Masaryk University Schol of Medicine and Brno University Hospital Department of Obstetrics and Gynecology Head: Prof. Pavel Ventruba, DrSc.,MBA General Medicine Obstetrics and Gynecology Seminary 2017 – 2018 – Autumn Semester Diabetes and pregnancy ppt_Hintergrund_neu_grau Diabetes and pregnancy Romana Gerychová znak110_med-2 Gynekologicko - porodnická klinika Fakultní nemocnice Brno LF MU Přednosta: prof. MUDr. Pavel Ventruba, DrSc. R. Gerychová, L. Hruban Gynekologicko – porodnická klinika MU a FN Brno Přednosta: prof. MUDr. P. Ventruba, DrSc., MBA logo_mu General Medicine Obstetrics and Gynecology Seminary 2015 – 2016 – Autumn Semester ppt_Hintergrund_neu_grau znak110_med-2 Physiological changes during pregnancy § insulin resistance § ↓ glucose tolerance ↑ gestation § largely due to the placental anti-insulin hormones (human placental lactogen, cortisol, glucagon) § ↓ the renal treshold for glucose fnb nove logo ppt_Hintergrund_neu_grau znak110_med-2 Hypothesis developing fetal tissue → maternal metabolism → fetal tissue damage → longtime/lasting effect postnatally § neuron § adipose cell § muscle cell § pancreatic β cell § fnb nove logo ppt_Hintergrund_neu_grau znak110_med-2 History § insulin discovery (1921- Banting a Best) § spontaneous conception very rare § 50% maternal mortality (keto-acidosis) § 50% fetal mortality § fnb nove logo ppt_Hintergrund_neu_grau znak110_med-2 Diabetes in pregnancy - classification § pre-existing diabetes type I – insulin-dependent (IDDM) (10%) type II – non-insulin dependent (NIDDM) (90%) § gestational diabetes pre-existing gestational diabetes (GDM) fnb nove logo ppt_Hintergrund_neu_grau znak110_med-2 Pre-existing diabetes § human insulin therapy § away regimen (plasma glucose level, HbA1c) § renal functions (urea, creat.clearance, proteinuria) § diabetic retinopathy (two-fold ↑ risk progression) § Candida infection, skin infection § metabolismus (hypoglykemie x ketoacidosis) fnb nove logo ppt_Hintergrund_neu_grau znak110_med-2 Gestational diabetes (GDM) § induced by maternal changes in carbohydrate metabolism and insulin sensitivity § usually asymptomatic § develops in second trimester § no increase in the congenital abnormality rate § increased risk of pre-eclampsia § incidence Europe 3-5% (EAPM, Working Group on Diabetes end Pregnancy, 2006) ↑ USA 7% (The Nation´s Health, Oct.2008) § fnb nove logo ppt_Hintergrund_neu_grau znak110_med-2 Screening for GDM - recommendation low risk § negative previous history § < 25 years old § BMI < 25 § negative obstetrics history § Screening test = oGTT (24 - 28 gestational week) fnb nove logo ppt_Hintergrund_neu_grau znak110_med-2 Screening for GDM - recommendation high risk (oGTT at once, repeat 24-28 gestational week) § obesity § corticotherapy § positive previous history of DM (family, …) fnb nove logo ppt_Hintergrund_neu_grau znak110_med-2 Recommendation ČGPS (Czech Republic) § screening all pregnant women !! § glucose 75g (100g USA) § blood glucose level on an empty stomach < 5.6 120 min < 7.7 controversy – oGTT …standard 5,5 – 10.0 – 8.5 fnb nove logo ppt_Hintergrund_neu_grau znak110_med-2 Maternal risk § congenital abnormalities ..1/33 fetuses (Currie D., The Nation´s Health Oct 2008) § abortion § preterm delivery § preeclampsia (hypertension, nephropathy – 30% risk) § infection (urinary tract, skin, Candida infection) § ↑ CS rate (↑ mortality, morbidity) § adverse pregnancy outcome § ↑ risk of developing NIDDM within 10-15 years (30-60%) fnb nove logo ppt_Hintergrund_neu_grau znak110_med-2 Fetal risk § ↑ two-four fold risk of perinatal morbidity/mortality § stillbirth (III. trimester, 36 gestational week) § macrosomia (4000, resp.4500g) § adverse pregnancy outcome § fetal hyperinsulinaemia → chronic hypoxia § organomegaly, placentamegaly § postnatal morbidity fnb nove logo ppt_Hintergrund_neu_grau znak110_med-2 Congenital abnormalities diabetic embryopathy (because of bad compensation of DM) § heart defects (8-10 week) § NTD (neural tube deseases) (4 week) § cleft lip § gastrointestinal tract § urinary tract § limbs defects (caudal regression) (16-18 day) fnb nove logo ppt_Hintergrund_neu_grau znak110_med-2 Diabetic embryopathy § VVV 006 p1010043 A CPG1_66 CPG1_68 VVV 013 Snímek 106 fnb nove logo ppt_Hintergrund_neu_grau znak110_med-2 Diabetic fetopathy § complex problem § maternal hyperglycaemia ↑ hyperinsulinemia ↑ insulin-like growth factor ↑ leptin ↑ glycogen ↑ lipogenesis ↑ proteosynthesis …… fetal macrosomia !! fnb nove logo ppt_Hintergrund_neu_grau znak110_med-2 Diabetic fetopathy § typical features - macrosomia - fat and plethoric - cushingoid face § large birth weight § organomegaly heart, lungs, liver, thymus, spleen, adrenal gland § brain, kidney are normal § placentomegaly § fnb nove logo ppt_Hintergrund_neu_grau znak110_med-2 Diabetic fetopathy diabetic macrosomia (> 4000g, resp.> 90.centil resp. > 2SD) § birth injury - shoulder dystocia - fractures (clavicle, long bones) - brachial plexus injury (paresis) § postnatal morbidity fnb nove logo ppt_Hintergrund_neu_grau znak110_med-2 Diabetic fetopathy IMG_0009 fnb nove logo ppt_Hintergrund_neu_grau znak110_med-2 Diabetic fetopathy P1000554 P1000559 OLISAROVA_2 fnb nove logo ppt_Hintergrund_neu_grau znak110_med-2 Follow up during pregnancy § cardiotocography § ultrasound § selfmonitoring blood glucose level § insulin pump § neonatal intensive care unite fnb nove logo ppt_Hintergrund_neu_grau znak110_med-2 Ultrasound § estimated date of pregnancy (delivery) § UZ anomaly scan: I.trimestr (11-14 week) II.trimestr (18-23 week) fetal echocardiography § fetal growth (AC, 3-6 weeks) § dynamic fetal observation Doppler, biophysical score) fnb nove logo ppt_Hintergrund_neu_grau znak110_med-2 Ultrasound § image011 image009 image007 image004 image006 © www.centrus.com fnb nove logo ppt_Hintergrund_neu_grau znak110_med-2 Obstetric management § estimating maternal complications (high blood pressure, preeclampsia, nephropathy,…) § estimating risk of preterm delivery (betamimetic drugs !!, corticosteroids!!) § timing of delivery (controversial) early elective delivery x RDS § mode of delivery (controversial) spontaneous x CS fnb nove logo ppt_Hintergrund_neu_grau znak110_med-2 Medical management § goal – achieve maternal near normoglycaemia § diet, regimen (individual counselling-modification) - calories (low-sugar, low-fat, high-fibre) - diet structure (35-40%carbonhydrate, 20-25%proteins, 35-40%fat) - 6-7 times daily § home blood glucose monitoring (daily, weekly) § lifestyle, physical activity § pharmacotherapy (insulin)… fetal/maternal complications prevention fnb nove logo ppt_Hintergrund_neu_grau znak110_med-2 time glycaemia (mmol/l) fasting 5,6 1 h postprandial 7,2 - 7,8 2 h postprandial 6,6 Goal therapy fnb nove logo ppt_Hintergrund_neu_grau znak110_med-2 Pharmacotherapy § diet § insulin (human, analogs) short-acting, intermediate-acting fnb nove logo ppt_Hintergrund_neu_grau znak110_med-2 Newborn neonatal morbitidy prevention § early cord clamping (polycytaemia) § avoid warm losse ! (34°C – incubator) § fetal monitoring (24h after delivery) § infusion therapy § glucose level monitoring § neonatologist investigation (congenital anomalies) § early feed (breast-feeding 4-6h after delivery) § fnb nove logo ppt_Hintergrund_neu_grau znak110_med-2 Newborn neonatal morbidity symptoms § polycythaemia § RDS (respiratory distress syndrom) § hypoglycaemia § hypocalcemia, hypomagnesemia, jaundice fnb nove logo ppt_Hintergrund_neu_grau znak110_med-2 Postpartal care pre-existing DM § insulin therapy return to pre-pregnancy levels § breast-feeding support GDM § individual counselling (age, risk, glycaemia) § dietary regimen, lifestyle (on demand) § 6-12 weeks after delivery oGTT …30-50% risk NIDDM fnb nove logo ppt_Hintergrund_neu_grau znak110_med-2 Conclusion § increasing number of diabetic pregnant § high-quality physician care (pre-pregnaancy councelling, education, selfmonitoring) § high-quality obstetric care (feto-maternal specialist) § perinatal, neonatal intensive care units § close specialist collaboration § fnb nove logo