Presentation on theme: "Medical Complication In Pregnancy Diabetes. At the beginning of the 20th century, diabetic women suffered from infetility, and the rare women achieving."— Presentation transcript:
At the beginning of the 20th century, diabetic women suffered from infetility, and the rare women achieving pregnancy faced a poor prognosis. Maternal death was a real threat,and perinatal survival a more 40 percent.
The availability of insulin since 1922, restored fertility and virtually abolished maternal mortality. At the same time, perinatal survival did not change appreciatably. Since 1949 White Classification was developed, permitted individualized timing and mode of delivery, then perinatal mortality was reduced (nearly equivalent to that observed in normal pregnancies.)
I. Classification Type I Diabetes Mellitus ----insulin-dependent ----immune-mediated and developed in genetically susceptible persons ----concordance rate for diabetes in monozygous twins is less than 50%
Type II diabetes ----noninsulin-dependent ----no HLA association ----familial occurrence ----concordance rate for diabetes in monozygous twins is 100%
Gestational Diabetes Mellitus Diabetes is the most common medical complication of pregnancy. Patient can be seperated into those diagnosed during pregnancy It is estimated that 90 percent of all pregnacies complicated by diabetes are due to gestational diabetes Approximately 15 percent of women with gestational diabetes will exibit fasting hyperglycemia
Classification during pregnancy Table 1 gives a classification recommended by the American College of Obstetricians and Gynecologists in 1986.
classonset Fasting plasma glucose 2-hour postprandial glucose therapy A1Gestational<105mg/dl<120mg/dlDiet A2Gestational>105mg/dl>120mg/dlInsulin Class Age of onset(yr) Duration(yr) Vascular disease Therapy B>20<10NoneInsulin C10-19 NoneInsulin D <10>20 Benign retinopathy Insulin FAny nephropathy Insulin R Any Proliferative retinopathy Insulin HAny HeartInsulin T Any Transplantation of kianey Insulin
II. Diagnosis (I)Diagnosis of Overt Diabetes during Pregnancy i.presence of classical signs and symptoms (such as polydipsia, polyuria, unexplained weight loss) ii.a random plasma glucose level greater than 200mg/dl or fasting glucose>= 126mg/dl iii.presence of ketoacidosis
(II)Diagnosis of gestational diabetes i.High risk factors: a familial history of diabetes, given birth to large infants, unexplained fetal losses, obesity ii.Screaning 50g oral glucose challenge test: A value of 140mg/dl(7.8mmol/l)or higher will identify 80% of all women with gestational diabetes
iii.Diagnosis criteria If the results of 50g oral glucose challenge test exceed 7.8mmol/l, a diagnostic 100g oral glucose tolerance test is performed.
Table 2 American college of Obstetricians and Gynecologists 1994 Criteria for Diagnosis of GestationalDiabetes Using 100g of Glucose Taken Orally Timing of Measure ment Plasma Glucose National diabetes Data Group(1979) Carpenter and Coustan(1982) Fasting105mg/dl(5.6mmol/l)95 1hour190mg/dl(10.5mmol/l)180 2hour165mg/dl(9.2mmol/l)155 3hour145mg/dl(8.0mmol/l)140
III.Maternal and Fetal Effects I)Maternal Effects i.increasing abortion rate ii.increasing incidence of Pregnancy- Induced Hypertension(PIH) iii.tend to be infection iv.polyhydramnios v.Macrosomia vi.Be susceptible to ketoacidosis
(II)perinatal Effects i.Macrosomia incidence is as high as 25-40% ii.Intrauterine Growth Retardation (restriction) iii.Preterm Labor iv.Fetal Anomalies v.Stillbirth,Fetal death vi.Congenital Malformations
IV.Management (I)Diet Nutritional counseling is a cornerstone in management The goals of such therapy are: i.To provide the necessary nutrients for the mother and fetus ii.To control glucose level iii.To prevent starvation ketosis
Table 3 Recommend Daily Caloric Intake and Pregnancy Weight Grain in Women with Gestational Diabetes with and without Concomitant Insulin Therapy Current Weight in Relation to Ideal Body Weight Daily Caloric Intake(kcal/kg) Recommend Pregnancy Weight Grain <80-90%36-4028-40 80-1203025-35 120-1502415-25 >15012-1815-25
(II)Insulin therapy i.Indication---Insulin therapy is usually recommend when standard dietary management does not consistantly maintain the fasting plasma glucose at less than 105mg/dl or the 2-hour postprandial plasma glucose at less than 120mg/dl ii.At the beginning, a total dose of 20-30 units given once daily, before breakfast. The total dose is usually divided into two thirds intermediate-acting insulin and a third short-acting insulin
(III)Preconception i.Control preconception glucose to optimal level(by using insulin) ii.Hemoglobin AIc measurement
IV.Prenatal Care (I)First trimester i.Careful monitoring of glucose control is essential to management ii.Diet:Total caloric intake of 30- 35kcal/kg of ideal body weight
(II)Second trimester i.Maternal serum AFP ii.Ultrasonoscan(at 18-20w) to detect neural-tube defects and other anomalies (III)Third trimester i.Weekly visits to monitor glucose control and to evaluate for preeclampsia ii.Serial ultrasonography to evaluate fetal growth and amnionic fluid volume iii.Other fetal surveillance tests iv.Accept hospitalization from 34w until delivery
V.Delivery (I)Timing of delivery i.Women with gestational diabetes who do not require insulin ii.Women with gestational diabetes who require insulin iii.Overt diabetes women iv.Others v.If severe hypertantion,preeclampsia or other complications develop,delivery is carried out even though the ratio is less than 2.0 L/S
(II)Mode of delivery i.In gneral, women with GDM(who does not requre insulin), the way of delivery is spontaneous labor ii.Women with sonographic diagnosis of fetal macrosomia, elective induction of labor or cesarean section to prevent shouder dystocia iii.In the overtly diabetic women(besides class A), cesarean delivery has commonly been used to avoid traumatic birth of a large infant, or to avoid maternal or fetal complication due to more advanced diabetes.Especially for those with vascular diseases
(III)Control the blood glucose Maintain a near normal glycemia level Reduce the dose of insulin on the day of delivery, and ½ postpartum (IV)Prevention of infection
(V)Neonatal care i.detecting of blood glucose, plasma calcium, plasma bilirubin ii.Be care for a preterm neonatal iii.To find respiratory distress and treatment iv.Prevention of postpartun hemorrhge