Lịch sử, khám lâm sàng và đánh giá phòng thí nghiệm của bác sĩ • Lịch sử: điều trị và kiểm soát bệnh tiểu đường, sẩy thai, dị thường của thai nhi, macrosomia, LGA và kiểm soát sinh • Thuốc men: nếu tăng huyết áp, chuyển sang methyldopa hoặc hydralazine, chất ức chế | 144 TYPE 2 DIABETES Patient planning pregnancy History physical exam and laboratory evaluation by clinician History diabetes therapy and control miscarriages fetal anomalies macrosomia LGA and birth control Medications if hypertensive switch to methyldopa or hydralazine ACE inhibitors and beta blockers contraindicated in pregnancy Complications hypoglycemia unawareness retinopathy nephropathy neuropathy Discuss pregnancy-related risks including association of hyperglycemia with maternal and fetal complications Physical exam include funduscopic eye exam with dilation by ophthalmologist Laboratory CBC UA UC thyroid studies 24 hour urine for creatinine clearance and albumin HbA1c EKG SMBG Targets More than 50 of SMBG values within range Pre-meal 70-100 mg dL mmol L Post-meal 140 mg dL mmol l 1 hour after start of meal 120 mg dL mmol L 2 hours after start of meal No severe assisted or nocturnal hypoglycemia Goals may be changed for hypoglycemia unawareness HbA1c Target At least 2 values 1 month apart within normal range Monitoring SMBG up to 7 times day before and 2 hours after start of meals and at bedtime HbA1c at least 2 values 1 month apart Correlate SMBG and HbA1c assess nutritional status self-management skills and psychological status Patient on sulfonylurea metformin a-glucosidase inhibitor meglitinide thiazolidinedione. YES NO Stop oral agent except glyburide and start insulin or glyburide regimen Note All oral agents except glyburide pass the placental barrier . MBG nd or bAcwithin arge ange YES NO Work with patient to establish BG control Re-assess current therapy Start or adjust intensified regimen as needed see Insulin Stage 3 or 4 Continue with birth control Continue co-management with a diabetes specialist Follow-up Medical phone every 1-2 weeks then office visit every 1-2 months Education every 2-3 months or as needed Figure Guidelines for Pregestational and Gestational Diabetes PATIENT EDUCATION 145 Patient education All patients .
