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There are two common situations where diabetes and pregnancy come together. These are:
Insulin-dependent diabetesIn a mother with insulin dependent diabetes the objectives for treatment of diabetes in pregnancy are as follows:
By doing this, the risks are reduced of any malformation to the baby, which will be more guaranteed to grow healthily. There is a much greater likelihood of a normal delivery and that the baby will be free of problems in the days following birth. Individual advice and medical practice do vary in some respects between different clinics, but adherence to these principles greatly reduces the risks of problems for pregnant women with insulin dependent diabetes. Gestational diabetesIf you are found, on routine testing of urine or blood to have diabetes during your pregnancy, you may have gestational diabetes. This form of diabetes usually resolves after delivery of the baby. Gestational diabetes appears to pose less of a risk to the baby than if the mother has insulin-dependent diabetes, but that risk is not thought to be sufficiently low for gestational diabetes to be ignored. Therefore, we recommend the mother to commence blood glucose testing, to receive dietary advice, and if the blood glucose levels remain high to commence treatment with injections of insulin. Usually, it is possible to stop such treatment immediately after delivery of your baby. If you have had gestational diabetes, remember that you are likely to experience the same problem in a subsequent pregnancy. There is also an increased risk in the long term of developing permanent non-insulin dependent diabetes, and as a result of this risk it is advised that women who have had gestational diabetes should try not to gain weight in middle age. Weight gain is one of the main factors responsible for causing diabetes in adults. An American Diabetes Association expert committee recently recommended a change in the names of the two main types of diabetes because the former names caused confusion. The type of diabetes that was known as Type I, juvenile-onset diabetes, or insulin-dependent diabetes mellitus (IDDM) is now type 1 diabetes. The type of diabetes that was known as Type II, noninsulin-dependent diabetes mellitus (NIDDM), or adult-onset diabetes is now type 2 diabetes. The new names reflect an effort to move away from basing the names on treatment or age at onset. A Lower Number To Diagnose Diabetes The expert committee also recommended a lower fasting plasma glucose (FPG) value to diagnose diabetes. The new FPG value is 126 milligrams per deciliter (mg/dL) or greater, rather than 140 mg/dL or greater. This recommendation was based on a review of the results of more than 15 years of research. This research showed that a fasting blood glucose of 126 mg/dL or greater is associated with an increased risk of diabetes complications affecting the eyes, nerves, and kidneys. When diagnosis was based on a blood glucose value of 140 mg/dL or greater, these complications often developed before the diagnosis of diabetes. The experts believe that earlier diagnosis and treatment can prevent or delay the costly and burdensome complications of diabetes. The prior criteria for diagnosing diabetes relied heavily on performing an oral glucose tolerance test (OGTT). In this test, the person must come in fasting, drink a glucose syrup, and have a blood sample taken 2 hours later. This complicated procedure made detection and diagnosis of diabetes a difficult and cumbersome process, and the expert committee recommended that it be eliminated from clinical use. The change to using fasting plasma glucose for determining the presence of diabetes will make detection and diagnosis of diabetes more routine. The fasting value can be easily obtained during routine physician visits, in clinics at the place of employment, and other situations. Currently, about 5 to 6 million adults in the United States have diabetes but do not know it. The simpler testing method of measuring fasting glucose should help identify these people so they can benefit from treatment sooner. People at High Risk for Diabetes The experts suggest that adults age 45 years and older be tested for diabetes. If their blood glucose is normal at the first test, they should be tested at 3-year intervals. People under age 45 should be tested if they are at high risk for diabetes. These high-risk factors include
The committee states that diabetes can be detected by any of three positive tests. To confirm the diagnosis, there must be a second positive test on a different day.
As mentioned above, the committee recommended that the OGTT not be used. Testing for Diabetes During Pregnancy The expert panel also suggested a change in the testing for diabetes during pregnancy, stating that women at low risk for gestational diabetes do not need to be tested. This low-risk group includes women who are
All women who are not in the low-risk category should be tested for gestational diabetes during the 24th to 28th weeks of pregnancy. The testing procedure requires drinking a glucose drink and measuring blood glucose 1 hour later. If the blood glucose value is 140 mg/dL or greater, the woman should be evaluated further.
The glucose test is a snapshot, a still photograph of a moving picture. It tells what the blood glucose level was at the moment it was collected. The fasting blood glucose level (collected after an 8 to 10 hr fast) is used to screen for and diagnose diabetes and pre-diabetes. An oral glucose tolerance test (OGTT / GTT) may also be used to diagnose diabetes and pre-diabetes but, according to the American Diabetes Association, two tests (either the fasting glucose or the OGTT) should be done at different times in order to confirm the diagnosis. The OGTT involves a fasting glucose, followed by the patient drinking a standard amount of a glucose solution to ?challenge? their system, followed by another glucose test two hours later. Gestational diabetes is a temporary type of hyperglycemia seen in some pregnant women, usually late in their pregnancy. Almost all pregnant women are screened for gestational diabetes between their 24th and 28th week of pregnancy using a 1 hour glucose challenge. If the blood glucose is high, they are considered at risk of developing gestational diabetes and they will undergo further testing. Diabetics must monitor their own blood glucose levels, often several times a day, to determine how far above or below normal their glucose is and to determine what oral medications or insulins they may need. This is usually done by placing a drop of blood from a finger prick onto a plastic indicator strip and then inserting the strip into a glucometer, a small machine that provides a digital readout of the blood glucose. In those with suspected hypoglycemia, glucose levels are used as part of the "Whipple triad" to confirm a diagnosis.
When is it ordered? This test can be used to screen healthy individuals for diabetes and pre-diabetes, because diabetes is a common disease that begins with few symptoms. Screening for glucose may occur at public health fairs or as part of workplace health programs. It may also be ordered as part of a routine physical exam. Screening is especially important for people at high risk of developing diabetes -- those with a family history of diabetes, those who are overweight, and those who are more than 40 to 45 years old. The glucose test may also be ordered to help diagnose diabetes and hypoglycemia when someone has symptoms of hyperglycemia such as:
or of hypoglycemia, such as:
Glucose testing is also done in emergency settings to determine if low or high glucose is contributing to symptoms such as fainting and unconsciousness. If a patient has pre-diabetes (characterized by fasting or OGTT levels that are higher than normal but lower than those defined as diabetic) their doctor will order a glucose at regular intervals to monitor their progress. With known diabetics, doctors will order glucose levels in conjunction with other tests such as: insulin and C-Peptide to monitor insulin production, and hemoglobin A1c to monitor glucose control over a period of time. Diabetics will self check their glucose, once or several times a day, to monitor glucose levels and to determine treatment options. Pregnant women are usually screened for gestational diabetes late in their pregnancies, unless they have symptoms earlier or have had gestational diabetes with a previous child. When a woman has gestational diabetes, her doctor will usually order glucose levels throughout the rest of her pregnancy and after delivery to monitor her condition.
What does the test result mean? Is there anything else I should know? High levels of glucose most frequently
indicate
diabetes but many other diseases and conditions can also cause
elevated glucose. The following information summarizes the meaning of
the test results. These are based on the clinical practice
recommendations of the American Diabetes Association.
Some of the other diseases and conditions that can result in elevated glucose levels include:
Moderately increased levels may be seen with pre-diabetes. This condition, if left un-addressed, often leads to type 2 diabetes. Low glucose levels (hypoglycemia) are also seen with:
In most cases, test results are reported as numerical values rather than as "high" or "low", "positive" or "negative", or "normal". In these instances, it is necessary to know the reference range for the particular test. However, reference ranges may vary by the patient's age, sex, as well as the instrumentation or kit used to perform the test. To learn more about reference ranges, please see the article, Reference Ranges and What They Mean. To learn the reference range for your test, consult your doctor or laboratorian.
Hypoglycemia is characterized by a drop in blood glucose to a level where first it causes nervous system symptoms (sweating, palpitations, hunger, trembling, and anxiety), then begins to affect the brain (causing confusion, hallucinations, blurred vision, and sometimes even coma and death). An actual diagnosis of hypoglycemia requires satisfying the "Whipple triad." These three criteria include:
Primary hypoglycemia is rare. People may have symptoms of hypoglycemia without really having low blood sugar. In such cases, dietary changes such as eating frequent small meals and several snacks a day and choosing complex carbohydrates over simple sugars may be enough to ease symptoms. Those with fasting hypoglycemia may require IV (intravenous) glucose, if dietary measures are insufficient.
What is gestational diabetes? Gestational diabetes is a type of diabetes that starts during pregnancy. If you have diabetes, your body isn't able to use the sugar (glucose) in your blood as well as it should, so the level of sugar in your blood becomes higher than normal. Gestational diabetes affects about 4% of all pregnant women. It usually begins in the fifth or sixth month of pregnancy (between the 24th and 28th weeks). Most often, gestational diabetes goes away after the baby is born. How can gestational diabetes affect me and my baby? High sugar levels in your blood can be unhealthy for both you and your baby. If the diabetes isn't treated, your baby may be more likely to have problems at birth. For example, your baby may have a low blood sugar level or jaundice, or your baby may weigh much more than is normal. Gestational diabetes can also affect your health. For instance, if your baby is very large, you may have a more difficult delivery or need a cesarean section. What can I do if I have gestational diabetes? You will need to follow a diet suggested by your doctor, exercise regularly and have blood tests to check your blood sugar level. You may also need to take medicine to control your blood sugar level. What changes should I make in my diet? Your doctor may ask you to change some of the foods you eat. You may be asked to see a registered dietitian to help you plan your meals. You should avoid eating foods that contain a lot of simple sugar, such as cake, cookies, candy or ice cream. Instead, eat foods that contain natural sugars, like fruits. If you get hungry between meals, eat foods that are healthy for you, such as raisins, carrot sticks, or a piece of fruit. Complex sugars, which are found in foods like pasta, breads, rice, potatoes and fruit, are good for both you and your baby. It's also important to eat well-balanced meals. You may need to eat less at each meal, depending on how much weight you gain during your pregnancy. Your doctor or dietitian will talk to you about this. Why is exercise important? Your doctor will suggest that you exercise regularly at a level that is safe for you and the baby. Exercise will help keep your blood sugar level normal, and it can also make you feel better. Walking is usually the easiest type of exercise when you are pregnant, but swimming or other exercises you enjoy work just as well. Ask your doctor to recommend some activities that would be safe for you. If you're not used to exercising, begin by exercising for 5 or 10 minutes every day. As you get stronger, you can increase your exercise time to 30 minutes or more per session. The longer you exercise and the more often you exercise, the better the control of your blood sugar will be. You do need to be careful about how you exercise. Don't exercise too hard or get too hot while you are exercising. Ask your doctor what would be safe for you. Depending on your age, your pulse shouldn't go higher than 140 to 160 beats per minute during exercise. If you become dizzy, or have back pain or other pain while exercising, stop exercising immediately, and call your doctor. If you have uterine contractions (labor pains, like stomach cramps) or vaginal bleeding, or your water breaks, call your doctor right away. What tests will I need to have during my pregnancy? Your doctor will ask you to have regular blood tests to check your blood sugar level. These tests will let your doctor know if your diet and exercise are keeping your blood sugar level normal. A normal blood sugar level is less than 105 mg per dL when you haven't eaten for a number of hours before the test (fasting) and less than 120 mg per dL 2 hours after a meal. If your blood sugar level is regularly higher than these levels, your doctor may ask you to begin taking a medicine called insulin to help lower it. You may be asked to see a specialist if you have to start taking insulin. 糖尿病與妊娠（Diabetes and Pregnancy) ※糖尿病母親胎兒之先天異常、 心臟血管系統
Transposition of great vessels （Cardiovascular） Ventricular septal defect Atrial septal defect Hypoplastic left ventricle Situs inversus Anomalies of aorta 中樞神經系統 Anencephaly Central nervous system Encephalocele Menigomyelocele Holoprosencephaly Microcephaly 骨骼系統 Caudal regression syndrome （Skeletal） Spinal bifida
泌尿生殖系 Abscent kidney (Potter syndrome) （Genitourinary） Polycystic kidneys Double ureter 腸胃系統 Tracheoesophageal fistula （Gastrointestinal） Bowel atresia Imperforate anus Classification of diabetes during pregnancy
Type of maternal diabetes Type I Ketoacidosis Type II obesity; hypertension Metabolic control and timing Early pregnancy birth defects & spontaneous abortion Late pregnancy hyperinsulinemia, overgrowth, stillbirth, Polyththemia, RDS Maternal vascular complications Retinopathy worsening during pregnancy Nephropathy edema, hypertension, IUGR Atherosclerosis maternal death
Gestational Diabetes Fetal risk hyperinsulinemia and macrosomia stillbirth Maternal risk hypertensive disorder of pregnancy Diabetes following pregnancy Metabolic control
Fasting glucose
<
Fasting glucose
>
妊娠與糖尿病-
A
Any Any
None A-
B Over
C
D Before
F Any Any Nephropathy Insulin R Any Any Proliferative retinopathy Insulin H Any Any Heart disease Insulin
妊娠與糖尿病-
Class Fasting Plasma Glucose Postprandial Plasma Glucose
A-
A-
週數： 對象：肥胖者、有糖尿病（家族）史者、產檢有尿糖者等。（理論上應每位孕婦皆做）。
作法：不用禁食、服用
＊
NDDG*
Carpenter
O’Sullivan
WHO
Plasma 妊娠期間血糖控制目標（Rigid Control）
早餐前
午餐、晚餐、睡前
飯後
£
凌晨 Insulin regimens for diabetic women during pregnancy
Regimen
Regimen
Regimen
Regimen
胰島素劑量從妊娠早期每公斤理想體重
早餐前RI: NPH =
晚餐前RI: NPH =
Work-up and management during hospitalization for pregnant diabetes:
1.
SMA
2. EKG
3.
U/A & U/C;
4. Consultation for Ophthalmologist, Dietian, social worker and diabetologist.
5.
DM diet
6.
Blood sugar monitoring: AC & PC
7. Adjust insulin requirement
Fetal well-being surveillance 1. Baseline ultrasound examination
2.
Daily fetal movement (DFMR) since
3. NST 4. Biophysical profile 5. Doppler ultrasound examination
Tocolytic agents for pregnant diabetics 1. Magnesium sulfate 2. Prostaglandin synthase inhibitor 3. b-mimetic (last resort)
4.
if ritodrine used, add KC
Management for pregnant diabetics admitted in labor floor ̣ Assessment of fetal lung maturity Ultrasound evaluation for good control diabetics Amniocentesis: lung maturity profile (PG, L/S ratio) ̣ On continuous fetal monitoring ̣ May on diet prior to active labor
̣
Monitor blood sugar q
̣
Prepare IV fluid: N/S
̣ NPO when in active labor
̣
If blood sugar >
̣
IV fluid: N/S
increase RI at
̣
If blood sugar ranging between
switch IV fluid to D
̣
If blood sugar <
switch IV fluid D
̣
When in active phase of labor (cervical dilatation over
switch IV fluid to D
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