Diabetes managemen

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Diabetes managemen

  1. 1. 임신 때 당뇨병 관리 김 성 훈 관동의대 제일병원 내과
  2. 2. Contents • Epidemiology of diabetes in pregnancy • Risks to the mother and the baby • Preconception counselling and prepregnancy care • Management of hyperglycemia in pregnancy • Diagnosis and management of GDM
  3. 3. 증 례 1 • 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. 4. Classification of diabetes in pregnancy • Type 1 diabetes (results from β-cell destruction, usually leading to absolute insulin deficiency) • Type 2 diabetes (results from a progressive insulin secretory defect on the background of insulin resistance) • Other specific types of diabetes due to other causes, e.g., genetic defects in β-cell function, genetic defects in insulin action, diseases of the exocrine pancreas (such as cystic fibrosis), and drug- or chemical-induced (such as in the treatment of HIV/AIDS or after organ transplantation) • Gestational diabetes mellitus (GDM) (diabetes diagnosed during pregnancy that is not clearly overt diabetes)
  5. 5. 한국모자보건학회지 14: 170-80, 2010 임신중당뇨병 임부의 유병률 및 의료이용 추이
  6. 6. Issues • Epidemics of obesity and T2DM -> numbers of women with T2DM become pregnant ↑ • Frequently undiagnosed T2DM before pregnancy • Lack of preconception care • ↑Cx of pregnancy due to the coexistence of obesity and T2DM
  7. 7. Risks of diabetes in pregnancy (I) • Fetal macrosomia • Birth trauma (to mother and baby) • Induction of labor or cesarean section
  8. 8. Accelerated fetal growth
  9. 9. Risks of diabetes in pregnancy (II) • Miscarriage • Congenital malformation • Stillbirth
  10. 10. Glucose control and risk of malformation Guerin A. Diabetes Care 30:1920, 2007
  11. 11. Glucose control and risk of malformation Guerin A. Diabetes Care 30:1920, 2007 For every 1% decrease in A1c, there is approximately 50% relative risk reduction for a congenital anomaly
  12. 12. 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
  13. 13. 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
  14. 14. 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
  15. 15. 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
  16. 16. Kitzmiller JL et al:Diabetes Care 2008;31:1060-1079 Diabetic nephropathy
  17. 17. Cardiovascular disease – Untreated CAD : a high mortality during pregnancy – Successful pregnancies after coronary revascularization in women with diabetes – Exercise tolerance should be normal : to tolerate the increased cardiovascular demands of gestation
  18. 18. 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.
  19. 19. Laboratory and special exam of pregnant women with preexisting diabetes Kitzmiller JL et al:Diabetes Care 2008;31:1060-1079
  20. 20. Management of hyperglycemia in pregnancy
  21. 21. 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 % Kitzmiller JL et al:Diabetes Care 2008;31:1060-1079
  22. 22. Recommended targets for capillary glucose during pregnancy Source Fasting 1 h Peak 2 h Premeal ADA GDM 95 140 - 120 - ADA preexisting 60-99 - 100-129 - 60-99 IDF 99 - 144 - - NICE 63-106 140 - - - ADIPS 99 144 126 126 - Mathiesen 72-110 140 72-144 - 72-110
  23. 23. 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
  24. 24. Medical Nutrition Therapy (MNT) • Individualized MNT • Basic plan: dietary recommendations for all pregnant women, adjusted to the individual needs • 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
  25. 25. 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
  26. 26. 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
  27. 27. 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
  28. 28. Insulin therapy during pregnancy • Basal–bolus insulin regimens (MDI) or CSII are recommended for optimal glycaemic control in pregnancy in women with pre- existing diabetes • Oral antidiabetic drugs in women with type 2 diabetes should be discontinued and insulin initiated and titrated to achieve the recommended glycaemic control prior to conception
  29. 29. Pharmacokinetics of human insulin and insulin analogs Type of insulin Onset of action Peak plasma values Duration of action Regular human insulin 30-60 min 1-3 h 5-7 h NPH insulin 60-90 min 8-12 h 18-24 h Insulin lispro 15-60 min 0.5-1 h 2-4 h Insulin aspart 10-20 min 1-3 h 3-5 h Insulin glulisine 10-20 min 1-2 h 3-5 h Glargine 4-5 h No peak >24 h Detemir 4-6 h No peak 20 h
  30. 30. 증 례 2 • 임신 28주의 32세 여성 • 임신 27주에 50g OCT:1시간 혈당이 174 mg/dL • 100g OGTT: fasting-97 mg/dL, 1 hour-189 mg/dL, 2 hour-166mg/dL, 3 hour-140mg/dL • 신장 164cm, 체중은 75kg (임신전 68kg) • 혈압 110/70mmHg, 신체 검사, 소변검사나 다른 검사 소견은 정상
  31. 31. 임신성 당뇨병의 진단기준 당뇨병 진료지침 2013, 대한당뇨병학회
  32. 32. Management of GDM
  33. 33. Summary of antepartum care • Medical Nutritional therapy • Regular exercise • Maternal SMBG or fetal AC for intensified Tx • Insulin remains the mainstay of Tx • glyburide and metformin may be offered as an alternative
  34. 34. Management of women with prior GDM Buchanan TA et al. Nat. Rev Endocrinol 8: 639, 2012
  35. 35. Summary 1. Preconception detection and management of T2DM may become a critical public health issue 2. Women with diabetes who are reproductive age need preconception counselling and prepregnancy care in the 6-12 months before pregnancy 3. The key to improving outcome of pregnancy in women with diabetes is strict glycemic control 4. Diagnosing and treating GDM can reduce perinatal complications and postpartum follow up and prevention of DM is important

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