임신과당뇨병 - 김희숙 교수

김희숙 (서울대학교 간호대학)

2012.06.12.

임신과 당뇨병

Contact : kimhs02041@hotmail.com

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Contents

• GDM

- Glycemic Index

- Breastfeeding & DM

- Incidence and Risk Factors of

T2DM after GDM

• Preconception Care & DM

• Pregnancy outcomes in PGDM

• Suggestion & Discussion

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GDM

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GDM 관리의 중요성

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• Glucose intolerance of variable severity, with

onset or first recognition during pregnancy

Definition of GDM

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Screening and Diagnosis

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임신성 당뇨병 진단기준

당뇨병 진료지침 2011, 대한당뇨병학회

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ADA: Standards of Medical Care in Diabetes—2010. Diabetes Care 33:S11-S61, 2010

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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

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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)>

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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

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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

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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

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• 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

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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

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• 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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Hee-Sook Kim, kimhs02041@hotmail.com

임신과 당뇨병

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