به نام خداوند جان و خرد

1. به نام خداوند جان و خرد

2. GDM,Diabetes and Pregnancy Dr.Nader Taheri Endocrinologist

3. GDM was defined as : • any degree of glucose intolerance with onset or first recognition during pregnancy • whether or not the condition persisted after pregnancy, • not excluding the possibility that unrecognized glucose intolerance antedated or begun concomitantly with the pregnancy .

4. prevalence • The prevalence of hyperglycemia in pregnancy varies in direct proportion to the prevalence of type 2 diabetes in a given population or ethnic group. • In 1964, the prevalence of hyperglycemia in pregnancy was 1% to 4%, the current estimate is 7% to 14%.

5. PREGNANCY: A DIABETOGENIC STATE • Normal pregnancy viewed as • a progressive insulin resistance, • mediated by increasing placental antiinsulin hormones including: • progesterone • human placental lactogen • cortisol • growth hormone • and tumor necrosis factor (TNF)-a.

6. This prepares the mother for the increased demands of the fetus for amino acids and glucose in the latter half of pregnancy • Mild postprandial hyperglycemia serves to increase the amount of time • maternal glucose levels are elevated above the basal after a meal, • thereby increasing the flux of ingested nutrients from mother to the fetus.

7. GDM in Postpartem • not just a pregnancy problem. • Soon after birth, 90% to 95% of • women with hyperglycemia in pregnancy are diabetes-free . • By 6 to 12 weeks,4% to 9% are diagnosed with T2DM.

8. GDM in Postpartem • By 36months, 30% have • metabolic syndrome, • abnormal lipid profile, • hypertension, • and central adiposity. • By 5 years, 50% have T2DM.

9. GDM in Postpartem • Therefore, standard OGTT used : • 6 weeks after child birth • and then, yearly

10. Consequences of GDM

12. DIGNOSIS • Screen for undiagnosed type 2 diabetes : • at the first prenatal visit • in mothers with diabetes risk factors, using standard 75g OGTT.

13. Testing considered in adults who are overweight and who have one additional risk factors: • physical inactivity • first-degree relative with diabetes • high-risk race/ethnicity • women with past history of macrosomy or GDM • hypertension

14. A1C 5.7%, IGT, or IFG on previous testing • severe obesity, acanthosis nigricans • history of CVD • HDL cholesterol level less than 35 mg/dL • or a triglyceride level more than 250 mg/dL • women with PCOS

15. Dignosis of GDM • Perform a 75-g OGTT, • with plasma glucose measurement at • fasting • 1h • and 2 h, • at 24–28 weeks’ gestation • in women, not previously diagnosed with overt diabetes.

16. The OGTT should be performed in the • morning after an overnight fast of at least • 8 h. • The diagnosis of GDM is made when any of • the following plasma glucose values are • exceeded: • Fasting > or = 92 mg/dL • 1 h > or =180 mg/dL • 2 h > or =153 mg/dL

17. Most American providers have used • a two-step method involving • a nonfasting 1-hour 50-g oral glucose screen (glucose loading test) • with a subsequent diagnostic 3-hour 100-g OGTT • for those who failed the initial screen test.

18. Women who fail the 1-hour glucose loading test screen • take a 3-hour 100-g OGTT • and are considered to have GDM • if two of the four values equal or exceed the cut points of : • fasting BG 95 mg/dL, • 1-hour after 100-g OGTT of 180 mg/dL, • 2-hour of 155 mg/dL, • and 3-hour of 140 mg/dL

19. Internationally, • more than 10 different ways of diagnosing hyperglycemia in pregnancy • included one- or two-step procedures primarily using a 2-hour 75-g OGTT but with a variety of different cut points required to diagnose hyperglycemia in pregnancy. • now, no worldwide standard existed for the diagnosis of hyperglycemia in pregnancy.

20. Women with an abnormal 3-hour OGTT who are less than 24 weeks gestation • have undiagnosed T1DM, • T2DM, • or prediabetes • but the diagnosis of preexisting diabetes or prediabetes can only be made definitively after delivery • regardless of the severity of hyperglycemia

22. Treatment • The cornerstone for GDM management is • healthy eating(MNT) • and appropriate physical activity. • The meal plan is to attain • euglycemia • and adequate nutrition for the growth and development of the fetus.

23. The achievement of these goals is based on • the individualized medical nutrition therapy (MNT) plan • developed by the registered dietitian. • Registered dieticians • should be central to the management team

24. Principles of healthy eating during pregnancy • Distribute carbohydrates intake among three meals and three snacks spaced at 2.5- to 3-hour intervals. • Skipping meals or snacks result in • hypoglycemia, • ketone production, • or overeating later in the day.

25. Macronutrient distribution: • Carbohydrates: 40%–50%; • ideally, carbohydrates should be combined with protein. • Fat: <30%; use nuts, peanut butter, canola oil, or olive oil as primary sources of fat • Protein: 30%; look for lean meats, fish.

26. WEIGHT MANAGEMENT

27. In one study, women who gained more than recommended by the IOM were • three times more likely to have an infant with large for gestational age (LGA) • and 1.5 times more likely to have an infant with hypoglycemia or hyperbilirubinemia, • compared with women whose weight gain was in the recommended range.

28. Staying Active • Exercise facilitates the glucose uptake • regulates hepatic glucose output, • Reduce insulin resistance, • improve caloric expenditure, • and enhance weight loss.

29. Staying Active • A 10-minute walk, timed at 30 minutes after each meal • Help to control postmeal glucose excursions and reduce the need for insulin.

39. Intrapartum Insulin Management • The goals of intrapartum insulin management • to maintain maternal normoglycemia: BG 70–110 mg/dL, • to optimize fetal tolerance of labor and prevent neonatal hypoglycemia

40. Intrapartum Insulin Management • Women with hyperglycemia in pregnancy generally do not require insulin during labor • because the uterine muscle contractions of the labor process • increase insulin sensitivity • and reduce insulin needs

41. Intrapartum Insulin Management • When intrapartum insulin is needed • it is optimally delivered by intravenous drip • The usual dose of intermediate-acting subcutaneous insulin is given • at bedtime the night before inductin of labor • but the morning dose is withheld.

43. POSTPARTUM RISKS • The most immediate risk postpartum is the risk for neonatal hypoglycemia. • BG cutoffs for neonatal hypoglycemia vary slightly , • but on average the value of 45 mg/dL or less is • consistent with the need for intervention.

44. POSTPARTUM RISKS • Hypoglycemia can be attenuated by • within the first hour of life, breastfeeding • and every 2 hours, breastfeeding • The healthy newborn dried off and kept warm • Acquisition of colostrum by the newborn stimulate hepatic gluconeogenesis.

45. Preconception care of type 1 and type 2 diabetic patients

46. A1C levels should be • as close to normal, as possible (7%),before conception is attempted. • Diabetic retinopathy, • nephropathy, • neuropathy, • and CVD • should be evaluated • and, if indicated, treated .

47. Medications used • be evaluated prior to conception, • Since drugs commonly used may be contraindicated or not recommended in pregnancy, including • statins, • ACE inhibitors, • ARBs, • and most noninsulin therapies.

48. Major congenital malformations remain • the leading cause of mortality and • serious morbidity in infants of mothers • with type 1 and type 2 diabetes. • The risk of malformations increases continuously with • increasing maternal glycemia during the • first 6–8 weeks of gestation,

49. Planned pregnancies greatly facilitate preconception diabetes care. • Unfortunately,two-thirds of pregnanciesin women with diabetes are unplanned,

50. To minimize the occurrence of malformations, • standard care for all women with diabetes who have childbearing potential, • beginning at the onset of puberty or at diagnosis, should include • 1) education about the risk of malformations associated with unplanned pregnancies • 2) use of effective contraception at all times, unless the patient has good metabolic control