Li Ruzhi
Ob&Gy Hospital, Fudan University
Diabetes is a endocrinological disorder.
The prevalence of diabetes is about 3% in
the whole population.
the characteristics of diabetes is elevated
plasma glucose levels.
Diabetes is a common complication of
pregnancy.
The prevalence of diabetes is about 15%
in the pregnant women.
The more and more attention was paid to
diabetes during pregnancy.
The glucose metabolism is mainly
controlled by insulin.
The insulin is secreted by pancreatic cell.
The insulin promote the glucose
metabolism in tissues throughout the body.
As the blood glucose is utilized, the blood
glucose levels would be lowered.
In two conditions, the blood glucose will
be elevated.
One is the insufficient insulin secretion by
beta cells.
The other is the decreased insulin activity.
The insulin activity is called as the insulin
sensitivity.
The placenta can secrete a variety of
hormones.
These hormones include estrogen,
progesterone, cortisol, human placental
lactogen, human chorionic gonadotropin,
etc.
The hormones produced by placenta
antagonize the effects of insulin.
It is estimated that the insulin sensitivity will
be decreased by 40% in the 3rd trimester.
The decreased insulin sensitivity is the
key for the mechanism of GDM.
For GDM, there are no placental
hormones after delivery of placenta, so
the insulin sensitivity and the blood
glucose levels would be restored to the
normal.
Pregestational or overt: be diagnosed
before pregnancy.
Gestational diabetes Mellitus(GDM) : be
diagnosed during pregnancy.
GDM is more common than the overt
diabetes.
Definition: any degree carbohydrate intolerance
with onset or first recognition during pregnancy.
GDM is more common than the overt diabetes.
The GDM account for more than 90% of the
whole diabetes during pregnancy.
GDM could contain some pregestaional
diabetes.
The pregnancy and diabetes can impact
each other.
On one hand, the pregnancy can
aggravate the diabetes.
On the other hand, diabetes can exert
adverse effects on the pregnant effects.
The insulin sensitivity is lowered during
pregnancy.
We should adjust the dosage of insulin
according to the placenta status.
The overt diabetes has more adverse
effects than the GDM.
The adverse effects on the fetus
The adverse effects on the pregnant
women.
Miscarriage, preterm birth and fetal death
Congenital malformation
Macrosomia
hydramnios
Hypoglycemia
Respiratory distress syndrome
cardiomyopath
Hyperglycemia can results in the
elevated the incidence of Miscarriage,
preterm birth and fetal death.
In general, Miscarriage, preterm birth and
fetal death are more rare in GDM
population than in overt population.
The overt diabetes is related to the
pregestational daibetes.
The incidence of the congenital
malformation is not elevated in GDM
women.
Glucose can cross the placenta.
The Maternal hyperglycemia can cause
the fetal hyperglycemia.
The hyperglycemia would stimulate the
growth of fetus, then macrosomia will
occur.
The fetal growth restriction can be seen
in the women with overt diabetes, which
is related to the vascular disorders.
If women with diabetes during
pregnancy could not get sufficient
energy, the fetal growth will be
influenced.
Although diabetic pregnancies are often
complicated by hydramnios, the cause is unclear.
A likely explanation is that fetal hyperglycemia
causes polyuria. In a study from Parkland
Hospital, Dashe and co-workers (2000) found that
the amnionic fluid index parallels the amnionic
fluid glucose level among women with diabetes.
This finding suggests that the hydramnios
associated with diabetes is a result of increased
amnionic fluid glucose concentration.
The fetus produces its own insulin to
modulate its blood glucose.
The hyperinsulinemia will occur in
response to the hyperglycemia in the fetus.
After delivery, the blood glucose provided
by mother will be stopped, but the insulin
production would not be reduced, so the
hyperglycemia will results in the newborns.
The newborn respiratory distress
syndrome is related to the fetal lung
immaturity.
Hyperinsulinemia inhibits fetal lung
maturity.
So diabetes can result in the respiratory
distress syndrome.
Elevated incidence of the preeclampsia.
Dystocia
Infection
Ketoacidosis
Preeclampsia is related to glucose control
.
Hypertension that is induced or
exacerbated by pregnancy is the major
complication that most often forces
preterm delivery in diabetic women.
Distocia is associated with macrosomia.
Should distocia can results into serious
birth trauma.
Although it affects only approximately 1
percent of diabetic pregnancies,
ketoacidosis remains one of the most
serious complication .
The incidence of fetal loss is about 20
percent with ketoacidosis .
Pregnant women usually have
ketoacidosis with lower blood glucose
levels than when nonpregnant.
Most patients with GDM have normal
fasting glucose levels.
The challenge of glucose tolerance must
be done for most cases with GDM.
Routine fasting glucose measurement
Assess GDM risk.
Normal:<5.1 mmol/l
Suspected pregestational diabetes:
>7.0mmol/l
Suspected GDM: 5.1-7.0 mmol/l
The maternal age: young or old
Weight before pregnancy: normal or obese
The history of abnormal glucose
metabolism
The history of poor obstetrical outcome
The familial history of abnormal glucose
metabolism
OGTT should be done.
There are some controversies.
whether the universal or selective OGTT
should be done?
Which blood glucose level should be the
optimal cutoff for diagnosis?
In our country, every pregnant woman is
advised to do OGTT at about 24 weeks of
gestation.
If the GDM symptoms are present after
24 weeks, the OGTT should be done
again.
In 2008, the new diagnosis criteria for
GDM was established.
This diagnosis criteria is based on results
of the Hyperglycemia and Adverse
Pregnancy Outcome (HAPO) study.
Most of countries adopt this criteria at
present.
There is a consensus that once diabetes is
diagnosed, the treatment should be
recommended for diabetes during
pregnancy.
The goals of treatment are to prevent
macrosomia, avoid ketosis, and detect
pregnancy complications (eg,
hypertension, intrauterine growth
restriction, and fetal distress).
The management includes diet, exercise
and insulin.
The goals of diet therapy in GDM are to avoid
ketosis, achieve normal blood glucose levels, obtain
proper nutrition, and gain weight appropriately.
The amount and distribution of carbohydrate should
be based on clinical outcome measures (eg,
hunger, blood glucose levels, weight gain), but a
minimum of 175 g of carbohydrate per day should
be provided.
Carbohydrate should be distributed throughout the
day in 5 to 7 meals and snacks.
Use of a lowglycemic index diet decreases the
need for insulinto maintain euglycemia.
Experts recommend that women with
GDM should exercise regularly to control
blood glucose levels.
but an improvement in clinical outcomes
has not been demonstrated from
compliance with this recommendation.
Traditionally, insulin is used if dietary
management does not maintain blood
glucose at normal levels.
Insulin may be initiated at 0.7 U/kg actual
body weight/d given in divided dosages:
two-thirds of the daily dosage before
breakfast and the remainder of the dosage
before dinner.
Insulin therapy require close monitoring
and adjustment based on blood glucose
levels, meal choices, and activity levels.
The goal of intrapartum GDM management
is to avoid operative delivery, shoulder
dystocia, birth trauma, and neonatal
hypoglycemia.
For patients who have maintained
excellent control of blood glucose levels
with diet and exercise, delivery is
recommended at 40 weeks.
For patients with medication-requiring
GDM, induction at 38 to 39 weeks
gestation is recommended
In general, women with gestational
diabetes who do not require insulin seldom
require early delivery or other
interventions.
Elective cesarean delivery to avoid
brachial plexus injuries in macrosomic
infants is an important issue.
In most women with GDM, hyperglycemia
rapidly resolves shortly after delivery.
It is reasonable to measure a single
random or fasting blood glucose level
before discharge from the hospital.
Postpartum glucose tolerance testing is important
for women who had GDM.
Women with GDM have a 7-fold increased risk of
developing type 2 diabetes mellitus compared with
those who had a normoglycemic pregnancy.
At 6 to 12 weeks postpartum, only one-third of
women with persistent glucose intolerance have an
abnormal fasting blood glucose level.
Therefore, to detect all women with glucose
intolerance, a 75-g, fasting, 2-hour, oral glucose
tolerance test is recommended.
