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Diabetes & pregnancy

Diabetes & pregnancy. Insulin. Diabetes & pregnancy. Impact of diabetes on pregnancy Impact of pregnancy on diabetes. Diabetes & pregnancy. Gestational diabetes (GDM) Pre-pregnancy diabetes (PGDM): type 1 or type 2 diabetes or MODY S ynonyms : overt diabetes, chronic diabetes.

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Diabetes & pregnancy

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  1. Diabetes & pregnancy

  2. Insulin

  3. Diabetes & pregnancy • Impact of diabetes on pregnancy • Impact of pregnancy on diabetes

  4. Diabetes & pregnancy • Gestational diabetes (GDM) • Pre-pregnancy diabetes (PGDM): type 1 or type 2 diabetes or MODY Synonyms: overt diabetes, chronic diabetes

  5. Diabetes Complicating Pregnancy

  6. Gestational diabetes Carbohydrate intolerance of variable severity with onset or first recognition during pregnancy

  7. GDM: pathomechanism theories • Exaggerated physiological changes in glucose metabolism: induction of hyperglycaemia • 1st half of pregnancy: high insulin sensitivity • 2nd half of pregnancy: increase of insulin resistance • Postpartum drop of insulin resistance

  8. GDM: pathomechanism theories • Preexisting type 2 diabetes unmasked or firstdiscovered during pregnancy

  9. Detection of GDM: step 1 & 2 • 1st visit: fasting glucose level < 100 mg/dl • Screening: universal or selective? • Method: 50 g glucose Oral Challenge Test (OCT) • Timing: between 24th and 28th week of gestation • No regard to the time of day or of last meal

  10. GDM: screening results • < 140 mg/dl: negative • 140 – 199 mg/dl:diagnostic test as soon as possible • ≥ 200 mg/dl:positive • *140 mg/dl: identifies 80% of women with GDM

  11. Detection of GDM: step 3 • Method: 75 g load 2-hour Oral Glucose Tolerance Test (OGTT) – according to WHO recommendation • 3 days before test: increase amount of carbohydrates intake ( 150 g/day at least) • 1 day before test: last meal at 6.00 a.m. • Overnight fast

  12. OGTT: thresholds • Fasting: < 100 mg/dl • 1-hour (optional): < 180 mg/dl • 2-hour: < 140 mg/dl

  13. Glucose tolerance curves

  14. GDM detection – no matters: • Unrecognized glucose intolerance having existed before the pregnancy • Glucose intolerance persistence or not after the pregnancy • Both conditions to be verified postpartum!

  15. GDM functional classification • Depends on therapy effectiveness • G1 – diet only • G2 – diet & insulin administration • Insulin analogues: accepted • Oral hypoglycaemic agents: contraindicated

  16. Fetal effects of GDM • Maternal hyperglycemia • Fetal hyperglycemia • Fetal response: hyperinsulinemia • Excessive fetal growth: macrosomia • Shoulder dystocia: birth trauma • Hydramnios (osmotic diuresis?) • Intrauterine fetal death in last 4–8weeks of pregnancy (excessive oxygen consumption? fetal asphyxia?)

  17. Neonatal effects of GDM • Excessive oxygen use in utero: polycythemia • Hyperbilirubinemia • Thrombosis • Hypoglycemia • Respiratory distress (Inhibition of lung maturation) • Longitudinal effects: obesity & diabetes

  18. Neonatal macrosomia

  19. Maternal effects of GDM • Hypertension • Cesarean delivery • Recurrence of GDM in subsequent pregnancy • Overt diabetes developement • (over 50 – 70% of women with GDM in 20-years period) • Metabolic syndrom development

  20. Maternal-fetal effects

  21. GDM: management • Diet: • 6 meals a day • Caloric restriction according to BMI • Eliminate: monosaccharides • Exercise • Empirical insulin therapy • Insulin: short-acting & long-acting • Never use combined insulin in pregnant woman!

  22. GDM: plasma glucose control Goals: • Fasting 60 – 90 mg/dl • 1-hour postprandial < 130 mg/dl

  23. GDM: postpartum consequences • 75-g 2-h OGTT 6 weeks postpartum (poor compliance) • If normal: regular reassessment (OGTT) at minimum 3-year intervals • Weight control & adequate physical activity prevent recurrence of GDM in subsequent pregnancies

  24. PGDM & pregnancy • 1st trimester: drop of insulin require – reduce insulin doses! • 2nd and 3rd trimester: insulin resistance gradual increase • Strict plasma glucose control necessary! • Glycated hemoglobin rate

  25. Fetal effects of PGDM • Abortion or preterm delivery • Congenital malformations • Macrosomia • Unexplained fetal demise & stillbirths > 35 week of gestation (impaired oxygene transport due to maternal hyperglycemia?) • Placental insufficiency & IUGR • Hydramnios

  26. Neonatal effects of PGDM • Respiratory distress • Hypoglycemia • Hypocalcemia • Hyperbilirubinemia • Cardiac hypertrophy • Impaired long-term cognitive development • Inheritance of diabetes

  27. Maternal effects of PGDM • Diabetic nephropathy • Diabetic retinopathy • Diabetic neuropathy • Preeclampsia • Ketoacidosis • Infections

  28. PGDM: management in pregnancy • Preconception counselling & education • Low glycated hemoglobin values • Multiple daily insulin injections • Continous subcutaneous insulin infusion • Diet • Fetal sonography: congenital anomalies, excessive growth, hydramnios/oligohydramnios

  29. Sequential vs continous insulin therapy

  30. Delivery in diabetic patient • GDM per se is not an indication to caesarean section! • Labor induction in GDM or B – C class PGDM, unless fetal macrosomia exists • Well-controlled B – C class PGDM: according to other medical conditions • D – N class PGDM: no alternative to caesarean delivery! • Remember adequate hydration & plasma glucose control during labor and delivery!

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