Gebelikte Diyabetes Mellitus
Özet
Gebeliğin en sık medikal komplikasyonlarından biri olan gestasyonel diyabet (GDM), pankreasın artan insülin direncini yenememesiyle ortaya çıkan karbonhidrat intoleransıdır. Küresel prevalansı yaklaşık %17 olan GDM; ileri anne yaşı, yüksek vücut kitle indeksi, ailede diyabet öyküsü ve polikistik over sendromu gibi faktörlerle ilişkilidir. GDM tanısı, 24-28. gebelik haftalarında tek veya iki basamaklı oral glukoz tolerans testleriyle konulur. Bu durum, maternal açıdan hipertansif hastalıklar ve uzun dönemde Tip 2 diyabet riskini artırırken; fetal açıdan makrozomi, omuz distozisi, polihidramnios ve neonatal hipoglisemi gibi olumsuz sonuçlara yol açabilir. Tedavide öncelikle tıbbi beslenme ve egzersiz uygulanır; glisemik hedeflere ulaşılamadığında ise plasentayı geçmeyen insülin veya alternatif olarak metformin ve gliburid gibi oral antidiyabetikler kullanılır. Diğer yandan, gebelik öncesinde var olan pregestasyonel diyabet ise fetal malformasyon riskini belirgin şekilde artırdığından sıkı glisemik kontrol ve prekonsepsiyonel danışmanlık gerektirir. Doğum zamanlaması glisemik kontrolün durumuna göre 34 ila 40 6/7 haftalar arasında planlanırken, postpartum dönemde hastaların diyabet gelişimi açısından uzun dönem takibi ve 4-12. haftalarda yeniden taranması kritik öneme sahiptir.
Gestational diabetes mellitus (GDM), one of the most common medical complications of pregnancy, is defined as carbohydrate intolerance that occurs when the pancreas fails to overcome increased insulin resistance. With a global prevalence of approximately 17%, GDM is associated with risk factors such as advanced maternal age, high body mass index, family history of diabetes, and polycystic ovary syndrome. Diagnosis is established between the 24th and 28th weeks of gestation using one- or two-step oral glucose tolerance tests. While GDM increases the maternal risk for hypertensive disorders and long-term Type 2 diabetes, it can cause adverse fetal outcomes including macrosomia, shoulder dystocia, polyhydramnios, and neonatal hypoglycemia. Treatment primarily involves medical nutrition therapy and exercise; if glycemic targets are not met, insulin, which does not cross the placenta, or alternative oral antidiabetics like metformin and glyburide are utilized. On the other hand, pregestational diabetes existing before pregnancy significantly elevates the risk of fetal malformations, thus requiring strict glycemic control and preconception counseling. While the timing of delivery is planned between 34 and 40 6/7 weeks based on glycemic control, long-term maternal follow-up for diabetes development and re-screening at 4-12 weeks postpartum are of critical importance.
Referanslar
Di Cianni, G., et al., Intermediate metabolism in normal pregnancy and in gestational diabetes. Diabetes/metabolism research and reviews, 2003. 19(4): p. 259-270.
Catalano, P.M., et al., Longitudinal changes in insulin release and insulin resistance in nonobese pregnant women. American journal of obstetrics and gynecology, 1991. 165(6): p. 1667-1672.
Parsons, J.A., T.C. Brelje, and R.L. Sorenson, Adaptation of islets of Langerhans to pregnancy: increased islet cell proliferation and insulin secretion correlates with the onset of placental lactogen secretion. Endocrinology, 1992. 130(3): p. 1459-1466.
Guariguata, L., et al., Global estimates of the prevalence of hyperglycaemia in pregnancy. Diabetes research and clinical practice, 2014. 103(2): p. 176-185.
Bulletins—Obstetrics, C.o.P., ACOG practice bulletin No. 190: gestational diabetes mellitus. Obstet Gynecol, 2018. 131(2): p. e49-e64.
Carreno, C.A., et al., Excessive early gestational weight gain and risk of gestational diabetes mellitus in nulliparous women. Obstetrics and gynecology, 2012. 119(6): p. 1227.
Kiani, F., et al., The risk factors of gestational diabetes mellitus: a systematic review and Meta-analysis study. diabetes, 2017. 10: p. 17.
Getahun, D., M.J. Fassett, and S.J. Jacobsen, Gestational diabetes: risk of recurrence in subsequent pregnancies. American journal of obstetrics and gynecology, 2010. 203(5): p. 467. e1-467. e6.
Tobias, D.K., et al., Association of history of gestational diabetes with long-term cardiovascular disease risk in a large prospective cohort of US women. JAMA internal medicine, 2017. 177(12): p. 1735-1742.
Gorgal, R., et al., Gestational diabetes mellitus: A risk factor for non‐elective cesarean section. Journal of Obstetrics and Gynaecology Research, 2012. 38(1): p. 154-159.
Hauth, J.C., et al., Maternal insulin resistance and preeclampsia. American journal of obstetrics and gynecology, 2011. 204(4): p. 327. e1-327. e6.
Yogev, Y., et al., Hyperglycemia and adverse pregnancy outcome (HAPO) study: preeclampsia. American journal of obstetrics and gynecology, 2010. 202(3).
Yogev, Y., E.M. Xenakis, and O. Langer, The association between preeclampsia and the severity of gestational diabetes: the impact of glycemic control. American journal of obstetrics and gynecology, 2004. 191(5): p. 1655-1660.
Ehrenberg, H.M., et al., The influence of obesity and diabetes on the risk of cesarean delivery. American journal of obstetrics and gynecology, 2004. 191(3): p. 969-974.
Kwik, M., et al., Outcomes of pregnancies affected by impaired glucose tolerance. Diabetes research and clinical practice, 2007. 77(2): p. 263-268.
Sovio, U., H.R. Murphy, and G.C. Smith, Accelerated fetal growth prior to diagnosis of gestational diabetes mellitus: a prospective cohort study of nulliparous women. Diabetes care, 2016. 39(6): p. 982-987.
Stotland, N., et al., Risk factors and obstetric complications associated with macrosomia. International journal of gynecology & obstetrics, 2004. 87(3): p. 220-226.
Åberg, A., et al., Impaired glucose tolerance during pregnancy is associated with increased fetal mortality in preceding sibs. Acta obstetricia et gynecologica Scandinavica, 1997. 76(3): p. 212-217.
Dudley, D.J., Diabetic-associated stillbirth: incidence, pathophysiology, and prevention. Obstetrics and gynecology clinics of North America, 2007. 34(2): p. 293-307.
Blank, A., G.D. Grave, and B.E. Metzger, Effects of gestational on perinatal morbidity reassessed: Report of the International Workshop on Adverse Perinatal Outcomes of Gestational Diabetes Mellitus, December 3-4, 1992. Diabetes care, 1995. 18(1): p. 127-129.
Dabelea, D., et al., Intrauterine exposure to diabetes conveys risks for type 2 diabetes and obesity: a study of discordant sibships. Diabetes, 2000. 49(12): p. 2208-2211.
Metzger, B.E., et al., Hyperglycemia and adverse pregnancy outcomes. New England journal of medicine, 2008. 358(19): p. 1991-2002.
Rosenstein, M.G., et al., Risk of stillbirth and infant death stratified by gestational age. Obstetrics and gynecology, 2012. 120(1): p. 76.
Association, A.D., Management of diabetes in pregnancy. Obstetrical & Gynecological Survey, 2017. 72(5): p. 264-266.
Vandorsten, J.P., et al., NIH consensus development conference: diagnosing gestational diabetes mellitus. NIH consensus and state-of-the-science statements, 2013. 29(1): p. 1-31.
Laird, J. and K.F. McFarland, Fasting blood glucose levels and initiation of insulin therapy in gestational diabetes. Endocrine Practice, 1996. 2(5): p. 330-332.
Weisz, B., et al., One hour versus two hours postprandial glucose measurement in gestational diabetes: a prospective study. Journal of Perinatology, 2005. 25(4): p. 241-244.
Association, A.D., 14. Management of diabetes in pregnancy: Standards of Medical Care in Diabetes—2021. Diabetes Care, 2021. 44(Supplement 1): p. S200-S210.
Bantle, J.P., et al., Nutrition recommendations and interventions for diabetes: a position statement of the American Diabetes Association. Diabetes care, 2008. 31: p. S61-S78.
Brown, J., G. Ceysens, and M. Boulvain, Exercise for pregnant women with gestational diabetes for improving maternal and fetal outcomes. Cochrane Database of Systematic Reviews, 2017(6).
Koren, R., Y. Toledano, and M. Hod, The use of insulin detemir during pregnancy: a safety evaluation. Expert opinion on drug safety, 2015. 14(4): p. 593-599.
Lv, S., J. Wang, and Y. Xu, Safety of insulin analogs during pregnancy: a meta-analysis. Archives of gynecology and obstetrics, 2015. 292(4): p. 749-756.
Herrera, K.M., et al., Randomized controlled trial of insulin detemir versus NPH for the treatment of pregnant women with diabetes. American journal of obstetrics and gynecology, 2015. 213(3): p. 426. e1-426. e7.
Castillo, W.C., et al., Trends in glyburide compared with insulin use for gestational diabetes treatment in the United States, 2000–2011. Obstetrics and gynecology, 2014. 123(6): p. 1177.
Mathiesen, E.R., et al., Risk of Major Congenital Malformations or Perinatal or Neonatal Death With Insulin Detemir Versus Other Basal Insulins in Pregnant Women With Preexisting Diabetes: The Real-World EVOLVE Study. Diabetes care, 2021. 44(9): p. 2069-2077.
Varner, M.W., et al., Pregnancies after the diagnosis of mild gestational diabetes mellitus and risk of cardiometabolic disorders. Obstetrics and gynecology, 2017. 129(2): p. 273.
Rowan, J.A., et al., Metformin versus insulin for the treatment of gestational diabetes. New England Journal of Medicine, 2008. 358(19): p. 2003-2015.
Hartling, L., et al., Benefits and harms of treating gestational diabetes mellitus: a systematic review and meta-analysis for the US Preventive Services Task Force and the National Institutes of Health Office of Medical Applications of Research. Annals of internal medicine, 2013. 159(2): p. 123-129.
Fadl, H., et al., Gestational diabetes mellitus and later cardiovascular disease: a S wedish population based case–control study. BJOG: An International Journal of Obstetrics & Gynaecology, 2014. 121(12): p. 1530-1536.
Kalafat, E., et al., Metformin for prevention of hypertensive disorders of pregnancy in women with gestational diabetes or obesity: systematic review and meta‐analysis of randomized trials. Ultrasound in Obstetrics & Gynecology, 2018. 52(6): p. 706-714.
Mauricio, D., et al., Islet cell autoimmunity in women with gestational diabetes and risk of progression to insulin‐dependent diabetes mellitus. Diabetes/metabolism reviews, 1996. 12(4): p. 275-285.
Kessous, R., et al., An association between gestational diabetes mellitus and long-term maternal cardiovascular morbidity. Heart, 2013. 99(15): p. 1118-1121.
Niu, B., et al., What is the optimal gestational age for women with gestational diabetes type A1 to deliver? American journal of obstetrics and gynecology, 2014. 211(4): p. 418. e1-418. e6.
Setji, T.L., A.J. Brown, and M.N. Feinglos, Gestational diabetes mellitus. Clinical diabetes, 2005. 23(1): p. 17-24.
Mellitus, P., Acog Practice Bulletin Summary. Obstet. Gynecol, 2018. 132: p. e228-e248.
Kitzmiller, J.L., et al., Preconception care for women with diabetes and prevention of major congenital malformations. Birth Defects Research Part A: Clinical and Molecular Teratology, 2010. 88(10): p. 791-803.
Tennant, P.W., et al., Pre-existing diabetes, maternal glycated haemoglobin, and the risks of fetal and infant death: a population-based study. Diabetologia, 2014. 57(2): p. 285-294.
Ehrenberg, H.M., B.M. Mercer, and P.M. Catalano, The influence of obesity and diabetes on the prevalence of macrosomia. American journal of obstetrics and gynecology, 2004. 191(3): p. 964-968.
Bell, R., et al., Peri-conception hyperglycaemia and nephropathy are associated with risk of congenital anomaly in women with pre-existing diabetes: a population-based cohort study. Diabetologia, 2012. 55(4): p. 936-947.
Guerin, A., R. Nisenbaum, and J.G. Ray, Use of maternal GHb concentration to estimate the risk of congenital anomalies in the offspring of women with prepregnancy diabetes. Diabetes care, 2007. 30(7): p. 1920-1925.
Tinker, S.C., et al., Specific birth defects in pregnancies of women with diabetes: National Birth Defects Prevention Study, 1997–2011. American journal of obstetrics and gynecology, 2020. 222(2): p. 176. e1-176. e11.
Chen, L., et al., Risk of congenital heart defects in offspring exposed to maternal diabetes mellitus: an updated systematic review and meta-analysis. Archives of gynecology and obstetrics, 2019. 300(6): p. 1491-1506.
Balsells, M., et al., Maternal and fetal outcome in women with type 2 versus type 1 diabetes mellitus: a systematic review and metaanalysis. The Journal of Clinical Endocrinology & Metabolism, 2009. 94(11): p. 4284-4291.
Nielsen, L.R., et al., Hypoglycemia in pregnant women with type 1 diabetes: predictors and role of metabolic control. Diabetes Care, 2008. 31(1): p. 9-14.
Arun, C. and R. Taylor, Influence of pregnancy on long-term progression of retinopathy in patients with type 1 diabetes. Diabetologia, 2008. 51(6): p. 1041-1045.
Relph, S., et al., Adverse pregnancy outcomes in women with diabetes-related microvascular disease and risks of disease progression in pregnancy: A systematic review and meta-analysis. PLoS medicine, 2021. 18(11): p. e1003856.
Bell, D.S., Heart failure: the frequent, forgotten, and often fatal complication of diabetes. Diabetes care, 2003. 26(8): p. 2433-2441.
Parker, J.A. and D.L. Conway, Diabetic ketoacidosis in pregnancy. Obstetrics and gynecology clinics of North America, 2007. 34(3): p. 533-543.
Mahmud, M. and D. Mazza, Preconception care of women with diabetes: a review of current guideline recommendations. BMC women's health, 2010. 10(1): p. 1-7.
Hellmuth, E., P. Damm, and L. Mølsted‐Pedersen, Oral hypoglycaemic agents in 118 diabetic pregnancies. Diabetic Medicine, 2000. 17(7): p. 507-511.
Gilbert, C., M. Valois, and G. Koren, Pregnancy outcome after first-trimester exposure to metformin: a meta-analysis. Fertility and sterility, 2006. 86(3): p. 658-663.
Tieu, J., et al., Screening for gestational diabetes mellitus based on different risk profiles and settings for improving maternal and infant health. Cochrane Database of Systematic Reviews, 2017(8).
Feig, D.S., et al., Metformin in women with type 2 diabetes in pregnancy (MiTy): a multicentre, international, randomised, placebo-controlled trial. The Lancet Diabetes & Endocrinology, 2020. 8(10): p. 834-844.
