Diabetes Mellitus

Liu Wei Department of Ob & Gy Ren Ji hospital

General Consideration
Diabetes mellitus complicating pregnancy Diabetes mellitus is diagnosed before this pregnancy Gestational diabetes mellitus (GDM) Carbohydrate intolerance of varying degree of severity with onset or first recognition during pregnancy. Incidence 1%-2% (our country); 1%-10% (other countries)

The impact of pregnancy on DM

1. 2. 1. 2. 3. The first half of pregnancy Relative insulin sensitivity: insulin requirement Morning sickness: hypoglycemia The latter half of pregnancy Increased insulin resistance: placental hormones Intakeintrapartum: hypoglycemia Postpartum: placental hormoneshypoglycemia

Effects on mother and fetus

1. 2. 3. 4. 5. 6. Effects on monther Spontaneous abortion Preeclampsia Infection: urinary infection Polyhydramnios () Fetal macrosomia(), dystocia() Ketoacidosis ()

Effects on mother and fetus

1. 2. 3. 4. 1. 2. Effects on fetus Fetal macrosomia Fetal growth restriction Premature labor Fetal malformation Effects on infant RDS Hypoglycemia

Diagnosis
Diabetes mellitus complicating pregnancy Already diagnosed or easy to be diagnosed GDM 1. History Family history of DM, urine glucose repeatedly (+), recurrent abortion or fetal death, candidal vaginitis()

Diagnosis
2. Lab examination 1) fasting plasma glucose(): 5.8mmol/L twice or more 2) glucose screening test (50g glucose) 1 hr postchallenge 7.8mmol/L oral glucose tolerance test, OGTT

Diagnosis
3) OGTT (75g glucose) Any two or more plasma glucose values exceed the following thresholds GDM 1 hr postchallenge: 5.6 mmol/L 2 hr postchallenge: 10.5 mmol/L 3 hr postchallenge: 9.2 mmol/L 4 hr postchallenge: 8.0 mmol/L One value exceed the threshold abnormal glucose tolerance

Classification
Whites classification of DM in pregnancy
A1: gestational diabetes not requiring insulin A2: gestational diabetes requiring insulin B: onset at 20 years of age or duration of <10 years C: onset at 10 to 19 years of age or duration of 20 years or any onset or duration but with background retinopathy or hypertension only F: nephropathy (>500mg proteinuria per day at <20 weeks of pregnancy) H: arterioscleroticheart disease, clinically evident R: proliferative diabetic retinopathy or vitreous hemorrhage T: history of renal transplant

Treatment

1. 2.

3. 4. 5.

Conception should be prevented in the patients with class D or F or R DM Diet management Meal plans: individualized Calories: 30 to 35 cal/kg (ideal body weight, IBW) per day. carbohydrates 40%-45%, protein 20%30%, fat 30% Concentrated sweets: forbidden Six meals per day, 2 to 3 hr apart The adequacy of calories intake may be assessed by using daily fasting urinary ketone levels

Treatment
1. 2. 3. Medication (insulin) 2g glucose 1 u insulin Early pregnancy: insulin Late pregnancy: insulin 50%-100%, peaking at 32 to 33 weeks 4. Postpartum: insulin1/3-1/2 5. Ketoacidosis: low-dose insulin, 0.1U/kg.h

Treatment
1) 2) 3) 4) Maternal antepartum care: plasma glucose, renal function, blood pressure Fetal surveillance: development of fetus, placental function, maturity of fetus Termination of pregnancy With other obstetric problems CS Keeping electrolytical balance Intrapartum: preventing hypoglycemia Postpartum: reducing the dose of insulin, preventing infection

END