1. 임신 때 당뇨병 관리
김 성 훈
관동의대 제일병원 내과

2. Contents
• Epidemiology of diabetes in pregnancy
• Risks to the mother and the baby
• Preconception counselling and
prepregnancy care
• Management of hyperglycemia in
pregnancy
• Diagnosis and management of GDM

3. 증 례 1
• 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 (results from β-cell destruction, usually
leading to absolute insulin deficiency)
• Type 2 diabetes (results from a progressive insulin
secretory defect on the background of insulin resistance)
• Other specific types of diabetes due to other causes, e.g.,
genetic defects in β-cell function, genetic defects in
insulin action, diseases of the exocrine pancreas (such as
cystic fibrosis), and drug- or chemical-induced (such as in
the treatment of HIV/AIDS or after organ
transplantation)
• Gestational diabetes mellitus (GDM) (diabetes diagnosed
during pregnancy that is not clearly overt diabetes)

5. 한국모자보건학회지 14: 170-80, 2010
임신중당뇨병 임부의 유병률 및 의료이용 추이

6. Issues
• Epidemics of obesity and T2DM ->
numbers of women with T2DM become
pregnant ↑
• Frequently undiagnosed T2DM before
pregnancy
• Lack of preconception care
• ↑Cx of pregnancy due to the
coexistence of obesity and T2DM

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

9. Accelerated fetal growth

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

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

13. Glucose control and risk of
malformation
Guerin A. Diabetes Care 30:1920, 2007
For every 1%
decrease in A1c,
there is
approximately 50%
relative risk
reduction for a
congenital anomaly

15. 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

16. 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

17. 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

18. 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

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

20. Cardiovascular disease
– Untreated CAD : a high mortality during pregnancy
– Successful pregnancies after coronary
revascularization in women with diabetes
– Exercise tolerance should be normal
: to tolerate the increased cardiovascular demands
of gestation

21. 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.

22. Laboratory and special exam of pregnant women with preexisting diabetes
Kitzmiller JL et al:Diabetes Care 2008;31:1060-1079

23. Management of hyperglycemia in pregnancy

24. 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 %
Kitzmiller JL et al:Diabetes Care 2008;31:1060-1079

25. Recommended targets for capillary
glucose during pregnancy
Source Fasting 1 h Peak 2 h Premeal
ADA GDM 95 140 - 120 -
ADA preexisting 60-99 - 100-129 - 60-99
IDF 99 - 144 - -
NICE 63-106 140 - - -
ADIPS 99 144 126 126 -
Mathiesen 72-110 140 72-144 - 72-110

26. 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

27. Medical Nutrition Therapy (MNT)
• Individualized MNT
• Basic plan: dietary recommendations for all
pregnant women, adjusted to the individual needs
• 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

28. 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

29. 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

30. 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

31. Insulin therapy during pregnancy
• Basal–bolus insulin regimens (MDI) or CSII
are recommended for optimal glycaemic
control in pregnancy in women with pre-
existing diabetes
• Oral antidiabetic drugs in women with type 2
diabetes should be discontinued and insulin
initiated and titrated to achieve the
recommended glycaemic control prior to
conception

32. Pharmacokinetics of human insulin and
insulin analogs
Type of insulin Onset of action Peak plasma values Duration of action
Regular human insulin 30-60 min 1-3 h 5-7 h
NPH insulin 60-90 min 8-12 h 18-24 h
Insulin lispro 15-60 min 0.5-1 h 2-4 h
Insulin aspart 10-20 min 1-3 h 3-5 h
Insulin glulisine 10-20 min 1-2 h 3-5 h
Glargine 4-5 h No peak >24 h
Detemir 4-6 h No peak 20 h

33. 증 례 2
• 임신 28주의 32세 여성
• 임신 27주에 50g OCT:1시간 혈당이 174 mg/dL
• 100g OGTT: fasting-97 mg/dL, 1 hour-189
mg/dL, 2 hour-166mg/dL, 3 hour-140mg/dL
• 신장 164cm, 체중은 75kg (임신전 68kg)
• 혈압 110/70mmHg, 신체 검사, 소변검사나 다른
검사 소견은 정상

34. 임신성 당뇨병의 진단기준
당뇨병 진료지침 2013, 대한당뇨병학회

36. Management of GDM

37. Summary of antepartum care
• Medical Nutritional therapy
• Regular exercise
• Maternal SMBG or fetal AC for
intensified Tx
• Insulin remains the mainstay of Tx
• glyburide and metformin may be
offered as an alternative

38. Management of women with prior GDM
Buchanan TA et al. Nat. Rev Endocrinol 8: 639, 2012

39. Summary
1. Preconception detection and management of T2DM
may become a critical public health issue
2. Women with diabetes who are reproductive age need
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
4. Diagnosing and treating GDM can reduce perinatal
complications and postpartum follow up and
prevention of DM is important