Present & Future of Diabetes Care in Pregnancy

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김희숙 Ph.D(서울대 간호대학 임상강사)

김희숙 Ph.D(서울대 간호대학 임상강사)

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  • 1. Present & Future of Diabetes Care in Pregnancy Hee-Sook Kim College of Nursing, Seoul National University, Seoul, Korea Contact : kimhs02041@hotmail.com
  • 2. Contents• Content Analysis of Counseling of Women with GDM• Development and Evaluation of an Integrated Self-Management Program for Women with Gestational Diabetes Mellitus• Recent Article about GDM• Development and Evaluation of an Integrated Program Using Smartphone in Pregnancy Women with Diabetes
  • 3. Content Analysis of Counseling of Women with GDM 조사기갂 : 2010. 07~11. 대상자 : 임싞성 당뇨병 임부 28명
  • 4. • 임싞 중에는 임부들이 잘 먹어야 한다고 생각하는데 갑자기 음식 조젃을 하는 것이 어려워요, 특히 과일을 맋이 먹어야식이 예쁜 아이를 낳을 수 있다고 하는데 과일도 갂식 개념으로 먹어야 해서 어려워요.요법 • 임싞 했으니 2인분으로 잘 먹어야 한다고 기본적으로 생각하는데 갑자기 양을 죿여야 하니 어렵네요. • 식품 교환표가 이해가 안되요. • 음식 맊들 때 설탕, 물엿도 당이 포함 되어있지요? • 임싞할 때 과일을 맋이 먹으면 아이가 예뻐짂다고 해서 맋이 먹었는데 지금은 1단위 밖에 못 먹어요. • 토란을 먹으니 혈당이 높게 나왔어요. 토란은 무슨 군에 속하나요? • 커피 한 모금 먹으면 안 되나요? 빵, 라면을 너무 좋아하는데... 먹으면 안되나요? 못 먹으면 눈물이 나고 미치겠어요! (젂화 상담 중 울음 터뜨림) • 갂단하게 분식을 먹고 혈당을 재니 높게 나오고 혈당관리가 안되요. • 외식을 못해서 불편해요. 음식 조젃이 불편해요. • 첫아이 가졌을 때는 임싞성 당뇨는 아니었어요. 가족 중에 부모님이 당뇨병이거든요. 빵과 떡을 좋아하고 하루에 1잒은 커피를 마시고 너무 좋아해요. 그런데 아이한테 는 안 좋겠죠? 제가 첫 아이 때 커피를 마셔서인지 우리 아이도 커피를 좋아해요. 임 싞 중 음식이 아이한테 영향이 있나 봐요. • 과일을 마음껏 못 먹어요. 위가 쓰려요. 가슴이 탁 막히는 것 같아요. • 추석 때 음식 조젃을 못해서 조젃 높게 나왔어요. • 무엇을 먹을 때 혈당이 높은가요? • 평상시 저녁 시갂에 커피를 마시고 커피를 옆에 두고 4-5시갂 동안 마시면서 일을 하는데, 이번에 임싞성 당뇨병 짂단 받고 커피를 죿이려고 하는데 쉽지 않네요.
  • 5. • 혈당 조젃을 위해 2시갂 동안 운동을 했는데 조기짂통이 와서 병원에 입원 했어요.운동 • 2시갂 동안 첫아이 어린이 집으로 데려다 주면서 운동해요.요법 • 칼로리는 비슶하게 하고 운동은 식후 30분 정도 걸어 다녀요. 아기 몸무게가 10월 28 일 산과에서 본 초음파상 1.8kg으로 적다고 해서 걱정이 돼요.스트 • 한번 혈당이 높으면 그것이 아이에게 영향을 미칠까 봐 스트레스가 쌓여요. • 나이 들어서 임싞하면 살이 찌고 잠도 자면 안 된다고 가족, 시댁식구들이 말했어요.레스 • 임싞 중에는 식이에 대한 욕구가 달라지고 임싞 주수가 증가할수록 더 먹고 싶은데, 정해짂 식사량 맊큼맊관리 먹어야 한다는 강박관념으로 힘들어요. • 임싞 중 정싞적 공허감을 무엇으로 채워야 할까요? 음식이 아닌 다른 것으로 하는 것 에도 한계가 있네요. 책이나 여행, 영화도 해보았으나 .... • 아버지가 후두암으로 수술하시고 입원 중으로 스트레스 맋이 받았고, 스트레스 받으면 커피가 마시고 싶어요.
  • 6. • 고혈당시 기분이 나쁘고 목이 말라요.자가 • 식사 시갂이 길어질 때 2시갂 동안 식사할 때, 빨리 먹을 때 혈당은 언제 측정해야 하나요?혈당 당이 낮게 나오는데 맞나요?결과 • (젂화상담) 죽 먹고 혈당을 쟀더니 높게 나왔어요. 혈당이 180정도 나와서 놀랬어요. • 직장 다니면서 혈당이 140정도 높게 나왔는데 과일과 밥을 같이 먹으면 높게 나오는 것 같아요. • 혈당체크 불편해요. • 혈당을 자주 체크했더니 손바닥 끝에 굳은살이 박혔어요. • 65로 저혈당이 가끔 나와요.인슐린 • 인슐린 : 인슐린 안 쓰려고 식이요법 철저히 시행했어요. • 인슐린 주사 맞으면 되니까 먹는 것 마음껏 먹어도 되지 않을까?요법 • 인슐린 부작용은 없나요? • 인슐린 맞고 배가 두 군데에 멍이 들었어요. • 혈당이 높게 나오면 알아서 인슐린 약을 올리면 되지 않을까요? • 인슐린 주사에 찔려서 손에 상처가 났는데 괜찮은가요?
  • 7. • 출산 후 임싞성 당뇨가 없어 지나요? • 임싞성 당뇨병에 대해서 확실히 알고 싶어요.산후 • 산후 피임을 어떻게 해야 하나요?관리 • 모유수유에 대해 알고 싶어요. • 임싞성 당뇨병 있는데 모유수유 가능한가요? (질문하는 임부들이 대분분이였음) • 잘 먹어야 모유 잘 나온다고 생각해서 아기 낳고 잘 먹어서 20kg나 쪘어요. • 내과와 산과에서 검사는 많이 하면서 검사 이유와 결과에 대해 설명을 안해주니까 답답해요.의료행위 • 진료실에서는 들을 수 없는 내용과 상담을 받아서 교육이 만족스러워요.설명요구 궁금한 것은 맋은데 짂료시갂이 짧아서...
  • 8. • 임싞성 당뇨병 걸렸다고 시어머니한테 말하지 못했어요. 이유는 아이에게 미칠 영향과 며느리에 대해서 못마땅해 하실까 봐서 말도 못했어요. • 임싞성 당뇨병이 걸리는 이유를 아니까 제 잘못이 아닌 줄 알고 그 동안 이것 때문에 힘들었던 것에임부 대해서 마음이 풀리네요. 시어머니가 “네가 먹는 것에 욕심이 많으니까 생긴 거야”라고 말해서 마음이정서 너무 힘들었어요. 오늘 제 잘못이 아닌 줄 알고 마음이 홀가분해졌어요 (눈물을 보임).측면 • 임싞성 당뇨병으로 제가 이젂에 잘못된 식습관으로 아이에게 영향을 미칠까 봐 죄책감이 들었어요. • 우울하고 답답해요. • 여동생인 임싞성 당뇨병이 있어서 옆에서 봐서 관리는 잘 알고 있어요. 교육받을 필요 없어요(화난 표정). • 혈당수치를 맞추려면 태아 성장에 방해가 될 것 같고, 후자 쪽을 먺저 생각하면 혈당 수치조젃이 힘들어서 어떻게 해야 핛지 모르겠어요.아기 • 혈당은 약갂 높게 나오는 상태인데, 아기 몸무게가 적어서 인슐린 보류 상태예요걱정 (걱정스런 표정). • 임싞성 당뇨병에서 아이는 괜찮은가요? • 이젂에 혈당이 높은 것은 아이에게 영향을 미치지 않을까요?
  • 9. Development and Evaluation of an Integrated Self-Management Programfor Women with Gestational Diabetes Mellitus Hee-Sook Kima, Sue Kimb, Sung-Hoon Kimc a College of Nursing, Seoul National University, Seoul, Korea b Nursing Policy Research Institute, College of Nursing, Yonsei University, Seoul, Korea c Diabetes Center, Division of Endocrinology & Metabolism, Department of Medicine, Cheil General Hospital & Women’s Healthcare Center, Kwandong University College of Medicine, Seoul, Korea This work was supported by the 2010 Seoul Nurse Association. •11
  • 10. Contents • Introduction • Purpose of study • Definition of term • Conceptual framework • Method • Results • Conclusion •12
  • 11. Introduction-1• Definition of GDM : Glucose intolerance of various degrees with onset or first recognition during pregnancy.• Diagnosis : between 26th & 28th week of pregnancy.• Prevalence : 4~14% Worldwide (ADA, 2003).• Only about 50% of women with GDM receive GDM education (Ko et al., 1999).• Lack of knowledge, wrong information & high demand for education (Che, 2000).• Experience difficulties due to lack of information (Hjelm, Berntorp, Frid, & Aberg, 2008). •13
  • 12. Information: Internet, Book, Family etcObstetrics Internal medicine •14
  • 13. Introduction-2• Emotional condition : Strong negative reaction (Hjelm., Berntorp., Frid., & Aberg. 2008). Anxiety : peak at 30th week (Danielis, et al., 2003).• Management of GDM : Internal medicine: concentrate on glycemic control. Obstetrics: concentrate on screening problems and maintaining health to prevent complications on mother and fetus.• Pregnant women left alone to handle directions by internal medicine and obstetrics, unable to integrate health management. •15
  • 14. Introduction-3• Pregnancy with GDM require more cautious care than ordinary diabetic patients.• Presently in Korea, no initiatives of integrated program exist in health care system.• Women with GDM need counseling & systematic education to improve self-management. •16
  • 15. Purpose of study• To develop an ISM program which could cover expected weaknesses from separately controlled obstetrics and internal medicine departments.• To evaluate the positive effects of each on self-management, glycemic control, and maternal identity in women with GDM. •17
  • 16. Definition of terms• Maternal identity : Recognition of maternal role taking behavior and emotion (Rubin, 1984). - Maternal role - Interaction between mother and fetus - Emotional response to pregnancy (Kim & Hong, 1996). •18
  • 17. Definition of terms_Integrated Self-Management Program• Integrate contents & methods in the management of glycemic control & maternal identity approach.• Contents : education, emotional support, & interaction with experts to participate in decision making about self- management. - dietary, exercise, SMBG, & stress management - prenatal & childbirth education.• Method : 5 times in 5 weeks - 3 times : 1 hour small group meeting - 2 times : supportive counseling by telephone.• The program was verified by an expert panel. •19
  • 18. Program development stage Stage Method Checking needs for women with GDM ∙ Literature review (contents & method od program) through literature review & survey ∙ Survey & interview (13 women with GDM) Development the preliminary protocol : ∙ Workbook for educationworkbook, telephone support manual, daily record ∙ Manual for telephone counseling for self-management ∙ Record of self-management Confirmation the expert ∙ Expert validity (5 member) validity Confirmation ∙ Clinical validity by women with GDM (3 member) & the clinical validity by women with GDM Development the final protocol ∙ Contents: self-management + maternal identity ∙ Methods: small group(3times)+telephone(2회) - client-based education - emotional support (self expression, listening, praise, encouragement) - decisional control (Q&A)
  • 19. Protocol of an integrated self-management program Times 1 2 3 4 5Gestation (Weeks) 29-30 30-31 31-32 32-33 33-34Topic Introduction Compliance Effects of GDM Compliance Care & Prevent of DM & Management of self-management on maternal- of self-management in postpartum of GDM newbornContent • Check of SM list • Check of SM list • Check of SM list • Q&A • Q&A • Q&A • Introduction of GDM • Exercise • Prevent of DM • Dietary • Stress management in postpartum • Emotional support • Emotional support • Emotional support • Taekyo • Taekyo • Taekyo • Abdominal breathing • Abdominal • Abdominal breathing breathing • Delivery • Effects of GDM on • Breastfeeding maternal-Newborn • Postpartum careMethod Small group meeting Telephone- Small group meeting Telephone- Small group meeting (Education & Support) counseling (Education & Support) counseling (Education & Support)GDM : Gestational Diabetes Mellitus, SM: Self-management •21
  • 20. Workbook •22
  • 21. Conceptual framework Client-professional Client singularity Health Outcome interaction Integrated self-Demographic Affective management program Self-managementcharacteristics response Cognitive Health care informationSocial influence appraisal ·client-based education Glycemic control : knowledge of Affective supportPrevious health GDM ·self expressioncare experience Intrinsic ·listening, praise, Maternal identity motivation encouragementEnvironmental : self- efficacy ofresources GDM management Decisional control ·small group meetings ·telephone-counseling ·record of self-managementGDM : Gestational Diabetes MellitusCoxs Interaction Model of Client Health Behavior (IMCHB, 1982) •23
  • 22. Method_Research DesignNonequivalent control group non-synchronized quasi-experimental design Type of group Control Experimental Time Pre-test C1 Post-test C2 C3 C4 Pre-test E1 Treatment X Post-test E2 E3 E4 • C1, E1 (before) : self-management , PP2, HbA1c, maternal identity, general characteristics • C2, E2 (after 3weeks) : PP2 • C3, E3 (immediately finish) : self-management, PP2, maternal identity • C4, E4 (2weeks after finish) : HbA1c • X : ISM Program (total 5 times) •24
  • 23. Method• A total of 55 GDM women recruited from Cheil General Hospital, Seoul, Korea.• Participants : assigned to an experimental (n=28) or control group (n=27). 24-30 week pregnant women who had been diagnosed as GDM as of July 30, 2010.• Exclusion criteria : a history of diabetes mellitus not related to pregnancy or the presence of high risk disease such as pregnancy induced hypertension. •25
  • 24. Method_ measurement The No. Cronbach’s α Items Measurement tool of items Range Pre-test Post-testSelf- Kim, Y. O. (1996) total 14 total 0-56Management ㆍDietary (7) (0-28) ㆍExercise (2) (0- 8) .84 .95 ㆍStress management (1) (0- 4) ㆍSMBG (3) (0-12) ㆍ Abdominal brething (1) (0- 4)2-h HLC-723 G7postprandial glucose, CV=1.5~2.8% (Tosoh comp., Japan)HbA1cMaternal identity Kim, H. W. (1996) total 40 total 40-160 ㆍ Maternal role (10) (10-40) .94 .96 ㆍ Interaction of mother-fetus (10) (10-40) ㆍ Emotional response (20) (20-80) •26
  • 25. Results •27
  • 26. (n=55)Table1. Homogeneity test of characteristics between the experimental and control groups Experimental (n=28) Control (n=27) Variable Items Χ2 / z p n(%) M±SD n(%) M±SD Age 〈35 15(53.6) 18(66.7) (year) 34.4±3.9 33.6±3.4 0.98 .322 ≥35 13(46.4) 9(33.3) Family Nuclear family 23(82.1) 23(85.2) ⧧0.09 1.000 type Large family 5(17.9) 4(14.8) ≤ High School 3(10.7) 6(22.2) Education ⧧1.33 .295 〉High School 25(89.3) 21(77.8) No 22(78.6) 18(66.7) Job 0.98 .322 Yes 6(21.4) 9(33.3) High 7(25.0) 8(29.6) Income 0.14 .700 Middle 21(75.0) 19(70.4) No 11(39.3) 14(51.9) Religion 0.87 .349 Yes 17(60.7) 13(48.1) Gestation 28.7±3.6 29.4±2.7 0.98 .320 (weeks) Yes 20(71.4) 19(70.4) Planned pregnancy 0.00 .931 No 8(28.6) 8(29.6) Primi 18(64.3) 14(51.9) Parity 0.87 .350 Multi 10(35.7) 13(48.1) •28 p <.05
  • 27. (n=55)Table2. Homogeneity test of metabolic parameter the experimental and control groups Experimental Control (Normal (n=28) (n=27) Variable z p ㆍGoal) M±SD M±SD Pre-gestational weight (kg) 57.5±13.6 59.1± 9.4 -0.11 .91 Maternal height (cm) 161.4± 5.8 159.7± 4.6 -1.63 .10 Pre-gestational BMI (kg/m2) (18.5-24.9)† 22.1± 5.5 23.2± 3.7 -0.82 .40 Total weight gain from 8.3±10.9 6.1± 3.8 -0.58 .55 pre-pregnancy to diagnosis (kg) 0-h 100g OGTT mg/dl) (95)* 85.6± 9.3 87.4±10.6 -0.38 .70 1-h 100g OGTT (mg/dl) (180)* 189.3±19.9 182.5±19.6 -1.16 .24 100g OGTT 2-h 100g OGTT (mg/dl) (155)* .20 179.6±22.4 170.7±20.7 -1.28 3-h 100g OGTT (mg/dl) (140)* 136.7±23.9 134.5±25.7 0.00 1.00 Fasting insulin at diagnostics (μU/mL) (2.6-24.9) 18.0± 8.5 16.7± 8.8 -0.37 .71 1-h insulin at diagnostics (μU/mL) 110.3±59.5 86.0±50.8 -1.75 .08 Fasting serum glucose at 2nd diagnostics (≤95)* 79.8±11.8 80.0± 9.5 -0.46 .64 (mg/dL) Systolic BP (mmHg) (≤120) 104.6±10.8 102.6±12.8 -0.50 .61 Diastolic BP (mmHg) (≤80) 62.2± 7.8 60.4± 7.4 -0.86 .38 •29 p <.05
  • 28. (n=55)Table3. Difference in self-management between the experimental and control groups Experimental Control (n=28) (n=27) variable range z p M±SD M±SD Pre-test 37.75±8.27 35.55±8.67 -1.037 .300 Total 0-56 Post-test 43.85±6.51 34.55±9.06 -3.802 <.001 Dietary Pre-test 19.21±4.49 18.30±4.50 -0.76 .452 0-28 Post-test 21.82±3.74 17.67±4.84 -3.57 <.001 Exercise Pre-test 4.57±2.25 4.19±2.35 -0.62 .536 0-8 Post-test 5.93±1.74 4.07±2.00 -3.67 <.001 Stress Pre-test 1.96±1.32 1.56±1.25 -1.18 .243 0-4 management Post-test 1.96±1.32 1.56±1.25 -3.31 .243 SMBG Pre-test 10.00±2.28 9.52±2.82 -0.70 .488 0-14 Post-test 11.29±1.76 9.22±2.76 -1.18 <.001 Abdominal Pre-test 1.96±1.32 1.56±1.25 -1.18 .243 0-4 breathing Post-test 1.96±1.32 1.56±1.25 -3.31 .243 p <.05 •30
  • 29. (n=55) Table4. Difference in glycemic control between the experimental and control groups Experimental Control (n=28) (n=27) variable z p M±SD M±SD2hours Pre-test 105.07±17.82 106.08±14.12 -0.418 .676postprandial 3rd week 101.71± 8.43 109.22±16.37 -1.98 .047Glucose Post-test 101.93± 9.54 108.04±13.97 -1.568 .117(mg/dL) Mean 101.82± 7.60 108.62±12.64 -2.434 .015 Pre-test 5.33± 0.42 5.24± 0.41 -8.837 .403HbA1c(%) Post-2week 5.50± 0.44 5.35± 0.42 -1.179 .238p <.05 •31
  • 30. Table5. Difference in maternal identity between the experimental and control groups (n=55) Experimental Control (n=28) (n=27) variable range z p M±SD M±SD Pre-test 125.10±17.54 115.33±17.26 -1.870 .062Total 40-160 Post-test 138.57±15.30 115.62±16.37 -4.489 <.001Maternal role Pre-test 29.32± 7.78 27.55± 5.08 -0.929 .353 10-40 Post-test 33.92± 5.03 27.40± 5.16 -4.077 <.001Interaction of Pre-test 28.64± 7.01 25.48± 7.35 -1.004 .315 10-40mother-fetus Post-test 32.96± 5.81 26.59± 6.08 -3.670 <.001Emotional Pre-test 67.14± 7.91 62.29± 9.70 -1.913 .056 20-80response Post-test 71.67± 6.57 61.62± 9.16 -3.880 <.001p <.05 •32
  • 31. Evaluation of ISM program
  • 32. 내용만족도 만족도 이해도 범위 주요 개념 프로그램 구성 M±SD M±SD 1-4GDM 자가관리 자가혈당 측정 3.36±0.55 3.61±0.49 1-4 식이요법 3.46±0.50 3.64±0.48 1-4 운동요법 3.46±0.50 3.68±0.47 1-4 스트레스 관리 3.46±0.50 3.61±0.49 1-4모성 정체성 태교 중요성 3.29±0.53 3.50±0.57 1-4 태교 방법 3.11±0.41 3.50±0.50 1-4 안젂핚 출산 3.25±0.44 3.64±0.48 1-4 산후관리 3.39±0.49 3.61±0.49 1-4 모유수유 3.54±0.50 3.64±0.48 1-4
  • 33. 진행만족도젂반적인 만족도 Mean S.D. 범위모임 횟수 (교육의 양) 3.46 0.48 1-4모임 시갂 3.49 0.56 1-4모임 장소 3.56 0.50 1-4교육 방법 3.60 0.50 1-4유인물 3.56 0.50 1-4강의 편성 3.56 0.50 1-4다른 임부들과 나눔 3.35 0.88 1-4 모임 상담 3.78 0.47 1-4상담 젂화 상담 3.78 0.47 1-4
  • 34. 유용성프로그램의 유용성 Mean S.D. 범위기대했던 목적 성취 3.53 0.50 1-4임싞성 당뇨병 자가 관리에 도움 3.67 0.50 1-4임싞성 당뇨병에 대한 불안 감소 3.64 0.50 1-4임싞성 당뇨병에 대한 걱정 감소 3.64 0.50 1-4임싞성 당뇨병에 대한 관리 자싞감 증가 3.60 0.50 1-4임싞 중 심상적 복식호흡 실천 3.74 0.48 1-4임싞 중 태교 실천 3.70 0.50 1-4임싞, 산후에 대한 어머니 역할 죾비에 도움 3.63 0.69 1-4
  • 35. 보완점 구분 내 용 (명수) 좋은 점 불안감소, 편안핚 마음, 자싞감 증가 (7) 좋은 정보와 지식 획득 (5) 혈당 관리의 중요성과 관리 도움 (4) 심상적 복식호흡으로 안정과 스트레스 관리에 도움 (3) 같은 임싞성 당뇨병 임부와 나눔 (3) 일대일 상담 및 맞춤식 교육 가능과 궁금증 해소 (2) 식이요법의 자세핚 설명 (1) 쉽고 편안핚 교육방법 (1) 산젂산후 관리 정보획득, 모유수유 방법 (1) 언제든지 상담가능과 친젃핚 상담 (1) 어려운 점 짂료대기 시갂으로 교육시갂 지키기 어려움 (1) 외래 짂료와 교육 병행의 어려움 (1) 개인사정으로 교육이 늦어짐 (1), 인슐린 투여 (1) 교육 횟수 증가(2), 모유수유 교육 더 추가 (1) 보충 점 운동요법 실습(1) 임싞성 당뇨병 짂단초기부터 교육받도록 홍보 (1) 임싞성 당뇨병 임부와 맊날 수 있는 모임 (1)
  • 36. Conclusion• Participation in an ISM program for GDM women improves self-management, maternal identity, and glycemic control.• First development and application of nursing intervention program showing positive effects of pregnant women with GDM.• IMCHB by Cox(1982) is theoretically viable model with positive effects on level of self-management, glucose, and maternal identity.• Motivating hospitals to set up the program by presenting evidence-based practice model of promoting health of pregnant women with GDM •38
  • 37. Conclusion _ limitation• Unable to do random selection of research participants due to limited access to pregnant women with GDM.• Unable to do longitudinal study of the effects of integrated self-management program on pregnancy and neonatal outcomes •39
  • 38. Conclusion• Further studies are needed to identify the effects of an ISM program on pregnancy and neonatal outcomes.• Repeated research on randomly selected pregnant women with GDM.• Repeated research in other hospitals and facilities on pregnant women vulnerable of GDM management.• Development of stress releasing program for pregnant women with GDM by enhancing abdominal breathing and research on its effects GDM. •40
  • 39. Recent Article about GDM
  • 40. Increasing Prevalence of Gestational Diabetes Mellitusin Korean Women from 2003 to 2009 Hee-Sook Kim, Jeong-Eun Park, Sung-Hoon Kim 2011년 제24차 대핚당뇨병학회 춘계학술대회, 대핚당뇨병학회
  • 41. Increasing Prevalence of Gestational Diabetes Mellitusin Korean Women from 2003 to 2009
  • 42. Prevalence of GDM 년도 2003 2006 2009 P GDM (n) 281 243 218 Total (n) 7532 6547 4560 GDM Prevalence 3.7 3.7 4.8 .006 (%)p<.05 (two-sided) Data source : 제일병원
  • 43. The Pregnancy & Neonatal Outcomes of Korean Women with Gestational Diabetes Mellitus 김희숙, 박정은, 김성훈 2011년 여성걲강갂호학회 춘계학술대회, 여성걲강갂호학회. (우수포스터상 수상)
  • 44. The Pregnancy & Neonatal Outcomes of Korean Women with Gestational Diabetes Mellitus
  • 45. The Predictors of Large-for-Gestational-Age (LGA) Neonates in Obese Gestational Diabetes Mellitus Women Hee-Sook Kim, Jeong-Eun Park, Sung-Hoon Kim,The 8th International Diabetes Federation Western Pacific Region Congress Abstract Book, 2010 IDF-WPR Congress, Oct 18, Bexco, Busan, Korea.
  • 46. The Predictors of Large-for-Gestational-Age (LGA) Neonates in Obese GDM women
  • 47. Table1. Predictors of LGA Neonates in obese GDM women analyzed with logistic regression analysis
  • 48. Effects of an Integrated Support Program on Emotional Responses in Women with Gestational Diabetes Mellitus Hee-Sook Kim, Sue Kim, Jeong-Eun Park The 21th World Congress on Psychosomatic Medicine; New Vision for Psychosomatic Medicine: Beyond Science and Borders, p.191, 2011 ICPM, Aug 26, 2011, National Museum of Korea, Seoul.
  • 49. Effects of an Integrated Support Program on Emotional Responsesin Women with Gestational Diabetes Mellitus
  • 50. Present & Future of Diabetes Care in Pregnancy Hee-Sook Kim, kimhs02041@hotmail.com