM
several years subsequent to
Evidence has accumulated ;
the association of GDM with
an increased risk of adverse
maternal and perinatal
GDM diagnosis ; 5 ~ 6% of
75g 2-hour OGTT
Based on demonstrated
glycemic levels and an
increased risk of obstetric and
GDM diagnosis ; 15 ~ 20% of
It is not well understood
whether additional GDM
women will benefit from
• The panel believes that there is not sufficient evidence to
adopt a one-step approach, such as that proposed by
• The panel is particularly concerned about the adoption of
new criteria that would increase the prevalence of GDM,
and the corresponding costs and interventions, without
clear demonstration of improvements in the most
clinically important health and patient-centered
• Thus, the panel recommends that the two-step approach
Fetal outcomes related to GDM
Potential maternal complications of GDM
J Matern Fetal Neonatal Med 2010;23(3):199-203
Effects of treating GDM ;
Meta-analysis of RCT
Risk Ratio (95% CI)
(birthweight >4000 g)
Admission to the NICU
Ann Intern Med. 2013;159:123-129
Recommended targets for home-monitored
glucose levels during pregnancy
Endocrinol Metab Clin N Am 2012;41:161–173
Ex) 1900kcal = 곡류군 8 단위 + 어육류군 ( 저지방 2 + 중지방 4) + 채소군 7 단위
+ 지방군 5 단위 + 우유군 2 단위 + 과일군 2 단위
• Unless contraindicated, physical activity should be
included in a pregnant woman’s daily regimen.
• Regular moderate-intensity physical activity (eg, walking)
can help to reduce glucose levels in patients with GDM.
1. Castorino K, Jovanovic L. Clin Chem. 2011;57(2):221-30. 2. ADA. Diabetes Care. 2004;27(suppl 1):S88-90.
3. Jovanovic L, et al. Mt Sinai J Med. 2009;76(3):269-80.
Oral agents for the management of GDM
When MNT alone fails, pharmacologic therapy is indicated
AACE guidelines recommend insulin as the optimal approach
Metformin and glyburide (sulfonylurea) are the 2 most commonly
prescribed oral antihyperglycemic agents during pregnancy.
category B, others
Metformin and glyburide may be
insufficient to maintain normoglycemia at
all times, particularly during postprandial
Due to efficacy and safety concerns, the ADA does not recommend
1. AACE. Endocr Pract. 2011;17(2):1-53. 2. Castorino K, Jovanovic L. Clin Chem. 2011;57(2):221-30.
3. ADA. Diabetes gestational diabetes mellitus (GDM)
2004;27(suppl 1):S88-90. Jovanovic
J Med. 2009;76(3):269-80.
oral antihyperglycemic agents forCare. of Pifizer, NY, NY, 2010. 6.4.Diabeta PI. L, et al. Mt SinaiU.S. Bridgewater, NJ, 2009.
5. Micronase PI. Pifizer. Division
When to add insulin
• If medical nutritional therapy (MNT) fails then
add insulin when glucose are:
≥ 105 mg/dL
≥ 95 mg/dL
≥ 155 mg/dL
≥ 130-140 mg/dL
≥ 130 mg/dL
≥ 120 mg/dL
Insulin use during pregnancy
• Insulin administration, dietary modifications in response to self-monitoring of
blood glucose (SMBG), hypoglycemia awareness and management
• Intermediate- or long-acting insulin administered by injection, or
• Rapid-acting insulin administered by insulin pump
• Recommended approach: rapid-acting insulin analogues
1. Jovanovic L, et al. Mt Sinai J Med. 2009;76(3):269-80. 2. AACE. Endocr Pract. 2011;17(2):1-53.
3. Castorino K, Jovanovic L. Clin Chem. 2011;57(2):221-30. 4. ADA. Diabetes Care. 2004;27(suppl 1):S88-90.
Characteristics of various insulin preparations
75% lispro protamine/25% lispro
70% aspart protamine/30% aspart
50% aspart protamine/50% aspart
Management during labor
During labor :
Maternal hyperglycaemia during labour ∝neonatal hypoglycaemia
→ target glycaemic control ; 72 ~ 144 mg/dl
For women with PGDM, an insulin infusion is usually required to
Women with GDM are usually able to maintain the required blood
glucose targets without requiring an intravenous insulin or with
reduced insulin dose.
After delivery :
PGDM; Insulin requirements fall to pre-pregnancy levels.
GDM: Hypoglycaemic agents can be discontinued following birth.
Breastfeeding is encouraged.
Postgrad Med J 2011; 87: 417-427
Risks factors for diabetes following a
gestational diabetes pregnancy
• Family origin with high prevalence of diabetes ; South
Asian, black Caribbean, Middle Eastern
• Insulin treatment in pregnancy
• Maternal obesity
• Weight gain postpartum
• Family history of diabetes
Postgrad Med J 2011; 87: 417-427
Suggested management of women
with prior GDM
At 1–4 months postpartum (6-8 wk)
Nat Rev Endocrinol 2012;8:639–649
Take home messages
Gestational diabetes mellitus (GDM) is caused by reduced
pancreatic β‑cell function, which results from the full spectrum of
causes of β‑cell dysfunction.
GDM is associated with a modest increase in adverse perinatal
outcomes, an increased risk of obesity in offspring and a high risk of
subsequent development of DM in mothers.
GDM is treated nutritionally; insulin or oral antidiabetic agents can
be added if maternal glucose levels and/or fetal growth parameters
indicate a sufficiently high risk of perinatal complications.
Long-term management of mothers includes assessment of
diabetes risk, and lifestyle and/or pharmacological approaches for
women at risk of type 2 diabetes mellitus.