-

33

3 .

3 .
4

 -

V/S: temp 37.0 oc, PR 20 /min, HR 80/min, BP 120/70 mmHg

70 . 160 . 70 .
GA: a woman with good conscious, look obesity
HEENT: no pale conjunctiva, no icteric sclera,
thyroid glands : not enlarged
Heart: normal S1S2, no murmur
Lungs: normal, on adventitious sound
Abdomen: no hepatosplenomegaly, no palpable mass,
uterine fundal height cant be palpated.

 -
( )
Extremities: no edema
Neurological signs: intact all

Hct
Thalassemia screening :
Blood group:
Urine albumin/glucose:
Serology: Anti-HIV
VDRL:
HBsAg:

34 g%,
negative
A, Rh positive
negative 2+
negative,
non reactive
negative


1.

2.

3.

1.

33

70 . 160 . 70
BMI 27.34 kg/m2
3 .
4

look obesity ,uterine fundal height cant be

palpated.

2.

Problem lists
Overweight
BMI 27.34 kg/m2
Look obesity

Gestational Diabetes mellitus

History of first degree relative of Diabetes mellitus
Urine glucose 2+

Suspected IUGR
Uterine fundal height cant be palpated at GA ~12
weeks

Problem 1: Overweight

Complications
Maternal Morbidity
Preeclampsia
Perinatal mortality/morbidity

Maternal Morbidity

Maternal morbidity

Preeclampsia
O'Brien and associates (2003) found that the
preeclampsia risk doubled with each 5 to 7
kg/m2 increase in prepregnancy BMI.

Perinatal morbidity
Rasmussen and associates (2008) found
increased incidence of neural-tube defects
1.2-fold increased risks in overweight
1.7-fold increased risks in obesity
3.1-fold increased risks in severely obese women
*compared with controls of normal weight

Perinatal morbidity
Two- to threefold increased incidence in heart
defects, and multiple anomalies in overweight
women

Perinatal mortality
Increased incidence of otherwise inexplicable
late-pregnancy stillbirths has been associated
with obesity
1.6-fold increase in the stillbirth rate in
women whose BMI was 25 to 29.9 kg/m2

Problem 2: GDM

Gestational diabetes
gestational = diabetes is induced by
pregnancy
Because of exaggerated physiological changes
in glucose metabolism
Gestational diabetes is type 2 diabetes unmasked
or discovered during pregnancy.

 Definition :GDM
: Pre-existing DM with pregnanacy

Maternal and Fetal Effects

Unlike in women with overt diabetes, fetal
anomalies are not increased

Macrosomia
Defined variably by different authors
The American College of Obstetricians and
Gynecologists (2000) defines macrosomic infants
as those whose birth weight exceeds 4,500 g.

The perinatal goal is avoidance of difficult

delivery due to macrosomia, with concomitant
birth trauma associated with shoulder
dystocia.

3.

Risk factor screening

Pregnant women
Evaluate risk factors
Low risk

Need not to screen

Moderate risk

50gm.GCT at GA
24-28 wk.

High risk
50gm.GCT at 1st ANC
and GA 24-28 wk. (if 1st
screening test < 140)

High risk GDM

BMI 27 kg/m2
Age 30 yr.
Previous macrosomia (BW4)
Previous GDM
Family history of diabetes (first-degree
relative with diabetes)
Previous unexplained stillbirth
Previous unexplained malformation

 screening
diagnosis

xerox

Two-step approach

GDM risk
assessment at
the first prenatal
visit

50gm.GCT 140
mg/dL

100 gm.OGTT

50-gram glucose challenge

test

glucose 50

1

Plasma sugar

100 grams Oral Glucose

Tolerance Test
The test should be performed in the
morning
After an overnight fast of at least 8 hr. but not
more than 14 hr.
After at least 3 days of unrestricted diet (150
gm CHO/day) and physical activity
The subject should remain seated and should
not smoke during the test

100 grams Oral Glucose

Tolerance Test
Sample
method

Whole blood
SomogyiNelson
(Unrounded)

Whole blood
SomogyiNelson
(Rounded off)

Plasma
(Carpenter
and Coustan
Adaptation)

Plasma
(National
Diabetes Data
Group)

fasting

90

90

95

105

1 hr.

165

165

180

190

2 hr.

143

145

155

165

3 hr.

127

125

140

145

Classification
Class

Onset

Fasting
Plasma
Glucose

2-hr Postpandrial
Glucose

Therapy

A1

Gestation

<105 mg/dl

And <120 mg/dl

Diet

A2

Gestation

>105 mg/dl

And/or 120 mg/dl

Insulin

Class

Age of
Onset

Duration
(yr)

Vascular Disease

Therapy

> 20

< 10

None

Insulin

10 19

10 19

None

Insulin

< 10

20

Benign Retinopathy

Insulin

Any

Any

Nephropathy

Insulin

Any

Any

PDR

Insulin

Any

Any

Heart

Insulin

Evaluate diabetes-related
complications
Diabetic retinopathy
Diabetic nephropathy

Diabetic retinopathy

Diabetic nephropathy

 2 slide
copy paste

CASE DISCUSSION

18

USG

18

50 gm GCT = 205 mg/dl

100 gm OGTT = (FBS) 140, (1 hr) 210, (2 hr)
190, (3 hr) 160 mg/dl
Gestational diabetes (GDM) A2


18
USG 18

50 gm GCT = 205 mg/dl

100gm OGTT=
FBS 140, 1hr 210, 2hr 190, 3hr 160 mg/dl
gestational diabetes (GDM)


1. GDM

2. GDM

3.


size

4. GDM

First trimester
History taking, physical examinations
Risk assessment
Dietary supplement
Iron
Folic

Patient education
HbA1C

Second trimester
History taking
Serum screening at GA 16-20 wks
U/S at GA 18-20 wks
Neural tube defect and other anomalies

Self-monitoring blood sugar

Premeal
2-hr postpandial

Monitor fetal growth

Repeat 100g OGTT at GA 24-28 wks

First ANC (GA 18 wk)

Give information
Risk assessment
BMI, BP, Urine protein/sugar
Lab I
Ultrasound

Confirm GA
structural anomalies
anatomical examination of
the four chamber view of the
fetal heart plus outflow tracts

Serum screening
Quadruple test ( AFP, hCG, uE3,
inhibin-A )

Counseling
Dietary advice
History and PE review diabetic
complication

Neuropathy
Nephropathy
Vasculopathy
Retinal assessment

Self-monitoring blood sugar

Premeal
2-hr PP
Keep 60-105, 80-120 mg/dL

update

Diet
Total caloric intake 30-35 kcal/kg ideal body
weight/day
Underweight = 40 kcal/kg ideal body weight/day
Ideal body weight > 120% = 24 kcal/kg ideal body
weight/day

3 meal, 3 snacks daily

Dietary composition :
55% carbohydrate, 20% protein, 25% fat (saturated fat
<10% )

Diet
70 . 160
BMI 27.34 kg/m2
Ideal body weight
= (160-100) [10%(160-100)]
= 54
% of ideal body weight
= 70/54 * 100
= 129

1,269 kcal/day
= 24*54
= 1,269 kcal/day

Third trimester
Routine antenatal care
Control blood sugar
Complication monitoring
Pregnancy-induced hypertension

Ultrasonography
Fetal growth
Amniotic fluid

Antepartum fetal monitoring

Fetal movement count, NST, BPP starting at GA 32-34 wks

Doppler ultrasonography of umbilical arteries

For pregnancy with vascular complication and poor fetal growth

Intrapartum
NPO
Blood sugar premeal
Choosing IV fluid

Monitoring blood sugar q 1-2 hr

Inform neonatologist
Considering dystocia if vaginal delivery

Timing and route of delivery

Try vaginal delivery at GA 38 wks
C/S if indicated by obstetrics indications
Hospitalization for controlling blood sugar
with endocrinologist 1 week prior to delivery

Postpartum care

Postpartum care
1. Observe patient for
Postpartum hemorrhage
Infection

2. Controlling of blood sugar

GDMA2

Stop insulin 2 3 days after delivery

Overt DM

Regular insulin 2 3 days adjusted with glucose level,

monitoring every 4 hours

Contraception
Combine oral pill
Low-dose OCP is recommended if no
contraindication

Progesterone-only oral or parenteral

No effect to cardiovascular system or
carbohydrate metabolism

Intrauterine device
Contraindicated because of risk of pelvic infection

Follow up
Glucose evaluation 6 10 weeks after delivery
75-g OGTT
If normal > reassess at a minimum of 3-year
intervals

5. GDM

Antepartum
Fetal complication
Maternal complications

Fetal complication

Miscarriage
early abortion is associated with poor glycemic control
HbA1c concentrations were > 12 percent or
persistent preprandial glucose concentrations were > 120 mg/dL

Preterm Delivery
the incidence of preterm birth was 28 percent
a fivefold increase compared with that of their normal population
Related with poor control GDM or GDM with hypertension

Fetal malformations
risk of fetal malformations is related with poorly controlled diabetes during both
preconceptionally and early in pregnancy and HbA1c > 10%
concluded that the etiology was multifactorial
M/C : CVS ( VSD ) , Skeletal system ( Caudal regression syndrome ) ,
neurovascular system ( NTD )
Diabetes is not associated with increased risk for fetal chromosomal
abnormalities

Macrosomia
infants whose birthweight exceeds 4000 g. or large-for-gestational age
The incidence of macrosomia rises when mean maternal blood
glucose concentrations > 130 mg/dL

Maternal hyperglycemia

fetal hyperinsulinemia

excessive fat deposition on the shoulders and trunk, which predisposes

them to shoulder dystocia or cesarean delivery

IUGR
whose mothers are diabetic with vascular complication
uteroplacental insufficiency
IUGR
IUGR<<macrosomia

Unexplained Fetal Demise

Unexplained
These infants are typically large-for-gestational age and die before labor,
usually at 35 weeks or later
hyperglycemia-mediated chronic aberrations in transport of oxygen and
fetal metabolites
maternal hyperglycemia>> osmotically induced villous edema
>>impaired fetal oxygen transport
increased frequency in
severe preeclampsia
vascular complications
Polyhydramnios

Polyhydramnios
fetal hyperglycemia causes polyuria
amnionic fluid index related with amnionic fluid glucose concentration

Maternal complications

Diabetic Nephropathy
Cause end-stage renal disease in is nearly 30 percent in
individuals with type 1 diabetes and ranges from 4 to 20 percent in those
with type 2 diabetes.
end-stage renal failure at a mean of 6 years after dm

the incidence of nephropathy in individuals with type 1 diabetes

decline with glucose control
a 25-percent decrease in the rate of nephropathy for each 10percent decrease in hemoglobin A1c levels.

Diabetic Nephropathy
nephropathy in type 1 disease begins with
microalbuminuria30 to 300 mg/24 h of albumin
After another 5 to 10 years, overt proteinuriamore than 300 mg/24 h
develops in patients destined to have end-stage renal disease

Diabetic Nephropathy
pregnant women with diabetes already have renal involvement
are at significantly increased risk for preeclampsia and for indicated
preterm delivery
no long-term sequelae of pregnancy on diabetic nephropathy
The incidence of either micro- or macroalbuminuria was not
increased in women with prior pregnancies compared with that of
nulliparas
end-stage renal failure at a mean of 6 years after dm

Diabetic retinopathy
Its prevalence is related to duration of diabetes.
first and most common visible lesions : nonproliferative retinopathy
severity
preproliferative retinopathy
pregnancy worsened proliferative retinopathy
laser photocoagulation and good glycemic control during pregnancy
decrease effects of pregnancy

Diabetic Neuropathy
Peripheral symmetrical sensorimotor diabetic neuropathy is
uncommon in pregnant women.
M/C : diabetic gastropathy in pregnancy >> nausea and vomiting >>
nutritional problems, and difficulty with glucose control.
Treatment : metoclopramide and H2-receptor antagonists

Diabetic Ketoacidosis
1-3 percent of diabetic pregnancies
The incidence of fetal loss is about 20 percent with ketoacidosis
Pregnant women usually have ketoacidosis with lower blood
glucose levels than when nonpregnant

Preeclampsia
risk factors for preeclampsia include any vascular complications
Hypertension is the major complication that most often forces
preterm delivery in diabetic women.
the perinatal mortality rate is increased 20-fold for preeclamptic
women with diabetes compared with that for those who remain
normotensive.

Infections
Almost all types of infections are increased in diabetic pregnancies.
80% percent of type 1 diabetes develop at least one infection
during pregnancy compared to 25 % without diabetes
wound complications after cesarean delivery x2-3 times
antepartum pyelonephritis xx 4 times

Common infections
include candida vulvovaginitis,
urinary infections,
respiratory tract infections,
puerperal pelvic infections

unity

slide slide

 GDM

Maternal risks
Birth asphyxia
Birth injury
Respiratory distress
Cesarean section

Fetal macrosomia
Maternal risks:
Protracted or arrested labor
Operative vaginal delivery
Cesarean delivery
Genital tract lacerations
Postpartum hemorrhage
Uterine rupture

Birth asphyxia
Results from compromised placental or
pulmonary gas exchange
Lead to hypoxia and hypercarbia
Fetal heart rate abnormalities,
low Apgar scores

Birth Injury

CPD
Shoulder dystocia
Brachial plexus injury,
Clavicular or humeral fractures,
Perinatal asphyxia,
Cephalohematoma,
Subdural hemorrhage,
Facial palsy

Respiratory distress
RDS
Premature delivery
Neonatal hyperinsulinemia delay surfactant
synthesis

Other causes:
TTN - C/S contributing factor

Cesarean section
Not an indication
Double rate due to macrosomia

 GDM

Neonatal hypoglycemia
Neonatal hypocalcemia

Hypomagnesemia

Neonatal hyperbillirubinemia
Cardiac hypertrophy
Polycythemia
Future development
Inheritance of diabetes

Neonatal hypoglycemia
Blood glucose levels < 40 mg/dL
Interruption of the intrauterine glucose supply
Persistent hyperinsulinemia

Neonatal hypoglycemia (cont.)

Jitteriness and/or tremors
Hypotonia
Change in level of consciousness (irritability,
lethargy, or stupor)
Apnea, bradycardia, and/or cyanosis
Tachypnea
Poor suck or poor feeding
Weak or high-pitched cry
Hypothermia
Seizures

Neonatal hypocalcemia
Total serum calcium concentration <7 mg/dL
or ionized calcium < 4 mg/dL
S/S : jitteriness, lethargy, apnea, tachypnea,
or seizures, respiratory distress, or suspected
infection.

Hypomagnesemia
< 1.5 mg/dL
Within the first three days after birth
Caused by increased urinary loss secondary to
diabetes
usually is transient and asymptomatic

Neonatal hyperbillirubinemia
most of these infants were premature

Immature hepatic bilirubin conjugation

enzymes

Cardiac hypertrophy
Caused by fetal hyperinsulinemia
Occur in mothers with poor glycemic control
Infants often are asymptomatic, but 5 to 10 percent
have respiratory distress or signs of poor cardiac
output or heart failure.

Polycythemia
Hematocrit of more than 65 %
Increased erythropoietin concentrations caused
by chronic fetal hypoxemia

LONG-TERM OUTCOME
Postnatal metabolic complications
Neurodevelopmental outcome
poorer intellectual performance
psychomotor development

6.

Antenatal care



insulin

Diet control
Goals :
provide necessary nutrients for mother and fetus
control glucose level
prevent starvation ketosis

CHO : Protein : Lipid = 55 : 20 : 25

4 /// 25/30/30/15

Ideal body weight = (Ht. - 100) (10% )

Exercise
Cardiovascular conditioning aerobic exercise

(upper trunk exercise)

20-30 23

insulin

Goal blood sugar

Goal BS

mg/dl

FBS

60-90

Before
lunch/dinner/snack
After meal 1 hr

60-105
140

After meal 2 hr

120

From 2-6 a.m.

60-90

 insulin

1.
2.

2-3 insulin
( GDM 30
insulin
)

 insulin
( )

insulin

Short acting
lispro
Insulin aspart
Regular insulin

< 0.25
<0.25
0.5-1

0.5-1.5
0.5-1.5
2-3

3-4
3-4
4-6

Intermediate acting
NPH
Lente

2-4
3-4

6-10
6-12

10-16
12-18

6-8

Dual

18-20

Long acting (
ultralente )
Combination

 insulin
Total daily requirement
1st trimester : 0.8 U/kg/day
2nd trimester : 0.7 U/kg/day
3rd trimester : 0.9 U/kg/day

2/3

NPH 2 : RI 1
1/3

NPH 1 : RI 1

ketone

ketoacidosis

Ultrasound 4-6
Fetal
movement
NST

28
BPP NST non
reactive
Lung maturity

(1-2 ) ( 2 )
34

39 39

Intrapartum

GA 38 wks ( )

-sympathomimetic (tocolytic)
ketoacidosis MgSO4
severe
preeclampsia


Regular insulin 0.5-2 U/hr glucose
5-10 g/hr
RI 8-10 U 5% D/NSS 100-120 ml/hr
DTX 1-4 . 70-120 mg/dl
insulin 5% D/NSS
. insulin
subcutaneous
insulin

LOW-DOSE INSULIN INFUSION

FOR THE INTRAPARTUM PERIOD
Blood glucose
(mg/dl)

Insulin Dosage
(U/hr)

Fluids
(125ml/hr)

< 100
100 - 140
141 - 180
181 - 220
> 220

0
1.0
1.5
2.0
2.5

D5 lactated Ringer
D5 lactated Ringer
Normal saline
Normal saline
Normal saline
From ACOG (1994)

Postpartum care

GDMA2 insulin
PPH, infection
: , ,
10 50%

75gOGTT 6-12

Table : postpartum evaluation

2-hour, 75-g OGTT (mg/dL)

Time tested

No diabetes

Impaired
glucose
tolerance

Fasting

< 115

< 140

140

, 1, 1 hr

All < 200

1 value 200

1 value 200

2 hr

< 140

140-199

200

Diabetes




insulin
( )

calories 500 kcal/d

Hypoglycemia

RDS
1 . 4
24 . < 40 mg/dl


: glucose
tolerance

(high risk pregnancy).

.
: , 2551 ( 2)
. .
, : .. , 2535 ( 4)
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4)
. 2554.

. : , 2554.


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