1. DiabetesAndPregnancy

2. Etiological Classification ►Type 1 A ■ Immune-mediated β-cell destruction ►Type 1 B ■ Idiopathic β-cell destruction ►Type 2 ■ Range from insulin resistance to insulin secretory defect with insulin resistance ►Genetic mutations in β-cell function ►Genetic defects in insulin action ►Genetic Syndromes-Down, Kleinfelter, Turner ►Diseases of exocrine pancreas-e.g., pancreatitis, … ►Endocrinopathies-e.g., Cushing Syndrome, … ►Drug or chemical induced-e.g., thiazides, … ►Infections-e.g., congenital rubellla, CMV

3. Gestational Diabetes ►Classification of Diabetes Complicating Pregnancy ClassOnsetFBS2-hr PPTherapy A1Gestational< 105 mg/dl< 120 mg/dlDiet A2Gestational> 105 mg/dl>120 mg/dlInsulin ClassVascular diseaseTherapy B and CNoneInsulin DBenign RetinopathyInsulin FNephropathyInsulin RProliferative RetinopathyInsulin HHeartInsulin

4. Screening Strategies ►Low-risk ■ Blood glucose testing not routinely required, if all of the following characteristics are present: ●Member of an ethnic group with a low prevalence of gestational diabetes ●No known diabetes in 1 st degree relatives ●Age < 25 yr ●Weight: normal before pregnancy ●No history of abnormal glucose metabolism ●No history of poor obstetrical outcome

5. Screening Strategies ►Average-risk ■ Perform blood glucose testing at 24-28 weeks using one of the following: ●Average-risk: women of hispanic african, native american, south or east asian origins ●High-risk: women with marked obesity, strong family history of type 2 diabetes, prior gestational diabetes, or glucosuria

6. Screening Strategies ►High-risk ■ Perform blood glucose testing as soon as feasible if gestational diabetes is not diagnosed, blood glucose testing should be repeated at 24-28 weeks or at any time a patient has symptoms or signs suggestive of hyperglycemia:

7. ACOG Criteria ►ACOG 2001 Criteria for Diagnosis of Gestational Diabetes Using 100-g GTT Plasma/Serum Carpenter et al. National Diabetes Plasma Data Group Statusmg/dl Fasting95105 1 hr180190 2 hr155165 3 hr140145

8. Postpartum Evaluation ►Postpartum evaluation for Glucose Intolerance in Women with Gestational Diabetes Normal Impaired fasting Glucose or Impaired Glucose ToleranceDiabetes Mellitus Fasting < 110 mg/dl110-125 mg/dl≥ 126 mg/dl 2-hr < 140 mg/dl*2-hr ≥ 140-199 mg/dl*2-hr ≥ 200 mg/dl* * Requires a 75-gr glucose load

9. Pregnancy Outcomes ►Preeclampsia ►Preterm birth ►Macrosomia ►Growth restriction ►Still Births ►Perinatal mortality

10. Pregnancy Outcomes ►Preeclampsia Frequency (%) ■ B: 12 ■ C: 22 ■ D: 23 ■ F: 54 ■ Total: 21

11. Pregnancy Outcomes ►Congenital Malformations (in type 1 DM) ■ Caudal regression ■ Situs inversus ■ Spina bifida, hydrocephaly, or other CNS defects ■ Aencephaly ■ Heart Anomalies (Transposition of great vessels, VSD, and ASD) ■ Anal-Rectal Atresia ■ Renal Anomalies (agenesis, cystic kidney, duplex ureter)

12. Management ►Diet: ■ 30-35 Cal/kg of ideal body weight ■ 3 meal and 3 snakes daily ■ 55% carbohydrate, 20% protein, 25% fat, and less than 10% saturated fat ■ Lower caloric intake in Obese women as long as weight loss and ketonuria are avoided ►Insulin: ■ Insulin is usually recommended when standard dietary management does not consistently maintained the FBS < 95 mg/dl, or 2-hr PP < 120 mg/dl (ACOG 2001)

13. Management ►Intrapartum Insulin Infusion: Blood Glucose (mg/dl) Insulin Dosage a (Unit/hour) Intravenous Fluids (125 ml/hr) < 1000D5 Lactated Ringer 100-1401D5 Lactated Ringer 141-1801.5Normal Saline 181-2202Normal Saline > 2202.5Normal Saline a Dilution is 25 unit of Regular insulin in 250 ml of normal saline with 25 ml flushed through line administrated intravenously. A finger-stick glucose test is performed every 1-2 hr. The insulin pump and intravenous solution are adjusted accordingly.

14. Adverse Effects ►Fetal Effects ■ Abortion ■ Preterm Delivery ■ Malformations ■ Unexplained fetal death ■ Hydramniosis ►Neonatal Effects ■ Neonatal Distress ■ Hypoglycemia ■ Hypocalcemia ■ Hyperbilirubinemia ■ Cardiac Hypertrophy ■ Long-term Cognitive Development ■ Inheritance of Diabetes ■ Altered Fetal Growth

15. Adverse Effects ►Maternal Effects ■ Diabetic Nephropathy ■ Diabetic Retinopathy ■ Diabetic Neuropathy ■ Preeclampsia ■ Ketoacidosis ■ Infections