Diary of self-control of a pregnant woman with gestational. What should be monitored in GDM? It will also be necessary to significantly limit the use
Blood sugar norms change periodically, and it is especially interesting that the blood sugar norm in pregnant women should be significantly lower than in an ordinary adult. In this regard, quite often pregnant women are diagnosed with "gestational diabetes". Since the urgency of the problem of GDM is very high, let us dwell on the pot-bellies and find out who should pay attention to their health.
Studies conducted by HAPO during the period 2000-2006 found that adverse pregnancy outcomes increased in direct proportion to the level of increase in blood sugar in the observed. We came to the conclusion that it is necessary to revise the norms of blood sugar levels in pregnant women. On October 15, 2012, the Russian meeting took place and new standards were adopted, on the basis of which doctors have the right to diagnose pregnant women with gestational diabetes mellitus, although the symptoms and signs of it may not appear (such diabetes is also called hidden).
The norm of blood sugar in pregnant women
What sugar should be in the blood of pregnant women? So, if the fasting venous plasma sugar level is greater than or equal to 5.1 mmol / l, but less than 7.0 mmol / l, then the diagnosis of "gestational diabetes mellitus" (GDM) is the place to be.
If, on an empty stomach, blood plasma glucose from a vein is above 7.0 mmol / l, a diagnosis of “manifest diabetes mellitus” is made, which in the near future is qualified as type 1 diabetes or type 2 diabetes.
At the consensus, the issue of performing an oral glucose tolerance test (OGTT) during pregnancy was thoroughly discussed. We came to the conclusion to refuse to carry it out before the 24th week, since until that time the pregnant woman is in a high risk group. Thus, at a period of 24-28 weeks (in some cases up to 32 weeks), pregnant women who have not had an increase in sugar more than 5.1 before that time are given a GTT test with 75 g of glucose (sweet water).
Glucose tolerance in pregnant women is not determined in the following cases:
- with early toxicosis of pregnant women;
- subject to strict bed rest;
- against the background of an acute inflammatory or infectious disease;
- during an exacerbation of chronic pancreatitis or in the syndrome of a resected stomach.
The sugar curve during GTT should normally not go beyond:
- fasting glucose less than 5.1 mmol/l;
- 1 hour after taking a glucose solution less than 10 mmol / l;
- 2 hours after taking a glucose solution, more than 7.8 mmol / l, but less than 8.5 mmol / l.
The analysis for glucose and the norm of blood sugar in pregnant women, which must be strived for:
- fasting sugar less than 5.1 mmol/l;
- sugar before meals is less than 5.1 mmol / l;
- sugar at bedtime is less than 5.1 mmol / l;
- sugar at 3 am less than 5.1 mmol/l;
- sugar 1 hour after eating less than 7.0 mmol/l;
- no hypoglycemia;
- no acetone in urine;
- blood pressure less than 130/80 mm Hg.
When is insulin given to pregnant women?
Diabetes mellitus during pregnancy is dangerous not only for a woman, but also for a child. A pregnant woman after childbirth runs the risk of acquiring type 1 or type 2 diabetes, and a baby can be born ahead of schedule quite large, but in immature lungs and other organs. In addition, the pancreas of the fetus with high sugars in the mother begins to work for two, and after birth, the baby has a sharp decrease in blood sugar (hypoglycemia) due to the activity of the pancreas. A child born to a woman with unregulated GDM is retarded and has a high risk of developing diabetes. Therefore, it is so important to monitor blood sugar levels and suppress a high jump with diet or insilin therapy. Treatment with insulin injections is prescribed only if it is not possible to regulate sugar with the help of a diet and is canceled immediately after childbirth.
- If within 1-2 weeks of careful monitoring, jumps in glucose above the norm are observed (2 times or more elevated sugar is recorded) and its norm in the blood of pregnant women is not maintained on a constant basis, insulin therapy is prescribed. The optimal drug and dosage is prescribed and selected only by the attending physician in the hospital.
- An equally important indication for the appointment of insulin is fetal fetopathy according to the results of ultrasound (large fetus, namely the large diameter of the abdomen, cardiopathy, bypass of the fetal head, edema and thickening of the subcutaneous fat layer and cervical fold, identified or increasing polyhydramnios, if there are more reasons for its appearance not found).
Selection of the drug and approval / correction of the insulin therapy regimen is carried out only by a doctor. Do not be afraid of insulin injections, because they are prescribed during pregnancy with subsequent cancellation after childbirth. Insulin does not get to the fetus and does not affect its development, it just helps the mother's pancreas cope with the load, which, as it turned out, is beyond her power.
Hypoglycemic tablets for pregnant women and during breastfeeding do not prescribe, as they are absorbed into the blood, and pass through the body of the child
Pregnancy in pregnant women with GDM
If the diagnosis of gestational diabetes mellitus is detected and confirmed by repeated tests, the following rules must be observed:
- A diet with the complete exclusion of easily digestible carbohydrates and restriction of fats (see the sample menu for a week below).
- Even distribution of the daily volume of food into 4-6 meals, and the periods between meals should be approximately 2-3 hours.
- Dosed physical exercise(at least 2.5 hours a day).
- Self-control, namely the definition:
- fasting glucose levels, before meals and 1 hour after meals using a glucometer. Periodically donate blood for sugar in the laboratory. Keep a food diary and record your blood sugar levels.
- determination of acetone in urine in the laboratory. If acetone is detected, it is necessary to increase the intake of carbohydrates before bedtime or at night;
- blood pressure;
- fetal movements;
- body weight.
What can you eat with gestational diabetes (diet number 9)
You can reduce sugar in GDM with the help of diet No. 9, it is not so complicated and strict, but, on the contrary, tasty and correct. The essence of the diet for diabetes is the complete exclusion of fast and easily digestible carbohydrates from the diet, nutrition should be complete and fractional (every 2-3 hours), since prolonged fasting should not be allowed. The following are clinical guidelines for nutrition in GDM.
It is forbidden:
- sugar,
- semolina,
- jam,
- sweets in the form of chocolates, sweets,
- ice cream,
- muffin (baking),
- shop juices and nectars,
- soda,
- fast food,
- dates,
- raisin,
- fig,
- bananas,
- grape,
- melon.
You can limited:
- durum wheat pasta;
- butter;
- inedible products;
- eggs (3-4 pieces per week);
- sausage.
Can:
- cereals (oatmeal, millet, buckwheat, barley, barley, corn);
- legumes (chickpeas, beans, peas, beans, soybeans);
- all fruits (except bananas, grapes and melons);
- fat-free cottage cheese;
- low-fat sour cream;
- meat (chicken, rabbit, turkey, beef);
- all vegetables (except carrots, beets, potatoes - in limited quantities);
- black bread.
Approximate menu for a week with gestational diabetes (how to keep sugar normal?)
Monday
Breakfast: buckwheat boiled in water, 180g; weak tea without sugar.
Snack: 1 orange, low-fat cheese 2 slices, black bread 1 slice.
Lunch: 50g boiled beets with garlic, 100ml pea soup (without smoked meats), 100g boiled lean meat, 2 slices black bread, tea with lemon.
Snack: fat-free cottage cheese 80g, crackers 2 pcs.
Dinner: mashed potatoes 120g, green peas 80g, black bread 1 slice, rosehip broth 200ml.
At night: bread 2 slices, cheese 2 slices and unsweetened tea.
Tuesday
Breakfast: wheat porridge 180g, unsweetened tea.
Snack: cottage cheese casserole 100g.
Lunch: vegetable salad 50g, beetroot soup or borscht 100 ml, boiled chicken 100g, black bread 2 slices, unsweetened tea.
Afternoon snack: 1 apple
Dinner: boiled buckwheat 120g, steamed pink salmon 120g, cucumber and tomato salad 50g, unsweetened tea.
At night: ryazhenka 200 ml.
Wednesday
Breakfast: oatmeal 150g, bread with butter 1 slice, tea without sugar.
Snack: fat-free cottage cheese with apples 150g.
Lunch: 100g pea soup (without smoked meats), 2 fish cakes, 100g wheat porridge, 2 slices of bread, green tea.
Snack: vegetable salad 150g.
Dinner: stewed cabbage 120g, steamed fish 100g, herbal decoction 200ml.
At night: low-fat natural yogurt 150 ml, bread 1 slice.
Thursday
Breakfast: 2 boiled eggs, 1 slice of rye bread with butter, unsweetened tea.
Snack: a piece of black bread with cheese, chicory.
Lunch: lentil soup 100 ml, beef 100g, buckwheat porridge 50g, black bread 1 slice, tea without sugar.
Snack: fat-free cottage cheese 80g, kiwi 3 pcs.
Dinner: vegetable stew 120g, boiled chicken fillet 100g, mint tea, bread 1 slice.
But night: ryazhenka 200 ml.
Friday
Breakfast: Corn porridge 150g, rye bread 1 slice, tea.
Snack: bread 1 slice, cheese 2 slices, apple 1 pc, rosehip tea.
Lunch: vegetable salad 50g, bean soup 100ml, beef stew with buckwheat 100g, bread 1 slice, unsweetened tea.
Snack: 1 peach, fat-free kefir 100 ml.
Dinner: boiled chicken 100g, vegetable salad 80g, fruit juice.
Before bed: 2 slices of bread, 2 slices of cheese and unsweetened tea.
Saturday
Breakfast: fat-free cottage cheese 150g, tea without sugar and a slice of bread with butter.
Snack: fruit or bran.
Lunch: carrot and apple salad 50g, fresh cabbage soup 150 ml, boiled meat 100g, black bread 2 slices.
Afternoon snack: 5-6 apricots
Dinner: millet porridge with fish or meat 150g, green tea.
Before going to bed: fat-free kefir 200 ml.
Sunday
Breakfast: barley porridge on the water 180g, chicory.
Snack: fruit salad with lemon juice 150g.
Lunch: vegetable soup with meatballs 150g, barley porridge with chicken 100g, vegetable salad 50g, tea without sugar.
Snack: pear 1 pc and biscuits 2 pcs.
Dinner: fish baked in foil 50g, vegetable stew 150g, chicory.
Before going to bed: yogurt 200ml.
As you can see, table number 9 is quite diverse, and if you develop the habit of eating like this all the time, your health will be in perfect order!
Delivery in gestational diabetes mellitus
By itself, the diagnosis of GDM is not an indication for early delivery or planned delivery. caesarean section, therefore, if a pregnant woman has no indications against natural childbirth, you can give birth yourself. Exceptions are cases when the child begins to suffer or the fetus is so large that natural childbirth becomes impossible.
GDM in most cases goes away after childbirth on its own, but the likelihood of acquiring type 1 or type 2 diabetes after 10-20 years always remains with a woman.
Currently, there are various special tools for self-measurement of blood sugar levels. If a pregnant woman is diagnosed with GDM as a result of diagnostic tests, then the doctor prescribes the patient a diet with a restriction of easily digestible carbohydrates and daily determination of blood sugar levels, or, in medical terms, glycemic control. Continuous self-monitoring of glycemia will help determine whether diet and physical activity alone is sufficient to maintain normal blood sugar levels, or whether additional insulin is needed to protect the fetus from the harmful effects of hyperglycemia (high blood sugar).
These include:
1. Devices for measuring blood sugar levels (glucometers), which allow you to accurately determine its level.
2. Visual test strips impregnated with a special chemical composition, which, interacting with a drop of blood, changes color. However, comparing the color of the test strip with the reference scale, one can only approximately determine the level of sugar (± 2-3 mmol / l). This is completely unacceptable during pregnancy, since in order to prevent the development of complications in the fetus, maximum compensation of carbohydrate metabolism is required. The criteria for adequate control of GDM are:
Fasting blood sugar Ј 5.2 mmol/l
Blood sugar 1 hour after eating Ј 7.8 mmol / l
Blood sugar 2 hours after eating Ј 6.7 mmol / l
A blood sugar level that exceeds the above figures is called hyperglycemia.
Painless examination is provided by special automatic devices for piercing the skin of fingers.
Your doctor will help you choose the right self-control products and tell you where to buy them.
You must measure your blood sugar at least 4 times a day. If you are prescribed only diet therapy, measurements are taken on an empty stomach and 1 or 2 hours after the main meals (the time for self-monitoring will be determined by your doctor). If you receive insulin injections, then the control must be carried out 8 times a day: on an empty stomach, before and 1 or 2 hours after the main meals, before bedtime and at 3 am.
Compensation of carbohydrate metabolism significantly reduces the risk of developing late toxicosis of pregnant women and diabetic fetopathy (DF). That is why it is so important to conduct regular self-monitoring of blood glucose 4-8 times a day. If you are on diet therapy, then post-meal sugar control will allow you to evaluate the effectiveness of the diet and determine the effect of various foods on glycemic levels. As the placenta grows, the amount of pregnancy hormones increases, which reduce the sensitivity of the cells of the mother's body to insulin. Regular self-monitoring of blood sugar levels allows you to prescribe insulin therapy in time if hyperglycemia persists.
Be sure to keep a self-monitoring diary, where you should note your blood sugar levels, the amount of carbohydrates you eat, your insulin dose, blood pressure and weight. Regular self-monitoring will help you correctly assess the changes taking place in your body, fearlessly make independent decisions in changing the tactics of insulin therapy, reduce the risk of pregnancy complications and diabetes, give birth healthy baby. Be sure to bring your diary with you to each visit to the endocrinologist.
Evaluation of the effectiveness of diet therapy, insulin therapy and self-control is carried out using a study of the level of fructosamine (combination of albumin protein with glucose). The fructosamine index can be considered as the average value of blood glucose during the 2 weeks preceding the study. The study of fructosamine makes it possible to quickly respond to the decompensation of carbohydrate metabolism. The content of fructosamine in the range of 235-285 µmol/l is considered normal.
In addition to controlling blood sugar levels, it is necessary to control the presence of ketone bodies in urine. We have already discussed that ketone bodies are breakdown products of cellular fat. They can appear when carbohydrates are restricted in the diet. Their significant concentration with inadequate insulin therapy or during fasting (for example, "fasting days"!) Can have a detrimental effect on the fetus, as oxygen delivery to its organs and tissues is reduced. Therefore, firstly, fasting days during pregnancy are excluded! Second, control ketone bodies in the following situations:
in the morning on an empty stomach to assess the adequacy of carbohydrate intake,
if glycemia in two or three studies in a row is higher than 13 mmol / l,
if you ate less carbohydrates than usual.
To determine the ketone bodies in the urine, special test strips are used, which are coated with a chemical composition that reacts with the ketone bodies of the urine. Such a test strip can be substituted under a stream of urine or lowered for a few seconds into a container of urine. In the presence of ketone bodies, the test field of the strip changes color. The color intensity depends on their concentration, which can be determined by comparing the color of the test strip with the reference scale.
The presence of ketone bodies in the urine should be reported to your doctor. He will help you understand the reason for their appearance and give appropriate recommendations.
At home, you can also control your blood pressure and weight gain yourself.
The upper limit of normal blood pressure for a pregnant woman is 130/85 mm Hg. Art. However, if your blood pressure before pregnancy and in the first trimester was, for example, 90/60 mm Hg, then the pressure is 120-130/80-85 mm Hg. st in the III trimester of pregnancy for you should be the reason for an unscheduled visit to the doctor. Arterial hypertension poses a threat to pregnancy.
How to measure blood pressure correctly?
A device for measuring pressure - a tonometer - consists of several parts:
Cuff: Must fit the size of the arm. If the arm circumference is less than 40 cm, a standard size cuff is used, more than 40 cm - a large size.
Scale: When there is no air in the cuff, the pointer should be at zero, the divisions should be clearly visible.
Bulb and valve: The valve controls the rate of pressure drop in the cuff. The inflation and deflation of air must be free.
Phonendoscope: used to listen for noises that occur when blood moves.
Rest 5 minutes in a sitting position before measuring.
· Apply the cuff so tight that you can put your finger under it.
· Before the first measurement, find the place of the pulsation of the artery in the cubital fossa, apply the membrane of the phonendoscope to this place.
Insert the "olives" of the phonendoscope into your ears so that they tightly cover the ear canal.
· Place the scale of the tonometer so that the divisions are clearly visible.
The hand on which the measurement will be taken must be freed from clothing, put on the table, straightened and relaxed.
· With the other hand, take a pear, screw the valve with your thumb and forefinger, quickly pump air into the cuff to a value of about 30 mm Hg. above your estimated systolic ("upper") pressure.
· Slightly turn off the valve and let the air out slowly. The rate of pressure drop should be no more than 2 mm Hg. per second.
The value of systolic pressure corresponds to the first beat of at least two consecutive beats.
The value of diastolic ("lower") pressure - the figure at which beats cease to be heard
· After the blows have ceased completely, open the valve.
Record the results in a self-monitoring diary.
Weight control should be carried out weekly in the morning, on an empty stomach, without clothes, after a bowel movement and Bladder. Only under these conditions you will receive reliable information about weight gain. Weight gain for each pregnant woman can be completely individual. However, in the third trimester of pregnancy, an increase of more than 350 g per week can serve as a warning symptom of latent edema. Symptoms of obvious edema, as well as other symptoms of late toxicosis of pregnant women, requiring urgent medical care, see How GDM Affects Pregnancy.
For timely warning and detection of these conditions, it is necessary, in addition to the above parameters, to monitor every two weeks:
· general urine analysis,
microalbuminuria (MAU) - the appearance of a microscopic amount of protein in the urine,
Urine culture (the presence of bacteria in the urine) - an indicator of the inflammatory process in the kidneys, if the general analysis of urine contains a lot of leukocytes.
How to monitor the development and condition of your baby.
Ultrasound examination (ultrasound)
This is a study using an apparatus that emits ultrasonic waves and creates an image of the organs and tissues of the mother and fetus on the screen. The study is safe for the health of mother and child. With the help of ultrasound, the gestational age is determined, the location of the placenta, the size of the fetus, its position, activity, respiratory movements, the volume of amniotic fluid, as well as malformations and signs of diabetic fetopathy are determined. Ultrasound examination of blood flow in the vessels of the uterus, placenta and fetus is called Doppler.
CTG - cardiotocography .
The test is used to confirm the good condition of the baby and is based on the principle of accelerating the fetal heart rate during its physical activity. To do this, special sensors are placed on the belly of the pregnant woman, which record uterine contractions and the fetal heartbeat. With each movement of the fetus, the woman must press a special button on the recording device. The baby's movements can be spontaneous or triggered by external influences, such as stroking the mother's abdomen. The recording of the fetal heartbeat is made during its movement. If the heart rate increases, then the test is considered normal.
Fetal movements.
The activity of the fetus reflects its condition. If you feel the fetal movements well, do not notice a decrease in their frequency or intensity, then the child is healthy and there is no threat to his condition. Conversely, if you notice a certain decrease in the frequency and intensity of fetal movements, then he may be in danger. Your doctor will ask you to count your baby's movements during the last trimester of your pregnancy. The lower limit of the norm is 10 strong shocks in the last 12 hours or 10 movements in 1 hour. If you do not feel the fetal movement or the number of movements was less than usual, consult a doctor immediately!
How does GDM affect childbirth and breastfeeding?
If your diabetes is under good control, your condition is satisfactory, your obstetric history is not burdened (the size of the fetus and pelvis correspond, the fetus is head presentation, etc.), the baby is of normal size, then you can give birth through the natural birth canal. Indications for caesarean section will be the presence of signs of diabetic fetopathy in the fetus, a violation of its vital functions, pregnancy complications, such as arterial hypertension, renal dysfunction, etc.
During childbirth, the need for insulin changes significantly. The level of contra-insulin hormones of pregnancy decreases sharply (since the placenta stops producing them), and the sensitivity of cells to insulin is restored. During labor, you may even be given intravenous glucose solution to prevent hypoglycemia. You probably won't need insulin after delivery, and your blood sugar levels will return to normal.
Breastfeeding is not contraindicated. This helps to quickly restore shape, reduce weight after childbirth, since a significant supply of calories accumulated during pregnancy is spent on milk synthesis. Approximately 800 kilocalories per day in the first 3 months after childbirth, and even a little more in the next 3 months.
The biggest benefit of breastfeeding is, of course, your baby. FROM breast milk it is given protection (immunity) from infections and all the necessary nutrients in ideal proportions.
How will gestational diabetes affect your health in the future?
For most women, GDM disappears after childbirth. 6-8 weeks after your baby is born, you should do a 75 g glucose exercise test to rule out type 2 diabetes. If you continue to need insulin after delivery, you may have developed type 1 diabetes during pregnancy. to your doctor for additional examination and selection of adequate therapy.
About half of all women with GDM develop type 2 diabetes several years after pregnancy. Therefore, you should check your fasting blood sugar every year. Regular exercise will help you reduce your risk of diabetes. physical exercises and maintaining normal body weight.
How will GDM affect your child's health in the future?
Most often, women with GDM are concerned about the question: "Will my child develop diabetes after birth?" Answer: "Probably not." However, such children most often suffer from overweight, metabolic disorders. They are at risk for developing type 2 diabetes later in life. Prevention of these diseases is proper nutrition, physical activity and maintaining a normal body weight.
Pregnancy planning
Be aware of the increased risk of developing GDM in the next pregnancy. Therefore, you should plan your pregnancy. This means that conception should be postponed until you have undergone a comprehensive examination by an endocrinologist and gynecologist, as well as by other specialists, if necessary.
RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical Protocols of the Ministry of Health of the Republic of Kazakhstan - 2014
Diabetes mellitus in pregnancy, unspecified (O24.9)
Endocrinology
general information
Short description
Approved
at the Expert Commission on Health Development
Ministry of Health of the Republic of Kazakhstan
Protocol No. 10 dated July 04, 2014
Diabetes mellitus (DM) is a group of metabolic (exchange) diseases characterized by chronic hyperglycemia, which is the result of a violation of insulin secretion, insulin action, or both of these factors. Chronic hyperglycemia in diabetes is accompanied by damage, dysfunction and failure of various organs, especially the eyes, kidneys, nerves, heart and blood vessels (WHO, 1999, 2006 with additions) .
This is a disease characterized by hyperglycemia, first diagnosed during pregnancy, but not meeting the criteria for "manifest" diabetes mellitus. GDM is a disorder of glucose tolerance of varying severity that occurs or is first diagnosed during pregnancy.
I. INTRODUCTION
Protocol name: Diabetes during pregnancy
Protocol code:
Code (codes) according to ICD-10:
E 10 Insulin-dependent diabetes mellitus
E 11 Non-insulin dependent diabetes mellitus
O24 Diabetes mellitus in pregnancy
O24.0 Pre-existing diabetes mellitus, insulin-dependent
O24.1 Pre-existing diabetes mellitus, non-insulin dependent
O24.3 Pre-existing diabetes mellitus, unspecified
O24.4 Diabetes mellitus during pregnancy
O24.9 Diabetes mellitus of pregnancy, unspecified
Abbreviations used in the protocol:
AH - arterial hypertension
BP - blood pressure
GDM - gestational diabetes mellitus
DKA - diabetic ketoacidosis
IIT - intensified insulin therapy
IR - insulin resistance
IRI - immunoreactive insulin
BMI - body mass index
MAU - microalbuminuria
ITG - impaired glucose tolerance
IGN - impaired fasting glycemia
LMWH - Continuous Glucose Monitoring
CSII - continuous subcutaneous insulin infusion (insulin pump)
OGTT - oral glucose tolerance test
PDM - pregestational diabetes mellitus
DM - diabetes mellitus
Type 2 diabetes - type 2 diabetes
Type 1 diabetes - type 1 diabetes
CCT - hypoglycemic therapy
FA - physical activity
XE - bread units
ECG - electrocardiogram
HbAlc - glycosylated (glycated) hemoglobin
Protocol development date: year 2014.
Protocol Users: endocrinologists, doctors general practice, internists, obstetrician-gynecologists, emergency physicians.
Classification
Classification
Table 1 Clinical classification of SD:
| type 1 diabetes | Destruction of pancreatic β-cells, usually resulting in absolute insulin deficiency |
| type 2 diabetes | Progressive impairment of insulin secretion against the background of insulin resistance |
| Other specific types of DM |
Genetic defects in β-cell function; Genetic defects in insulin action; Diseases of the exocrine part of the pancreas; - induced medicines or chemicals(in the treatment of HIV / AIDS or after organ transplantation); Endocrinopathy; infections; Other genetic syndromes associated with DM |
| Gestational diabetes | occurs during pregnancy |
Types of diabetes in pregnant women :
1) "true" GDM, which occurred during this pregnancy and is limited to the period of pregnancy (Appendix 6);
2) type 2 diabetes, manifested during pregnancy;
3) type 1 diabetes that manifested during pregnancy;
4) Pregestational diabetes type 2;
5) Pregestational diabetes type 1.
Diagnostics
II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT
List of basic and additional diagnostic measures
Basic diagnostic measures at the outpatient level(Appendix 1 and 2)
To detect hidden SD(on first visit):
- Determination of glucose on an empty stomach;
- Determination of glucose, regardless of the time of day;
- Glucose tolerance test with 75 grams of glucose (pregnant women with BMI ≥25 kg/m2 and risk factor);
To detect GDM (at 24-28 weeks gestation):
- Glucose tolerance test with 75 grams of glucose (all pregnant women);
All pregnant women with PDM and GDM
- Determination of glucose before meals, 1 hour after meals, at 3 am (glucometer) for pregnant women with PDM and GDM;
- Determination of ketone bodies in urine;
Additional diagnostic measures at the outpatient stage:
- ELISA - determination of TSH, free T4, antibodies to TPO and TG;
- LMWH (in accordance with Appendix 3);
- determination of glycosylated hemoglobin (HbAlc);
- Ultrasound of the abdominal cavity, thyroid gland;
The minimum list of examinations for referral to planned hospitalization:
- determination of glycemia: on an empty stomach and 1 hour after breakfast, before lunch and 1 hour after lunch, before dinner and 1 hour after dinner, at 22:00 and at 3:00 in the morning (glucometer);
- determination of ketone bodies in urine;
- UAC;
- OAM;
- ECG
Basic (mandatory) diagnostic examinations carried out at the hospital level(in case of emergency hospitalization, diagnostic examinations are performed that are not performed at the outpatient level):
- determination of glycemia: on an empty stomach and 1 hour after breakfast, before lunch and 1 hour after lunch, before dinner and 1 hour after dinner, at 22-00 and at 3 am
- biochemical blood test: determination of total protein, bilirubin, AST, ALT, creatinine, potassium, calcium, sodium, calculation of GFR;
- determination of activated partial thromboplastin time in blood plasma;
- determination of the international normalized ratio of the prothrombin complex in blood plasma;
- determination of soluble fibrinomonomer complexes in blood plasma;
- determination of thrombin time in blood plasma;
- determination of fibrinogen in blood plasma;
- determination of protein in urine (quantitatively);
- Ultrasound of the fetus;
- ECG (in 12 leads);
- determination of glycosylated hemoglobin in the blood;
- determination of the Rh factor;
- determination of the blood group according to the ABO system with tsoliklones;
- Ultrasound of the abdominal organs.
Additional diagnostic examinations carried out at the hospital level(in case of emergency hospitalization, diagnostic examinations are performed that were not performed at the outpatient level):
- LMWH (in accordance with Appendix 3)
- biochemical blood test (total cholesterol, lipoprotein fractions, triglycerides).
Diagnostic measures taken at the stage of emergency care:
- Determination of glucose in blood serum with a glucometer;
- determination of ketone bodies in urine with test strips.
Diagnostic criteria
Complaints and anamnesis
Complaints:
- when compensating SD are absent;
- with decompensated diabetes, pregnant women are concerned about polyuria, polydipsia, dry mucous membranes, and skin.
Anamnesis:
- SD duration;
- the presence of vascular late complications of diabetes;
- BMI at the time of pregnancy;
- pathological weight gain (more than 15 kg during pregnancy);
- burdened obstetric history (birth of children weighing more than 4000.0 grams).
Physical examination:
Type 2 diabetes and GDM are asymptomatic (Appendix 6)
SD type 1:
- dry skin and mucous membranes, decreased skin turgor, "diabetic" blush, enlarged liver;
- in the presence of signs of ketoacidosis, there are: deep Kussmaul breathing, stupor, coma, nausea, vomiting of "coffee grounds", a positive symptom of Shchetkin-Blumberg, defense of the muscles of the anterior abdominal wall;
- signs of hypokalemia (extrasystoles, muscle weakness, intestinal atony).
Laboratory research(Appendix 1 and 2)
table 2
1 If abnormal values were obtained for the first time and no symptoms hyperglycemia, the preliminary diagnosis of overt diabetes during pregnancy should be confirmed by fasting venous plasma glucose or HbA1c using standardized tests. In the presence of symptoms hyperglycemia one determination in the diabetic range (glycemia or HbA1c) is sufficient to establish the diagnosis of DM. If overt DM is detected, it should be qualified as soon as possible into any diagnostic category according to the current WHO classification, for example, type 1 DM, type 2 DM, etc.
2 HbA1c using the method of determination, certified in accordance with the National Glycohemoglobin Standardization Program (NGSP) and standardized in accordance with the reference values adopted in the DCCT (Diabetes Control and Complications Study).
If the HbA1c level<6,5% или случайно определенный уровень глюкозы плазмы <11,1 ммоль/л (в любое время суток), то проводится определение глюкозы венозной плазмы натощак: при уровне глюкозы венозной плазмы натощак ≥5,1 ммоль/л, но <7,0 ммоль/л устанавливается диагноз ГСД.
Table 3 Threshold values of venous plasma glucose for the diagnosis of GDM at the initial visit
Table 4 Threshold values of venous plasma glucose for the diagnosis of GDM during OGTT
1 Only the level of glucose in venous plasma is examined. The use of capillary whole blood samples is not recommended.
2 At any stage of pregnancy (one abnormal measurement of venous plasma glucose is sufficient).
Instrumental Research
Table 5 Instrumental studies in pregnant women with diabetes *
Revealing Ultrasound signs of diabetic fetopathy requires immediate correction of nutrition and LMWH:
. large fetus (diameter of the abdomen ≥75 percentile);
. hepatosplenomegaly;
. cardiomegaly/cardiopathy;
. bypass of the fetal head;
. swelling and thickening of the subcutaneous fat layer;
. thickening of the neck fold;
. newly diagnosed or increasing polyhydramnios with an established diagnosis of GDM (in case of exclusion of other causes of polyhydramnios).
Indications for specialist consultations
Table 6 Indications for specialist consultations in pregnant women with DM*
| Specialist | Goals of the consultation |
| Ophthalmologist's consultation | For the diagnosis and treatment of diabetic retinopathy: ophthalmoscopy with a wide pupil. With the development of proliferative diabetic retinopathy or a pronounced worsening of preproliferative diabetic retinopathy, immediate laser coagulation |
| Obstetrician-gynecologist consultation | For the diagnosis of obstetric pathology: up to 34 weeks of pregnancy - every 2 weeks, after 34 weeks - weekly |
| Endocrinologist's consultation | To achieve compensation for diabetes: up to 34 weeks of pregnancy - every 2 weeks, after 34 weeks - weekly |
| Therapist's consultation | To detect extragenital pathology every trimester |
| Nephrologist's consultation | For the diagnosis and treatment of nephropathy - according to indications |
| Cardiologist's consultation | For the diagnosis and treatment of complications of diabetes - according to indications |
| Neurologist's consultation | 2 times during pregnancy |
*If there are signs of chronic complications of diabetes, the addition of concomitant diseases, the appearance of additional risk factors, the question of the frequency of examinations is decided individually.
Antenatal management of pregnant women with diabetes is presented in Appendix 4.
Differential Diagnosis
Differential Diagnosis
Table 7 Differential diagnosis of diabetes in pregnant women
| Pregestational SD | Manifest diabetes during pregnancy | GSD (Appendix 6) |
| Anamnesis | ||
| DM diagnosed before pregnancy | Detected during pregnancy | |
| Venous plasma glucose and HbA1c values for diagnosing DM | ||
| Achievement of target parameters |
Fasting glucose ≥7.0 mmol/L HbA1c ≥6.5% Glucose regardless of time of day ≥11.1 mmol/l |
Fasting glucose ≥5.1<7,0 ммоль/л 1 hour after PHGT ≥10.0 mmol/l 2 hours after PHGT ≥8.5 mmol/l |
| Timing of diagnosis | ||
| Before pregnancy | At any stage of pregnancy | At 24-28 weeks of pregnancy |
| Carrying out PGGT | ||
| Not carried out | Carried out at the first visit of a pregnant woman at risk | It is carried out for 24-28 weeks to all pregnant women who did not have a violation of carbohydrate metabolism in the early stages of pregnancy |
| Treatment | ||
| Insulin therapy with multiple injections of insulin or continuous subcutaneous infusion (pump) | Insulin therapy or diet therapy (for type 2 diabetes) | Diet therapy, if necessary, insulin therapy |
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Treatment
Treatment goals:
The goal of treating diabetes in pregnant women is to achieve normoglycemia, normalize blood pressure, prevent complications of diabetes, reduce complications of pregnancy, childbirth and the postpartum period, and improve perinatal outcomes.
Table 8 Carbohydrate Targets During Pregnancy
Treatment tactics :
. Diet therapy;
. physical activity;
. learning and self-control;
. hypoglycemic drugs.
Non-drug treatment
diet therapy
In type 1 diabetes, an adequate diet is recommended: eating with enough carbohydrates to prevent "hungry" ketosis.
In GDM and type 2 diabetes, diet therapy is carried out with the complete exclusion of easily digestible carbohydrates and restriction of fats; uniform distribution of the daily volume of food for 4-6 receptions. Carbohydrates with a high content of dietary fiber should be no more than 38-45% of the daily caloric intake of food, proteins - 20-25% (1.3 g / kg), fats - up to 30%. For women with a normal BMI (18-25 kg/m2), a daily caloric intake of 30 kcal/kg is recommended; with excess (BMI 25-30 kg/m2) 25 kcal/kg; with obesity (BMI ≥30 kg / m2) - 12-15 kcal / kg.
Physical activity
For DM and GDM, dosed aerobic exercise is recommended in the form of walking for at least 150 minutes a week, swimming in the pool; self-monitoring is performed by the patient, the results are provided to the doctor. It is necessary to avoid exercises that can cause an increase in blood pressure and uterine hypertonicity.
. Patient education should provide patients with the knowledge and skills to help achieve specific therapeutic goals.
. Women who are planning a pregnancy, and pregnant women who have not been trained (primary cycle), or patients who have already been trained (for repeated cycles) are referred to the school of diabetes to maintain the level of knowledge and motivation or when new therapeutic goals appear, transfer to insulin therapy.
self control b includes the determination of glycemia using portable devices (glucometers) on an empty stomach, before and 1 hour after the main meals; ketonuria or ketonemia in the morning on an empty stomach; blood pressure; fetal movements; body weight; keeping a self-control diary and a food diary.
NMG system
Medical treatment
Treatment of pregnant women with diabetes
. If pregnancy occurs against the background of the use of metformin, glibenclamide, prolongation of pregnancy is possible. All other hypoglycemic drugs should be stopped until pregnancy and replaced with insulin.
Use only short-acting and intermediate-acting human insulin preparations, ultra-short-acting and long-acting insulin analogs permitted under Category B
Table 9 Insulin products approved for use in pregnant women (List B)
| Insulin preparation | Method of administration |
| Genetically engineered short-acting human insulins | Syringe, syringe pen, pump |
| Syringe, syringe pen, pump | |
| Syringe, syringe pen, pump | |
| Intermediate-acting human insulins | Syringe, syringe pen |
| Syringe, syringe pen | |
| Syringe, syringe pen | |
| Rapid acting insulin analogues | Syringe, syringe pen, pump |
| Syringe, syringe pen, pump | |
| Long-acting insulin analogues | Syringe, syringe pen |
During pregnancy, it is forbidden to use biosimilar insulin preparations that have not passed the full procedure for registration of medicines and pre-registration clinical trials in pregnant women.
All insulin preparations should be prescribed to pregnant women with the obligatory indication of the international non-proprietary name and trade name.
Insulin pumps with continuous glucose monitoring are the optimal means of administering insulin.
The daily requirement for insulin in the second half of pregnancy can increase dramatically, up to 2-3 times, in comparison with the initial requirement before pregnancy.
Folic acid 500 mcg per day up to the 12th week inclusive; potassium iodide 250 mcg per day throughout pregnancy - in the absence of contraindications.
Antibiotic therapy for detecting urinary tract infections (penicillins in the first trimester, penicillins or cephalosporins in the second or third trimesters).
Features of insulin therapy in pregnant women with type 1 diabetes
First 12 weeks in women with type 1 diabetes, due to the “hypoglycemic” effect of the fetus (i.e., due to the transfer of glucose from the mother’s bloodstream to the fetal bloodstream), they are accompanied by an “improvement” in the course of diabetes, the need for daily insulin use decreases, which can be manifested by hypoglycemic conditions with Somoji phenomenon and subsequent decompensation.
Women with diabetes on insulin therapy should be warned about the increased risk of hypoglycemia and its difficulty in recognizing during pregnancy, especially in the first trimester. Pregnant women with type 1 diabetes should be provided with glucagon supplies.
From 13 weeks hyperglycemia and glucosuria increase, the need for insulin increases (by an average of 30-100% of the pregestational level) and the risk of developing ketoacidosis, especially in the period of 28-30 weeks. This is due to the high hormonal activity of the placenta, which produces contra-insular agents such as chorionic somatomammatropin, progesterone, and estrogens.
Their excess leads to:
. insulin resistance;
. decrease in the sensitivity of the patient's body to exogenous insulin;
. an increase in the need for a daily dose of insulin;
. pronounced "dawn" syndrome with a maximum increase in glucose levels in the early morning hours.
With morning hyperglycemia, an increase in the evening dose of prolonged insulin is not desirable, due to the high risk of nocturnal hypoglycemia. Therefore, in these women with morning hyperglycemia, it is recommended to administer the morning dose of prolonged insulin and an additional dose of short / ultra-short-acting insulin or switching to insulin pump therapy.
Features of insulin therapy in the prevention of fetal respiratory distress syndrome: when prescribing dexamethasone 6 mg 2 times a day for 2 days, the dose of prolonged insulin is doubled for the period of dexamethasone administration. Glycemic control is prescribed at 06.00, before and after meals, at bedtime and at 03.00. to adjust the dose of short-acting insulin. Correction of water-salt metabolism is carried out.
After 37 weeks In pregnancy, the need for insulin may decrease again, which leads to an average decrease in the dose of insulin by 4-8 units / day. It is believed that the insulin-synthesizing activity of the β cellular apparatus of the pancreas of the fetus by this moment is so high that it provides a significant consumption of glucose from the mother's blood. With a sharp decrease in glycemia, it is desirable to strengthen control over the condition of the fetus due to the possible inhibition of the fetoplacental complex against the background of placental insufficiency.
In childbirth there are significant fluctuations in the level of glucose in the blood, hyperglycemia and acidosis may develop under the influence of emotional influences or hypoglycemia, as a result of the physical work done, the woman's fatigue.
After childbirth blood glucose drops rapidly (against the background of a drop in the level of placental hormones after birth). At the same time, the need for insulin for a short time (2-4 days) becomes less than before pregnancy. Then gradually blood glucose rises. By the 7-21st day of the postpartum period, it reaches the level observed before pregnancy.
Early toxicosis of pregnant women with ketoacidosis
Pregnant women need rehydration with saline solutions in the amount of 1.5-2.5 l / day, as well as orally 2-4 l / day with water without gas (slowly, in small sips). In the nutrition of a pregnant woman for the entire period of treatment, mashed food is recommended, mainly carbohydrate (cereals, juices, jelly), with additional salting, with the exception of visible fats. When glycemia is less than 14.0 mmol / l, insulin is administered against the background of 5% glucose solution.
Birth management
Planned hospitalization:
. the optimal term of delivery is 38-40 weeks;
. the optimal method of delivery is vaginal delivery with careful glycemic control during (hourly) and after childbirth.
Indications for caesarean section:
. obstetric indications for operative delivery (scheduled / emergency);
. the presence of severe or progressive complications of diabetes.
The term of delivery in pregnant women with diabetes is determined individually, taking into account the severity of the course of the disease, the degree of its compensation, the functional state of the fetus and the presence of obstetric complications.
When planning childbirth in patients with type 1 diabetes, it is necessary to assess the degree of fetal maturity, since delayed maturation of its functional systems is possible.
Pregnant women with DM and fetal macrosomia should be informed about the possible risks of complications from normal vaginal delivery, induction of labor and caesarean section.
With any form of fetopathy, unstable glucose levels, progression of late complications of diabetes, especially in pregnant women of the “high obstetric risk” group, it is necessary to resolve the issue of early delivery.
Insulin therapy during childbirth
For natural childbirth:
. glycemic levels must be maintained within 4.0-7.0 mmol/L. Continue infusion of extended insulin.
. When eating during childbirth, the introduction of short insulin should cover the amount of XE consumed (Appendix 5).
. Glycemic control every 2 hours.
. With glycemia less than 3.5 mmol / l, intravenous administration of a 5% glucose solution of 200 ml is indicated. With glycemia below 5.0 mmol / l, an additional 10 g of glucose (dissolve in the oral cavity). With glycemia more than 8.0-9.0 mmol / l intramuscular injection of 1 unit of simple insulin, at 10.0-12.0 mmol / l 2 units, at 13.0-15.0 mmol / l -3 units. , with glycemia more than 16.0 mmol / l - 4 units.
. With symptoms of dehydration, intravenous administration of saline;
. In pregnant women with type 2 diabetes with a low need for insulin (up to 14 units / day), insulin administration during labor is not required.
For operative childbirth:
. on the day of surgery, a morning dose of prolonged insulin is administered (with normoglycemia, the dose is reduced by 10-20%, with hyperglycemia, the dose of extended insulin is administered without correction, as well as an additional 1-4 units of short insulin).
. in the case of general anesthesia during childbirth in women with diabetes, regular monitoring of blood glucose levels (every 30 minutes) should be carried out from the moment of induction until the birth of the fetus and the woman's full recovery from general anesthesia.
. Further tactics of hypoglycemic therapy are similar to those for natural delivery.
. On the second day after the operation, with limited food intake, the dose of prolonged insulin is reduced by 50% (mainly administered in the morning) and short insulin 2-4 units before meals with glycemia more than 6.0 mmol/l.
Features of the management of childbirth in DM
. permanent cardiotographic control;
. thorough anesthesia.
Management of the postpartum period in diabetes
In women with type 1 diabetes after childbirth and with the onset of lactation, the dose of prolonged insulin can be reduced by 80-90%, the dose of short insulin usually does not exceed 2-4 units before meals in terms of glycemia (for a period of 1-3 days after birth). Gradually, within 1-3 weeks, the need for insulin increases and the dose of insulin reaches the pregestational level. That's why:
. adapt insulin doses, taking into account the rapid decrease in demand already on the first day after delivery from the moment the placenta is born (by 50% or more, returning to the original doses before pregnancy);
. recommend breastfeeding (warn about the possible development of hypoglycemia in the mother!);
. effective contraception for at least 1.5 years.
Benefits of insulin pump therapy in pregnant women with diabetes
. Women using CSII (insulin pump) are easier to reach target levels of HbAlc<6.0%.
. insulin pump therapy reduces the risk of hypoglycemia, especially in the first trimester of pregnancy, when the risk of hypoglycemia increases.
. in late pregnancy, when peaks in maternal blood glucose levels lead to fetal hyperinsulinemia, reducing glucose fluctuations in women using CSII reduces macrosomia and neonatal hypoglycemia.
. The use of CSII is effective in controlling blood glucose levels during delivery and reduces the incidence of neonatal hypoglycemia.
The combination of CSII and continuous glucose monitoring (CGM) achieves glycemic control throughout pregnancy and reduces the incidence of macrosomia (Appendix 3).
Requirements for CSII in pregnant women:
. start using CSII before conception to reduce the risk of spontaneous miscarriage and birth defects in the fetus;
. if pump therapy is started during pregnancy, reduce the total daily insulin dose to 85% of the total dose on syringe therapy, and in case of hypoglycemia, to 80% of the original dose.
. in the 1st trimester, the basal dose of insulin is 0.1-0.2 units / h, at a later date 0.3-0.6 units / h. Increase the ratio of insulin:carbohydrates by 50-100%.
. given the high risk of ketoacidosis in pregnant women, check for ketones in the urine if the blood glucose level exceeds 10 mmol/l and change infusion sets every 2 days.
. during delivery, continue using the pump. Set your temp basal rate to 50% of your maximum rate.
. When breastfeeding, reduce the basal rate by another 10-20%.
Medical treatment provided on an outpatient basis
Medical treatment provided at the inpatient level
List of Essential Medicines(100% chance of use)
. Short acting insulins
. Ultrashort-acting insulins (human insulin analogues)
. Intermediate-acting insulins
. Long-term, peakless insulin
. Sodium chloride 0.9%
List of additional medicines(less than 100% chance of application)
. Dextrose 10% (50%)
. Dextrose 40% (10%)
. Potassium chloride 7.5% (30%)
Drug treatment provided at the stage of emergency emergency care
. Sodium chloride 0.9%
. Dextrose 40%
Preventive actions(Annex 6)
. In persons with prediabetes, carry out annual monitoring of carbohydrate metabolism for early detection of diabetes;
. screening and treatment of modifiable risk factors for cardiovascular disease;
. to reduce the risk of developing GDM, conduct therapeutic measures among women with modifiable risk factors before pregnancy;
. all pregnant women, in order to prevent carbohydrate metabolism disorders during pregnancy, are advised to follow a balanced diet with the exception of foods with a high carbohydrate index, such as sugar-containing foods, juices, sweet carbonated drinks, foods with flavor enhancers, with the restriction of sweet fruits (raisins, apricots, dates , melon, bananas, persimmon).
Further management
Table 15 List of laboratory parameters requiring dynamic monitoring in patients with diabetes
| Laboratory indicators | Examination frequency |
| Self-monitoring of glycemia | At least 4 times daily |
| HbAlc | 1 time in 3 months |
| Biochemical blood test (total protein, bilirubin, AST, ALT, creatinine, calculation of GFR, electrolytes K, Na,) | 1 time per year (in the absence of changes) |
| General blood analysis | 1 time per year |
| General urine analysis | 1 time per year |
| Determination of albumin to creatinine ratio in urine | Once a year after 5 years from the moment of diagnosis of type 1 diabetes |
| Determination of ketone bodies in urine and blood | According to indications |
Table 16 List of instrumental examinations required for dynamic control in DM patients *
| Instrumental examinations | Examination frequency |
| Continuous Glucose Monitoring (CGM) | 1 time per quarter, according to indications - more often |
| BP control | Every visit to the doctor |
| Examination of the legs and evaluation of foot sensitivity | Every visit to the doctor |
| Neuromyography of the lower extremities | 1 time per year |
| ECG | 1 time per year |
| Checking equipment and examining injection sites | Every visit to the doctor |
| Chest X-ray | 1 time per year |
| Ultrasound of the vessels of the lower extremities and kidneys | 1 time per year |
| Ultrasound of the abdominal organs | 1 time per year |
*If there are signs of chronic complications of diabetes, the addition of concomitant diseases, the appearance of additional risk factors, the question of the frequency of examinations is decided individually.
. 6-12 weeks postpartum all women with GDM undergo OGTT with 75 g of glucose to reclassify the degree of carbohydrate metabolism disorder (Appendix 2);
It is necessary to inform pediatricians and GPs about the need to monitor the state of carbohydrate metabolism and prevent type 2 diabetes in a child whose mother has had GDM (Appendix 6).
Indicators of treatment efficacy and safety of diagnostic and treatment methods described in the protocol:
. achievement of the level of carbohydrate and lipid metabolism as close as possible to the normal state, normalization of blood pressure in a pregnant woman;
. development of motivation for self-control;
. prevention of specific complications of diabetes mellitus;
. absence of complications during pregnancy and childbirth, the birth of a live healthy full-term baby.
Table 17 Glycemic targets in patients with GDM
Hospitalization
Indications for hospitalization of patients with PSD *
Indications for emergency hospitalization:
- onset of diabetes during pregnancy;
- hyper/hypoglycemic precoma/coma
- ketoacidotic precoma and coma;
- progression of vascular complications of diabetes (retinopathy, nephropathy);
- infections, intoxications;
- accession of obstetric complications requiring emergency measures.
Indications for planned hospitalization*:
- All pregnant women are subject to hospitalization if they have diabetes.
- Women with pregestational diabetes are hospitalized routinely at the following gestational ages:
First hospitalization is carried out in the gestation period up to 12 weeks in a hospital of an endocrinological / therapeutic profile due to a decrease in the need for insulin and the risk of developing hypoglycemic conditions.
Purpose of hospitalization:
- addressing the issue of the possibility of prolonging pregnancy;
- detection and correction of metabolic and microcirculatory disorders of DM and concomitant extragenital pathology, training at the "School of Diabetes" (with prolongation of pregnancy).
Second hospitalization in the period of 24-28 weeks of pregnancy to the hospital of the endocrinological / therapeutic profile.
The purpose of hospitalization: correction and control of the dynamics of metabolic and microcirculatory disorders of DM.
Third hospitalization is carried out in the department of pathology of pregnant organizations of obstetrics of the 2nd-3rd level of regionalization of perinatal care:
- with type 1 and 2 diabetes in the period of 36-38 weeks of pregnancy;
- with GDM - in the period of 38-39 weeks of pregnancy.
The purpose of hospitalization is to assess the condition of the fetus, correct insulin therapy, choose the method and term of delivery.
*It is possible to manage pregnant women with DM in a satisfactory condition on an outpatient basis, if DM is compensated and all necessary examinations are performed
Information
Sources and literature
- Minutes of the meetings of the Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan, 2014
- 1. World Health Organization. Definition, Diagnosis, and Classification of Diabetes Mellitus and its Complicatios: Report of a WHO consultation. Part 1: Diagnosis and Classification of Diabetes Mellitus. Geneva, World Health Organization, 1999 (WHO/NCD/NCS/99.2). 2 American Diabetes Association. Standards of medical care in diabetes-2014. Diabetes Care, 2014; 37(1). 3. Algorithms of specialized medical care for patients with diabetes mellitus. Ed. I.I. Dedova, M.V. Shestakova. 6th edition. M., 2013. 4. World Health Organization. Use of Glycated Haemoglobin (HbAlc) in the Diagnosis of Diabetes Mellitus. Abbreviated Report of a WHO Consultation. World Health Organization, 2011 (WHO/NMH/CHP/CPM/11.1). 5. Russian national consensus "Gestational diabetes mellitus: diagnosis, treatment, postpartum care" / Dedov I.I., Krasnopolsky V.I., Sukhikh G.T. On behalf of the working group//Diabetes mellitus. - 2012. - No. 4. - P.4-10. 6. Nurbekova A.A. Diabetes mellitus (diagnosis, complications, treatment). Textbook - Almaty. - 2011. - 80 p. 7. Bazarbekova R.B., Zeltser M.E., Abubakirova Sh.S. Consensus on the diagnosis and treatment of diabetes mellitus. Almaty, 2011. 8. Selected issues of perinatology. Edited by Prof. R.J. Nadishauskienė. Publishing house Lithuania. 2012 652 p. 9. National Guideline "Obstetrics", edited by E.K. Ailamazyan, M., 2009. 10. NICE Protocol for Diabetes Mellitus During Pregnancy, 2008. 11. Insulin Pump Therapy and Continuous Glucose Monitoring. Edited by John Pickup. OXFORD, UNIVERSITY PRESS, 2009. 12.I. Blumer, E. Hadar, D. Hadden, L. Jovanovic, J. Mestman, M. HassMurad, Y. Yogev. Diabetes and Pregnancy: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab, November 2-13, 98(11):4227-4249.
Information
III. ORGANIZATIONAL ASPECTS OF PROTOCOL IMPLEMENTATION
List of protocol developers with qualification data:
1. Nurbekova A.A., Doctor of Medical Sciences, Professor of the Department of Endocrinology of KazNMU
2. Doshchanova A.M. - Doctor of Medical Sciences, Professor, Doctor of the Highest Category, Head of the Department of Obstetrics and Gynecology on internship at JSC "MUA";
3. Sadybekova G.T. - Candidate of Medical Sciences, Associate Professor, Endocrinologist of the highest category, Associate Professor of the Department of Internal Diseases for Internship at JSC "MUA".
4. Akhmadyar N.S., Doctor of Medical Sciences, Senior Clinical Pharmacologist of JSC NSCMD
Indication of no conflict of interest: no.
Reviewers:
Kosenko Tatyana Frantsevna, Candidate of Medical Sciences, Associate Professor of the Department of Endocrinology, AGIUV
Indication of the conditions for revising the protocol: revision of the protocol after 3 years and / or when new diagnostic / treatment methods with a higher level of evidence appear.
Attachment 1
In pregnant women, the diagnosis of diabetes is based on laboratory determinations of venous plasma glucose levels only.
Interpretation of test results is carried out by obstetrician-gynecologists, therapists, general practitioners. A special consultation with an endocrinologist to establish the fact of a violation of carbohydrate metabolism during pregnancy is not required.
Diagnosis of disorders of carbohydrate metabolism during pregnancy carried out in 2 phases.
1 PHASE. At the first visit of a pregnant woman to a doctor of any specialty for up to 24 weeks, one of the following studies is mandatory:
- Glucose of venous plasma on an empty stomach (determination of glucose of venous plasma is carried out after preliminary fasting for at least 8 hours and not more than 14 hours);
- HbA1c using a method of determination certified in accordance with the National Glycohemoglobin Standardization Program (NGSP) and standardized in accordance with the reference values adopted in the DCCT (Diabetes Control and Complications Study);
- venous plasma glucose at any time of the day, regardless of food intake.
table 2 Threshold values of venous plasma glucose for the diagnosis of overt (newly detected) DM during pregnancy
1 If abnormal values are obtained for the first time and there are no symptoms of hyperglycemia, then the provisional diagnosis of overt diabetes during pregnancy should be confirmed by fasting venous plasma glucose or HbA1c using standardized tests. In the presence of symptoms of hyperglycemia, a single determination in the diabetic range (glycemia or HbA1c) is sufficient to establish the diagnosis of diabetes. If overt DM is detected, it should be qualified as soon as possible into any diagnostic category according to the current WHO classification, for example, type 1 DM, type 2 DM, etc.
2 HbA1c using a method certified by the National Glycohemoglobin Standardization Program (NGSP) and standardized according to the DCCT (Diabetes Control and Complications Study) reference values.
In the event that the result of the study corresponds to the category of manifest (first detected) DM, its type is specified and the patient is immediately transferred for further management to an endocrinologist.
If the HbA1c level<6,5% или случайно определенный уровень глюкозы плазмы <11,1 ммоль/л (в любое время суток), то проводится определение глюкозы венозной плазмы натощак: при уровне глюкозы венозной плазмы натощак ≥5,1 ммоль/л, но <7,0 ммоль/л устанавливается диагноз ГСД.
Table 3
1 Only the level of glucose in venous plasma is examined. The use of capillary whole blood samples is not recommended.
2 At any stage of pregnancy (one abnormal measurement of venous plasma glucose is sufficient).
When first contacting pregnant women with BMI ≥25 kg/m2 and having the following risk factors held PGGT for the detection of latent type 2 diabetes(table 2):
. sedentary lifestyle
. 1st-line relatives with diabetes
. women with a history of large fetuses (more than 4000g), stillbirth, or established gestational diabetes
. hypertension (≥140/90 mmHg or on antihypertensive therapy)
. HDL 0.9 mmol/L (or 35 mg/dL) and/or triglycerides 2.82 mmol/L (250 mg/dL)
. the presence of HbAlc ≥ 5.7%, preceding impaired glucose tolerance or impaired fasting glycemia
. history of cardiovascular disease
. other clinical conditions associated with insulin resistance (including severe obesity, acanthosis nigricans)
. polycystic ovary syndrome
PHASE 2- is carried out at the 24-28th week of pregnancy.
To all women who did not have DM in early pregnancy, OGTT with 75 g of glucose is performed to diagnose GDM (Appendix 2).
Table 4 Threshold values of venous plasma glucose for the diagnosis of GDM
1 Only the level of glucose in venous plasma is examined. The use of capillary whole blood samples is not recommended.
2 At any stage of pregnancy (one abnormal measurement of venous plasma glucose is sufficient).
3 According to the results of OGTT with 75 g of glucose, at least one of the three venous plasma glucose values that would be equal to or above the threshold is sufficient to establish the diagnosis of GDM. If abnormal values are obtained in the initial measurement, glucose loading is not carried out; when receiving abnormal values at the second point, the third measurement is not required.
Fasting glucose, random meter blood glucose, and urine glucose (urine litmus test) are not recommended tests for diagnosing GDM.
Annex 2
Rules for conducting OGTT
PGTT with 75g of glucose is a safe exercise diagnostic test for the detection of carbohydrate metabolism disorders during pregnancy.
Interpretation of OGTT results can be carried out by a doctor of any specialty: obstetrician, gynecologist, internist, general practitioner, endocrinologist.
The test is performed on a normal diet (at least 150 g of carbohydrates per day) for at least 3 days prior to the study. The test is performed in the morning on an empty stomach after an 8-14-hour overnight fast. The last meal must necessarily contain 30-50 g of carbohydrates. Drinking water is not prohibited. The patient must be seated during the test. Smoking is prohibited until the end of the test. Drugs that affect blood glucose levels (multivitamins and iron preparations containing carbohydrates, glucocorticoids, β-blockers, β-agonists), if possible, should be taken after the end of the test.
PGTT is not carried out:
- with early toxicosis of pregnant women (vomiting, nausea);
- if it is necessary to comply with strict bed rest (the test is not carried out until the expansion of the motor regimen);
- against the background of an acute inflammatory or infectious disease;
- with exacerbation of chronic pancreatitis or the presence of dumping syndrome (syndrome of the resected stomach).
Determination of venous plasma glucose performed only in the laboratory on biochemical analyzers or on glucose analyzers.
The use of portable self-monitoring devices (glucometers) for testing is prohibited.
Blood sampling is carried out in a cold tube (preferably vacuum) containing preservatives: sodium fluoride (6 mg per 1 ml of whole blood) as an enolase inhibitor to prevent spontaneous glycolysis, as well as EDTA or sodium citrate as anticoagulants. The test tube is placed in water with ice. Then immediately (no later than the next 30 minutes) the blood is centrifuged to separate plasma and formed elements. The plasma is transferred to another plastic tube. In this biological fluid, the glucose level is determined.
Test execution steps
1st stage. After taking the first fasting venous blood plasma sample, the glucose level is measured immediately, because. upon receipt of results indicating overt (newly diagnosed) DM or GDM, no further glucose loading is performed and the test is terminated. If it is impossible to quickly determine the level of glucose, the test continues and is brought to an end.
2nd stage. When continuing the test, the patient should drink a glucose solution within 5 minutes, consisting of 75 g of dry (anhydrite or anhydrous) glucose dissolved in 250-300 ml of warm (37-40 ° C) non-carbonated (or distilled) drinking water. If glucose monohydrate is used, 82.5 g of the substance is needed to perform the test. The start of taking a glucose solution is considered the beginning of the test.
3rd stage. The next blood samples to determine the level of venous plasma glucose are taken 1 and 2 hours after the glucose load. If results are obtained indicating GDM after the 2nd blood draw, the test is terminated.
Appendix 3
The LMWH system is used as a modern method for diagnosing glycemic changes, identifying patterns and recurring trends, detecting hypoglycemia, correcting treatment and selecting hypoglycemic therapy; promotes patient education and participation in their care.
LMWH is a more modern and accurate approach than self-monitoring at home. LMWH measures glucose levels in the interstitial fluid every 5 minutes (288 measurements per day), providing the doctor and patient with detailed information regarding glucose levels and trends in its concentration, and also gives alarms in case of hypo- and hyperglycemia.
Indications for LMWH:
- patients with HbA1c levels above the target parameters;
- patients with a discrepancy between the level of HbA1c and the indicators recorded in the diary;
- patients with hypoglycemia or in cases of suspected insensitivity to the onset of hypoglycemia;
- Patients with fear of hypoglycemia, preventing the correction of treatment;
- children with high glycemic variability;
- pregnant women;
- patient education and involvement in their treatment;
- change in behavioral settings in patients who were not receptive to self-monitoring of glycemia.
Appendix 4
Special antenatal management of pregnant women with diabetes mellitus
| Gestational age | Management plan for a pregnant woman with diabetes |
| First consultation (together with an endocrinologist and an obstetrician-gynecologist) |
- Providing information and advice on optimizing glycemic control - Collection of a complete medical history to determine the complications of diabetes - Evaluation of all medications taken and their side effects - Passing an examination of the state of the retina and kidney function in case of a history of their violation |
| 7-9 weeks | Confirmation of pregnancy and gestational age |
| Full antenatal registration | Providing comprehensive information on diabetes during pregnancy and its impact on pregnancy, delivery and the early postpartum period and motherhood (breastfeeding and initial child care) |
| 16 weeks | Retinal examinations at 16-20 weeks in women with pregestational diabetes in case of detection of dibetic retinopathy during the first consultation of an ophthalmologist |
| 20 weeks | Ultrasound of the fetal heart in a four-chamber view and vascular cardiac outflow at 18-20 weeks |
| 28 weeks |
Ultrasound of the fetus to assess its growth and volume of amniotic fluid. Retinal examinations in women with pregestational DM in the absence of signs of dibetic retinopathy at the first consultation |
| 32 weeks | Ultrasound of the fetus to assess its growth and amniotic fluid volume |
| 36 weeks |
Ultrasound of the fetus to assess its growth and amniotic fluid volume Decision about: - timing and method of delivery - anesthesia during childbirth - correction of insulin therapy during childbirth and lactation - postpartum care - breastfeeding and its effect on glycemia - contraception and repeated postpartum 25 examination |
Conception is not recommended :
- HbA1c level >7%;
- severe nephropathy with serum creatinine >120 µmol/l, GFR<60 мл/мин/1,73 м2 суточной протеинурии ≥3,0 г, неконтролируемой артериальной гипертензией;
- proliferative retinopathy and maculopathy before laser coagulation of the retina;
- the presence of acute and exacerbation of chronic infectious and inflammatory diseases (tuberculosis, pyelonephritis, etc.)
Pregnancy planning
When planning pregnancy, women with diabetes are encouraged to achieve target levels of glycemic control without the presence of hypoglycemia.
With diabetes, pregnancy should be planned:
. an effective method of contraception should be used until proper examination and preparation for pregnancy has been carried out:
. education in the “diabetes school”;
. informing the patient with diabetes about the possible risk to the mother and fetus;
. achieving ideal compensation 3-4 months before conception:
- plasma glucose on an empty stomach / before meals - up to 6.1 mmol / l;
- plasma glucose 2 hours after eating - up to 7.8 mmol / l;
- HbA ≤ 6.0%;
. control of blood pressure (no more than 130/80 mm Hg. Art.), with hypertension - antihypertensive therapy (cancellation of ACE inhibitors before stopping the use of contraception);
. determination of the level of TSH and free T4 + AT to TPO in patients with type 1 diabetes (increased risk of thyroid diseases);
. folic acid 500 mcg per day; potassium iodide 150 mcg per day - in the absence of contraindications;
. treatment of retinopathy;
. treatment of nephropathy;
. to give up smoking.
CONTRAINDICATED during pregnancy:
. any tableted hypoglycemic drugs;
. ACE inhibitors and ARBs;
. ganglioblockers;
. antibiotics (aminoglycosides, tetracyclines, macrolides, etc.);
. statins.
Antihypertensive therapy during pregnancy:
. The drug of choice is methyldopa.
. With insufficient effectiveness of methyldopa, the following can be prescribed:
- calcium channel blockers;
- β1-selective blockers.
. Diuretics - for health reasons (oliguria, pulmonary edema, heart failure).
Annex 5
Replacement of products according to the XE system
1 XE - the amount of the product containing 15 g of carbohydrates
| Milk and Liquid Dairy Products | ||
| Milk | 250 ml | 1 glass |
| Kefir | 250 ml | 1 glass |
| Cream | 250 ml | 1 glass |
| Kumys | 250 ml | 1 glass |
| Shubat | 125 ml | ½ cup |
| Bread and bakery products | ||
| White bread | 25 g | 1 piece |
| Black bread | 30 g | 1 piece |
| crackers | 15 g | - |
| Breadcrumbs | 15 g | 1 st. a spoon |
| Pasta | ||
|
Vermicelli, noodles, horns, pasta, juicy |
2-4 st. spoons depending on the shape of the product | |
| Cereals, flour | ||
| Any cereal in boiled form | 2 tbsp with a slide | |
| Semolina | 2 tbsp | |
| Flour | 1 tbsp | |
| Potato, corn | ||
| Corn | 100 g | ½ cob |
| raw potatoes | 270 g||
Patients with diabetes are increasing every year, according to medical statistics. There are several varieties of pathology, and a certain form of the disease develops only in women during pregnancy. Gestational diabetes mellitus in pregnant women (GDM) is quite rare, ranging from 4% to 10% of women fall under the risk factor.
Symptoms and causes of gestational diabetes in pregnant women
Despite the fact that GDM is classified as a dangerous pathology, if it is detected in a timely manner, the disease is quite treatable. To avoid serious consequences, you need to have at least a small idea of \u200b\u200bhow the pathology manifests itself and what factors cause it to occur.
The symptoms of GDM are similar to those of type II diabetes:
- lack of appetite;
- not passing feeling of hunger;
- strong thirst;
- frequent urination causing discomfort and discomfort;
- jumps in blood pressure;
- vision problems.
Similar phenomena can be symptoms of other pathologies, however, if the pregnant woman is at risk, then a comprehensive examination is urgently needed.
Possible reasons
Doctors note that there are a lot of factors that can provoke an increase in blood sugar levels, but the most common are the following:
- genetic predisposition;
- obesity, overweight;
- chronic pathologies of the ovaries;
- late pregnancy.
The risk group includes women whose previous pregnancy was accompanied by the same pathology.
Note! Despite the fact that there are many factors for the occurrence of pathology, the main cause of GDM is the malfunction of the pancreas, which provokes insufficient production of insulin, which automatically increases the level of glucose in the blood.
Fetopathy of the fetus in gestational diabetes mellitus of pregnant women
Increased pregnant provokes the development of diabetic fetopathy in the fetus. The fetus that developed in a woman with GDM was necessarily in a state of constant hypoxia (experienced oxygen starvation). This phenomenon during childbirth provokes breathing problems, asphyxia. That is why the development of fetopathy is often considered the main predisposition to caesarean section.
Children born with the development of fetopathy have the following deviations from the norm:
- overweight (the weight of a premature baby does not differ from the norm of full-term babies);
- weak muscle tone;
- the sucking reflex is weak or completely absent;
- the baby periodically falls into a state of increased activity.
Some of the deviations gradually return to normal, however, most of the children born to mothers with gestational diabetes have serious health problems in the future:
- pathology of the kidneys, pancreas, liver, blood vessels;
- disproportionate development of the limbs;
- wrong size of the head, abdomen;
- lag in both physical and mental development;
- tendency to obesity;
- respiratory disorder.
Constant control of blood sugar levels can significantly reduce the degree of complications. Facilitate the course of pregnancy, exclude premature birth.
Important! Untreated GDM often leads to fetal loss, babies often die after birth, and are seriously injured during childbirth.
Indicators for GDM in pregnant women
When detecting diabetes in pregnant women, doctors are guided by the following indicators:
At the same time, there should be a complete absence of ketone bodies in the urine, there should not be hypoglycemia. The norm of arterial pressure should not go beyond 130/80 mm Hg. Art. If doubts arise during the analysis, another test is performed: the woman drinks 75 g of glucose dissolved in a glass of water, then the blood is again taken for analysis.
Pathology is diagnosed at 24-28 weeks of gestation. However, doctors strongly recommend taking appropriate tests even during pregnancy planning, since it is much more difficult to identify the development of pathology when carrying a fetus.
Insulin for pregnant women with gestational diabetes
When diagnosing GDM during pregnancy, doctors prescribe a therapeutic diet. With critical deviations from the norm, a decision is made to introduce insulin therapy. Insulin injections can be prescribed for the following deviations:
- fasting blood glucose above 5 mmol / l;
- after eating food (an hour later) more than 7.8 mmol / l;
- after eating (after 2 hours) - more than 6.7 mmol / l.
Each case is unique and the doctor, based on the methods of treatment, primarily focuses on the general condition of the patient, individual indicators (susceptibility to certain chronic pathologies, the presence of some diseases).
Note! During pregnancy, only insulin is used to lower blood sugar levels, and as an extreme, but highly effective measure, other medicines are strictly prohibited. After childbirth, treatment is canceled, addiction does not occur.
Diet for GDM in pregnant women
Not only doctors, but also pregnant women themselves should monitor the state of sugar. To do this, it is enough to adhere to the correct diet, namely, to abandon easily digestible foods, to adhere to fractional nutrition. In general, you need to follow the lifestyle, nutrition.
Allowed and prohibited products
Adhering to proper nutrition in the development of gestational diabetes during pregnancy, women should conditionally divide all food for themselves into three types: recommended; permitted, but in a limited dosage and strictly prohibited.
- any greens (parsley, onion feathers, cilantro, sorrel, dill, basil, spinach, etc.);
- all varieties of radish;
- vegetables fruits;
- pickled or fresh mushrooms;
- string beans;
- any drinks containing a sweetener;
- mineral water;
- tea, coffee, decoctions of medicinal herbs that do not contain cream and sugar.
Allowed foods can be eaten according to generally accepted standards, overeating and abuse is still not recommended.
Allowed Foods in Allowed Portions
There is a list of allowed foods that are allowed to be eaten in limited proportions. At the same time, you constantly need to monitor changes in sugar levels, if when using something specific, the indicator rises, then the product is excluded from the diet:
- low-fat: sausage (boiled), beef, chicken, fish;
- kefir, cottage cheese, cheese and low-fat milk;
- legumes (lentils, peas, beans);
- potato;
- any cereals, excluding rice and semolina;
- seafood;
- bakery products;
- soups based on cereals and lean meat;
- eggs;
- pasta;
- berries.
All this is desirable to include in the patient's diet a little, before lunch.
Forbidden
It is extremely forbidden to include in the diet of a patient with GDM foods that are high in sugar and fat:
- vegetable and butter oils;
- cream, fatty dairy and meat, as well as fish foods, such as salmon, pork;
- nuts;
- seeds;
- smoked meats;
- canned food;
- mayonnaise;
- sweet - honey, sugar, sweets, jam, cookies, juices, etc.;
- alcohol.
When compiling a diet for a patient with GDM, it is important to follow the recommendations of nutritionists, otherwise the sugar level will rise sharply and then the treatment will be significantly aggravated, which will certainly affect the condition of the fetus.
For understanding! Proper nutrition not only normalizes sugar levels, but also improves fat and carbohydrate metabolism, and also contributes to weight loss.
Table number 9, an approximate menu for the day
Endocrinologists in the development of gestational diabetes recommend that women adhere to the diet prescribed for table number 9. The diet will lower the level of glucose, improve the general condition by eating only simple foods.
Table number 9 completely excludes:
- dairy products;
- semi-finished products;
- pastries, pies, white bread;
- wheat cereals, white rice;
- sausages, other smoked meats;
- fatty meat and fish;
- pickled, salted vegetables;
- baked pumpkin;
- boiled beets;
- mashed potatoes;
- ice cream, butter, cottage cheese;
- chocolate, except bitter;
- more than three egg yolks per day.
Among the allowed products for table number 9, doctors distinguish:
- bran, whole grain bread products;
- hercules, pearl barley, millet, legumes;
- doctor's sausage, low-fat poultry and fish, beef;
- greens, vegetables and fruits, except for prohibited ones;
- fat-free low-salt cheese;
- coffee substitutes, unsweetened tea, compotes;
- kefir sauces.
- 8:00 am - a slice of bran bread, low-fat cheese, chicory;
- 10:00 am - baked turkey, buckwheat porridge with onions, herbal infusion;
- 12:00 - beef stew with vegetables, soup, tomato juice;
- 14:30 - apple, salad of greens and vegetables;
- 17:00 - cottage cheese, fresh berries, tea;
- 19:00 - kefir.
Portions are negotiated with the attending specialist, do not exceed the permissible norms.
Fruits and vegetables for diabetes in pregnancy
Despite the fact that the list of allowed foods is replenished with vegetables and fruits, not everything can be included in the patient's diet.
The following vegetables are considered so permitted - cabbage, cucumbers, tomatoes, beets, eggplants, carrots. Fruit can be any except dates, persimmons, raisins, grapes, figs, tangerines.
Foods that lower blood sugar
Proper food intake, choosing the right foods allows you to reduce blood sugar levels in a natural way. So recommended are:
- seafood;
- green vegetables;
- avocados, oranges, lemons, apples;
- soybeans, peas, beans, lentils;
- dill, ginger, mustard greens;
- cherry, fresh onion, spinach.
It is best to use these foods fresh, boiled, stewed, baked without adding fats and sugar.
Prevention measures
- Healthy lifestyle
- Proper nutrition
- Keeping a pregnancy diary of self-control
- Systematic consultations of specialists (gynecologist, if necessary, endocrinologist)
- Sports (yoga,), swimming, walking.
Despite the fact that physicians identify a number of preventive measures, it is impossible to prevent GDM one hundred percent. Therefore, it is necessary to pass the appropriate tests even before planning a pregnancy in order to exclude the occurrence of a terrible pathology during the gestation of the fetus.
Content
Pregnancy is a period of increased stress on the internal organs of a woman. At this time, chronic pathological processes may decompensate or new ones may arise. One of these diseases is gestational diabetes (GDM), which does not pose a particular threat to the expectant mother, but in the absence of therapy negatively affects the intrauterine development of the child, increases the risk of early infant mortality.
What is gestational diabetes
Due to hormonal imbalance during pregnancy, a special form of diabetes can develop - gestational. This pathology in obstetrics is diagnosed in about 4% of women. More often, an increase in blood glucose levels is observed in patients under the age of 18 or after 30 years. As a rule, signs of gestational diabetes mellitus occur in the 2nd or 3rd trimester of pregnancy. Symptoms of the disease completely disappear on their own after the birth of a child. Sometimes the pathology remains in women after childbirth, being the cause of the development of type 2 diabetes.
Reasons for development
Scientists have not reliably elucidated the mechanism of development of gestational diabetes. It is assumed that the body's impaired glucose tolerance begins due to hormones blocking the production of the right amount of insulin. In most cases, the pancreas releases additional portions of insulin into the blood during pregnancy. If a woman's body does not produce the right amount, then there is a decrease in glycogen synthesis, which becomes the main factor in the development of gestational diabetes.
The risk group for the formation of pathology includes patients who are addicted to smoking, the use of drugs and alcoholic beverages. Aggravating factors are: history of polyhydramnios, stillbirth, large fetus, overweight before pregnancy. Other causes of the development of the disease:
- heredity;
- polycystic ovary syndrome;
- autoimmune diseases;
- viral infections in early pregnancy.
Symptoms
Diabetes mellitus of pregnant women is expressed moderately, manifesting itself in the 2nd or 3rd trimester. An excessive increase in a woman's body weight, skin itching, a feeling of thirst, an increase in daily diuresis occur not only in the gestational type of the disease, therefore, laboratory tests are required to make a diagnosis. The main symptom of pathology is an increase in the concentration of glucose in the blood. In addition to the above symptoms, patients complain of rapidly emerging fatigue, loss of appetite.
A sign of the development of GDM on the part of the fetus is a rapid increase in its mass, excessive deposition of fatty tissue, incorrect proportions of body parts. In a pregnant woman, an increase in glucose levels can provoke the following conditions:
- blurred vision;
- chronic fatigue;
- dry mouth;
- recurrence of previously transferred infectious diseases;
- copious and frequent urination.
Consequences of diabetes during pregnancy
For a woman, gestational diabetes is dangerous with late toxicosis, high blood pressure and edema during pregnancy. Decompensation of GDM is sometimes the cause of perinatal death. The main consequences of the disease for the mother:
- hypertrophy of β-cells of the pancreas;
- intrauterine fetal death;
- disorders of carbohydrate metabolism;
- fetal macrosomia;
- dysplastic obesity;
- hepatomegaly;
- premature delivery;
- damage to the birth canal;
- recurrent urinary tract infections;
- preeclampsia;
- preeclampsia and eclampsia;
- fungal infections of the mucous membranes.
Clinical observations indicate that the vast majority of GDM resolves immediately after delivery. When the placenta leaves, which is the most hormone-producing organ, blood sugar normalizes in a pregnant woman. While the woman is in the hospital, doctors continue to monitor her glucose levels. In order to identify residual disorders of carbohydrate metabolism and analyze whether the patient is at risk of diabetes in the future, she needs to retake the glucose tolerance test 2 months after birth.
For a child
The danger to the developing fetus depends on the degree of GDM compensation. The most serious complications are observed in uncompensated diabetes mellitus. The impact on the child is expressed in the following:
- Malformations of the fetus in early pregnancy. Since the pancreas of the child has not yet been formed at a short time, the maternal organ has a double load. Violation of its functionality due to high glucose levels leads to the immaturity of the respiratory, cardiovascular and digestive systems of the baby, intrauterine hypoxia.
- Uncontrolled sugar levels lead to diabetic fetopathy. Excess glucose, which crosses the placenta in unlimited quantities, is deposited as fat. Because of this, there is an accelerated growth of the fetus, there is a disproportion of parts of his body: small limbs, a large belly, enlarged heart, liver.
- After ligation of the umbilical cord in a newborn, the intake of excess glucose is disrupted, its concentration sharply decreases, and hypoglycemia sets in. This leads to a violation of mental development, neurological disorders.
- After birth, children have an increased risk of developing diabetes mellitus and obesity with signs of metabolic syndrome. A child is often born with an enlarged pancreas, impaired lipid metabolism, and excess fat.
Diagnostics
At the first visit to the doctor, a pregnant woman must definitely take a blood test for sugar. If fasting glucose is above 7 mmol / l, and glycated hemoglobin exceeds 6.5%, then the woman is highly likely to have diabetes. The diagnosis is considered established if poor blood counts are combined in a pregnant woman with hypoglycemia. The optimal time to screen for diabetes is between 24 and 28 weeks. During this period, a glucose tolerance test is used for diagnosis.
Its essence is to take venous blood on an empty stomach to measure glucose, and then after a load of fast carbohydrates after 60 and 120 minutes. As carbohydrates, 82.5 g of glucose monohydrate and 75 g of glucose anhydrite are used, which are dissolved in a glass of warm water, and then given to drink by the pregnant woman. To diagnose gestational diabetes, the result of a glucose tolerance test is sufficient, since it accurately describes the rate of absorption of sugar from the blood of a pregnant woman.
If the concentration of glucose in the blood on an empty stomach is less than 5.1, after 1 hour - 10.0, and after 2 hours not higher than 8.5 mmol / liter - this is the norm. With the development of gestational diabetes, the indicators will be: from 5.1 to 6.9 mmol / liter on an empty stomach, after 1 hour - above 8.5, and after 2 hours - from 8.5 to 11 mmol / liter. Conditions in which it is recommended to postpone the glucose tolerance test:
- toxicosis;
- infection or acute inflammation of tissues and organs;
- pathologies of the gastrointestinal tract that violate the absorption of glucose.
How to lower sugar during pregnancy
Diagnosing GDM while expecting a baby is not a cause for panic. If treatment is started on time, visits the doctor regularly, follow the prescribed therapy, then complications for the mother and baby can be avoided, and the development of diabetes mellitus in the future can be excluded. The patient is monitored simultaneously by a gynecologist and an endocrinologist. A pregnant woman with GDM until 29 weeks needs to see doctors 2 times / month, then weekly. To normalize glucose, moderate exercise and diet are prescribed. In some cases, insulin therapy is used.
Hypoglycemic drugs are prohibited during pregnancy, so insulin is prescribed in the form of injections. The doctor chooses the regimen of insulin therapy according to the self-monitoring diary, which the patient with GDM keeps on her own: daily she notes blood sugar measured by a glucometer, the presence of ketones in the urine, pressure, fetal activity, weight, menu, carbohydrate content in it. As a rule, long-acting insulin is not needed for gestational diabetes in pregnant women, since the woman has enough of her own hormone.
In GDM, only short or ultrashort peptide hormone is injected. Insulin injections are administered subcutaneously with special dispensers or disposable syringe pens. As an auxiliary treatment, doctors can prescribe drugs for microcirculation of fetoplacental insufficiency and vitamin-mineral complexes. After childbirth, insulin therapy is immediately canceled, it does not cause addiction.
Diet
The main treatment for gestational diabetes in pregnant women is a diet that takes into account the weight of the woman, her physical activity. Diet therapy includes the correction of nutrition, composition and caloric content of food. The menu of a patient with GDM should ensure the supply of essential vitamins and nutrients, improve the functioning of the gastrointestinal tract. Pregnancy nutrition rules:
- eat little and often (3 main meals and 3 snacks);
- drink more than 1.5 liters of fluid per day;
- regulate the amount of carbohydrates up to 40%, protein - up to 40%, fats - up to 20%;
- increase the amount of fiber in the diet, because it adsorbs and removes glucose from the intestines.
The menu of a pregnant woman must include vegetables, fruits, fish, meat, greens. Allowed products:
- all types of cabbage;
- all greens;
- cucumbers;
- zucchini;
- radish;
- eggplant;
- raw carrots;
- grapefruits;
- Strawberry;
- cherry;
- apples;
- lemons;
- avocado.
You can not postpone or skip the set meal time for a long time. For a woman with GDM, a complete ban is established on sugar, pastries, sugar-containing desserts, and fast food. With diabetes in pregnant women, one should not resort to complete starvation and bring oneself to exhaustion. To lower your blood glucose levels, you should limit your intake of saturated fats to 10%. To do this, you need to cook exclusively in vegetable oil, switch to lean meats and fish. Prohibited products include:
- salo;
- smoked meats;
- fatty fish or meat broths;
- butter;
- high-fat dairy products;
- pickles, marinades;
- freshly prepared fruit juices;
- grape;
- bananas;
- watermelon;
- melon;
- pumpkin;
- dates;
- potato;
- boiled carrots.
Physical exercises
Regular exercise can help reduce insulin resistance and prevent weight gain. The exercise program is compiled individually for each patient, depending on the level of training and health status. Low-intensity exercises for pregnant women are water aerobics, swimming, brisk walking. It is not allowed to perform movements while lying on the stomach or back, to raise the legs or torso. Sports that can cause injury are not suitable: horseback riding, cycling, rollerblading, skating.
The minimum time for exercise for gestational diabetes is 150 minutes per week. If you feel any discomfort, the load should be stopped, if you feel well - resume. Examples of exercises for pregnant women with this endocrine pathology:
- Sit on the floor with your hands behind you. Turn your torso together with your head, first in one direction, then in the other. Breathe evenly, do not hold your breath. Repeat the movements 5 times in each direction.
- Lie on your left side, stretch both arms in front of you, put them on top of each other. Slowly raise your right hand and pull it back as far as possible without turning your head and body. Hold for a few seconds, then come back. Perform 4 exercises, then turn to the right side and repeat the same.
- Sit on the floor, press your hips and knees together, put your heels under your buttocks, stretch your arms in front of you. Tilt the body along with the head slowly, trying to touch the floor with the forehead. Then come back. If your stomach is in the way, spread your knees a little. Do 3 to 5 reps.
Gestational diabetes and childbirth
Delivery in diabetes mellitus can be natural or by caesarean section. Tactics is prescribed depending on the parameters of the woman's pelvis, the weight of the fetus, the degree of compensation for the disease. In case of independent childbirth, to assess the dynamics of glycemia, glucose levels are monitored every 2 hours, and if the woman in labor is prone to hypoglycemia, hourly. If the pregnant woman was on insulin therapy, then during childbirth the drug is administered using an infusion pump.
If insulin was not administered during pregnancy, then the decision to use it during childbirth is made in accordance with the current level of glycemia. During caesarean section, glucose monitoring is done before surgery, then just before the baby is removed, then after the baby is removed, and then every 2 hours. With a timely diagnosis and the achievement of stable compensation for the disease during pregnancy, the prognosis is favorable for the mother and child.
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