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دکتر فاطمه بهادری Associate Professore, Perinatologist Urmia University of Medical Sciences
کنگره ملی راهکارهای ارتقای سالمت و کاهش مرگ و میر مادری
1393مهر ماه
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Type of diabet in pregnancy Pre pregnancy diabet
type 1 type 2 diabetesmaturity onset diabetes of the young (MODY) autosomal dominant Gestational diabetClass A1Class A2
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ديابت آشكار preexisting(Overt)
ديابت حاملگي
(Gestational)
A1(85%)
A2(15%) 90%
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women with gestational diabetes mellitus receive treatment (Grade 1A) medical nutritional therapyexercise self-monitoring of blood glucose levels insulin therapy
improves perinatal outcome
preeclampsia macrosomiashoulder dystocia
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Calories are generally divided over
three meals and two to four snacks 40 percent carbohydrate20 percent protein40 percent fat
Medical nutritional therapy
initial approach
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Self blood glucose monitoring
effectiveness of medical nutritional therapy
ADA and ACOG glucose targets are:●Fasting blood glucose concentration ≤95 mg/dL (5.3 mmol/L)●One-hour postprandial blood glucose concentration ≤140 mg/dL (7.8 mmol/L)●Two-hour postprandial glucose concentration ≤120 mg/dL (6.7 mmol/L)
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moderate exercise as part of the treatment plan
no medical or obstetrical contraindications
to this level of physical activity (Grade 1B)
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Absolute contraindications
Relative contraindications
Significant cardiac disease
Restrictive lung diseaseCervical insufficiencyMultiple gestationPlacental abruptionPlacenta previaPremature laborRuptured fetal
membranesPreeclampsiagestational hypertension
Severe anemiaUnevaluated arrhythmiaBronchitisPoorly controlled
diabetes, primary hypertension, seizure
disorder, or thyroid disease
Extreme obesity, malnutrition, or eating
disorderSedentary lifestyleFetal growth restrictionHeavy smoking
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insulin therapy
with nutritional therapy exercise alone
do not achieve adequate glycemic control
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Self-Monitored Capillary Blood Glucose Goals Specimen Level (mg/dL)
Fasting ≤ 95 Premeal ≤ 100 1-hr postprandial ≤ 140 2-hr postprandial ≤ 120 0200–0600 ≤60 Mean (average) 100 Hemoglobin A1c ≤ 6%
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A1 - Euglycemia achieved with diet and exercise
A2 - Require medication to achieve
euglycemia
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management Gestational Diabetes
A1 (Diet controlled) Targeted scan at 16-18 wks (no fetal echo) Fasting & 2 hr PPG weeklyGrowth scan
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Gestational Diabetes
A2 (not controlled with diet alone) Targeted scan at 16-18 wks (no fetal echo) Fasting & 2 hr PPGGrowth scan every 4 wks after insulin or oral medication started (but no earlier than 26 wks) Twice wkly antenatal testing at 28 - 32 wks
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Timing of delivery
Preterm delivery only for the usual Obstetric indications preeclampsia fetal growth restriction abruption premature labor with or without premature rupture of
membranes non-reassuring fetal testing
Maternalworsening Maternal renal function active proliferative retinopathy
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Time of delivery
Class A1 term gestation
Class A2 39 weeks
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ACOG recommends
cesarean delivery in diabeticestimated fetal weight exceeds 4,500 g
protracted laborfailure of descent
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Ultrasoundin pregestational diabet Dating scan at 8 – 12 wks Nuchal translucency 11-14 wks Targeted scan including fetal echo at
18-20 wks Growth scan at 26 wks and every 4
wks thereafter NST + AFI twice wkly starting at 32
wks; 28 -wks if poorly controlled or class D- T.
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بروز ديابت آشكار
عوارض قلبي عروقي مرتبط با ليپيدهاي غيرطبيعي سرم
هيپرتانسيون
چاقي شكمي
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از ديابت عوارض مادريروي حاملگيقبل موجود
پره اكالمپسي كتواسيدوز عفونت بخصوص
پيلونفريت هيپرتانسيون
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از قبل عوارض جنيني ديابت روي حاملگيموجود سندرم ديسترس
جنيني مرگ ومير بدون
علتپلي هيدرآمنيوسكارديوميوپاتي به ارث بردن
ديابت
سقط آنومالي جنينيپرترم ليبرماكروزومي هيپوگليسمي
نوزاد هيپربيلي
روبينميهيپوگليسمي
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حاملگي قبل
اول ماهه سه
دوم ماهه سه
سوم ماهه سه
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70قندخون ناشتا بين حفظ گردد100تا
قندخون يكساعت بعد غذا حفظ گردد.140كمتر از ساعت بعد غذا 2قندخون حفظ گردد120كمتر از
روي محدوده A1هموگلوبين فوقاني طبيعي يا نزديك به آن
قرار گيرد. g 400مصرف فوالت روزانه
2 اسيدفوليك روزانه mg4يا ماه قبل حاملگي و ادامه آن تا
ماهه اول حاملگي3
- قبل حاملگي بايد
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- سه ماهه اول
تبديل داروي خوراكي به انسولين
تنظيم دوز انسولينبررسي از نظر رتينوپاتي
ومعرفي به چشم پزشكبررسي از نظر عمل كليه با اندازه گيري پروتئين ادرار و
كليرانس كراتينين E.CGانجام
كشت ادرار روزانه mg75مصرف آسپرين
در بيماران داراي واسكولوپاتي
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- سه ماهه دوم
اندازه گيري آلفافتوپروتئين سرم حاملگي16مادر در هفته
حاملگي18-20سونوگرافي در هفته -22اكوكارديوگرافي جنيني در هفته
حاملگي20
بررسي از نظر آنومالي هاي جنيني با:
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- سه ماه سوم
2 هفته و هفته اي 34 تا 32 از هفته NSTانجام بار
يا پروفيلCST غير طبيعي بود انجام NSTاگر جهت بررسي از نظر ماكروزومي ACاندازه گيري
حاملگي35بستري كردن در بيمارستان از هفته
در بيماراني كه دچار مشكالت عروقي اند يا توجه :قندخون آنها بخوبي كنترل نمي شود ارزيابي و
مونينور بايد زودتر و بيشتر انجام گيرد.
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Serum & insulin in labor
--1
1,52
2.5
<70100<
100-140141-180220-181
>220
dextrose 5%Ringer lactate
D5
Ringer lactate D5
Normal salinNormal salinNormal salin
Serum 125cc/hour dose of insulinu/hr
Serum BS
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ريسك فاكتورهاي احتمالي افزايش بدون توجيه در ديابت جنین مرگ ومير
و حاملگيزنان ديابتيك با اختالالت عروقي
زنان ديابتيك با پره اكالمپسيزنان ديابتيك دچار هيدرآمنيوسزنان ديابتيك با جنين ماكروزومزنان ديابتيك با قندخون كنترل
نشدهزنان ديابتيك دچار كتواسيدوزيس
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Postpatrum
gestational diabetes are at increased risk of developing diabetes after
pregnancy
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Management post delivery
1-3 day post delivery
Postpartum
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Postdelivery (1–3 d) Fasting random plasma glucose
Detect persistent, overt diabetes
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Classification of the American Diabetes Association (2013)
Early postpartum (6–12 wk) 75-g, 2-hr OGTT Postpartum classification of glucose
metabolism 1-yr postpartum 75-g, 2-hr OGTT Assess glucose metabolism AnnuallyFasting plasma glucose Assess glucose
metabolism Triannually
75-g, 2-hr OGTT Assess glucose metabolism Prepregnancy
75-g, 2-hr OGTT Classify glucose metabolism
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ساعت آزمايش
ناشتا
ساعت 2بعد
غيرديابتي
110<
140<
اختالل تحمل تست گلوكز
125-110
199-140
ديابتيك
126
200
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انفوزيون انسولين و سرم تراپي حين زايمان براساس گلوكز خون
دوزانسولين u/hr
--1
5/12
5/2
گلوكز خون
70<100<
140-100180-141220-181
220>
در cc125مايعات ساعت%5دكستروز
D5رينگرالكتات
D5رينگرالكتات
سالين نرمالسالين نرمالسالين نرمال
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با دوز كم مگر بيمار ocp استفاده از واسكولوپاتي يا سابقه طوالني مدت بيماري
ايسكميك قلبي داشته باشد.IUD استقاده از
استفاده از پروژسترون تنها عقيم سازي
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Maternal Hyperglycemia
Fetal Hyperglycemia
Fetal Hyperinsulinemia
↑Fetal substrate uptake ↑Oxygen uptake Lung Surfactant↓
Respiratory Distress Syndorme
Lipids / Amino acid ↑ Hypoxemia
Polycythemia Marosomia
↑Erythropoietin
? SB
↑BMR
PATHOGENIC EVENTS
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Maternal Diabetes Glucose crosses
placenta
Carbohydrate surplus of fetus
Increased secretion of insulin
Stimulation of protein, lipid & glycogen synthesis Free amino acid
Stimulatory effect on development of B cells
Release Insulin like growth factor
MACROSOMIA
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Teratogen Period ofexposure
ComplicationsType of
Diabetes
Aberrantfuel mixture
Hyper insulinaemia
Hyper insulinaemia Foetus
delivery
GDM
PGDM
1st trimester
2nd trimester
3rd trimester
Spontaneous abortionsEarly growth delayCongenital anomalies
Spontaneous abortionsEarly growth delayCongenital anomalies
MacrosomiaSelective
OrganomegalyCNS
development delay
Chronic hypoxiaStillbirth
MacrosomiaSelective
OrganomegalyCNS
development delay
Chronic hypoxiaStillbirth
Birth injuryBirth injury
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Thank your attention