마더리스크라운드 발표자료

1. Management of diabetes
in pregnancy
So Young Park, M.D.

2. 용어 정의
• 임신성 당뇨병 (gestational diabetes, GDM) :
기존에 당뇨병이 없는 상태에서 임신 기간중에
진단된 당뇨병
• 임신전 당뇨병 (preexisting diabetes, PGDM) :
임신전에 당뇨병이 진단되어 있는 경우

3. GDM
• 임신과 관련한 위험
- 태아의 고인슐린혈증
- 거대아
- 사산
- 양수과다증
- 임신중 고혈압
- 분만후 당뇨병의 위험
성 증가
vs.
PGDM
• 당뇨병 종류
- 제 1 형 당뇨병
- 제 2 형 당뇨병
• 임신과 관련한 위험
- 임신초기 ; 선천성 기형 ,
자연유산
- 임신후기 ; 고인슐린혈증
, 거대아 , 사산 , 호흡곤란
증

4. Background
• In 1939, ‘‘benign glycosurics are more likely to give birth
to larger babies than do normal women’’
• In 1952, a link between higher maternal glucose during
pregnancy and neonatal hypoglycemia hypothesizing the
involvement of fetal hyperinsulinemia
• In 1957, ‘‘gestational diabetes’’ by Carrington
• O’Sullivan focused on the long-term risk of diabetes
developing in high risk women and using the pregnancy
OGTT proposed using an upper cutoff of 2SD above the
mean.

5. O’Sullivan criteria for diagnosing GDM
with subsequently derived values

6. Pathophysiology of GDM
Gestational Diabetes: Caring for Yourself and Your Baby, IDC Publishing

7. Diagnosis of GDM
• Two step approach
- Perform screen using 50 g oral glucose load
and check blood glucose at 1 hour

8. Diagnosis of GDM
* Two or more values meeting or exceeding the cut points are
required for diagnosis.

9. • An observational study
• 23,316 pregnant women
• A 75 g OGTT with sampling at 0, 1, and 2 hours
• Primary outcomes : large for gestational age (LGA), clinical
neonatal hypoglycemia, cord blood C-peptide > the 90th percentile,
primary cesarean section delivery rate

10. Frequency of primary outcomes across
the glucose categories (HAPO study)
N Engl J Med 2008;358:1991-2002

11. International Association of Diabetes in
Pregnancy Study Groups (IADPSG)
Recommendations
Diabetes Care 2010;33:676–81

12. Screening for and diagnosis of GDM
Diabetes Care. 2013;36 (suppl 1):S67–S74.

13. ACOG position
•
•
•
•
•
vs. IADPSG/ADA position
Two-step approaches
screening 50g
→ 100g 3-hour OGTT
Based on the likelihood that a
woman would develop DM
several years subsequent to
pregnancy
Evidence has accumulated ;
the association of GDM with
an increased risk of adverse
maternal and perinatal
outcomes.
GDM diagnosis ; 5 ~ 6% of
the population
•
•
Single-step approaches
75g 2-hour OGTT
•
Based on demonstrated
associations between
glycemic levels and an
increased risk of obstetric and
perinatal morbidities.
•
GDM diagnosis ; 15 ~ 20% of
the population
It is not well understood
whether additional GDM
women will benefit from
treatment.
•

14. • The panel believes that there is not sufficient evidence to
adopt a one-step approach, such as that proposed by
the IADPSG.
• The panel is particularly concerned about the adoption of
new criteria that would increase the prevalence of GDM,
and the corresponding costs and interventions, without
clear demonstration of improvements in the most
clinically important health and patient-centered
outcomes.
• Thus, the panel recommends that the two-step approach
be continued.

15. Fetal outcomes related to GDM

16. Potential maternal complications of GDM
J Matern Fetal Neonatal Med 2010;23(3):199-203

17. Effects of treating GDM ;
Meta-analysis of RCT
Outcome
Risk Ratio (95% CI)
Fetal
Shoulder dystocia
0.42 (0.23–0.77)
Neonatal hypoglycemia
1.18 (0.92–1.52)
Macrosomia
(birthweight >4000 g)
0.50 (0.35–0.71)
Admission to the NICU
0.96 (0.67–1.37)
Maternal
Cesarean delivery
0.90 (0.79–1.01)
Preeclampsia
0.62 (0.43–0.89)
Ann Intern Med. 2013;159:123-129

18. Recommended targets for home-monitored
glucose levels during pregnancy
(95)
(60-99)
(100-129)
(99)
(63-106)
(140)
(99)
(144)
(72-108)
본원
120a
(120)
(140)
70-100
(144)
(126)
(126)
(140)
100-140
90-120
90-
Endocrinol Metab Clin N Am 2012;41:161–173

19. Medical management
• Self-glucose monitoring
• Diet/Exercise
• Oral agents
• Insulin

20. Self-glucose monitoring
• The cornerstone of
diabetes management in
GDM
• Glucose monitoring ≥3
times daily
- Morning fasting
- 2-hour postprandial
(breakfast, lunch, and dinner)
- Before bed

21. Medical nutrition therapy (MNT)
• Medical nutrition therapy (MNT) and lifestyle changes
can effectively manage 80% to 90% of mild GDM cases.
• MNT nutritional goals and recommendations:
– Choose healthy low-carbohydrate, high-fiber sources of nutrition,
with fresh vegetables as the preferred carbohydrate sources
– Avoid sugars, simple carbohydrates, highly processed foods,
dairy, juices, and most fruits
– Eat frequent small meals to reduce risk of postprandial
hyperglycemia and preprandial starvation ketosis
• As pregnancy progresses, glucose intolerance typically
worsens; patients may ultimately require insulin therapy.
1. Chitayat, L, et al. Diabetes Technology & Therapeutics. 2009;11:S105-111. 2. ADA. Diabetes Care. 2013;36(suppl 1):S11-66.
3. ADA. Diabetes Care. 2004;27(suppl 1):S88-90. 4. Castorino K, Jovanovic L. Clin Chem. 2011;57(2):221-30.
5. Jovanovic L, et al. Mt Sinai J Med. 2009;76(3):269-80. 6. Mathiesen ER, et al. Endocrinol Metab Clin N Am. 2011;40:727-738.

22. 식사요법의 실제
• 3 식 + 2~4 간식
• 표준체중 계산 : (kg)=( 키 cm-100)x0.9
• 총열량 (kcal)= 표준체중 x25~30kcal + 300~350kcal
• 영양소 배분 :
탄수화물 50%, 단백질 20%, 지방 25-30%
• 식품군 1 단위당 칼로리 :
곡류군 (100 칼로리 ), 어육류군 (50~100 칼로리 ),
채소군 (20 칼로리 ), 지방군 (45 칼로리 ),
우유군 (125 칼로리 ), 과일군 (50 칼로리 )

23. 식품 교환표
Ex) 1900kcal = 곡류군 8 단위 + 어육류군 ( 저지방 2 + 중지방 4) + 채소군 7 단위
+ 지방군 5 단위 + 우유군 2 단위 + 과일군 2 단위

24. Physical activity
• Unless contraindicated, physical activity should be
included in a pregnant woman’s daily regimen.
• Regular moderate-intensity physical activity (eg, walking)
can help to reduce glucose levels in patients with GDM.
1. Castorino K, Jovanovic L. Clin Chem. 2011;57(2):221-30. 2. ADA. Diabetes Care. 2004;27(suppl 1):S88-90.
3. Jovanovic L, et al. Mt Sinai J Med. 2009;76(3):269-80.

25. Oral agents for the management of GDM
•
When MNT alone fails, pharmacologic therapy is indicated
–
•
AACE guidelines recommend insulin as the optimal approach
Metformin and glyburide (sulfonylurea) are the 2 most commonly
prescribed oral antihyperglycemic agents during pregnancy.
Medication
Crosses
Placenta
FDA Classification
Notes
Metformin
Yes
Category B
Glyburide
Minimal
transfer
Some formulations
category B, others
category C
Metformin and glyburide may be
insufficient to maintain normoglycemia at
all times, particularly during postprandial
periods
•
Due to efficacy and safety concerns, the ADA does not recommend
1. AACE. Endocr Pract. 2011;17(2):1-53. 2. Castorino K, Jovanovic L. Clin Chem. 2011;57(2):221-30.
3. ADA. Diabetes gestational diabetes mellitus (GDM)
2004;27(suppl 1):S88-90. Jovanovic
J Med. 2009;76(3):269-80.
oral antihyperglycemic agents forCare. of Pifizer, NY, NY, 2010. 6.4.Diabeta PI. L, et al. Mt SinaiU.S. Bridgewater, NJ, 2009.
5. Micronase PI. Pifizer. Division
Sanofi-Aventis

26. When to add insulin
• If medical nutritional therapy (MNT) fails then
add insulin when glucose are:
ADA
ACOG
Fasting
≥ 105 mg/dL
≥ 95 mg/dL
1-H postprandial
≥ 155 mg/dL
≥ 130-140 mg/dL
2-H postprandial
≥ 130 mg/dL
≥ 120 mg/dL

27. Insulin use during pregnancy
Patient Education
• Insulin administration, dietary modifications in response to self-monitoring of
blood glucose (SMBG), hypoglycemia awareness and management
Basal Insulin
• Intermediate- or long-acting insulin administered by injection, or
• Rapid-acting insulin administered by insulin pump
Postprandial hyperglycemia
• Recommended approach: rapid-acting insulin analogues
1. Jovanovic L, et al. Mt Sinai J Med. 2009;76(3):269-80. 2. AACE. Endocr Pract. 2011;17(2):1-53.
3. Castorino K, Jovanovic L. Clin Chem. 2011;57(2):221-30. 4. ADA. Diabetes Care. 2004;27(suppl 1):S88-90.

28. Characteristics of various insulin preparations
Onset, h
Peak, h
Duration, h
FDA
category
0.25~0.5
0.5~2.5
3~5
B
<0.25
1~3
3~5
B
2~4
4~10
10~16
B
Detemir (Levemir®)
2
No peak
7.6~24
B
Glargine (Lantus®)
2
No peak
11~24
C
Rapid-acting analogs
Lispro (Humalog®)
Aspart (Novorapid®)
Intermediate-acting
NPH, isophane
Long-acting analogs
Premixed
75% lispro protamine/25% lispro
B
70% aspart protamine/30% aspart
B
50% aspart protamine/50% aspart
B

29. Management during labor
During labor :
•
•
•
Maternal hyperglycaemia during labour ∝neonatal hypoglycaemia
→ target glycaemic control ; 72 ~ 144 mg/dl
For women with PGDM, an insulin infusion is usually required to
achieve normoglycaemia.
Women with GDM are usually able to maintain the required blood
glucose targets without requiring an intravenous insulin or with
reduced insulin dose.
After delivery :
•
•
•
PGDM; Insulin requirements fall to pre-pregnancy levels.
GDM: Hypoglycaemic agents can be discontinued following birth.
Breastfeeding is encouraged.
Postgrad Med J 2011; 87: 417-427

30. Risks factors for diabetes following a
gestational diabetes pregnancy
• Family origin with high prevalence of diabetes ; South
Asian, black Caribbean, Middle Eastern
• Insulin treatment in pregnancy
• Maternal obesity
• Weight gain postpartum
• Family history of diabetes
Postgrad Med J 2011; 87: 417-427

31. Suggested management of women
with prior GDM
At 1–4 months postpartum (6-8 wk)
Nat Rev Endocrinol 2012;8:639–649

32. Take home messages
•
Gestational diabetes mellitus (GDM) is caused by reduced
pancreatic β‑cell function, which results from the full spectrum of
causes of β‑cell dysfunction.
•
GDM is associated with a modest increase in adverse perinatal
outcomes, an increased risk of obesity in offspring and a high risk of
subsequent development of DM in mothers.
•
GDM is treated nutritionally; insulin or oral antidiabetic agents can
be added if maternal glucose levels and/or fetal growth parameters
indicate a sufficiently high risk of perinatal complications.
•
Long-term management of mothers includes assessment of
diabetes risk, and lifestyle and/or pharmacological approaches for
women at risk of type 2 diabetes mellitus.

33. Thank you for your attention…