임신과당뇨병 - 김희숙 교수
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  • 1. 임신과 당뇨병 김희숙 (서울대학교 간호대학) 2012.06.12.Contact : kimhs02041@hotmail.com •1
  • 2. Contents• GDM - Glycemic Index - Breastfeeding & DM - Incidence and Risk Factors of T2DM after GDM• Preconception Care & DM• Pregnancy outcomes in PGDM• Suggestion & Discussion •2
  • 3. GDM •3
  • 4. GDM 관리의 중요성 •4
  • 5. Definition of GDM• Glucose intolerance of variable severity, withonset or first recognition during pregnancy •5
  • 6. Screening and Diagnosis •6
  • 7. •7
  • 8. 임신성 당뇨병 진단기준 당뇨병 진료지침 2011, 대한당뇨병학회 •8
  • 9. ADA: Standards of Medical Care in Diabetes—2010. Diabetes Care 33:S11-S61, 2010 •9
  • 10. Goals of management1. To prevent perinatal mortality & morbidity2. To achieve and maintain normoglycemia •10
  • 11. Intervention MNT ExerciseStress Insulincontrol •11
  • 12. Blood glucose goals (by ADA)• Fasting whole blood glucose ≤ 95 mg/dL• 1-h postprandial whole blood glucose ≤ 140 mg/dL• 2-h postprandial whole blood glucose ≤ 120 mg/dL •12
  • 13. Glycemic Index (당지수) •13
  • 14. 당지수 (Glycemic index)란?• 혈당이 오르는 정도를 표현한 수치로 포도당을 마신후 혈당이 오르는 정도를 100%로 하고, 다 른 음식의 혈당을 올리는 정도를 비교하는 수치• 당지수가 낮을수록 혈당이 천천히 상승 •14
  • 15. 그림. 혈당지수가 낮은 식품(A)과 혈당지수가 높은 식품(B)의 섭취가 위장관의 포도당 흡수와 식후 혈당에 미치는 영향 •15
  • 16. 고 당지수식품 중 당지수 식품 저 당지수 식품 (70이상) (56-69) (55이하) 백미 79-90 현미 50-60 콩 18 흰식빵 70 보리빵 65 전곡빵 30-45 감자 80-100 요구르트 64 우유 27콘플레이크 84 잡곡플레 66 올브랜 42 수박 70 이크 플레이크 바나나 53 사과 36 •16
  • 17. 식품별 당지수식품군별 식품 예 (당지수) 흰 맵쌀(83), 흰찹쌀(86~98), 흰빵(70), 통밀빵(55), 현미밥(50),곡류군 알랑미(38~58), 통보리(25), 감자(85), 고구마(61), 옥수수(48)어육류군 강남콩(28), 검정콩(20), 메주콩(18), 고기(0), 생선(0), 치즈(0)지방군 호두(0), 아몬드(0), 땅콩(14), 올리브 기름(0)우유군 우유(27) 수박(72), 파인애플(59), 바나나(52),복숭아(45),포도(46),오렌지(42),과일군 사과(34), 자몽(25)채소군 푸른 채소(0), 브로콜리(0), 시금치(0) <참고: 저혈당과 인슐린(2008)> •17
  • 18. 현미와 백미의 영양소 비교 현미영양소 백미 섬유질 쌀눈비타민B군 32~33% 65% 2~3%단백질 12~15% 730mg/100g 6~7%지방질 22~24% 칼슘 ⧻ 9mg/100g + 인 300mg/100g 철분 ⧻ - •18
  • 19. •19
  • 20. Dietary advice in pregnancy for preventing GDMThis is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published In The Cochrane Library, 2011, Issue 2 •20
  • 21. • Glucose is the primary source of energy for fetal growth (Moses 2006; Scholl 2004), making maternal glucose levels influential on pregnancy outcomes - a primary consideration in gestational diabete management.• Glycaemic index (GI) qantitatively defines the effect of carbohydrate based foods on blood glucose levels.• The GI value of a food is the response of blood glucose to a particular food, compared with an equivalent amount of the standard glucose (Foster-Powell 2002). •21
  • 22. •22
  • 23. •23
  • 24. •24
  • 25. •25
  • 26. •26
  • 27. •27
  • 28. •28
  • 29. •29
  • 30. Breastfeeding & DM •30
  • 31. GDM에서 모유수유 해야하는 이유① 혈당조절 효과 - 모유수유를 30분간 하면 50~100mg/dL 혈당 감소 - 임신성 당뇨병 산모의 4~12주 모유수유 후 공복혈당 낮아짐1) (모유수유 93± 13, 인공수유 98± 17mg/dL)② 열량 소모 : 평균 25%의 인슐린 요구량 감소1)③ 모유수유를 최소2개월이상 한 임산부 자녀 : 그렇지 않은 경우보다 제 1형 당뇨병 이환 될 확률 감소2) (당뇨병 예방에 도움이 되는 물질 함유)④ 영아 소아비만과 초기 당뇨병에 대한 보호효과 2)➄ 산후 당뇨병 예방3)1) American Diabetes Association. (2009). Medical management of pregnancy complicated by diabetes.2) Taylor, J. S., Kacmar, J E., Nothnagle, M., Lawrence, R. (2005). A systematic review of the literature associating breastfeeding with type 2 diabetes and GDM. Journal of the American College of Nutrition, 24(5), 320-326.3) Schwarz, E. B., Brown, J. S., Creasman, J. M. et al. (2010). Lactation and maternal risk of type 2 diabetes: Apopulation-based study. The American Journal of Medicine, 123(9). 863e1-e6. •31
  • 32. •32
  • 33. Incidence and Risk Factors ofT2DM after GDM Pregnancy •33
  • 34. • GDM affects 2-5% of all pregnancies in Korean women.• In a mixed ethnic population cohort of Chicago USA, as much as 50% of GDM women progressed to T2DM within 5 years Postpartum.• Both environmental and genetic factors are thought to contribute to the development of T2DM after GDM •34
  • 35. Incidence of T2DM after GDM in Koreans Ref> 곽수헌 (서울대병원 내분비내과, 2011 ICDM 발표자료) •35
  • 36. Postpartum complications• Recurrence of GDM : ~ 50% in Korean women (Kwak SH et al, Diabetes Care 31: 1867, 2008)• Development of T2DM : 35-60% within 10 years• A higher incidence of the metabolic syndrome• Early atherosclerosis (endothelial dysfunction) : increased risk of chronic hypertension and CVD •36
  • 37. Maternal follow-up• CVD risk factor assessment• Breast feeding• Contraception or pregnancy planning• Diabetes prevention •37
  • 38. Preconception Care & DM •38
  • 39. Fetal Programing• “자궁 안에서 출생후의 평생건강이 결정된다” (David Baker, England, 1991) - 임신 전 및 임신 중 영양부족 - 임신 중 스트레스 - 임신 중 탈수증 등 → 저 체중아 출생 → 성인에서의 평생 건강의 질 ↓ 각종 대사증후군 쉽게 노출된다는 이론 (당뇨, 고혈압, 고지혈증, 비만 등)• 임신전과 임신 중 관리 강조 •39
  • 40. •40
  • 41. •41
  • 42. Preconception care for diabetic women for improving maternal and infant health This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published In The Cochrane Library, 2011, Issue 2 •42
  • 43. • Current guidelines in many countries including Australia, the United Kingdom and United States recommend preconception care of diabetic women.• Pregnant women with type I or type II diabetes are at a greater risk of adverse outcomes in pregnancy such as high blood pressure(gestational hypertension) and preterm births.• Pregnancy can also accelerate the development of diabetic complications(retinopathy, nephropathy, neuropathy, ischaemic heart disease, cerebrovascular disease, peripheral vascular disease). •43
  • 44. • Babies born to mothers with type I or type II diabetes diagnosed before pregnancy may be larger and are at greater risk of infant death and congenital abnormality (such as neural tube defects including anencephaly and spina bifida).• These infants are also at risk of developing type II diabetes in the long term. Because of the strong association between good control of a woman’s blood sugars (glycaemic control), as measured by haemoglobinA1c, and reduced congenital anomalies, glycaemic targets are central to preconception care. •44
  • 45. •45
  • 46. •46
  • 47. • This review evaluating preconception care management protocols for women with pre-existing diabetes identified only one trial (involving 53 women) that was eligible for inclusion.• None of the prespecified outcomes of the review were reported by this trial.• Haemoglobin A1c data were reported as mean changes from baseline and could not be included in this review.• Therefore, it is unclear what effect preconception care for diabetic women has on maternal and infant health outcomes based on evidence from randomised controlled trials. •47
  • 48. •48
  • 49. •49
  • 50. •50
  • 51. •51
  • 52. Pregnancy Outcome in Pregnancy Women with Diabetes •52
  • 53. Pregnancy Outcomes in Pregnancy Women with Type 1 and Type 2 Diabetes Hee-Sook Kima, Moon-Young Kimb, Jeong-Eun Parkc, Sung-Hoon Kimc a Collegeof Nursing, Seoul National University, Seoul, Korea b Department of Obstetrics and Gynecology, c Diabetes Center, Division of Endocrinology & Metabolism, Department of Medicine, Cheil General Hospital & Women’s Healthcare Center, Kwandong University College of Medicine, Seoul, Korea •53
  • 54. Pregnancy Outcomes in Pregnancy women withType 2 diabetes & Nondiabetes Patient Matched Age, Prepregnancy BMI and Parity Hee-Sook Kima, Moon-Young Kimb, Jeong-Eun Parkc, Sung-Hoon Kimc a College of Nursing, Seoul National University, Seoul, Korea b Department of Obstetrics andc Diabetes Center, Division of Endocrinology & Metabolism, Department of Medicine, Cheil General Hospital & Women’s Healthcare Center, Kwandong University College of Medicine, Seoul, Korea •54
  • 55. Suggestion• Teratogen Checklist & EMR 기록 추가• 병원내 “고위험 임신교육과 자조모임” 운영과 활성화 : ex. GDM & PGDM• Preconception Education 개발과 적용 : 대학생/가임기 여성/고위험 여성 “임신전 생식건강증진 교육프로그램 개발과 평가”• 산후 T2DM 예방 프로그램 개발과 평가 •55
  • 56. •56
  • 57. •57
  • 58. •58
  • 59. GDM 교육요구도 조사 •59
  • 60. 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 •60
  • 61. Small group meeting •61
  • 62. Telephone counseling My glucose level is 100. What was your But it’s really hard to control diet. glucose level I’m frustrated. Because I can’t eat last week? bread & ramen. •62
  • 63. 임신과 당뇨병Hee-Sook Kim, kimhs02041@hotmail.com •63