MATERI

Pre Gestational Diabetes:

Diabetes is present prior pregnancy

What is gestational diabetes

Carbohydrate intolerance of variable

severity with onset or first recognition

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during pregnancy with a probable resolution
after the end of pregnancy.
Prevalance 3 – 5 % ( HKFM)
Gestational diabetes mellitus ( 90%)

Pregestational diabetes mellitus ( 10%)

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 Risk Factor
• Prior unexplained stillbirth
• Prior infant with congenital anomaly
• Prior macrosomic infant
• History of GDM
• Family history of Diabetes
• Obesity

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• Chronic use of steroid.
• Glycosuria
• Polyhidramnios
Screening
Low risk
 Screening may not be necessary
 Family history diabetes (-)
 Aged < 25 th
 BMI <25
 No history of adversed obstetric

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outcomes ass with GDM (-)
 Ethnic
Average risk
 Universal screening : the best GA screening is 24 –
28 weeks.
 ethnic
 Obesity, Family history, history of DMG, glycosuria.

High risk

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 First prenatal visit, if early screening is negative, a
repeated screen should be performed at 24 – 28
weeks gestation
 Pathogenesis of Type I DM
Genetic
HLA-DR3/4 Environment
Viral infe..? Autoimmune Insulitis
• PS Glomerulonephritis Ab to ß cells/insulin
• Graves, Hashimoto thyroiditis.
• Rheumatic heart disease
• SLE, Collagen vascular disease
• Rheumatoid arthritis.
ß cell

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Destruction

Type I / IDDM Insulin deficiency

 Pathophysiology of type 2 diabetes mellitus

Genetic
Genetic

Hyperinsulinaema Hyperinsulinaema Type 2 DM

+ + ↑insuline resistance
Insuline resistance Normal glucose Posprandial ↓β-cell function
↓β-cell function
tolerance hyperglycaemia ↑hepatic glucose
production

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Glucotoxicity
Risk factor and makers Lipotoxicity
Ethnic population Latent autoimmunity
Obesity
Puberty
Family history
PCO
Acanthosis nigricans
 Other Causes of Diabetes Mellitus

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S Silbernagl et al. Color Atlas of Pathophysiology, Thieme 2000 : 286-93
 Kriteria Diagnostic
One step strategy

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Perform a 75-g OGTT, with plasma glucose measurement when patient is fasting and at 1 and 2 h, at 24-28

weeks of gestation in women not previously diagnosed with overt diabetes.

The OGTT should be performed in the morning after an overnight fast of at least 8 h.
 2 step strategy

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Step 1: Perform a 50-g GLT (nonfasting), with plasma glucose measurement at 1 h, at 24–28 weeks of gestation in

women not previously diagnosed with overt diabetes.If the plasma glucose level measured 1 h after the load is >130

mg/dL, 135 mg/dL, or140 mg/dL

Step 2: The 100-g OGTT should be performed when the patient is fasting.
 GESTATIONAL DIABETES REPERCUSIONS ON:

Embryo Fetus Newborn

Abortions
Malformations
Growth
alterations
MACROSOMIA

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Alterations of
IUGR
maturity
Metabolic alterations
Respiratory distress
Hypoglicemia
syndrome Distocia
Hypocalemia
Hyperbilirubinemia
Perinatal asphyxia
Policitemia
Fetal problems associated with maternal hyperglycemia
according to trimester gestation

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PEDERSEN Hypothesis
MATERNAL
HYPERGLYCEMIA
MATERNAL HYPER
AMINO ACIDEMIA
FETAL
HYPERGLYCEMIA
FETAL HYPER AMINO
ACIDEMIA
FETAL PANCREATIC
HYPERPLASIA

FETAL

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HYPERINSULINEMIA

MACROSOMIA ORGANOMEGALY e.g. INCREASED SURFACTANT

LIVER, BRAIN ERYTHROPOESIS PRODUCTION

TRAUMATIC VAGINAL NEONATAL POLICYTHAEMIAHYALLINE

MEMBRANE
DELIVERY DISEASE

NEONATAL
 Problems of GDM: fetal

Pre gestasional Gestasional

Cardiac( including great vessel
anomalies) : most common
Central nervous system: 7.2%
Skeletal: cleft lip/palate, caudal
• Increases the risk of fetal
macrosomia
• Birth trauma, Prematurity
• Neonatal hypoglycemia
• Jaundice
• Polycythemia

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regression syndrome • Hypocalcemia,
hypomagnesemia
Genitourinary tract: ureteric
duplication

 Gastrointestinal : anorectal atresia

 Problems of GDM: maternal

• Weight gain
• Maternal hypertensive disorders
• Cesarean delivery (due fetal growth disorders)
• Long term risk of type 2 diabetes mellitus
• Progression of retinopathy

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• Progression of nephropathy
• Coronary artery disease
Glycemic Targets During Pregnancy: AACE & ADA Guidelines1,2

Patients with
Glucose
Patients with GDM Preexisting T1DM or
Increment
T2DM
Preprandial, ≤95 mg/dL (5.3 mmol/L) Premeal, bedtime, and
premeal overnight glucose:
60-99 mg/dL
(3.4-5.5 mmol/L)

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Postprandial, 1-hour post-meal: ≤140 mg/dL Peak postprandial glucose
post-meal (7.8 mmol/L) or 100-129 mg/dL
2-hour post-meal: ≤120 mg/dL (5.5-7.1 mmol/L)
(6.7 mmol/L)

A1C A1C ≤6.0%   

1. AACE. Endocr Pract. 2011;17(2):1-53.

2. ADA. Diabetes Care. 2013;36(suppl 1):S11-66.
 Diabetes in Pregnancy: Management
Approaches

Early referral to a Individualized

specialist is essential
Collaborative effort
among obstetrician
endocrinologist,
ophthalmologist,
treatment plans:
Glucose monitoring
Medical nutrition
therapy (MNT)
Pharmacotherapy

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registered dietitian, and Exercise
nurse educator Weight
All team members should management
be engaged in patient strategies
education/care prior to and
Psychological
throughout pregnancy2
support

1. Castorino K, Jovanovic L. Clin Chem. 2011;57(2):221-30.

2. Mathiesen ER, et al. Endocrinol Metab Clin N Am. 2011;40:727-738.
 Take home messages

 Poorly controlled diabetes increased risks of miscarriage, congenital

malformations, fetal death, preeclampsia, polyhydramnios, macrosomia, birth

injury, RDS, jaundice, hypoglycemia, hypocalcemia

 Preconception counseling should include weight loss, exercise, appropriate diet

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 In pregestational diabetics, fasting glucose ≤95 mg/dL and two-hour

postprandial ≤120 mg/dL (or one-hour postprandial ≤140 mg/dL)

 Women with GDM should be screened for diabetes six to eight weeks
postpartum.
 terimakasih

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1. Which of the following has not been
shown to lower the risk for infection after
cesarean delivery?
• a. Spontaneous separation of the
placenta
• b. Chlorhexidine-alcohol skin preparation
• c. Single-dose antibiotics prior to skin
incision
• d. Surgeons changing gloves after
delivery of the placenta
• 2. In more than 90% of women, metritis
responds to treatment with antibiotics
within what period of time?
• a. 12–24 hours
• b. 24–36 hours
• c. 48–72 hours
• d. 72–96 hours
3. Which of the following is an evidence-based
statement about the use of vacuum-assisted
wound closure devices in obstetrics?
• a. It prevents wound infection.
• b. It is superior to standard dressings.
• c. Provider time is decreased substantially.
• d. It is significantly more cost effective than
standard dressings.
4. A 30-year-old G2P2 presents on postoperative day 6 to the emergency
room complaining of drainage from her cesarean incision. The cesarean
delivery was for failure to progress after a long induction. The patient is
currently afebrile. Her body mass index is 47 kg/m2 . The patient reports
that she sat down yesterday and felt a pop. Shortly thereafter, she noticed
pink/light brown drainage coming from her incision. She endorses chills
and skin irritation around the incision. Lochia has been normal. On your
exam, her skin is erythematous near the incision. There is serosanguinous
drainage from the wound. Although the patient has good pain tolerance,
why do you elect to take her to the operating room to evaluate the
incision?

• a. You plan to proceed with hysterectomy.

• b. You want to open the wound, debride necrotic tissue, and then close
it back up using en bloc closure.
• c. You want to place a negative-pressure wound therapy system and that
can only be done in the operating room.
• d. You are concerned that the fascia may not be intact and if so, the
fascia needs to be closed in the operating room.
5. Which of the following statements
about necrotizing fasciitis is false?
• a. It is common with low mortality
rates.
• b. Three risk factors are diabetes,
obesity, and hypertension.
• c. Surgical debridement of infected
tissue should leave wide margins
of healthy bleeding tissue.
• d. Early diagnosis, surgical
debridement, antimicrobials, and
intensive care are paramount to
successful treatment.
• 6. Which of the following
statements about an ovarian
abscess in the puerperium is
true?
• a. Rupture is rare
• b. Usually affects both ovaries
• c. Women present 4–6 weeks
after delivery
• d. It is thought to be caused by
bacterial invasion of the ovary
through a rent in the capsule.
• 7. Which of the following is a risk factor for
episiotomy dehiscence?
• a. Smoking
• b. Infection
• c. Genital warts
• d. All of the above
8. A 22-year-old G1P1 presents 6 days after a vaginal delivery. Her
course was complicated by chorioamnionitis and a second-degree
perineal laceration. The patient is complaining of pain and drainage
from her vagina. On exam, her laceration repair is open and draining
purulent material. Which of the following would not be a step in your
management?
• a. Intravenous antibiotics
• b. Debridement of necrotic tissue
• c. Establishment of adequate analgesia prior to debridement
• d. Intravenous antibiotics, debridement of necrotic tissue in the
operating room, and then immediate closure of the laceration
• 9. What is the case-fatality rate of toxic
shock syndrome?
• a. 1–2%
• b. 5–6%
• c. 10–15%
• d. 20–25%
10. A 20-year-old G1P1 presents 3 days postpartum
after a vaginal delivery for fever, headache, nausea/
vomiting, and lower abdominal pain. The patient’s
boyfriend reports that she got sick very quickly and
is “not making sense when she talks.” On exam, the
patient has severe abdominal pain and foul-
smelling lochia. She is hypotensive and tachycardic.
She appears extremely ill. Which of the following is
the most likely diagnosis?
• a. Listeriosis
• b. Pyelonephritis
• c. Gastroenteritis
• d. Toxic shock syndrome
11. Which of the following is
the best treatment for toxic
shock syndrome?
• a. Supportive care
• b. Supportive care and
antibiotics
• c. Supportive care,
antibiotics, and wound
debridement if necessary
• d. There is no necessary
treatment as it will resolve
on its own over time
• 12. What is the incidence of mastitis?
• a. 1%
• b. 3%
• c. 10%
• d. 15%
13. When is mastitis most likely to occur?
• a. Postpartum day 1
• b. Postpartum day 5
• c. 3–4 weeks postpartum
• d. 6–9 months postpartum
14. What percentage of women with mastitis
develop an abscess?
• a. 1%
• b. 3%
• c. 10%
• d. 15%
15. Which of the following is not expected in
cases of mastitis?
• a. Fever
• b. Chills
• c. Breast firmness
• d. Symptoms in
both breasts
• 16. According to the World Health
Organization, with no contraceptive use, a
sexually active woman has what risk for
pregnancy over a year?
• a. 65%
• b. 70%
• c. 75%
• d. 85%
17. In contrast to the answer to Question 16
typical use of combination oral contraceptive
pills by a sexually active woman has what risk
for pregnancy over the first year of use?
• a. 3%
• b. 9%
• c. 13%
• d. 17%
18. Which of the following is not considered a
long-acting reversible contraceptive method?
• a. Levonorgestrel implant
• b. Copper intrauterine device
• c. Depot medroxyprogesterone acetate
• d. All of the above are long-acting reversible
contraceptive methods
19. Which of the following statements
properly describe the intrauterine
device?
• a. Mirena is a levonorgestrel-eluting
device, and it is approved for 5 years
of use following insertion.
• b. Liletta contains 52 mg of
levonorgestrel, and it is approved for
5 years of use following insertion.
• c. Skyla is the largest of the
intrauterine devices, and it is
approved for 3 years of use
following insertion.
• d. ParaGard is not considered a
“chemically active” intrauterine
device, and it is approved for 7 years
of use following insertion.
20. Which of the following
statements properly
characterizes expulsion of an
intrauterine device?
• a. The cumulative expulsion
rate after 3 years is 20%.
• b. Expulsion is most
common in the final years of
approved use.
• c. If a woman is unable to
palpate the trailing strings,
she should be evaluated.
• d. All of the above
21. Which of the following radiologic tests is
most helpful in the treatment planning or a
patient with suspected advanced ovarian cancer?
a. Transvaginal sonography
• b. Positron emission tomography
• c. Magnetic resonance imaging of the pelvis
• d. Computed tomography of the abdomen and
pelvis
22. Which of the following cell types of
ovarian cancer is NOT associated with
endometriosis?
• a. Clear cell
• b. Endometrioid
• c. Papillary serous
• d. All of the above
23. Which of the ollowing is NOT a characteristic
of Krukenberg tumors?
• a. They are almost always bilateral.
• b. They usually arise from primary gastric
tumors.
• c. They are usually the only site of metastatic
disease.
• d. They are composed of mucinous and signet
ring adenocarcinoma cells.
24. What is the most common method of
ovarian cancer spread?
• a. Lymphatic
• b. Hematogenous
• c. Direct extension
• d. Tumor exfoliation
25. Approximately what percentage o women
with ovarian cancer clinically confined to the
ovaries will be upstaged by surgery?
• a. 1 percent
• b. 30 percent
• c. 60 percent
• d. 90 percent
TERIMA KASIH