上海交通大学医学院：《妇产科学》（双语） 4 Diabetes mellitus

Diabetes mellitus Liu wei Department of ob gy Ren Ji hospital

Diabetes Mellitus Liu Wei Department of Ob & Gy Ren Ji hospital

General Consideration Diabetes mellitus complicating pregnancy Diabetes mellitus is diagnosed before this pregnancy Gestational diabetes mellitus (GDM) Carbohydrate intolerance of varying degree of severity with onset or first recognition during pregnancy. Incidence 1%0-2%(our country); 1%0-10%(other countries)

General Consideration • Diabetes mellitus complicating pregnancy Diabetes mellitus is diagnosed before this pregnancy • Gestational diabetes mellitus (GDM) 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 1. Relative insulin sensitivity: insulin requirementy Morning sickness: hypoglycemia The latter half of pregnancy 1. Increased insulin resistance: placental hormones 2. Intake intrapartum: hypoglycemia 3. Postpartum: placental hormones -hypoglycemia

The impact of pregnancy on DM • The first half of pregnancy 1. Relative insulin sensitivity: insulin requirement↓ 2. Morning sickness: hypoglycemia • The latter half of pregnancy 1. Increased insulin resistance: placental hormones↑ 2. Intake↓intrapartum: hypoglycemia 3. Postpartum: placental hormones↓→hypoglycemia

Effects on mother and fetus Effects on monther 1. Spontaneous abortion 2. Preeclampsia 3. Infection: urinary infection 4. Polyhydramnios(羊水过多) 5. Fetal macrosomia(巨大儿), dystocia(难产) 6. Ketoacidosis(酮症酸中毒)

Effects on mother and fetus • Effects on monther 1. Spontaneous abortion 2. Preeclampsia 3. Infection: urinary infection 4. Polyhydramnios (羊水过多) 5. Fetal macrosomia(巨大儿), dystocia(难产) 6. Ketoacidosis (酮症酸中毒)

Effects on mother and fetus Effects on fetus 1. Fetal macrosomia 2. Fetal growth restriction 3. Premature labor 4. Fetal malformation Effects on infant 1. RDS 2. Hypoglycemia

Effects on mother and fetus • Effects on fetus 1. Fetal macrosomia 2. Fetal growth restriction 3. Premature labor 4. Fetal malformation • Effects on infant 1. RDS 2. Hypoglycemia

Diagnosis Diabetes mellitus complicating pregnancy Already diagnosed or easy to be diagnosed GDM 1. History Family history of DM, urine glucose repeatedly (+) recurrent abortion or fetal death, candidal vaginitis((假丝酵母菌阴道炎)

Diagnosis • Diabetes mellitus complicating pregnancy Already diagnosed or easy to be diagnosed • GDM 1. History Family history of DM, urine glucose repeatedly (+), recurrent abortion or fetal death, candidal vaginitis(假丝酵母菌阴道炎)

Diagnosis 2. Lab examination l) fasting plasma glucose(空腹血糖) >5. 8mmol/L twice or more 2) glucose screening test糖筛查(50 g glucose) I hr postchallenge 27.8mmol/L-y oral glucose tolerance test,OGTT糖耐量

Diagnosis 2. Lab examination 1) fasting plasma glucose(空腹血糖): ≥5.8mmol/L twice or more 2) glucose screening test 糖筛查 (50g glucose) 1 hr postchallenge ≥7.8mmol/L→ oral glucose tolerance test, OGTT糖耐量

Diagnosis 3)OGTT (75g glucose) Any two or more plasma glucose values exceed the following thresholds- GDM I 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

Diagnosis 3) 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 gestational dia betes not requiring insulin A2: gestational diabetes requiring insulin B: onset at >20 years of age or duration of 20 years or any onset or duration but with background retinopathy视网膜病 or hypertension on F: nephropathy g#F(500mg proteinuria per day at <20 weeks of pregnancy H: arteriosclerotic动脉粥样硬化 theart disease, clinically evident R: proliferative diabetic retinopathy or vitreous hemorrhage玻璃体出 血 T: history of renal transplant

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 500mg proteinuria per day at <20 weeks of pregnancy) H: arteriosclerotic动脉粥样硬化heart disease, clinically evident R: proliferative diabetic retinopathy or vitreous hemorrhage玻璃体出 血 T: history of renal transplant

Treatment Conception should be prevented in the patients with class d or f or r dm Diet management 1. Meal plans: individualized 2. Calories: 30 to 35 cal/kg(ideal body weight, IBW) per day. carbohydrates 40%-45%, protein 20% 30%,fat30% 3. Concentrated sweets: forbidden 4. Six meals per day, 2 to 3 hr apart 5. The adequacy of calories inta ke may be assessed by using daily fasting urinary ketone levels

Treatment • Conception should be prevented in the patients with class D or F or R DM • Diet management 1. Meal plans: individualized 2. Calories: 30 to 35 cal/kg (ideal body weight, IBW) per day. carbohydrates 40%-45%, protein 20%- 30%, fat 30% 3. Concentrated sweets: forbidden 4. Six meals per day, 2 to 3 hr apart 5. The adequacy of calories intake may be assessed by using daily fasting urinary ketone levels