Transcript Slide 1

 DIABETESOT
E NARU[UVAWE NA
JAGLENOHIDRATNIOT METABOLIZAM KADE
POSTOI APSOLUTEN ILI RELATIVEN
NEDOSTATOK NA INSULIN
 VO HRONI^NITE FORMI ,DIJABETOT E
ASOCIRAN SO DOLOGORO^NI VASKULARNI
KOMPLIKACII :
RETINOPATIJA
NEFROPATIJA
NEVROPATIJA
VASKULARNI ZABOLUVAWA
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GLIKOZATA JA POMINUVA PLACENTATA,KOJA FETUSOT JA
KORISTI KAKO PRIMAREN IZVOR ZA ENERGIJA
POMINUVA SO OLESNETA DIFUZIJA, SO POMO[ NA
RECEPRORI VO TROFOBLASTOT
PO 20 G.N SE RAZVIVA INSULINSKA REZISTENCIJA
INSULNISKATA REZISTENCIJA E REZULTAT NA
ZGOLEMUVAWE NA KORTIZOLOT I HUMANIOT
PLACENTAREN LAKTOGEN
KONCENTRACIJA NA GLUKAGONOT I KATEHOLAMINITE E
NEPROMENET
Hormoni asocirani so modifikacija na insulninskata sekrecija i
dejstvo
Hormone
Estrogens
Modification
↑ Insulin concentration
↑ Insulin binding
↓ Glucose transport
Progesterone
↓ Insulin binding
↓ Suppression of hepatic neoglucogenesis
↑ Insulin resistance
Cortisol
↓ Phosporylation of insulin receptor
↓ Insulin receptor substrate-1
↓ Insulin sensitivity
↑ Insulin secretion
↑ Insulin synthesis
Placental lactogen (hypothalamo–
pituitary–inter-renal, growth hormone ↑ Utilization and glucose oxidation
and prolactin)
↑ cAMP metabolism
↑ β-cell number
↑ β-cell mass
Glucagon
↑ Insulin resistance
1.UMERENA HIPOGLIGEMIA
NA GLADNO I PREKU NO]
2.HIPERGLIKEMIJA PO
OBROK
HIPERINSULINEMIJA I INSULINSKA REZISTENCIJA (DVOJNO
POGOLEMA SEKRECIJA VO VTOR TRIMESTAR )
ZGOLEMENA PRODUKCIJA NA HORMONI VO PLACENTA
POKA^UVAWE NA TELESNA TE@INA VO BREMENOST
MEHANIZAM NA ADAPTACIJA
Gestational Diabetes Mellitus: an Opportunity to Prevent Type 2 Diabetes and Cardiovascular Disease in
Young Women
Graziano Di Cianni, Alessandra Ghio, Veronica Resi, Laura Volpe
DisclosuresWomen's Health. 2010;6(1):97-105.
Maternal hyperglycemia due to:
- increased insulin resistance
- inadequate insulin response
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In the third trimester:
insulin resistance increases by 40–60%
(compared with pre-pregnancy measures)
BETA KLETKITE VO PANKREASOT NA MAJKATA NE MO@AT DA
ODGOVORAT SO ZGOLEMENA SEKRECIJA NA INSULIN
FETALNA HIPERGLIGEMIJA
HIPERPLAZIJA NA BETA KLETKI KAJ FETUS
FETALNA HIPERINSULINEMIJA
FETALNA MAKROZOMIJA
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Rekurentni postprandijalni hiperglikemi~ni epizodi
Zgolemuvaweto na gligemijata kaj majkata i fetusot se pridru`eni so epizodi na fetalna
hiperinsulinemija
Fetalnata hiperinsulinemija rezultira so zgolemeno deponirawe na vi{okot
nutritienti,so sto se javuva makrozomija
Vi{okot na energija e asocirano so konverzija na glikozata vo masti ,{to doveduva
namaluvawe na koncentracijata na kislorod kaj fetusot
Fetalna hipooksija -katekolamini- hipertenzija, srcevoremodelirawe i hipertrofija na
miokard
Stimulacija na eritropoetin.hiperplazija na Er i zgolemuvawe na hematokritot
Polocitemija(>65%) se javuva kaj 5-10% kaj novorodenite na dijabeti~nite majki
Namaluvawe na rO2 kaj fetusot
Zgolemeniot hematokrit doveduva do potnatalna hiperbilirubinemija
МЕТАБОЛНИ НАРУШУВАЊА
Дијабетес
 Бременост, комплицирана со инсулин зависен дијабет е една
од најзначајните ризични групи во акушерството денес.
 Поради малиот број на случаи, контролата на дијабетот треба
да се врши во универзитетски и во централни болници.
 Дијабетот го зголемува ризикот од малформации, но тие може
да се редуцираат со добро регулирање на гликемијата пред
концепција.
 Значајна е соработката помеѓу гинекологот акушер и
интернистот во текот на бременоста.
 Внимателно следење во примарна здравствена заштита од
првиот триместар продолжува на интервали од 1-2 недели, а
краток престој во болница во опстетрички оддел се индицира
индивидуално.
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Ризикот за мајката подоцна во бременоста вклучува
оштетување на бубрезите, нарушување во гликозниот
баланс, влошување на дијабетичната ретинопатија,
зголемен ризик за прееклампсија и полихидрамнион.
Ризиците за фетусот се малформации, спонтан абортус,
предвремени контракции, интраутерина смрт,
макросомија со рамена дистокија и Ербова пареза.
Проблемите во неонаталната адаптација се зголемени,
вклучувајќи хипогликемија, хипокалцемија,
хипербилирубинемија и респираторен дистрес синдром.
Се дава инсулинска терапија со мултипли инјектирања,
со цел да се постигне нормогликемија.
Ако фреквенцијата на контролни посети е доволно честа (
на 1-2 неделни интервали), третманот може да се
спроведува во домашни услови во текот на бременоста.
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Кратки периоди на хоспитализација се планираат
индивидуално. Континуирано надгледување се индицира
доколку има компликации.
Не постојат доволно докази за да се направи генерална
препорака за употреба на орални антидијабетици (metformin,
glibenclamide) во третманот на гестациски дијабетес или дијабет
во бременост. За нивна употреба може да се размислува во
посебни случаи.
Доколку е акушерски возможно, се планира вагинално
породување во терминот на раѓање.
Индикациите за царски рез се опстетрички, како пелвична
диспропорција, фетал дистрес во прво родилно време,
влошување на прееклампсијата и абнормална фетална
презентација.
Пролиферативна ретинопатија кај мајката и оштеување на
бубрезите се исто така индикации за царски рез.
JAGLENOHIDRATNA
INTOLERANCIJA
OD
RAZLI^EN INTENZITET ,KOJA ZAPO^NUVA ILI PRV
PAT SE OTKRIVA VO TEK NA BREMENOSTA
-tuka e vklu~en i neprepoznaen ,preegzistira~ki diabet koj postel pred
bremenost, no se otkriva prv pat vo bremenost
(t.n.overt diabetes-”skrien”)
-po tekot i klini~kata slika e sli~en na DM tip 2
-spored razli~ni studii od 15% do 65 % od pacientkite so GDM }e
razvijat DM tip 2 za 5 do 15 godini
-potreba od kontrola na glikemijata po poroduvaweto i pred planirawe
na slednata bremenost
VO BREMENOST:
 HTA KAJ 1 OD 10 BREMENOSTI
 CARSKI REZ 30%
 PE 20-30%
 POLIHIDRAMNION 20%
 PPI 30-45%
DOLGORO^NI RIZICI:
DM TIP2 -50% za 5-10 godini
PO PORODUVAWE NARU[ENA GLIKOZNA
TOLERANCIJA 80%
 DA!
 NO,KAKO….
VISOK RIZIK
-GDM VO PRETHODNA BREMENOST ILI
PREDIJABETES(NARU[ENA GLIKEMIJA NA GLADNO ILI
GLIKOZNA TOLERANCIJA)
-FAMILIJARNA ANAMNEZA ZA TIP 2
-VOZRAST NAD 25 GODINI
-BMI >25KG/M2
-ANAMNEZA OD PRETHODNA BREMENOST
(RTM>4500G,MRTVORODENO,SPONTAN
ABORTUS,GLIKOZURIJA)
-PCOSY
NIZOK RIZIK(NE SE PREPORA^uVA SKRINING SPORED ADA)
VOZRAST POD 25 GODINI
BMI POD 25
NE PRIPAGA NA ETNI^KA GRUPA SO SKLONOST KON DMTIP2
BEZ POZITIVNA FAMILIJARNA ANAMNEZA
BEZ ISTORIJA ZA PREDIJABETES
NEMA POZITIVNA AKU[ERSKA ANAMNEZA
SREDEN RIZIK-PACEINTKITE KOI NE PRIPA\AAT KON
PRETHODNITE DVE GRUPI I KAJ NIV SE PRAVI 75GOGTT
POMEGU 24-28 G.N
Prospektivna ,multicentri~na (15 centri) slepa
observaciona studija(23 316pacientki vo period od
2000-2006 godina)
Site pacientki se testirani so 75gOGTT pome|u
24-28 g.n
 glikemija na gladno, po 1 ~as i po 2 ~asa
Isklu~eni pacientki so FPG > 5.8 (105); po 2 ~asa
> 11.1 (200) ili random glikemija > 8.9(160)
HAPO study group.New Eng J Med 2008;351:1991-2002
PREDMET NA HAPO SUDIJA DA SE RAZJASNI ASOCIJACIJATA POME\U
NIVOTO NA GLIKOZA PONISKO OD VREDNOSTITE ZA DIJAGNOZA NA GDM
SO PERINATALNIOT ISHOD
PRIMARNI PARAMETRI
RODILNA TE@INA >90 TA PERCENTILA
PRIMAREN CARSKI REZ
NEONATALNA HIPOGLIKEMIJA
C-PEPTIDE VO PAP^ANIK >90 TA PERCENTILA
SEKUNDARNI PARAMETRI
PREKLAMPSIJA
PREDVREMENOS PORODUVAWE
RAMENA DISTOKIJA/RODILNA TRAUMA
HIPERBILIRUBINEMIJA
NICU
GLU
mmol/L
1
2
3
4
5
6
NA
GLADNO
<4.2
4.2-4.4 4.4-4.7 4.7-4.9 5.0-5.2 5.3-5.5 >5.6
PO 1
^AS
<5.8
5.9-7.3 7.4-8.6 8.7-9.5 9.610.7
PO 2
^ASA
<5
5.1-6.0 6.1-6.9 7.0-7.7 7.8-8.7 8.8-9.8 >9.9
10.811.7
7
>11.8
GLU
mmol/L
1
2
3
4
5
6
NA
GLADNO
<4.2
4.2-4.4 4.4-4.7 4.7-4.9 5.0-5.2 5.3-5.5 >5.6
PO 1
^AS
<5.8
5.9-7.3 7.4-8.6 8.7-9.5 9.610.7
PO 2
^ASA
<5
5.1-6.0 6.1-6.9 7.0-7.7 7.8-8.7 8.8-9.8 >9.9
10.811.7
7
>11.8
Parameta
r/frekefen
cija(%)
1
2
3
4
5
6
7
RTM>90
ta per.
6
7
10
13
15
17
25
C-peptid
vofet.seru
m>90 ta
per.
5
6
8
10
15
21
30
Primaren
SC
12
15
18
21
24
25
27-30
Neon.hipo
glikemija
2
2
2.1
2.3
2.4
3.0
4.5
PREPORAKI:
1.SITE BREMENI SO INTERMEDIEREN RIZIK,KAKO I SO VISOK RIZIK I
NEGATIVEN oGTT- I TRIMESTAR TREBA DA NAPRAVAT 75g oGTT
vo 24-28 g.n.,nautro po gladuvawe od 8 ~asa,i merewe na glikemija na
venska plazma
2.DIJAGNOZA NA DIJABETES VO BREMENOST
VREME NA ODREDUVAWE
RANDOM
PO NO]NO GLADUVAWE
GLIKEMIJA(mmol/L)
DM1/DM2
GDM
=/>11.1
=/> 7.0
HbA1C
=/> 6.5%
FPG
Po 1 ~as
Po 2 ~asa
-------
-----
--5.1
10.0
8.5
NE
DA
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Identify and treat more
women at risk
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Most women will only need
dietary and lifestyle
modification
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No proven risk to
intervention
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Simple strategy
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No evidence that
identifying more “lower risk”
women will improve
outcomes.
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More money…
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Increased labeling of
women as “GDM” leads to
increased interventions.
TERMINI:GDM I MANIFESTEN SE
BAZIRAAT NA STEPENOT NA
GLIKOZNOTO NA RU[UVAWE I VOZRASTA
NA PACIENTKATA
SE PREPORA^UVA SKRINIG ILI TEST ZA
DIJAGNOZA NA DIJABET VO
BREMENOST(LEVEL 1B)
HbA1C ako e <6.5%,oGTT vo 24-28
g.n.(Level2C)-one step approach
NEMA UNIFORMEN KONCENSUS KOJ E
PRIFATEN VO SVETOT ZA METODITE NA
SKRINING ,DIJAGNOSTI^KI KRITERIUMI ILI
MENAXMENT ZA GDM
Univerzalen ili selektiven skrining?
Rizik faktori ili 50g GCT?
75 gr ili 100 gr oGTT(one step aproach/two step aproach)
WHO - ADA - CDA - ADIPS -IADPSG
37
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1%-14% OD SITE BREMENOSTI (populacija)
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Okolu 90% se gestaciski dijabet
Vo Anglija sekoja godina se pojavuvaat
sekoja godina po 2%-5%
 okolu 87.5% od bremenostite komplicirani
so dijabet e gesttaciski diabet
 7.5% tip 1 diabetes
 5%
tip 2 diabetes
GODINA
VK.PORODUVA
WA
INSULIN
NEZAVISENTIP2
INSULIN
ZAVISEN
GESTACISKI
2009
4979
10
16
78
2010
4927
6
12
54
2011
4868
8
11
81
2013
5506
7
20
87
2014
5536
8
12
105
120
100
80
insulin nezavisen
60
insulin zavisen
gestaciski
40
20
0
2009
2010
2011
2012
2013
Diabetes vo premenosta se dijagnosticira( 2006
WHO kriteriumi) ako eden ili pove}e od slednive
kriteriumi se zadovoleni:
 glikemija na gladno vo plazma≥ 7.0 mmol/l (126
mg/ dl)
 glikemija po 2 ~asa ≥ 11.1 mmol/l (200 mg/dl)po
75g oGTT
 random glikemija ≥ 11.1 mmol/l (200 mg/ dl) vo
prisustvo na simptomi na dijabetes
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@enite so dijagnosticiran GDM treba da
napravat 75g dvo~asoven OGTT, 6‐12
nedeli po poroduvaweto
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Imaat rizik od 30% za rekurentnost na GDM vo
slednata bremenost i da razvijat DM tip2 za
slednite 10-20 godini
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Glikemija na gladno(kapilarna krv):
≤ 5.0mmol/L
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Glikemija po 1 ~as po obrok: ≤ 7.4mmol/L
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Glikemija po 2 ~asa po obrok:≤6.7mmol/L
Diabetes in pregnancy
 Management of diabetes and its
complications from pre-conception to
the postnatal period
 Issued: March 2008 last modified: July
2008
 NICE clinical guideline 63
guidance.nice.org.uk/cg63
National Institute for Health and Clinical Excellence (NICE)
preporaki
za samotestirawe vo bremenosta se slednive vrednosti;
Glikemija na gladno - 3.5 and 5.9 mmol/l (63 and 106 mg/dl)
Glikemija 1 ~as po obrok :<7.8 mmol/l (<140 mg/dl)
Canadian Diabetes Association (CDA) :
Glikemija na gladno -3.8 to 5.2 mmol/l;
1-h po obrok -5.5 to 7.7 mmol/l;
2-h po obrok -5.0 to 6.6 mmol/l
Spontani abortusi, pre-eklampsia i predvremeno
poroduvawe
Diabeti~na retinopatija mo`e da bide vlo{ena
rapidno za vreme na bremenosta
Mrtvorodenost,kongenitalni malfromacii
makrozomija,rodilni traumi,zgolemen prinatalen
mortalitet
Naru{ena postnatalna adaptacija
(hipoglikemi, hipokalcemija,hipomagnezemija,
hiperbilirubinemija,policitemija)
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Sproveduvawe na dobra glikemiska kontrola pred
kocepcija i za vreme na bremenosta go namaluva rizikot
za :
Spontani abortusi,kongenitalni malformacii,
mrtvorodenost i neonatalna smrt
LGA plod,indukcija na poroduvawe i Sectio Caesarea
Rizikot mo`e da se namali ,no ne mo`e da se eliminira
Bremenosta da bide planirana , po vospostavuvawe na
dobra glikemiska kontrola
Ako BMI >27 kg/m2 sovet za redukcija na telesnata
te`ina (NICE clinical guideline 43)
Folna kiselina (5 mg/dnevno) do 12 g.n.(redukcija na
NTD)
Procenka na retinopatija
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Ako nema dijabeti~na retinopatija pred bremenost, kontrola na
oftalmolog vo prv trimestar,ako e normalno, povtorno vo 28 g.n.
Ako ima diabeti~na retinopatija, potrebni se dopolnitelni procenki
pome|u16-20 g.n.
Procenka od nefrolog
 mikroalbumnurija
 kreatinin (=/>120 micromol/l ) ili
 eGFR <45 ml/minuta/1.73 m2
Odr`uvawe na glikemijata:
na gladno pome|u 3.5-5.9 mmol/l
postprandijalnata pod 7.8 mmol/l
 Voo~uvawe na rizikot na pacientka so insulin za
hipoglikemi~ni epizodi(osobeno vo prv trimesesar
 Kaj pacientki so suspektna ketoacidoza(pr.hiperemeza)
hospitalen tretman
 Obavezno antenatalno isleduvawe na srce vo 18-20
g.n.
(four-chamber view of the fetal heart and outflow
tracts )
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analozi na brzodejstvuva~ki insulin)-asparat i lispro
bolus dozi pred obrok
 Se sugeriraat analozi so dolgodejstvo za vreme na bremenosta
 isophane insulin (NPH insulin) kako prv izbor za dolgo dejstvo za
vreme na bremenosta-BAZALEN INSULIN
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Indikacija za voveduvawe na insulin
Glikemija na gladno >5.8
1 ~as po obrok
>7.8
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Kaj selektirana grupa na pacienki upotrebata na IP bi mo`ele da
obezbedat dobra glikemiska kontrola
Ovi naparavi se programirani da infundiraat razli~ni koli~ini na bazalen i
bolus insulin koi postepeno se menuvaat dodeka pacientkata spie ili od
bilo koi pri~ini e prezafatena
Doka`ana e nivnata efektivnost vo pove}e studii
Hieronimus et al reported similar HbA1C levels, macrosomia rates,
and cesarean rates in 33 pregnant women managed with insulin
pump, compared with 23 receiving multiple insulin injections
Lapolla et al found no differences in glycemic control or perinatal
outcome between 25 women treated with insulin pump in
pregnancy and 68 women who received conventional insulin
treatment
Kaj pacientkite so gestaciski dijabet sovet
za namaluvawe na telesnata te`ina
,dieta,ve`bi)
 Odreduvawe na glikemija na gladno po 6
nedeli od porodivawe
 Edna{ godi{no
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Ovoj termin se koristi za da se odvojata lu|e koi se so
zgolemen rizik za razvoja na diabetes
Imaat ili naru{ena FPG ili naru{ena glikozna tolerancija
Naru{ena FPG e sostojba kaj koja glikemijata na gladno e
poka~ena (100-125 mg/dL)-6.9 do 8.6 mmol/l- po no}no
gladuvawe,ne nedovolno da se klasificira kako dijabetes
Naru{ena glikozna tolerancija e sostojba koga e poka~ena
koncentracijata na glikoza po 2~asa pri oGTT (140-199
mg/dL)9.6-13.7 mmol/l no nedovolno visoka da se klasificira za
dijabetes
Ovie pacientki se so visok rizik za razvoj na GDM vo tek na
bremenostaTreba da im se ponudi skrining vo prv trimestar
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2-~asoven 75 g oral glucose tolerance test (OGTT)
Za skrining i dijagnoza na GDM(spored kriteriumi za
WHO)
Pacientki koi imale GDM vo prethodnata bremenost , se
sovetuva samokontrola na glikemija ili 75g. oGTT vo 1618 g,
povtoren oGTT vo 28 nedela(ako prethodnite rezultati se
normalni)
pacientki so bilo koj drug rizik faktor treba da im se
ponudi 2 ~asoven 75g OGTT vo 24-28 gestaciska
nedela
OGTT ne se koristi pred 24 g.n bidej}i normalnite
vrednosti do toj period na gestacijata ne se seu{te utvrdeni
Cosson E, Valensi P, Carbillon L,Diabetes & metabolism : 2014 Oct 1
pg
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BMI > 27 kg/m2 kaloriski vnes (do 25 kcal/kg/den)
Umereni ve`bi -30 minuti dnevno
Hipoglikemi~na terapija se voveduva ako :
so gorenavedeniot re`im se postignat celnite glikemii vo preiod od 1 do 2
nedeli po Dg.GDM
Na UZ se verificira po~etna fetalna makrozomija(AC>70 ta percentila)
Hipoglikemi~nata terapija se individualizira za sekoja pacientka -sorabotka
pome|u edndokrinolog i ginekolog)
HbA1c ne se koristi rutinski za procena na glikemiskata kontrola vo vtoriot i
tretiot trimestars
Metformin
-JA MINUVA PLACENTATA, NO NAJVEROJATNO NEMA TERATOGEN EFEKT
- NICE I CDA go vklu~uvaat ovoj lek za tretman na GDM i za tretman na tip2 DM
Sulfonylurea-kaj nas
se kontraindicirani
Glibenclamide (glyburide) ( Langer
)
NICE I CDA include glibenclamide (glyburide) as an option for treatment of
GDM (although it is not licensed for this indication)
pome|u 10%-20% }e imaat potreba od oralni hipoglikemici ili
insulinska terapija , vo kolku dietata i ve`bite se neefektivni vo
kontrola na glikemijata
Skriningot za GDM koj bi opfa}al glikemija na gladno, random
glikemija ,glikoza challenge test i analiza na urinata za glikoza ne
se prifa}aat kako metodi za dijagnoza na GDM
Dijagnozata za GDM mo`e da dovede do zgolemuvawe na
monitoringot i intrevenciite vo tek na bremenosta i poroduvaweto



T.N.rapid-acting insulin analozi(aspart i lispro) imaat prednost
nad solubilniot human insulin za vreme na bremenosta
Pacientkite na insulinski tretman se sovetuvaat za rizikot od
hipoglikemija .nepo`elna osobeno vo prv trimestar
Na pacientkite koi se na insulin (TIP 1 DM , I TIP2 DM –IDDM)
treba da im se ponudi kontinuirana subkutana infuzija so insulin
(CSII or insulin pump therapy) vo kolkunemo`e da se postigne
adekvatna glikemi~na kontola so pove}ekratni dnevni inekcii na
insulin koi se bez zna~itelna hipoglikemija
Ako 24 ~asovnata proteinurija dostignuva do
2 g/l da se upati na Nefrolog
 eGFR ne se koristi vo tek na bremenosta za
procena na renalna funkcija
 Kreatinin >120 mmol/(zna~ajno)
 Ako proteinurija e >5 g/L obavezno
tromboprofilaksa

7–9 weeks Confirm viability of pregnancy and gestational age.
 Screening for congenital malformations
Fourchamber view of the fetal heart and outflow tracts at 18–20
weeks

SLEDEWE NA FETALEN RAST I SOSTOJBA NA
PLODOT
ultrasound monitoring of fetal growth and amniotic fluid volume
every 4 weeks from 28 to 36 weeks
 Routine monitoring of fetal well-being before 38 weeks is not
recommended in pregnant women with diabetes, unless there is a
risk of intrauterine growth restriction
 Women with diabetes and a risk of intrauterine growth restriction
(macrovascular disease and/or nephropathy) will require an
individualised approach to monitoring fetal growth and well-being

32 g.n.- UZ procena na fetalniot rast i AFI
36 g.n. - UZ procena na fetalniot rast i AFI
Informacii i sovet za :
-vremeto, na~inot menaxment na poroduvaweto
-analgezia i anaestezija
-promeni vo hipoglikemi~nata terapija za vreme i poroduvaweto
-informacii za rizici za novorodenoto
-motivacija za doewe kako na~in za regulacija na glikemiskata kontrola
-kontracepcija i sledewe po poroduvaweto
38 g.n. da se ponudi indukcija na poroduvaweto ili SC ako e indiciran
-ako pacientkata saka spontan po~etok na poroduvaweto edna{ nedelno
testovi za procena na fetalnata sostojba do 41 g.n.
Pacientkite e potrebno paraleno da ja dobivaat i rutinskata antenatalna kontrola
kako za zdravi bremeni `eni
(NICE guideline 62)
Vklu~uva pregled za nulipari vo 25 g.n i 31 g.n. vo 34 g.n.
DM ne e kontraindikacija za administracija
na kortikosteroidi za zreewe na fetalno
belodrobie ili za tokoliza
 Kaj pacientkite na insulinska terapija ,za
vreme na kortikoterapija
 Potreben e tesen monitoring na glikemija i
plodot
 Betamimeticite ne bi trebalo da se koristat
za tokoliza kaj DM

Pregnant women with diabetes who have
a normally grown fetus should be offered
elective birth through induction of labour,
or by elective caesarean section if
indicated, after 38 completed weeks.
Diabetes should not in itself be considered
a contraindication to attempting vaginal
birth after a previous caesarean section.
Pregnant women with diabetes who have
an ultrasound-diagnosed macrosomic
fetus should be informed of the risks and
benefits of vaginal birth,induction of
labour and caesarean section.
Published
Induction of labour. NICE clinical guideline 70 (2008)
 Type 2 diabetes: the management of type 2 diabetes. NICE clinical guideline 66 (2008).
 Antenatal care: routine care for the healthy pregnant woman. NICE clinical guideline 62 (2008).
 Intrapartum care: care of healthy women and their babies during childbirth. NICE clinical
guideline 55 (2007).
 Postnatal care: routine postnatal care of women and their babies. NICE clinical guideline 37
(2006).
 Type 1 diabetes: diagnosis and management of type 1 diabetes in children, young people and
adults. NICE clinical guideline 15 (2004).
 Caesarean section. NICE clinical guideline 13 (2004).
 Continuous subcutaneous insulin infusion for the treatment of diabetes mellitus. NICE technology
appraisal guidance 151 (2008).
 Guidance on the use of patient-education models for diabetes. NICE technology appraisal
guidance 60 (2003).
 Guidance on the use of glitazones for the treatment of type 2 diabetes. NICE technology
appraisal guidance 63 (2003).
 Guidance on the use of long-acting insulin analogues for the treatment of diabetes – insulin
glargine. NICE technology appraisal guidance 53 (2002).
 Improving the nutrition of pregnant and breastfeeding mothers and children in low income
households. NICE public health guidance 11 (2008)

Miscarriage 9-14% strong association between the degree of glycemic control
before pregnancy and the miscarriage rate
Birth defects





major birth defects occur in 1-2% of the population. In women with overt
diabetes and suboptimal glycemic control before conception, the likelihood
of a structural anomaly is increased 4- to 8-fold(18%)
two-thirds of birth anomalies involve the cardiovascular and central nervous
systems
genitourinary, gastrointestinal, and skeletal anomalies
periconceptional glycemic control is the main determinant of abnormal fetal
development in diabetic women
the rate of anomalies was only 3.4% with glycosylated hemoglobin values
(HbA1C) of less than 8.5%, versus 22.4% with poorer glycemic control in the
periconceptional period (HbA1C >8.5%)
Growth restriction
 Although most fetuses of diabetic mothers exhibit growth
acceleration, growth restriction occurs with significant
frequency in pregnancies in women with preexisting type 1
diabetes. The most important predictor of fetal growth
restriction is underlying maternal vascular disease. Specifically,
pregnant patients with diabetes-associated retinal or renal
vasculopathies and/or chronic hypertension are most at risk for
growth restriction.
Obesity
 Excessive body fat stores, stimulated by excessive glucose
delivery during diabetic pregnancy, often extends into
childhood and adult life. Maternal obesity, common in type 2
diabetes, appears to significantly accelerate the risk of infants
being LGA. Approximately 30% of fetuses of women with
diabetes mellitus in pregnancy are large for gestational age
(LGA). In preexisting diabetes mellitus, this incidence appears
to be slightly higher (38%)
Macrosomia
 Macrosomia is typically defined as a birth weight above the
90th percentile for gestational age or greater than 4000 g.
Macrosomia occurs in 15-45% of babies born to diabetic
women, a 3-fold increase from normoglycemic controls.
 Maternal obesity has a strong and independent effect on fetal
macrosomia
 Birth weight is largely determined by maternal factors other
than hyperglycemia, with the most significant influences being
gestational age at delivery, maternal prepregnancy body
mass index (BMI), maternal height, pregnancy weight gain, the
presence of hypertension, and cigarette smoking
Birth injury

Injuries of birth, including shoulder dystocia and brachial plexus
trauma, are more common among infants of diabetic mothers, and
macrosomic fetuses are at the highest risk.
Although shoulder dystocia occurs in 0.3-0.5% of vaginal deliveries
among healthy pregnant women, the incidence is 2- to 4-fold higher in
women with diabetes.
 With strict glycemic control, the birth injury rate has been shown to be
only slightly higher than controls (3.2 vs 2.5%).
 Currently, clinical ability to predict shoulder dystocia is poor. Warning
signs during labor (labor protraction, suspected fetal macrosomia, need
for operative vaginal delivery) successfully predict only 30% of these
events.
Respiratory problems
 The nondiabetic fetus achieves pulmonary maturity at a mean
gestational age of 34-35 weeks. By 37 weeks' gestation, more than 99%
of healthy newborn infants have mature lung profiles as assessed by
phospholipid assays


diabetic pregnancy, the risk of respiratory distress may not pass until
after 38.5 gestational weeks
1.75-pati se zgolemuva rizikot za neonatalni
komplikacii pri hiperglikemija (HAPO)
 FPG >95mg/dL(>6.5 mmol/L) - abnormalna


A retrospective cohort study involving all pregnant women who underwent screening for GDM at a tertiary
medical center between 2008 and 2011. Diagnosis of GDM during the study period was based on the CDA 2008
recommendations of universal screening with a 50g-oral glucose challenge test (GCT, threshold 140 mg/dL (7.8
mmol/L)) and a diagnostic test using a fasting 2-hour 75g-oral glucose tolerance test (OGTT). Diagnosis of GDM
required the presence of >=2 abnormal values, while a single abnormal value was diagnostic of impaired glucose
intolerance (IGT). Since the OGTT thresholds based on the IADPSG criteria are lower than the CDA 2008 thresholds
(92 mg/dL (5.1 mmol/L), 180 mg/dL (10.0 mmol/L), and 153 mg/dL (8.5) mmol/L), we identified a group of women
who would have been diagnosed as GDM based on the IADPSG criteria, but not the CDA 2008 criteria (OGTTIADPSG group). The pregnancy outcome of that group, as well as that of women with a positive OGTT according
to the CDA 2008 criteria (OGTT-CDA group) and women with a negative OGTT (OGTT-NEGATIVE group) was
compared to that of a control group consisting of women with a negative GCT test (GCT-NEGATIVE group).

CONCLUSION
The use of the IADPSG criteria instead of the CDA criteria
would result in a considerable increase in the rate of GDM,
but also appears to identify additional women at similar
risk of adverse pregnancy outcome

American journal of obstetrics and gynecology : 2014 Aug 27 pgMayo K, Melamed N, Vandenberghe
H, Berger H
SPORED ADA/IDAPSG
What is the clinical and cost
effectiveness of the three main available
screening techniques for gestational
diabetes: risk factors, two-stage
screening by the glucose challenge test
and OGTT,
 and universal OGTT (with or without
fasting)?


Multicentre blinded RCT
treatment Vs non treatment of GDM.
1000 women with GDM randomized
NNT for SD/birth trauma = 200
<5,1mmol/L (92 mg/dL) од 24 до 28 гестациска седмица се изведува 2-часовен тест
на оптоварување со 75g гликоза наутро, по гладување во тек на ноќта, кај сите
бремени жени кај кои претходно не е дијагностициран ДМ или ГДМ порано во
бременоста.
2-часовен ОГТ Тест со 75 g гликоза
Гликемија
гранични вредности за ГДМ
на гладно
5,1mmol/L (92 mg/dL)
1 час по оптоварување
10,0 mmol/L (180 mg/dL)
2 часа по оптоварување
8,5 mmol/L (153 mg/dL)
·
·
·
·
ГДМ се дијагностицира ако една или повеќе вредности се еднакви или
поголеми од граничните вредности (назначени во табелата). Вредностите
пониски од назначените се дефинираат како нормални.
Постои заклучок дека не се направени доволно студии за тоа дали постои
бенефит од генерализирано тестирање за дијагноза и третман на ГДМ пред
вообичаениот период од 24-та до 28-ма гестациска седмица
Сите жени со дијагноза за ГДМ или ДМ во тек на бременост треба да
направат иследување за гликемија по породувањето.
Не се препорачува одредување на ниво на Хемоглобин А1c за скрининг за
ГДМ.


Higher Gestational Weight Gain in Type 1
Diabetes Linked to Higher Birth Weight
The new fi ndings support the idea that greater attention should be paid to
the care of women with type 1 diabetes,with a particular focus not only on
glycemic control but also on ensuring appropriate weight gain during
pregnancy.
Secher et al. Higher gestational weight gain is associated with increasing off spring birth weight
independent of maternal
glycemic control in women with type 1 diabetes. Diabetes Care 2014;37:2677–2684
ADIPS does not currently recommend the use of the term “Overt Diabetes” (as proposed by IADPSG) to
describe marked hyperglycaemia (consistent with diabetes if detected outside pregnancy) first
detected in pregnancy
Recommendations for early testing for GDM for women with risk factor(s)
Moderate risk factors for GDM
• Ethnicity: Asian, Indian subcontinent, Aboriginal, Torres Strait Islander, Pacific
Islander, Maori, Middle Eastern, non‐white African
• BMI 25 – 35 kg/m2
High risk factors for GDM
• Previous GDM
• Previously elevated blood glucose level
 • Maternal age ≥40 years
 • Family history DM (1st degree relative with diabetes or a sister with GDM)
 • BMI > 35 kg/m2
 • Previous macrosomia (baby with birth weight > 4500 g or > 90th centile)
 • Polycystic ovarian syndrome
 • Medications: corticosteroids, antipsychotics
“high risk” of GDM (one high risk factor or two moderate risk factors)
should undergo a 75 g POGTT
Women considered as moderate or high risk but with normal early pregnancy glucose testing should
have arepeat POGTT at the usual time of 24‐28 weeks’gestation
Nankervis A, McIntyre HD, Moses R, Ross GP, Callaway L, Porter C, Jeffries W,
Boorman C, De Vries B, McElduff A for the Australasian Diabetes in Pregnancy