임신과당뇨병 - 김희숙 교수
TRANSCRIPT
Contents
• GDM
- Glycemic Index
- Breastfeeding & DM
- Incidence and Risk Factors of
T2DM after GDM
• Preconception Care & DM
• Pregnancy outcomes in PGDM
• Suggestion & Discussion
•2
GDM
•3
GDM 관리의 중요성
•4
• Glucose intolerance of variable severity, with
onset or first recognition during pregnancy
Definition of GDM
•5
Screening and Diagnosis
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임신성 당뇨병 진단기준
당뇨병 진료지침 2011, 대한당뇨병학회
•8
ADA: Standards of Medical Care in Diabetes—2010. Diabetes Care 33:S11-S61, 2010
•9
1. To prevent perinatal mortality & morbidity
2. To achieve and maintain normoglycemia
Goals of management
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MNT Exercise
Stress
control Insulin
Intervention
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Blood glucose goals (by ADA)
• Fasting whole blood glucose ≤ 95 mg/dL
• 1-h postprandial whole blood glucose ≤ 140 mg/dL
• 2-h postprandial whole blood glucose ≤ 120 mg/dL
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Glycemic Index (당지수)
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당지수 (Glycemic index)란?
• 혈당이 오르는 정도를 표현한 수치로 포도당을 마신후 혈당이 오르는 정도를 100%로 하고, 다른 음식의 혈당을 올리는 정도를 비교하는 수치
• 당지수가 낮을수록 혈당이 천천히 상승
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그림. 혈당지수가 낮은 식품(A)과 혈당지수가 높은 식품(B)의 섭취가 위장관의 포도당 흡수와 식후 혈당에 미치는 영향
•15
고 당지수식품
(70이상)
중 당지수 식품
(56-69)
저 당지수 식품
(55이하)
백미
흰식빵
감자
콘플레이크
수박
79-90
70
80-100
84
70
현미
보리빵
요구르트
잡곡플레
이크
바나나
50-60
65
64
66
53
콩
전곡빵
우유
올브랜
플레이크
사과
18
30-45
27
42
36
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식품별 당지수
식품군별 식품 예 (당지수)
곡류군 흰 맵쌀(83), 흰찹쌀(86~98), 흰빵(70), 통밀빵(55), 현미밥(50),
알랑미(38~58), 통보리(25), 감자(85), 고구마(61), 옥수수(48)
어육류군 강남콩(28), 검정콩(20), 메주콩(18), 고기(0), 생선(0), 치즈(0)
지방군 호두(0), 아몬드(0), 땅콩(14), 올리브 기름(0)
우유군 우유(27)
과일군 수박(72), 파인애플(59), 바나나(52),복숭아(45),포도(46),오렌지(42),
사과(34), 자몽(25)
채소군 푸른 채소(0), 브로콜리(0), 시금치(0)
<참고: 저혈당과 인슐린(2008)>
•17
영양소 현 미
백 미 섬유질 쌀눈
비타민B군 32~33% 65% 2~3%
단백질 12~15% 730mg/100g 6~7%
지방질 22~24%
칼슘 ⧻ 9mg/100g +
인 300mg/100g
철분 ⧻ -
현미와 백미의 영양소 비교
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Dietary advice in pregnancy
for preventing GDM
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published
In The Cochrane Library, 2011, Issue 2
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• Glucose is the primary source of energy for fetal growth
(Moses 2006; Scholl 2004), making maternal glucose levels
influential on pregnancy outcomes - a primary consideration in
gestational diabete management.
• Glycaemic index (GI) qantitatively defines the effect of
carbohydrate based foods on blood glucose levels.
• The GI value of a food is the response of blood glucose to a
particular food, compared with an equivalent amount of the
standard glucose (Foster-Powell 2002).
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Breastfeeding & DM
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GDM에서 모유수유 해야하는 이유
① 혈당조절 효과
- 모유수유를 30분간 하면 50~100mg/dL 혈당 감소
- 임신성 당뇨병 산모의 4~12주 모유수유 후 공복혈당 낮아짐1)
(모유수유 93± 13, 인공수유 98± 17mg/dL)
② 열량 소모 : 평균 25%의 인슐린 요구량 감소1)
③ 모유수유를 최소2개월이상 한 임산부 자녀 :
그렇지 않은 경우보다 제 1형 당뇨병 이환 될 확률 감소2)
(당뇨병 예방에 도움이 되는 물질 함유)
④ 영아 소아비만과 초기 당뇨병에 대한 보호효과 2)
➄ 산후 당뇨병 예방3)
1) American Diabetes Association. (2009). Medical management of pregnancy complicated by diabetes.
2) Taylor, J. S., Kacmar, J E., Nothnagle, M., Lawrence, R. (2005). A systematic review of the literature associating breastfeeding with type 2 diabetes
and GDM. Journal of the American College of Nutrition, 24(5), 320-326.
3) Schwarz, E. B., Brown, J. S., Creasman, J. M. et al. (2010). Lactation and maternal risk of type 2 diabetes: Apopulation-based study.
The American Journal of Medicine, 123(9). 863e1-e6.
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Incidence and Risk Factors of T2DM after GDM Pregnancy
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• GDM affects 2-5% of all pregnancies in Korean women.
• In a mixed ethnic population cohort of Chicago USA, as much as 50% of GDM women progressed to T2DM within 5 years Postpartum.
• Both environmental and genetic factors are thought to contribute to the development of T2DM after GDM
•34
Incidence of T2DM after GDM in Koreans
Ref> 곽수헌 (서울대병원 내분비내과, 2011 ICDM 발표자료) •35
Postpartum complications
• Recurrence of GDM
: ~ 50% in Korean women
(Kwak SH et al, Diabetes Care 31: 1867, 2008)
• Development of T2DM
: 35-60% within 10 years
• A higher incidence of the metabolic syndrome
• Early atherosclerosis (endothelial dysfunction)
: increased risk of chronic hypertension and CVD
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Maternal follow-up
• CVD risk factor assessment
• Breast feeding
• Contraception or pregnancy planning
• Diabetes prevention
•37
Preconception Care & DM
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Fetal Programing
• “자궁 안에서 출생후의 평생건강이 결정된다”
(David Baker, England, 1991)
- 임신 전 및 임신 중 영양부족
- 임신 중 스트레스
- 임신 중 탈수증 등
→ 저 체중아 출생 → 성인에서의 평생 건강의 질 ↓
각종 대사증후군 쉽게 노출된다는 이론
(당뇨, 고혈압, 고지혈증, 비만 등)
• 임신전과 임신 중 관리 강조
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Preconception care for diabetic women for
improving maternal and infant health
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published
In The Cochrane Library, 2011, Issue 2
•42
• Current guidelines in many countries including Australia, the
United Kingdom and United States recommend
preconception care of diabetic women.
• Pregnant women with type I or type II diabetes are at a greater
risk of adverse outcomes in pregnancy such as high blood
pressure(gestational hypertension) and preterm births.
• Pregnancy can also accelerate the development of diabetic
complications(retinopathy, nephropathy, neuropathy,
ischaemic heart disease, cerebrovascular disease, peripheral
vascular disease).
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• Babies born to mothers with type I or type II diabetes
diagnosed before pregnancy may be larger and are at greater
risk of infant death and congenital abnormality (such as
neural tube defects including anencephaly and spina bifida).
• These infants are also at risk of developing type II diabetes
in the long term. Because of the strong association between
good control of a woman’s blood sugars (glycaemic control),
as measured by haemoglobinA1c, and reduced congenital
anomalies, glycaemic targets are central to preconception
care.
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• This review evaluating preconception care management
protocols for women with pre-existing diabetes identified only
one trial (involving 53 women) that was eligible for inclusion.
• None of the prespecified outcomes of the review were reported
by this trial.
• Haemoglobin A1c data were reported as mean changes from
baseline and could not be included in this review.
• Therefore, it is unclear what effect preconception care for
diabetic women has on maternal and infant health outcomes
based on evidence from randomised controlled trials.
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Pregnancy Outcome in Pregnancy Women with Diabetes
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Pregnancy Outcomes in Pregnancy Women with
Type 1 and Type 2 Diabetes
Hee-Sook Kima, Moon-Young Kimb, Jeong-Eun Parkc, Sung-Hoon Kimc
a College of Nursing, Seoul National University, Seoul, Korea b Department of Obstetrics and Gynecology, c Diabetes Center, Division of Endocrinology & Metabolism, Department of Medicine,
Cheil General Hospital & Women’s Healthcare Center, Kwandong University College of Medicine, Seoul, Korea
•53
Pregnancy Outcomes in Pregnancy women with
Type 2 diabetes & Nondiabetes Patient Matched Age,
Prepregnancy BMI and Parity
Hee-Sook Kima, Moon-Young Kimb, Jeong-Eun Parkc, Sung-Hoon Kimc
a College of Nursing, Seoul National University, Seoul, Korea b Department of Obstetrics and c Diabetes Center, Division of Endocrinology & Metabolism, Department of Medicine,
Cheil General Hospital & Women’s Healthcare Center, Kwandong University College of Medicine, Seoul, Korea
•54
• Teratogen Checklist & EMR 기록 추가
• 병원내 “고위험 임신교육과 자조모임”
운영과 활성화 : ex. GDM & PGDM
• Preconception Education 개발과 적용 :
대학생/가임기 여성/고위험 여성
“임신전 생식건강증진 교육프로그램
개발과 평가”
• 산후 T2DM 예방 프로그램 개발과 평가
Suggestion
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GDM 교육 요구도 조사
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Protocol of an integrated self-management program
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Times 1 2 3 4 5
Gestation (Weeks) 29-30 30-31 31-32 32-33 33-34
Topic
Introduction
& Management
of GDM
Compliance
of self-management
Effects of GDM
on maternal-
newborn
Compliance
of self-management
Care & Prevent of DM
in postpartum
Content
• Check of SM list
• Q&A
• Check of SM list
• Q&A
• Check of SM list
• Q&A
• Exercise
• Stress management
• Prevent of DM
in postpartum
• Introduction of GDM
• Dietary
• Emotional support
• Taekyo
• Abdominal breathing
• Emotional support
• Taekyo
• Abdominal
breathing
• Effects of GDM on
maternal-Newborn
• Emotional support
• Taekyo
• Abdominal breathing
• Delivery
• Breastfeeding
• Postpartum care
Method
Small group meeting
(Education & Support)
Telephone-
counseling
Small group meeting
(Education & Support)
Telephone-
counseling
Small group meeting
(Education & Support)
GDM : Gestational Diabetes Mellitus, SM: Self-management
Small group meeting
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Telephone counseling
What was your glucose level
last week?
My glucose level is 100.
But it’s really hard to control diet.
I’m frustrated. Because I can’t eat bread & ramen.
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