妇产科课件：Pregnancy complicated with Diabetes

1、Pregnancy complicated with Diabetes,Diabetes in Pregnancy,Pre-gestational Diabetes: Type1 DM+ Type2 DM 10%20% Gestational Diabetes Mellitus (GDM) : 80% GDM Diet therapy GDM Diet+Insulin,After 1921 (insulin discovery),Insulin treatment for diabetes began, and maternal and fetal outcome improved signi

2、ficantly. Now, the PNM of pregnant women with DM is similar to normal pregnant women. But, perinatal morbidity is still high.,Fig 1. Perinatal Mortality rate in diabetic pregnancy (1890-1981),Effects of Pregnancy upon Glucose Metabolism,Placental hormones 125(7):1212-1213,High risk factors of GDM,Ag

3、e 30 years old Obesity and/ or PCOS Rapidly weight gain during pregnancy Family history with diabetes Poor obstetric history history of GDM, history of NRDS, fetal defects, macrosomia, polyhydramnios,Hanson MA,et al: Early life opportunities for prevention of diabetes in low and middle income countr

4、ies. BMC public health 2012;12: 1025.,孕期环境暴露影响子代慢性疾病发病风险,GDM 诊断界值？,HAPO研究（Hyperglycemia and Adverse Pregnancy）,HAPO研究始于2000年7月，北美洲、欧洲、中东、亚洲和澳洲的9个国家15个研究中心参与，23316名符合入组条件的孕妇进行双盲的前瞻性研究. 收集入组孕妇的背景数据和临床检验数据、分娩结局。研究中仅仅对空腹血糖（fasting plasma glucose, FPG）5.8mmol/L或服糖后2小时血糖11.1mmol/L或随机血糖8.9mmol/L者进行血糖管理和干预。

5、 HAPO研究将75gOGTT三项中各点血糖值分别分为7级，研究结果发现，随OGTT各点血糖值级别增加，LGA、剖宫产率（首次）、新生儿低血糖及脐血C肽不良妊娠结局的发生率均明显增加。,HAPO结果进行分析，发现OGTT三项血糖值对结局的影响并无明确拐点，GDM诊断界值：OGTT 空腹5.1mmol/L，1小时10.0mmol/L 2小时8.5mmol/L（1.75倍OR）,Diagnosis of GDM,GDM is diagnosed by 75g OGTT 24-28 GWs GDM can be diagnosed by any one abnormal values of 75g

6、OGTT (5.1, 10.0,8.5mmol/L),WHO criteria for diagnosis and classification of hyperglycaemia first detected during pregnancy （WHO,2013）,早孕期筛查诊断出孕前漏诊的糖尿病（overt diabetes）,Prevalence of GDM in China,20052009年 GDM患病率 14.6 2011-2012年 17.5%,孙伟杰，杨慧霞.中华妇产科杂志，2007 魏玉梅，杨慧霞.中华妇产科杂志，2011 Zhu WW, Yang HX, et al. D

7、iabetes Care, 2013,Birth weight/ neonatal adiposity,Fetal hyperinsulinemia,Type 2 diabetes,Cesarean section delivery,Shoulder dystocia/ birth injury,Preeclampsia,GDM during next pregnancy,Type 2 diabetes,Obesity,Cardiovascular disease,Why we bother to screen GDM ?,Long-term and short-term effects bo

8、th for mothers 248(8):949-52,Type 2 diabetes,Neonatal life,Pregnancies,Middle age,Normal glucose tolerance,Insulin resistance,Life span,GDM,GDM,Pregnancy as a stress test for future metabolic syndrome,Insulin resistance,Effect of GDM on the Fetus,Placenta,MATERNAL,FETAL,INSULIN RELEASE,GLUCOSE UTILI

9、ZATION,HYPERGLYCEMIA,BIRTHWEIGHT,HYPERINSULINEMIA,HYPERGLYCEMIA,E m b r y o - F e t u s,Delivery,Period Of exposure,1st trimester 2nd trimester 3rd trimester,organogenesis,Spontanetous abortions Early growth delay Congenital anomalies,Macrosomia Organomegaly CNS development delay Chronic hypoxemia S

10、till birth,Birth injury,A d u l t,Obesity Impaired glucose tolerance Diabetes syndrome-X,Behavior intellect deficit,Fetal malformation and HbA1c,Roy Taylor. et al. BMJ. 2007; 334: 742-745,An offspring of a diabetic mother delivered at 38 weeks gestation being large, oedematous and plethora,Maternal

11、Determinants of Obesity 115:e290-6.,GDM组 大于胎龄儿,GDM组 适于胎龄儿,非GDM组 大于胎龄儿,非GDM组 适于胎龄儿,患病率15%,患病率5.3%,该地区一般人群MS普遍患病率为4.8%,患病率3.0%,患病率4.2%,A vicious circle,Hossain et al: Obesity and Diabetes in the Developing World A Growing Challenge. NEJM 356 (2007) 213-215.,妈妈， 快点让我处在 正常血糖中吧,Management of Gestational

12、Diabetes,Diet SeIf glucose monitoring Oral hypoglycemics Insulin administration Education about diabetes,Diet Caveats,Dietary compliance is key to successful management of GDM. Diets restricted in calories predispose to ketosis. Carbohydrate restricted diets may improve control and reduce complicati

13、ons.,SeIf glucose monitoring,Blood Glucose Monitoring,Blood glucose test: (pre-meal, 2h post-meal ,0 a.m. or bedtime) Capillary glucose chemical test strips as the standard of care for pregnancy monitoring Glycohemoglobin (HbA1c),Glucosuria is more likely to occur (lower renal threshold),SeIf glucos

14、e monitoring,The target glucose levels,FBG 45: 479-483,妊娠期间接受治疗 妊娠期间没有接受治疗,糖尿病合并妊娠和胎儿严重先天畸形发生率,Cheung NW, et al. Australian and New Zealand Journal of Obstetrics and Gynaecology. 2005; 45: 479-483,糖尿病者妊娠前血糖控制目标,目标 血浆（mmol/L） 全血mmol/L,空腹和餐前血糖 4.4-6.1 3.9-5.6 餐后2h血糖 5.6-8.6 5.0-7.8 HbA1c 7%，尽可能降到正常 避免

15、低血糖,First trimester (pre-existing diabetes),Tight control of blood glucose levels Congenital malformation Ophthalmology consult,Insulin secretion is higher after meals,24 hour clock,Top line, pregnancy,Lower line,non-pregnant,Insulin uU/ml,Pregnancy (top line),Non-pregnant (lower line),孙伟杰，杨慧霞等（2005

16、） 中华围产医学杂志,Prenatal Obstetric Management,Prenatal diagnosis Assessing fetal growth Periodic fetal monitoring from 32GWs (NST、AFI) Plan Timing and Route of Delivery Confirmation of fetal maturity,DELIVERY OF DIABETIC PATIENTS,With well-controlled blood glucose, the time of delivery is before the esti

17、mated due date GDMA1: 40GWs GDMA2/Pre-GDM:38-39GWs Amniocentesis only for uncontrolled GDM or early delivery (37 GWs),Delivery & Postpartum,Risk of dystocia Risk of shoulder dystocia Reduced insulin requirement postpartum Long-term counseling,Pre-gestational Diabetes Mellitus (Summary),Provide preco

18、nception care Optimize glucose and avoid hypoglycemia. Evaluate fetal development and growth. Manage renal, eye, or other end organ damage. Assess mother for complications and fetus for well-being. Encourage breast-feeding, contraception and preconception care.,Neonatal monitoring,Avoid neonatal hyp

19、oglycemia: early feeding Examine for congenital malformations NRDS Polycytemia Birth trauma 鼓励母乳喂养 /,Postpartum Management of GDM,FBG is measured before discharge 75g 2-hr OGTT is repeated between 6 - 12 weeks after delivery,Case Report,A 26-year-old gravida 2，para 1001 Hispanic female presents for her initial prenatal visit. According to her last menstrual period, she is at approximately 16 weeks of gestation. She discloses her obstetric history of a previous uncomplicated vaginal delivery of a 4560-g infant at 40weeks of gestation. She