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Diabetes mellitus and reproductive system of woman. A. Tiselko, N. Borovik, O. Volgina Reproductive endocrinology department Ott’s Research Institute of.

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Presentation on theme: "Diabetes mellitus and reproductive system of woman. A. Tiselko, N. Borovik, O. Volgina Reproductive endocrinology department Ott’s Research Institute of."— Presentation transcript:

1 Diabetes mellitus and reproductive system of woman. A. Tiselko, N. Borovik, O. Volgina Reproductive endocrinology department Ott’s Research Institute of Obstetrics and Gynecology Saint-Petersburg, 2011

2 Women in reproductive age (18-44 yo) with diabetes mellitus in Russia women Morbidity 261,8 per Morbidity 261,8 per Diabetes mellitus register, Russia, 2006

3 Гипергликемия Hyperglycemia Оvary insufficiency Abnormalities of gonadotropin’s secretion Autoimmune oophoritis

4 Compensation of diabetes metabolic disturbances Restoration of ovulatory cycle

5 Before insulin discovery Maternal mortality Perinatal mortality 44%60%44%60% Hare JW, White P: Pregnancy in diabetes complicated by vascular disease. Diabetes 26: , 1977

6 Diabetes mellitus – the disease that still leads to complicated course of pregnancy and delivery and forms some problems in foetus and newborn

7 Decompensated diabetes mellitus and it’s influence on pregnancy coursе Noncarring of pregnancy – 20-30% Gestosis – 40-79% (O. Arzhanova, 2006; Ecbom P., 2001) Polyhydramnios % Urogenital infections % Placental insufficiency, preterm delivery % Caesarian section %

8 Frequency of congenital malformations development in case of maternal type 1 diabetes mellitus (%) 50 <6.9< – 8.5 >8.6>8.6>10.0>10.0>14.4> – 1% 4 – 5% 10 – 15% 20%20% 40%40% HbA1c (%)

9 Decompensated diabetes mellitus and it’s influence on foetus’ and newborn’s development Foetus abnormalitiesFoetus abnormalities 20-40% of cases - anencephalia, - ventricular septal defect, atrial septal defect, - Fallot’s tetrad, - atresia of anus and rectum Diabetic fetopathyDiabetic fetopathy 75-85% of cases - macrosomia, - neonatal hypoglycemia, - hypocalcemia, hypomagnesemia, - polycythemia,hyperbilirubinemi a, - cardiomyopathy, - immaturity of lung and central nervous system - hepatomegaly

10 Components that define the risk of diabetes complications development: fasting glucose (a), postprandial hyperglycemia (b), glucose variability (c) Monnier L. et al. Horm Metab Res 2007; 39: 683 – 686 b c b а с Fasting glucose Oxidative stress activation Glucose variability Risk of complications PPG

11 Glucose monitoring: new possibilities and standarts ? Glucose monitoring and glucometr usage Glucose monitoring trough subcutaneous sensor Glucose monitoring with alarming sensir signals Only adequate monitoring of glucose level predetermine the optimal insulin therapy

12 Glycemic profile during normal pregnancy

13 Glycemic control in woman with type 1 diabetes,НbA1c 6, 7% Insulin therapy: Detemir TID (7+6+8 IU), Aspart QID (6-8 IU)

14 Hypoglycemia: hemodinamic effects hypoglycemia ↑ cardiac output ↑ periferal systolic BP ↓ central BP ↑ coagulability B.M. Frier, 2010 Catecholamine Acetylcholone Cortisole Hypercalcemia Hypomagnesemia

15 imperfection of multiple daily injections regimen : Non-physiological method (subcutaneous insulin depot)Non-physiological method (subcutaneous insulin depot) Inadequate speed of insulin action during carbohydrates, proteins consumtionInadequate speed of insulin action during carbohydrates, proteins consumtion Absence of physiologically acting basal insulinAbsence of physiologically acting basal insulin Absence of possibility to inject insulin before every mealAbsence of possibility to inject insulin before every meal

16 Advantages of insulin pump Maximal imitation of physyiological insulin injection – continuous preset infusion of insulin (basal) and bolus injection before every meal Only insulin of shot/ultrashot usage –Small doses of insulin with possibility to inject 0,1 – 0,025 IU –Absence of insulin depot in subcutaneous tissue –Predictable insulin pharmacodynamic –Possibility to stop infusion in case of hypoglycemia – Different types of boluses

17 Analysis of diabetes compensation degree, features of pregnancy and delivery course in women with type 1 diabetes mellitus was performed on insulin pump therapy (CSII) - n=90 on multip;e daily injection regimen (MDI) - n= 90 For all women continuous glucose monitoring was performed (during I,II, III trimesters)

18 Continuous glucose monitoring systems ( CGMS, CGM Paradigm Real-time Medtronic ) and insulin pumps from Medtronic and Accu-Chek companies

19 Glucose level in patients on MDI and CSII MDI CSII Avg. glucose Glucose after breakfast Glucose after lunch Glucose after dinner

20 HbA1c during I, II and III trimester of pregnancy on MDI and CSII With high degree of correlation between HbA1c and boluses frequency (r 0,57) MDI CSII beforeI trimesterII trimesterIII trimester

21 Glucose variability measuremrnts: SD (а), MOOD (б), CONGA (в) on CSII and MDI

22 Features of pregnancy course on MDI and CSII MDICSII p n=90 Time of gestosis manifestation34,3±0,431±0,6<0,0001 Frquency of severe gestosis. %17,99,6 Sys BP134±2,6117±2,3<0,001 Dias BP84±1,572,1±1,34<0,001 GFR, III trimester of pregnancy96,9±3,6107,7±2,3<0,05 Daily protein loss, III trimester of pregnancy 0,5±0,10,09±0,1<0,0001 Delivery time36,7±0,337,9±0,3<0,01 Frequency of cesarean section %87,977,6 Frequency of urgent cesarean section% 13,512,8

23 Hemostasis system features on MDI and CSII MDI CSII p n=65 Degree of erythrocytes aggregation 76,9±2,6974,6±3,4 Rate of aggregation 76,4±4,0172,2±4,2 D-dimer level 616±60416±53,9<0,01 Fibrinogen level 3,82±0,143,68±0,13 Antitрrombin III level 105,8±4,695±4,3 Von Willebrand factor level 2,34±0,21,51±0,16<0,01 With high degree of correlation between glucose variability and fibrinogen level(r 0,6)

24 Insulin demand during delivery decreases in 70-80% risk of maternal and newborn hypoglycemia is very high Visual control of glucose level during delivery helps to program doses of insulin with maximal precision

25 Neonatal hypoglycemia Increasing of maternal glucose level during pregnancy more than 6,7 mmol/l stimulates foetus’ insulin production, that can lead to hypoglycemia after the delivery Frequency of neonatal hypoglycemia – 64% and it is not depend on macrosomia presence* PEDIATRICS Vol. 103 No. 4 April 1999, pp *Nationwide prospective study in the Netherlands BMJ 2004;328:915

26 Real-time glucose monitoring Planned cesarean section (10.30 am) Patient with type 1 diabetes

27 Real-time glucose monitoring during delivery in woman with type 1 diabetes (extraction of newborn at 6 pm)

28 Pregnancy and delivery outcomes in women with type 1 dibetes mellitus on MDI and CSII MDI CSIIp n=90 Newborn’s glycemia during delivery (mmol/l) 3,70±0,193,3±0,18 Newborn’s glycemia after 2 hours after delivery (mmol/l)2,30±0,102,9±0,11<0,01 Newborn’s weght (gr) 3428±109,4 delivery time 36,7±0,3 3425±94,7 delivery time 37,9±0,3 Diabetic fetopathy frequency %77,4%46,2% Frequency of congenital malformations % 3,4%1,6%

29 Real-time glucose monitoring, continuous subcutaneous insulin infusion optimise glucose control in patients with type 1 diabetes during pregnancy, decrease the risk of maternal and newborn’ morbidity, New technologies usage in diabetes patients during pregnancy must be the standard of care


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