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 < 105 mg/dl (class A1)

        Fasting glucose > 105 mg/dl (class A2)      

妊娠與糖尿病-1 (From American Colledge of Obstetricians and Gynecologist)

A             Any                   Any                      None                     A-1, diet only

B              Over 20             < 10                      None                      Insulin

C              10 to 19            or 10 to 19             None                        Insulin

D             Before 10          or > 20               Benign retinopathy         Insulin 

F               Any                  Any                   Nephropathy                     Insulin

R              Any                   Any                  Proliferative retinopathy     Insulin

H              Any                   Any                  Heart disease                   Insulin

 妊娠與糖尿病-2

Class     Fasting Plasma Glucose               Postprandial Plasma Glucose

A-1      < 105 mg/dL      and       < 120 mg/dL

A-2      > 105 mg/dL     and / or    > 120 mg/dL

 DM Screen:

週數：24 ~ 28 weeks GA.

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50 gm葡萄糖水，一小時後測血糖（sensitivity 80%; specificity 90%）。若sugar ³ 140 mg/dL，則需做100 gm葡萄糖水之OGTT (oral glucose tolerance test)。

＊100 gm glucose tolerance test：需空腹至少8小時，先測空腹血糖值，然後喝下100 gm之葡萄糖水，之後隔1, 2, 3小時抽血，若四個數值中有任二數值異常則稱為妊娠糖尿病。

NDDG*     100 gm     105      190     165    145          Plasma

Carpenter     100 gm     95        180      155     140          Plasma

O’Sullivan   100 gm     90       165     145     125          Whole blood

WHO      75 gm       £ 140       £ 200     

 Plasma
 

妊娠期間血糖控制目標（Rigid Control）

早餐前                                   69 ~ 90

午餐、晚餐、睡前            60 ~ 105

飯後                                        £ 120

凌晨2:00 ~ 6:00                    > 60

  Insulin regimens for diabetic women during pregnancy

Regimen 1 * short + intermediate        short + intermediate                  -

Regimen 2  short + intermediate      short            short + intermediate                  -

Regimen 3  short   short   short+intermediate   or long

Regimen 4   short short   short  Intermediate                or long Regimen 5    Constant infusion pump         

胰島素劑量從妊娠早期每公斤理想體重0.6單位，逐漸增加至足月之每公斤體重1單位左右。給法通常以短效型（regular insulin）搭配中長效型（NPH），分成早餐前及晚餐前二次給藥（餐前15 ~ 30分鐘）。

早餐前RI: NPH = 1:2

晚餐前RI: NPH = 1:1 (劑量約為早餐前之1/3)

Work-up and management during hospitalization for pregnant diabetes:

1.  SMA 12, HbA1c

2.  EKG

3.  U/A & U/C; 24 hr urine for CCr

4.  Consultation for Ophthalmologist, Dietian, social worker and diabetologist.

5.  DM diet 1800 kcal/day

6.  Blood sugar monitoring: AC & PC 1 hr tid. Plasma or Glucometer

7.  Adjust insulin requirement

Fetal well-being surveillance

1.  Baseline ultrasound examination

2.  Daily fetal movement (DFMR) since 32 wks GA

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 KC1 40 meq in 500 ml fluid

Management for pregnant diabetics admitted in labor floor

 ò Assessment of fetal lung maturity

        Ultrasound evaluation for good control diabetics

        Amniocentesis: lung maturity profile (PG, L/S ratio)

ò On continuous fetal monitoring

ò May on diet prior to active labor

ò Monitor blood sugar q2 ~ 4h

ò Prepare IV fluid: N/S 500 c.c. + RI 50 u (discard initial 50 c.c.)

ò NPO when in active labor

ò If blood sugar > 110 mg%: N/S run 100 c.c./hr

ò IV fluid: N/S 500 c.c. + RI 50 run 0.5 u/hr (5 mgtt/min)

  increase RI at 0.5 u increment per hour according to sugar level

ò If blood sugar ranging between 60 ~ 110 mg%

  switch IV fluid to D5S 500 c.c. run 100 ml/hr

ò If blood sugar < 60 mg%

  switch IV fluid D5S 500 c.c.

        165 ml/hr when BW 50 ~ 59.9 kg

        180 ml/hr when BW 60 ~ 64.9 kg

        195 ml/hr when BW 65 kg and over

ò When in active phase of labor (cervical dilatation over 4 cm)

  switch IV fluid to D5S

        165 ml/hr when BW 50 ~ 59.9 kg

        180 ml/hr when BW 60 ~ 64.9 kg

        195 ml/hr when BW 65 kg and over