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
• The first half of pregnancy
• Relative insulin sensitivity: insulin requirement↓
• Morning sickness: hypoglycemia
• The latter half of pregnancy
• Increased insulin resistance: placental hormones↑
• Intake↓intrapartum: hypoglycemia
• Postpartum: placental hormones↓→hypoglycemia
Effects on mother and fetus
• Effects on monther
• Spontaneous abortion
• Preeclampsia
• Infection: urinary infection
• Polyhydramnios
• Fetal macrosomia( dystocia
• Ketoacidosis (
Effects on mother and fetus
• 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
• History
Family history of DM, urine glucose repeatedly (+), recurrent abortion or fetal death, candidal vaginitis
• Lab examination
• fasting plasma glucose(: ≥5.8mmol/L twice or more
• glucose screening test (50g glucose)
1 hr postchallenge ≥7.8mmol/L→ oral glucose tolerance test, OGTT
• 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
• White’s 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 retinopathyor hypertension only F: nephropathy 肾病(>500mg proteinuria per day at <20 weeks of pregnancy)
H: arteriosclerotic heart disease, clinically evident
R: proliferative diabetic retinopathy or vitreous hemorrhage
T: history of renal transplant
Treatment
• 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
• Medication (insulin)
• 2g glucose → 1 u insulin
• Early pregnancy: insulin↓
• Late pregnancy: insulin ↑50%-100%, peaking at 32 to 33 weeks
• Postpartum: insulin↓1/3-1/2
• Ketoacidosis: low-dose insulin, 0.1U/kg.h
• 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
