김성훈 관동대학교 의과대학 내과 교수

1. Type 2 diabetes in pregnancy
김성훈
관동의대 제일병원 내과

2. Contents
• Case
• Risks of diabetes in pregnancy
• Risks of pregnancy for the mother with
diabetes
• Risk factors for poor outcome in T2DM
• Prepregnancy care
• Management of hyperglycemia in
pregnancy

3. 증례
• 37세, 임신 9주 (gravida 3, para 2)
• 둘째 아이: 4세, 출생 체중(4500 g)
Hx of neonatal jaundice and hypoglycemia
• Random glucose; 325 mg/dl, A1C: 8.9%
• 지난 임신때 당뇨 진단 받지 않았고, 이번 임
신에서 prepregnancy care 받지 않았음
• 신장 161 cm, 체중 79 kg, BMI 30.5 kg/m2
• 망막검사: mild NPDR

4. Classification of diabetes in pregnancy
• Type 1 diabetes (β-cell destruction)
- Autoimmune
- idiopathic
• Type 2 diabetes (insulin resistance with
insulin secretory defect)
• Other specific types (e.g. genetic
defects of β-cell function)
• Gestational diabetes

5. Issues of concern
• Epidemics of obesity and T2DM ->
increase in No of women with T2DM
• Frequently undiagnosed T2DM before
pregnancy
• Lack of preconception care
• Increase in Cx of pregnancy due to the
coexistence of obesity and T2DM

6. Risks of diabetes in pregnancy (I)
• Fetal macrosomia
• Birth trauma (to mother and baby)
• Induction of labor or cesarean section

8. Accelerated fetal growth

9. Risks of diabetes in pregnancy (II)
• Miscarriage
• Congenital malformation
• Stillbirth

11. Glucose control and risk of
malformation
Guerin A. Diabetes Care 30:1920, 2007

14. Risks of diabetes in pregnancy (III)
• Transient neonatal morbidity
- hypoglycemia, hypocalcemia,
hypomagnesemia, hyperbilirubinemia,
erythremia, hypertrophic cardiomyopathy,
respiratory distress syndrome
• Neonatal death
• Obesity and/or diabetes developing
later in the baby’s life

15. Maternal complications in
diabetic pregnancy
• Hypoglycemia, ketoacidosis
• Pregnancy induced hypertension
• Pyelonephritis, other infections
• Polyhydramnios
• Preterm labor
• Worsening of chronic complications-
retinopathy, nephropahty, neuropathy,
cardiac disease

16. Risks of pregnancy for the
mother with diabetes
• Pregnancy may affect pre-existing
micro- and macrovascular disease but
does not usually have any long-term
detrimental effect on either
retinopathy or nephropathy
• Risk of women with established
cardiovascular disease

17. Diabetic Retinopathy
– Diabetic retinopathy may accelerate during pregnancy
– Risk can be reduced by
• Gradual attainment of good metabolic control before
conception
• Preconceptual laser photocoagulation
– Baseline dilated comprehensive eye examination and
follow-up
; necessary before conception and during pregnancy
– Pre-existing diabetes should be counseled on the risk of
development and progression of diabetic retinopathy

18. Diabetic nephropathy
Kitzmiller JL et al:Diabetes Care 2008;31:1060-1079

19. Cardiovascular disease
– Untreated CAD is associated with a high mortality
rate during pregnancy
– Successful pregnancies have been undertaken
after coronary revascularization in women with
diabetes
– Exercise tolerance should be normal to maximize
the probability that the patient will tolerate the
increased cardiovascular demands of gestation

20. Potential contraindications to pregnancy
• Ischemic heart disease
• Active proliferative retinopathy, untreated
• Renal insufficiency: Ccr <50 ml/min or serum
Cr >2 mg/dl or heavy proteinuria (> 2g/24 h) or
hypertension (BP >130/80 mmHg despite
treatment)
• Severe gastroenteropathy
:nausea/vomiting, diarrhea

21. Remaining Problems
• A high prevalence of congenital anomalies
and spontaneous abortions in infant of
diabetic mothers (IDMs)
• Care of the woman with severe
complications of diabetes
• Care of the ―difficult patient‖ who often
presents late for antenatal care and/or
nonadherent

22. Comparison of pregnancy
outcomes in T1 and T2DM
J clin Endocrinol Metab 94:4284-91, 2009

25. Risk factors for poor outcome in T2DM
• Obesity
- congenital malformations: NTDs (esp. spinal
bifida), omphalocele, and heart defects
- perinatal mortality
- delivery by cesarean section
- macrosomia
- hypertensive disorders
• Ethnicity: Asian > Caucasian
• Poor pregnancy preparation

26. Paradigm shift
• Detection/diagnosis of diabetes in early
pregnacy
• To consider recommendations for
preconception screening to identify
patients with abnormal glucose
tolerance before conception

27. Women at very high risk for DM
1) prior history of GDM or delivery of
LGA infant
2) Strong family history of T2DM
3) Diagnosis of PCOS
4) severe obesity (or BMI ≥ 30)

28. Screen for undiagnosed T2DM at the first prenatal visit in
those with risk factors, using standard diagnostic criteria (B)
ADA: Standards of Medical Care in Diabetes—2011. Diabetes Care 34:S11-S61, 2011

29. 임신성 당뇨병의 진단기준
당뇨병 진료지침 2011, 대한당뇨병학회

30. The Pre-Preganacy Clinic
• Pregnancy planning/Contraceptive advice
• Optimize control and explain glycemic goals during pregnancy.
• Switch Type 2 diabetics to insulin. Review educational needs.
• Genetic counselling.
• Congenital malformations.
• Perinatal complications.
• Assessment of diabetic complications.
• Review smoking, alcohol, medications, folic acid.

31. Laboratory and special exam of pregnant women with preexisting diabetes

32. Management of hyperglycemia in pregnancy

33. Glycemic control and perinatal outcome (I)
• Before pregnancy, in order to prevent excess
spontaneous abortions and major congenital
malformations, target A1C is as close to normal
as possible without significant hypoglycemia. (B)
• Ensure effective contraception until stable and
acceptable glycemia is achieved. (E)
• Excellent glycemic control in the first
trimester continued throughout pregnancy is
associated with the lowest frequency of
maternal, fetal, and neonatal complications. (B)
Kitzmiller JL et al:Diabetes Care 2008;31:1060-1079

34. Glycemic control and perinatal outcome (II)
• Throughout pregnancy, optimal glycemic goals:
- premeal, bedtime, and overnight glucose 60–99
mg/dl
- peak postprandial glucose 100–129 mg/dl
- mean daily glucose <110 mg/dl
- A1C <6.0. (B)
• Higher glucose targets may be used in patients
with hypoglycemia unawareness or the inability
to cope with intensified management. (E)

35. Assessment of metabolic control
• SMBG: daily and fingerstick
• Postprandial capillary glucose 1hr after
beginning the meal: postmeal peak glucose
• CGM: T1D, esp, hypoglycemia unawareness
• Urine ketone: ill or persistent hyperglycemia
(>200 mg/dl)
• A1C:monthly

36. Medical Nutrition Therapy (MNT)
• Individualized MNT
• Basic plan: dietary recommendations for all
pregnant women, adjusted to the individual
needs of the patient
• CHO and caloric contents: modified based on
the woman’s height, weight, and degree of
glucose intolerance
• Carbohydrate-restricted diet; small frequent
meals and high-fiber and low GI foods

37. Goals for weight gain (1)
Prepregnancy BMI Total wt.gain (kg) Rate of wt.gain(2&3Tri.)kg/wk
Underweight (<18.5) 12.5 - 18 0.51 (0.44-0.58)
Normal weight (18.5-24.9) 11.5 - 16 0.42 (0.35-0.50)
Overweight (25-29.9) 7 - 11.5 0.28 (0.23-0.33)
Obese (≥30) 5 - 9 0.22 (0.17-0.27)
Institute of Medicine, 2009

38. Goals for weight gain (2)
• Less weight gain is safe and has a
beneficial effect on perinatal outcomes
in obese women: a weight gain of 0-7
pounds was associated with the least
macrosomia
Cheng YW et al. Gestational weight gain and gestational diabetes
mellitus: perinatal outcomes. Obstet Gynecol 112:1015-1022, 2008

39. Gynecol Endocrinol. 2010 Dec 29. [Epub ahead of print]

40. Exercise/Physical activity
• Educate women with diabetes as to
benefits of appropriate daily physcial
activity (reduce blood glucose, weight
gain and insulin requirements)
• Encourage regular exercise, at least 30
min/day

41. Insulin therapy
• Intensive regimen of multiple injections
in a basal-bolus fashion (MDI) or an
insulin pump (CSII)

42. Insulin profiles as used in pregnancy

43. Insulin profiles as used in pregnancy

44. Insulin Analogues in DM Pregnancy
• Rapidly acting analogues (aspart and lispro): safe
• Basal analogues not proven safe, but datemir safe in
recent trial.
We still used NPH insulin
• But during organogenesis, the risk to the fetus from
hyperglycemia is greater than any theoretical risk from
analogue insulin. Thus ? Continue analogue till 8-10 wks.

45. Summary and Conclusions
1. Preconception detection and management of T2DM
is a critical public health issue: universal preconception
screening for diabetes, with a minimun of a fasting glucose,
adding an OGTT in high risk individuals
2. Women with type 2 diabetes, who are reproductive
age are given preconception counselling and
prepregnancy care in the 6-12 months before
pregnancy
3. The key to improving outcome of pregnancy in
women with diabetes is strict glycemic control