Medical Complication
In Pregnancy
Diabetes
At the beginning of the 20th
century,diabetic women suffered
from infetility,and the rare women
achieving pregnancy faced a poor
prognosis,Maternal death was a
real threat,and perinatal survival a
more 40 percent,
The availability of insulin since 1922,
restored fertility and virtually
abolished maternal mortality,
At the same time,perinatal survival
did not change appreciatably,Since
1949 White Classification was
developed,permitted individualized
timing and mode of delivery,then
perinatal mortality was reduced
(nearly equivalent to that observed
in normal pregnancies.)
I,Classification
Type I Diabetes Mellitus
----insulin-dependent
----immune-mediated and
developed in genetically susceptible
persons
----concordance rate for diabetes in
monozygous twins is less than 50%
Type II diabetes
----noninsulin-dependent
----no HLA association
----familial occurrence
----concordance rate for diabetes in
monozygous twins is 100%
Gestational Diabetes Mellitus
Diabetes is the most common
medical complication of pregnancy,
Patient can be seperated into those
diagnosed during pregnancy
It is estimated that 90 percent of all
pregnacies complicated by diabetes
are due to gestational diabetes
Approximately 15 percent of women
with gestational diabetes will exibit
fasting hyperglycemia
Classification during pregnancy
Table 1 gives a classification
recommended by the American
College of Obstetricians and
Gynecologists in 1986,
class onset Fasting plasma glucose 2-hour postprandial
glucose
therapy
A1 Gestational <105mg/dl <120mg/dl Diet
A2 Gestational >105mg/dl >120mg/dl Insulin
Class Age of onset(yr) Duration(yr) Vascular disease Therapy
B >20 <10 None Insulin
C 10-19 10-19 None Insulin
D <10 >20 Benign
retinopathy
Insulin
F Any Any nephropathy Insulin
R Any Any Proliferative
retinopathy
Insulin
H Any Any Heart
Insulin
T Any Any Transplantation
of kianey
Insulin
II,Diagnosis
(I)Diagnosis of Overt Diabetes during
Pregnancy
i.presence of classical signs and
symptoms (such as polydipsia,polyuria,
unexplained weight loss)
ii.a random plasma glucose level greater
than 200mg/dl or fasting glucose>=
126mg/dl
iii.presence of ketoacidosis
(II)Diagnosis of gestational diabetes
i.High risk factors,a familial history
of diabetes,given birth to large
infants,unexplained fetal losses,
obesity
ii.Screaning
50g oral glucose challenge test,A
value of 140mg/dl(7.8mmol/l)or
higher will identify 80% of all women
with gestational diabetes
iii.Diagnosis criteria
If the results of 50g oral glucose
challenge test exceed 7.8mmol/l,a
diagnostic 100g oral glucose
tolerance test is performed,
Table 2 American college of Obstetricians
and Gynecologists 1994 Criteria for
Diagnosis of GestationalDiabetes Using 100g
of Glucose Taken Orally
Timing of
Measure
ment
Plasma Glucose
National diabetes Data
Group(1979)
Carpenter and
Coustan(1982)
Fasting 105mg/dl(5.6mmol/l) 95
1hour 190mg/dl(10.5mmol/l) 180
2hour 165mg/dl(9.2mmol/l) 155
3hour 145mg/dl(8.0mmol/l) 140
III.Maternal and Fetal
Effects
I)Maternal Effects
i.increasing abortion rate
ii.increasing incidence of Pregnancy-
Induced Hypertension(PIH)
iii.tend to be infection
iv.polyhydramnios
v.Macrosomia
vi.Be susceptible to ketoacidosis
(II)perinatal Effects
i.Macrosomia incidence is as high
as 25-40%
ii.Intrauterine Growth Retardation
(restriction)
iii.Preterm Labor
iv.Fetal Anomalies
v.Stillbirth,Fetal death
vi.Congenital Malformations
(III)Infant Effects
i.Neonatal Respiratory Distress
Syndrome
ii.Neonatal Hypoglycemia
iii.Hypocalcemia
iv.Hyperbilirubinamia
IV.Management
(I)Diet
Nutritional counseling is a
cornerstone in management
The goals of such therapy are,
i.To provide the necessary
nutrients for the mother and fetus
ii.To control glucose level
iii.To prevent starvation ketosis
Table 3 Recommend Daily Caloric Intake
and Pregnancy Weight Grain in Women with
Gestational Diabetes with and without
Concomitant Insulin Therapy
Current Weight
in Relation to
Ideal Body
Weight
Daily Caloric
Intake(kcal/kg)
Recommend
Pregnancy
Weight Grain
<80-90% 36-40 28-40
80-120 30 25-35
120-150 24 15-25
>150 12-18 15-25
(II)Insulin therapy
i.Indication---Insulin therapy is usually
recommend when standard dietary
management does not consistantly
maintain the fasting plasma glucose at
less than 105mg/dl or the 2-hour
postprandial plasma glucose at less than
120mg/dl
ii.At the beginning,a total dose of 20-30
units given once daily,before breakfast,
The total dose is usually divided into two
thirds intermediate-acting insulin and a
third short-acting insulin
(III)Preconception
i.Control preconception glucose to
optimal level(by using insulin)
ii.Hemoglobin AIc measurement
IV.Prenatal Care
(I)First trimester
i.Careful monitoring of glucose
control is essential to management
ii.Diet:Total caloric intake of 30-
35kcal/kg of ideal body weight
(II)Second trimester
i.Maternal serum AFP
ii.Ultrasonoscan(at 18-20w) to detect
neural-tube defects and other anomalies
(III)Third trimester
i.Weekly visits to monitor glucose control
and to evaluate for preeclampsia
ii.Serial ultrasonography to evaluate fetal
growth and amnionic fluid volume
iii.Other fetal surveillance tests
iv.Accept hospitalization from 34w until
delivery
V.Delivery
(I)Timing of delivery
i.Women with gestational diabetes who
do not require insulin
ii.Women with gestational diabetes who
require insulin
iii.Overt diabetes women
iv.Others
v.If severe hypertantion,preeclampsia or
other complications develop,delivery is
carried out even though the ratio is less
than 2.0 L/S
(II)Mode of delivery
i.In gneral,women with GDM(who does not
requre insulin),the way of delivery is
spontaneous labor
ii.Women with sonographic diagnosis of fetal
macrosomia,elective induction of labor or
cesarean section to prevent shouder dystocia
iii.In the overtly diabetic women(besides
class A),cesarean delivery has commonly
been used to avoid traumatic birth of a large
infant,or to avoid maternal or fetal
complication due to more advanced
diabetes.Especially for those with vascular
diseases
(III)Control the blood glucose
Maintain a near normal glycemia
level
Reduce the dose of insulin on the
day of delivery,and ? postpartum
(IV)Prevention of infection
(V)Neonatal care
i.detecting of blood glucose,plasma
calcium,plasma bilirubin
ii.Be care for a preterm neonatal
iii.To find respiratory distress and
treatment
iv.Prevention of postpartun
hemorrhge
In Pregnancy
Diabetes
At the beginning of the 20th
century,diabetic women suffered
from infetility,and the rare women
achieving pregnancy faced a poor
prognosis,Maternal death was a
real threat,and perinatal survival a
more 40 percent,
The availability of insulin since 1922,
restored fertility and virtually
abolished maternal mortality,
At the same time,perinatal survival
did not change appreciatably,Since
1949 White Classification was
developed,permitted individualized
timing and mode of delivery,then
perinatal mortality was reduced
(nearly equivalent to that observed
in normal pregnancies.)
I,Classification
Type I Diabetes Mellitus
----insulin-dependent
----immune-mediated and
developed in genetically susceptible
persons
----concordance rate for diabetes in
monozygous twins is less than 50%
Type II diabetes
----noninsulin-dependent
----no HLA association
----familial occurrence
----concordance rate for diabetes in
monozygous twins is 100%
Gestational Diabetes Mellitus
Diabetes is the most common
medical complication of pregnancy,
Patient can be seperated into those
diagnosed during pregnancy
It is estimated that 90 percent of all
pregnacies complicated by diabetes
are due to gestational diabetes
Approximately 15 percent of women
with gestational diabetes will exibit
fasting hyperglycemia
Classification during pregnancy
Table 1 gives a classification
recommended by the American
College of Obstetricians and
Gynecologists in 1986,
class onset Fasting plasma glucose 2-hour postprandial
glucose
therapy
A1 Gestational <105mg/dl <120mg/dl Diet
A2 Gestational >105mg/dl >120mg/dl Insulin
Class Age of onset(yr) Duration(yr) Vascular disease Therapy
B >20 <10 None Insulin
C 10-19 10-19 None Insulin
D <10 >20 Benign
retinopathy
Insulin
F Any Any nephropathy Insulin
R Any Any Proliferative
retinopathy
Insulin
H Any Any Heart
Insulin
T Any Any Transplantation
of kianey
Insulin
II,Diagnosis
(I)Diagnosis of Overt Diabetes during
Pregnancy
i.presence of classical signs and
symptoms (such as polydipsia,polyuria,
unexplained weight loss)
ii.a random plasma glucose level greater
than 200mg/dl or fasting glucose>=
126mg/dl
iii.presence of ketoacidosis
(II)Diagnosis of gestational diabetes
i.High risk factors,a familial history
of diabetes,given birth to large
infants,unexplained fetal losses,
obesity
ii.Screaning
50g oral glucose challenge test,A
value of 140mg/dl(7.8mmol/l)or
higher will identify 80% of all women
with gestational diabetes
iii.Diagnosis criteria
If the results of 50g oral glucose
challenge test exceed 7.8mmol/l,a
diagnostic 100g oral glucose
tolerance test is performed,
Table 2 American college of Obstetricians
and Gynecologists 1994 Criteria for
Diagnosis of GestationalDiabetes Using 100g
of Glucose Taken Orally
Timing of
Measure
ment
Plasma Glucose
National diabetes Data
Group(1979)
Carpenter and
Coustan(1982)
Fasting 105mg/dl(5.6mmol/l) 95
1hour 190mg/dl(10.5mmol/l) 180
2hour 165mg/dl(9.2mmol/l) 155
3hour 145mg/dl(8.0mmol/l) 140
III.Maternal and Fetal
Effects
I)Maternal Effects
i.increasing abortion rate
ii.increasing incidence of Pregnancy-
Induced Hypertension(PIH)
iii.tend to be infection
iv.polyhydramnios
v.Macrosomia
vi.Be susceptible to ketoacidosis
(II)perinatal Effects
i.Macrosomia incidence is as high
as 25-40%
ii.Intrauterine Growth Retardation
(restriction)
iii.Preterm Labor
iv.Fetal Anomalies
v.Stillbirth,Fetal death
vi.Congenital Malformations
(III)Infant Effects
i.Neonatal Respiratory Distress
Syndrome
ii.Neonatal Hypoglycemia
iii.Hypocalcemia
iv.Hyperbilirubinamia
IV.Management
(I)Diet
Nutritional counseling is a
cornerstone in management
The goals of such therapy are,
i.To provide the necessary
nutrients for the mother and fetus
ii.To control glucose level
iii.To prevent starvation ketosis
Table 3 Recommend Daily Caloric Intake
and Pregnancy Weight Grain in Women with
Gestational Diabetes with and without
Concomitant Insulin Therapy
Current Weight
in Relation to
Ideal Body
Weight
Daily Caloric
Intake(kcal/kg)
Recommend
Pregnancy
Weight Grain
<80-90% 36-40 28-40
80-120 30 25-35
120-150 24 15-25
>150 12-18 15-25
(II)Insulin therapy
i.Indication---Insulin therapy is usually
recommend when standard dietary
management does not consistantly
maintain the fasting plasma glucose at
less than 105mg/dl or the 2-hour
postprandial plasma glucose at less than
120mg/dl
ii.At the beginning,a total dose of 20-30
units given once daily,before breakfast,
The total dose is usually divided into two
thirds intermediate-acting insulin and a
third short-acting insulin
(III)Preconception
i.Control preconception glucose to
optimal level(by using insulin)
ii.Hemoglobin AIc measurement
IV.Prenatal Care
(I)First trimester
i.Careful monitoring of glucose
control is essential to management
ii.Diet:Total caloric intake of 30-
35kcal/kg of ideal body weight
(II)Second trimester
i.Maternal serum AFP
ii.Ultrasonoscan(at 18-20w) to detect
neural-tube defects and other anomalies
(III)Third trimester
i.Weekly visits to monitor glucose control
and to evaluate for preeclampsia
ii.Serial ultrasonography to evaluate fetal
growth and amnionic fluid volume
iii.Other fetal surveillance tests
iv.Accept hospitalization from 34w until
delivery
V.Delivery
(I)Timing of delivery
i.Women with gestational diabetes who
do not require insulin
ii.Women with gestational diabetes who
require insulin
iii.Overt diabetes women
iv.Others
v.If severe hypertantion,preeclampsia or
other complications develop,delivery is
carried out even though the ratio is less
than 2.0 L/S
(II)Mode of delivery
i.In gneral,women with GDM(who does not
requre insulin),the way of delivery is
spontaneous labor
ii.Women with sonographic diagnosis of fetal
macrosomia,elective induction of labor or
cesarean section to prevent shouder dystocia
iii.In the overtly diabetic women(besides
class A),cesarean delivery has commonly
been used to avoid traumatic birth of a large
infant,or to avoid maternal or fetal
complication due to more advanced
diabetes.Especially for those with vascular
diseases
(III)Control the blood glucose
Maintain a near normal glycemia
level
Reduce the dose of insulin on the
day of delivery,and ? postpartum
(IV)Prevention of infection
(V)Neonatal care
i.detecting of blood glucose,plasma
calcium,plasma bilirubin
ii.Be care for a preterm neonatal
iii.To find respiratory distress and
treatment
iv.Prevention of postpartun
hemorrhge
