during pregnancy, induced by pregnacy Fasting hyperglycemia ( < 105 class A1, > 105 class A2) Fasting hyperglycemia, macrosomia, fetal anomalies not increase Class A2 unexplained stillbirth, hypertension and increasing of CS MACROSOMIA Maternal hyperglycemia, caused fetal hyperinsulinemia, excessive fat deposition, anthropometrically different from LAG infant \shoulder dystocia, cephalopelvic disproportion Neonatal hyperinsulinemia, hypoglycemia SCREENING Performed between 24 – 28 weeks of gest in women not known to have glucose intoleran Using 50 g oral glucose, if value > 140 mg/dl, then are test with 100 g oral glucose Dx: with 75 g 2 hours or 100 g 3 hours oral glucose tolerance test after an overnight fast DIAGNOSIS Dx of GD using 100 g oral glucose Plasma glucose Timing (1979) (1982) Fasting 105 95 1 hour 190 180 2 hours 165 155 3 hours 145 140 MANAGEMENT Insulin therapy recommended when standard diet therapy does not maintain: the fasting plasma glucose < 105 mg/dl, 2 hours PP < 120 mg/dl Or capillary glucose level < 95 mg/dl fasting (1997) Or nutritional management fails maintain fasting blood glucose < 95 mg/dl, or 2 hours PP blood glucose level < 120 mg/dl DIET The goal of diet therapy: 1) provide nutrient for the mother and fetus, 2) control glucose level, and 3) prevent starvation ketosis Significant caloric restriction (1200-1800 kcal/day) has been shown to reduce hyperglycemia and and plasma triglyceride with no increse in ketonuria. Although maternal weight gain and macroso may be decrease, the safety has not been established OBSTETRICAL MANAGEMENT GD who do not require insulin seldom require early delivery or intervention There is no consessus antepartum fetal testing necessary Elective induction to curtail fetal growth and prevent shoulder dystocia controversial If require insulin, receive antepartum fetal testing and managed as overt diabetes POSTPARTUM CARE 50% women with GD developing overt diabetes within 20 years Should undergo glucose evaluation 6 – 12 weeks after delivery A 75 g oral glucose tolerance test is recommended Fasting < 115 mg/dl (no diabetes), < 140 mg/dl (impaired glucose tolerance), > 140 mg/dl (diabetes) PREGESTATIONAL OVERT DIABETES Known to have diabetes before pregnancy Using White classification, the end organ derangement, involving eyes, kidney and heart, have significant effects on pregnancy Dx ketoacidosis or random plasma glucose > 200 mg/dl, or fasting plasma glucose > 126 mg/dl Embrio, fetus and mother can experiences complication WHITE CLASSIFICATION OF DIABETIC PREGNANCIES A. GTT abnormal, no symptoms, euglycemia with appropriate diet without insulin B. Adult onset (age >=20), short duration (<10 yrs) C. Relatively young onset (age 10-19) or relatively long duration (10-19 yrs) D. Very young onset (age < 10 yrs) or very long duration (>= 20 yrs) or evidence of background retinopathy. Continue F. Renal disease R. Proliferative retinopathy RF. Both renal disease and proliferative retinopathy G. Multiple reproductive failure (habitual abortion and/stillbirths) H. Arteriosclerotic heart disease T. Pregnancy after renal transplantation EFFECTS ON THE FETUS- NEONATE Abortion: Initial glycohemoglobin A1 >12%. Malformation: incidence 5-10%, is not associated with chromosomal abnormalities, poorly controle preconception and early in pregnancy, lower glycosylated hemoglobin values. Unexplained fetal demise: no factor, no plac insuf, growth restiction, oligohydramnion Hypothesis: hyperglycemia mediated chronic aberration in transport of oxygen and fetal metab Macrosomia, hydramnios (fetal polyuria), preterm NEONATAL EFFECTS Respiratory distress: lung maturation delaye Hypoglycemia: hyperplasia beta islet cell Hypocalcemia: cause has not been explain Hyperbilirubinemia: pathogenesis uncertain Cardiac hypertrophy: macrosomia, hyperinsulinemia Inheritance of diabetes: if both parents has diabetes, the risk 20%. MATERNAL COMPLICATION Preeclampsia: Ketoacidosis Infections Diabetic nephropathy Diabetic retinopathy Diabetic neuropathy MANAGEMENT Preconception: prevent early pregnancy loss and congenital marformation, preconceptional glucose control by insulin preprandial glucose level 70-100 mg/dl, postprandial <140 and < 120 at 1 and 2 hours respectively, folate 400 ug given preconceptional and during early pregnancy Continue First trimester: Monitoring of glucose control, hospitalized during firs trim to glucose control program, education and to assess the extent of vacular complication, total caloric intake 30-35 kcal/kg, given as three meals and three snacks daily intake of: 55 % CH, 20% protein, and 25 % fat, less than 10% saturated fat. Obese may be manage with lower caloric as long as weight loss and ketonuria are avoided Continue Second trim: US at 18-20 weeks to detect NTD Third trim: Weekly visit to monitor glucose control and evaluate for PE, serial US at 3-4 weeks interval to evaluate exessive and insufficiency growth and AF volume Hospitalized for poorly control and hypetension Continue Fetal suveillance program begin between 26-32 weeks depend on clinical risk factor for fetal death, ante partum testing at least weekly DELIVERY Delivery is planned after 38 weeks Class B and C recommended CS to avoid traumatic birth More advanced diabetes, with vascular disease CS Labor induction when fetus not large and cervix favorable