RCHR (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 Healthcare Development
Ministry of Health of the Republic of Kazakhstan
Protocol No. 10 dated July 04, 2014
Diabetes mellitus (DM) is a group of metabolic (metabolic) diseases characterized by chronic hyperglycemia, which is the result of impaired insulin secretion, insulin action, or both. 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 identified during pregnancy, but not meeting the criteria for “manifest” diabetes. GDM is a disorder of glucose tolerance of varying severity that arose or was first identified during pregnancy.
I. INTRODUCTORY PART
Protocol name: Diabetes mellitus during pregnancy
Protocol code:
ICD-10 code(s):
E 10 Insulin-dependent diabetes mellitus
E 11 Non-insulin-dependent diabetes mellitus
O24 Diabetes mellitus during pregnancy
O24.0 Pre-existing insulin-dependent diabetes mellitus
O24.1 Pre-existing non-insulin-dependent diabetes mellitus
O24.3 Pre-existing diabetes mellitus, unspecified
O24.4 Diabetes mellitus occurring during pregnancy
O24.9 Diabetes mellitus in pregnancy, unspecified
Abbreviations used in the protocol:
AH - arterial hypertension
BP - blood pressure
GDM - gestational diabetes mellitus
DKA - diabetic ketoacidosis
IIT - intensive insulin therapy
IR - insulin resistance
IRI - immunoreactive insulin
BMI - body mass index
MAU - microalbuminuria
IGT - impaired glucose tolerance
IFG - impaired fasting glucose
LMWH - continuous glucose monitoring
CSII - continuous subcutaneous infusion of insulin (insulin pump)
OGTT - oral glucose tolerance test
PSD - pregestational diabetes mellitus
DM - diabetes mellitus
Type 2 diabetes - type 2 diabetes mellitus
Type 1 diabetes - type 1 diabetes mellitus
SST - hypoglycemic therapy
PA - physical activity
XE - grain units
ECG - electrocardiogram
HbAlc - glycosylated (glycated) hemoglobin
Date of protocol development: year 2014.
Protocol users: endocrinologists, general practitioners, therapists, obstetricians-gynecologists, emergency medical services doctors.
Classification
Classification
Table 1 Clinical classification of diabetes:
| Type 1 diabetes | Destruction of pancreatic β-cells, usually leading to absolute insulin deficiency |
| Type 2 diabetes | Progressive impairment of insulin secretion secondary to insulin resistance |
| Other specific types of diabetes |
Genetic defects in β-cell function; Genetic defects in insulin action; Diseases of the exocrine pancreas; - induced by drugs or chemicals (during the treatment of HIV/AIDS or after organ transplantation); Endocrinopathies; Infections; Other genetic syndromes associated with diabetes |
| Gestational diabetes | occurs during pregnancy |
Types of diabetes in pregnant women :
1) “true” GDM that occurred during a given pregnancy and is limited to the period of pregnancy (Appendix 6);
2) type 2 diabetes manifested during pregnancy;
3) type 1 diabetes 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 identify hidden diabetes(at first appearance):
- Determination of fasting glucose;
- 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 a risk factor);
To detect GDM (at gestational age 24-28 weeks):
- Glucose tolerance test with 75 grams of glucose (all pregnant women);
To all pregnant women with PSD and GDM
- Determination of glucose before meals, 1 hour after meals, at 3 a.m. (with a 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;
- NMG (in accordance with Appendix 3);
- determination of glycosylated hemoglobin (HbAlc);
- Ultrasound of the abdominal organs, thyroid gland;
Minimum list of examinations for referral for 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 10 pm and 3 am (with a 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 carried out that were not carried out 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 10 pm and 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 (quantitative);
- Ultrasound of the fetus;
- ECG (12 leads);
- determination of glycosylated hemoglobin in the blood;
- determination of the Rh factor;
- determination of blood group according to the ABO system using cyclones;
- Ultrasound of the abdominal organs.
Additional diagnostic examinations carried out at the hospital level(in case of emergency hospitalization, diagnostic examinations are carried out that were not carried out at the outpatient level):
- NMG (in accordance with Appendix 3)
- biochemical blood test (total cholesterol, lipoprotein fractions, triglycerides).
Diagnostic measures carried out at the stage of emergency care:
- Determination of glucose in blood serum with a glucometer;
- determination of ketone bodies in urine using test strips.
Diagnostic criteria
Complaints and anamnesis
Complaints:
- with compensation there are no SDs;
- with decompensation of diabetes, pregnant women are concerned about polyuria, polydipsia, dry mucous membranes and skin.
Anamnesis:
- duration of diabetes;
- presence of late vascular 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)
Type 1 diabetes:
- dry skin and mucous membranes, decreased skin turgor, “diabetic” blush, increased liver size;
- if there are signs of ketoacidosis, the following occur: deep Kussmaul breathing, stupor, coma, nausea, vomiting “coffee grounds”, positive Shchetkin-Blumberg sign, defence 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, then a 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 To establish a diagnosis of diabetes, one determination in the diabetic range (glycemia or HbA1c) is sufficient. If manifest diabetes is detected, it should be classified as soon as possible into any diagnostic category according to the current WHO classification, for example, type 1 diabetes, type 2 diabetes, etc.
2 HbA1c using the determination method, certified in accordance with the National Glycohemoglobin Standardization Program (NGSP) and standardized in accordance with the reference values accepted 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 initial presentation
Table 4 Threshold values of venous plasma glucose for the diagnosis of GDM during OGTT
1 Only venous plasma glucose levels are examined. The use of capillary whole blood samples is not recommended.
2 At any stage of pregnancy (one abnormal value of venous plasma glucose measurement is sufficient).
Instrumental studies
Table 5 Instrumental studies in pregnant women with diabetes *
Revealing Ultrasound signs of diabetic fetopathy requires immediate nutritional correction and LMWH:
. large fetus (abdominal diameter ≥75th percentile);
. hepatosplenomegaly;
. cardiomegaly/cardiopathy;
. double contour of the fetal head;
. swelling and thickening of the subcutaneous fat layer;
. thickening of the neck fold;
. newly identified or increasing polyhydramnios with an established diagnosis of GDM (if other causes of polyhydramnios are excluded).
Indications for specialist consultations
Table 6 Indications for pregnant women with diabetes for consultation with specialists*
| Specialist | Goals of consultation |
| Consultation with an ophthalmologist | For the diagnosis and treatment of diabetic retinopathy: performing ophthalmoscopy with a wide pupil. With the development of proliferative diabetic retinopathy or marked worsening of preproliferative diabetic retinopathy - immediate laser coagulation |
| Consultation with an obstetrician-gynecologist | For diagnosing obstetric pathology: up to 34 weeks of pregnancy - every 2 weeks, after 34 weeks - weekly |
| Consultation with an endocrinologist | To achieve diabetes compensation: up to 34 weeks of pregnancy - every 2 weeks, after 34 weeks - weekly |
| Consultation with a therapist | To identify extragenital pathology every trimester |
| Nephrologist consultation | For the diagnosis and treatment of nephropathy - according to indications |
| Consultation with a cardiologist | For the diagnosis and treatment of diabetes complications - according to indications |
| Neurologist consultation | 2 times during pregnancy |
*If there are signs of chronic complications of diabetes, the addition of concomitant diseases, or the appearance of additional risk factors, the issue of the frequency of examinations is decided individually.
Antenatal management of pregnant women with diabetes mellitus is presented in Appendix 4.
Differential diagnosis
Differential diagnosis
Table 7 Differential diagnosis of diabetes in pregnant women
| Pregestational diabetes | Overt diabetes during pregnancy | GSD (Appendix 6) |
| Anamnesis | ||
| DM was diagnosed before pregnancy | Detected during pregnancy | |
| Values of venous plasma glucose and HbA1c for the diagnosis of diabetes | ||
| Achieving 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 OGHT ≥10.0 mmol/l 2 hours after OGHT ≥8.5 mmol/l |
| Timing of diagnosis | ||
| Before pregnancy | At any stage of pregnancy | At 24-28 weeks of pregnancy |
| Carrying out OGHT | ||
| Not carried out | Performed at the first visit of a pregnant woman at risk | It is carried out at 24-28 weeks for all pregnant women who have not had a violation of carbohydrate metabolism in the early stages of pregnancy |
| Treatment | ||
| Insulin therapy using multiple insulin injections or continuous subcutaneous infusion (pumps) | Insulin therapy or diet therapy (for T2DM) | Diet therapy, insulin therapy if necessary |
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Treatment
Treatment goals:
The goal of treatment of 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;
. training and self-control;
. hypoglycemic drugs.
Non-drug treatment
Diet therapy
For type 1 diabetes, it is recommended to follow an adequate diet: a diet with sufficient carbohydrates to prevent “hunger” ketosis.
For GDM and type 2 diabetes, diet therapy is carried out with the complete exclusion of easily digestible carbohydrates and the limitation of fats; uniform distribution of daily food volume into 4-6 meals. Carbohydrates with a high content of dietary fiber should make up no more than 38-45% of the daily calorie intake, proteins - 20-25% (1.3 g/kg), fats - up to 30%. For women with a normal BMI (18-25 kg/m2), a daily calorie 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 diabetes and GDM, dosed aerobic physical activity is recommended in the form of walking for at least 150 minutes per 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 increased blood pressure and uterine hypertonicity.
. Patient education should provide patients with the knowledge and skills to help them achieve specific therapeutic goals.
. Women planning a pregnancy and pregnant women who have not undergone training (initial cycle), or patients who have already completed training (for repeated cycles), are sent to the diabetes school to maintain the level of knowledge and motivation or when new therapeutic goals arise and transfer to insulin therapy.
Self-control b includes determination of glycemia using portable devices (glucometers) on an empty stomach, before and 1 hour after 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.
CMG system
Drug treatment
Treatment of pregnant women with diabetes
. If pregnancy occurs while using metformin or glibenclamide, pregnancy may be prolonged. All other glucose-lowering medications should be stopped before pregnancy and replaced with insulin.
Only short- and intermediate-acting human insulin preparations, ultra-short-acting and long-acting insulin analogues approved under category B are used
Table 9 Insulin preparations approved for use in pregnant women (list B)
| Insulin drug | Method of administration |
| Genetically engineered short-acting human insulins | Syringe, syringe pen, pump |
| Syringe, syringe pen, pump | |
| Syringe, syringe pen, pump | |
| Genetically engineered human insulins of medium duration of action | Syringe, syringe pen |
| Syringe, syringe pen | |
| Syringe, syringe pen | |
| Ultra-short-acting insulin analogues | Syringe, syringe pen, pump |
| Syringe, syringe pen, pump | |
| Long-acting insulin analogues | Syringe, syringe pen |
During pregnancy, it is prohibited to use biosimilar insulin preparations that have not undergone the full procedure for drug registration and pre-registration clinical trials in pregnant women.
All insulin preparations must be prescribed to pregnant women with the obligatory indication of the international nonproprietary name and trade name.
The optimal means of administering insulin is insulin pumps with continuous glucose monitoring capabilities.
The daily need for insulin in the second half of pregnancy can increase sharply, up to 2-3 times, compared to the initial need before pregnancy.
Folic acid 500 mcg per day until the 12th week inclusive; potassium iodide 250 mcg per day throughout pregnancy - in the absence of contraindications.
Antibiotic therapy when a urinary tract infection is detected (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, type 1 diabetes due to the “hypoglycemic” effect of the fetus (i.e. due to the transition of glucose from the mother’s bloodstream to the fetus’s bloodstream) is accompanied by an “improvement” in the course of diabetes, the need for daily use of insulin decreases, which can manifest itself in hypoglycemic states with Somogyi phenomenon and subsequent decompensation.
Women with diabetes on insulin therapy should be warned about the increased risk of hypoglycemia and its difficulty in recognizing it during pregnancy, especially in the first trimester. Pregnant women with type 1 diabetes should be provided with glucagon supplies.
From 13 weeks hyperglycemia and glycosuria increase, the need for insulin increases (on average by 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, producing counterinsular agents such as chorionic somatomammatropin, progesterone, and estrogens.
Their excess leads to:
. insulin resistance;
. reducing 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.
In case of morning hyperglycemia, increasing the evening dose of extended-release insulin is not advisable due to the high risk of nocturnal hypoglycemia. Therefore, in these women with morning hyperglycemia, it is recommended to administer a morning dose of long-acting insulin and an additional dose of short-acting/ultra-short-acting insulin or switching to pump insulin 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 extended-release insulin is doubled for the period of dexamethasone administration. Glycemic control is prescribed at 06.00, before and after meals, before bedtime and at 03.00. to adjust the dose of short-acting insulin. Correction of water-salt metabolism is carried out.
After 37 weeks During pregnancy, the need for insulin may decrease again, which leads to an average reduction in the insulin dose by 4-8 units/day. It is believed that the insulin-synthesizing activity of the β-cell apparatus of the fetal pancreas is so high at this point that it ensures 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 pheoplacental complex against the background of placental insufficiency.
During childbirth Significant fluctuations in blood glucose levels occur, hyperglycemia and acidosis may develop under the influence of emotional influences or hypoglycemia as a consequence of physical work done or the woman’s fatigue.
After childbirth blood glucose decreases rapidly (against the background of a drop in the level of placental hormones after birth). In this case, the need for insulin for a short time (2-4 days) becomes less than before pregnancy. Then gradually blood glucose increases. 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 a volume of 1.5-2.5 l/day, as well as orally 2-4 l/day with still water (slowly, in small sips). In the diet of a pregnant woman for the entire period of treatment, pureed food is recommended, mainly carbohydrate-rich (cereals, juices, jelly), with additional salting, excluding visible fats. When glycemia is less than 14.0 mmol/l, insulin is administered against the background of a 5% glucose solution.
Management of childbirth
Planned hospitalization:
. the optimal period of delivery is 38-40 weeks;
. The optimal method of delivery is vaginal delivery with careful glycemic control during (hourly) and after birth.
Indications for cesarean section:
. obstetric indications for surgical delivery (planned/emergency);
. the presence of severe or progressive complications of diabetes.
The timing of delivery in pregnant women with diabetes is determined individually, taking into account the severity 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 maturity of the fetus, since delayed maturation of its functional systems is possible.
Pregnant women with diabetes and fetal macrosomia should be informed about the possible risks of complications during normal vaginal delivery, induction of labor, and cesarean section.
In case of 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
During natural childbirth:
. Glycemic levels must be maintained within 4.0-7.0 mmol/l. Continue administration of extended-release insulin.
. When eating during childbirth, the administration of short-acting insulin should cover the amount of XE consumed (Appendix 5).
. Monitor glycemia every 2 hours.
. For glycemia less than 3.5 mmol/l, intravenous administration of a 5% glucose solution of 200 ml is indicated. For glycemia below 5.0 mmol/l, an additional 10 g of glucose (dissolve in the mouth). When glycemia is 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.
. For 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.
During operative delivery:
. on the day of surgery, a morning dose of extended-release insulin is administered (for normoglycemia, the dose is reduced by 10-20%; for hyperglycemia, the dose of extended-release insulin is administered without adjustment, as well as an additional 1-4 units of short-acting insulin).
. In the case of the use of general anesthesia during labor 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 complete recovery from general anesthesia.
. Further tactics of hypoglycemic therapy are similar to those for natural delivery.
. On the second day after surgery, with limited food intake, the dose of long-term insulin is reduced by 50% (mainly administered in the morning) and short-term insulin 2-4 units before meals with glycemia more than 6.0 mmol/l.
Features of childbirth management with diabetes
. constant cardiotographic monitoring;
. thorough pain relief.
Management of the postpartum period with diabetes
In women with type 1 diabetes after childbirth and with the onset of lactation, the dose of long-term insulin can be reduced by 80-90%; the dose of short-term insulin usually does not exceed 2-4 units before meals according to the glycemic level (for a period of 1-3 days after childbirth). Gradually, over 1-3 weeks, the need for insulin increases and the insulin dose reaches the pregestational level. That's why:
. adapt insulin doses taking into account the rapid decrease in need already in the first day after birth from the moment of birth of the placenta (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.
Advantages of insulin pump therapy in pregnant women with diabetes
. Women using CSII (insulin pump) have an easier time achieving target HbAlc levels<6.0%.
. Insulin pump therapy reduces the risk of hypoglycemia, especially in the first trimester of pregnancy, when the risk of hypoglycemia increases.
. During late pregnancy, when peaks in maternal blood glucose levels lead to fetal hyperinsulinemia, decreased glucose fluctuations in women using CSII reduce macrosomia and neonatal hypoglycemia.
. the use of CSII is effective in controlling blood glucose levels during labor and reduces the incidence of neonatal hypoglycemia.
The combination of CSII and continuous glucose monitoring (CGM) can achieve glycemic control at all stages of pregnancy and reduce the incidence of macrosomia (Appendix 3).
Requirements for CSII in pregnant women:
. initiate use of CSII before conception to reduce the risk of spontaneous miscarriage and congenital fetal defects;
. 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 initial dose.
. in the 1st trimester the basal dose of insulin is 0.1-0.2 units/hour, in later stages 0.3-0.6 units/hour. Increase the insulin:carbohydrate ratio by 50-100%.
. Given the high risk of ketoacidosis in pregnant women, check for ketones in the urine if blood glucose levels exceed 10 mmol/L and change infusion systems every 2 days.
. Continue using the pump during delivery. Set your temp basal to 50% of your maximum.
. If breastfeeding, reduce your basal rate by another 10-20%.
Drug treatment provided on an outpatient basis
Drug treatment provided at the inpatient level
List of essential medicines(100% chance of use)
. Short-acting insulins
. Ultra-short-acting insulins (analogues of human insulin)
. Intermediate-acting insulins
. Long-acting non-peak 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 emergency stage
. Sodium chloride 0.9%
. Dextrose 40%
Preventive actions(Appendix 6)
. In persons with prediabetes, conduct 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, carry out therapeutic measures among women with modifiable risk factors before pregnancy;
. In order to prevent carbohydrate metabolism disorders during pregnancy, all pregnant women are recommended to follow a balanced diet with the exclusion of foods with a high carbohydrate index, such as sugar-containing foods, juices, sweet carbonated drinks, foods with flavor enhancers, and limiting sweet fruits (raisins, apricots, dates , melon, bananas, persimmons).
Further management
Table 15 List of laboratory parameters requiring dynamic monitoring in patients with diabetes
| Laboratory indicators | Frequency of examination |
| Self-monitoring of glycemia | At least 4 times daily |
| HbAlc | 1 time every 3 months |
| Biochemical blood test (total protein, bilirubin, AST, ALT, creatinine, GFR calculation, electrolytes K, Na,) | Once a year (if there are no 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 date of diagnosis of type 1 diabetes |
| Determination of ketone bodies in urine and blood | According to indications |
Table 16 List of instrumental examinations necessary for dynamic monitoring in patients with diabetes *
| Instrumental examinations | Frequency of examination |
| Continuous glucose monitoring (CGM) | Once a quarter, more often if indicated |
| Blood pressure control | At every doctor visit |
| Examination of the legs and assessment of foot sensitivity | At every doctor visit |
| Neuromyography of the lower extremities | 1 time per year |
| ECG | 1 time per year |
| Checking equipment and inspecting injection sites | At every doctor visit |
| X-ray of the chest organs | 1 time per year |
| Doppler ultrasound of the vessels of the lower extremities and kidneys | 1 time per year |
| Ultrasound of the abdominal organs | 1 time per year |
*If signs of chronic complications of diabetes appear, concomitant diseases appear, or additional risk factors appear, the issue of the frequency of examinations is decided individually.
. 6-12 weeks after birth all women who have had 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 suffered from GDM (Appendix 6).
Indicators of treatment effectiveness and safety of diagnostic and treatment methods described in the protocol:
. achieving the level of carbohydrate and lipid metabolism as close as possible to the normal state, normalizing 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, 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:
- debut of diabetes during pregnancy;
- hyper/hypoglycemic precoma/coma
- ketoacidotic precoma and coma;
- progression of vascular complications of diabetes (retinopathy, nephropathy);
- infections, intoxications;
- addition of obstetric complications requiring emergency measures.
Indications for planned hospitalization*:
- All pregnant women are subject to hospitalization if they are diagnosed with diabetes.
- Women with pregestational diabetes are routinely hospitalized during the following periods of pregnancy:
First hospitalization carried out during pregnancy up to 12 weeks in an endocrinological/therapeutic hospital due to a decrease in the need for insulin and the risk of developing hypoglycemic conditions.
Purpose of hospitalization:
- resolving the issue of the possibility of prolonging pregnancy;
- identification and correction of metabolic and microcirculatory disorders of diabetes and concomitant extragenital pathology, training at the “School of Diabetes” (for prolongation of pregnancy).
Second hospitalization at 24-28 weeks of pregnancy to an endocrinological/therapeutic hospital.
The purpose of hospitalization: correction and control of the dynamics of metabolic and microcirculatory disorders of diabetes.
Third hospitalization carried out in the department of pathology of pregnant women of obstetrics organizations of 2-3 levels of regionalization of perinatal care:
- with diabetes types 1 and 2 at 36-38 weeks of pregnancy;
- for GDM - at 38-39 weeks of pregnancy.
The purpose of hospitalization is to assess the condition of the fetus, correct insulin therapy, and select the method and timing of delivery.
*It is possible to manage pregnant women with diabetes in satisfactory condition on an outpatient basis, if diabetes is compensated and all necessary examinations have been carried out
Information
Sources and literature
- Minutes of 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 Complications: 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 for specialized medical care for patients with diabetes mellitus. Ed. I.I. Dedova, M.V. Shestakova. 6th issue. 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 manual “Obstetrics”, edited by E.K Ailamazyan, M., 2009. 10. NICE Protocol on diabetes during pregnancy, 2008. 11. Pump insulin 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 information:
1. Nurbekova A.A., Doctor of Medical Sciences, Professor of the Department of Endocrinology of KazNMU
2. Doshchanova A.M. - MD, professor, doctor of the highest category, head of the department of obstetrics and gynecology for 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"
Disclosure of no conflict of interest: No.
Reviewers:
Kosenko Tatyana Frantsevna, Ph.D., Associate Professor, Department of Endocrinology, AGIUV
Indication of the conditions for reviewing the protocol: revision of the protocol after 3 years and/or when new diagnostic/treatment methods with a higher level of evidence become available.
Annex 1
In pregnant women, diabetes is diagnosed based on laboratory determinations of venous plasma glucose levels only.
Interpretation of test results is carried out by obstetricians-gynecologists, therapists, and general practitioners. A special consultation with an endocrinologist is not required to establish the fact of a carbohydrate metabolism disorder during pregnancy.
Diagnosis of carbohydrate metabolism disorders during pregnancy carried out in 2 phases.
PHASE 1. When a pregnant woman first visits a doctor of any specialty for up to 24 weeks, one of the following studies is mandatory:
- fasting venous plasma glucose (venous plasma glucose determination is carried out after preliminary fasting for at least 8 hours and no more than 14 hours);
- HbA1c using a determination method certified in accordance with the National Glycohemoglobin Standardization Program (NGSP) and standardized in accordance with the reference values accepted 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 manifest (newly diagnosed) diabetes during pregnancy
1 If abnormal values are new and there are no symptoms of hyperglycemia, then a preliminary diagnosis of overt diabetes during pregnancy should be confirmed by fasting venous plasma glucose or HbA1c using standardized tests. If symptoms of hyperglycemia are present, one determination in the diabetic range (glycemia or HbA1c) is sufficient to establish a diagnosis of diabetes. If manifest diabetes is detected, it should be classified as soon as possible into any diagnostic category according to the current WHO classification, for example, type 1 diabetes, type 2 diabetes, etc.
2 HbA1c using a determination method certified in accordance with the National Glycohemoglobin Standardization Program (NGSP) and standardized in accordance with the reference values accepted by the DCCT (Diabetes Control and Complications Study).
If the result of the study corresponds to the category of manifest (first detected) diabetes, its type is specified and the patient is immediately transferred to an endocrinologist for further management.
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 venous plasma glucose levels are examined. The use of capillary whole blood samples is not recommended.
2 At any stage of pregnancy (one abnormal value of venous plasma glucose measurement is sufficient).
When first contacting pregnant women with BMI ≥25 kg/m2 and having the following risk factors held OGTT to detect latent type 2 diabetes(table 2):
. sedentary lifestyle
. 1st degree relatives suffering from diabetes
. women with a history of delivery of a large fetus (more than 4000g), stillbirth or established gestational diabetes
. hypertension (≥140/90 mmHg or on antihypertensive therapy)
. HDL level 0.9 mmol/L (or 35 mg/dL) and/or triglyceride level 2.82 mmol/L (250 mg/dL)
. presence of HbAlc ≥ 5.7% preceding impaired glucose tolerance or impaired fasting glucose
. history of cardiovascular diseases
. other clinical conditions associated with insulin resistance (including severe obesity, acanthosis nigricans)
. polycystic ovary syndrome
PHASE 2- carried out at 24-28 weeks of pregnancy.
To all women, in whom diabetes was not detected in the early stages of pregnancy, an 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 venous plasma glucose levels are examined. The use of capillary whole blood samples is not recommended.
2 At any stage of pregnancy (one abnormal value of venous plasma glucose measurement is sufficient).
3 According to the results of an OGTT with 75 g of glucose, at least one value of venous plasma glucose level out of three, which would be equal to or above the threshold, is sufficient to establish a diagnosis of GDM. If abnormal values are obtained in the initial measurement, a glucose load is not performed; If anomalous values are obtained at the second point, a third measurement is not required.
Fasting glucose, random blood glucose testing with a glucose meter, and urine glucose testing (urine litmus test) are not recommended tests for diagnosing GDM.
Appendix 2
Rules for conducting OGTT
OGTT with 75g glucose is a safe stress diagnostic test for detecting carbohydrate metabolism disorders during pregnancy.
Interpretation of OGTT results can be carried out by a doctor of any specialty: obstetrician, gynecologist, therapist, general practitioner, endocrinologist.
The test is performed on the background of a normal diet (at least 150 g of carbohydrates per day) for at least 3 days preceding the test. The test is performed in the morning on an empty stomach after an 8-14 hour overnight fast. The last meal must contain 30-50 g of carbohydrates. Drinking water is not prohibited. The patient must sit during the test. Smoking is prohibited until the test is completed. Medicines that affect blood glucose levels (multivitamins and iron supplements containing carbohydrates, glucocorticoids, β-blockers, β-adrenergic agonists), if possible, should be taken after the end of the test.
OGTT is not performed:
- with early toxicosis of pregnant women (vomiting, nausea);
- if it is necessary to adhere to strict bed rest (the test is not carried out until the motor mode has expanded);
- against the background of an acute inflammatory or infectious disease;
- in case of exacerbation of chronic pancreatitis or the presence of dumping syndrome (resected stomach syndrome).
Determination of venous plasma glucose performed only in the laboratory on biochemical analyzers or glucose analyzers.
The use of portable self-monitoring devices (glucometers) for testing is prohibited.
Blood is drawn into 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 ice water. 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. It is in this biological fluid that the glucose level is determined.
Test execution steps
1st stage. After collecting the first fasting venous blood plasma sample, the glucose level is measured immediately, because If results are obtained indicating manifest (newly identified) diabetes or GDM, no further glucose loading is performed and the test is stopped. If it is impossible to quickly determine the glucose level, the test continues and is completed.
2nd stage. When continuing the test, the patient must 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) drinking still (or distilled) water. If glucose monohydrate is used, 82.5 g of the substance is needed to complete the test. The start of taking the glucose solution is considered the start of the test.
3rd stage. The following blood samples to determine venous plasma glucose levels are taken 1 and 2 hours after the glucose load. If results indicating GDM are received after the 2nd blood draw, the test is stopped.
Appendix 3
The LMWH system is used as a modern method for diagnosing changes in glycemia, identifying patterns and recurring trends, identifying hypoglycemia, adjusting treatment and selecting glucose-lowering therapy; promotes patient education and participation in their care.
CGM is a more modern and precise approach than home self-monitoring. CGM allows you to measure 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 alarm signals for hypo- and hyperglycemia.
Indications for LMWH:
- patients with HbA1c levels above target parameters;
- patients with a discrepancy between the HbA1c level and the values recorded in the diary;
- patients with hypoglycemia or in cases of suspected insensitivity to the onset of hypoglycemia;
- patients with fear of hypoglycemia that prevents treatment correction;
- children with high glycemic variability;
- pregnant women;
- patient education and involvement in their treatment;
- changing behavioral attitudes in patients who were not receptive to self-monitoring of glycemia.
Appendix 4
Special antenatal care for pregnant women with diabetes mellitus
| Gestational age | Management plan for a pregnant woman with diabetes |
| First consultation (together with an endocrinologist and obstetrician-gynecologist) |
- Providing information and advice on optimizing glycemic control - Collection of a complete medical history to determine complications of diabetes mellitus - Assess all medications taken and their side effects - Passing an examination of the condition of the retina and kidney function if there is a history of their impairment |
| 7-9 weeks | Confirmation of pregnancy and gestational age |
| Complete antenatal registration | Providing comprehensive information on diabetes during pregnancy and its impact on pregnancy, childbirth 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 when divbetic retinopathy is detected during the first consultation with 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 amniotic fluid volume. Retinal examinations in women with pregestational diabetes in the absence of signs of diubetic 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 - child care after childbirth - breastfeeding and its effect on glycemia - contraception and repeated postpartum 25 examination |
Conception is not recommended :
- HbA1c level >7%;
- severe nephropathy with serum creatinine level >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.)
Planning a pregnancy
When planning pregnancy, women with diabetes are recommended to achieve target levels of glycemic control without the presence of hypoglycemia.
In case of diabetes, pregnancy should be planned:
. An effective method of contraception should be used until adequate evaluation and preparation for pregnancy has been made:
. training in “diabetes school”;
. informing a 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%;
. blood pressure control (no more than 130/80 mm Hg), for hypertension - antihypertensive therapy (withdrawal of ACE inhibitors before stopping the use of contraception);
. determination of the level of TSH and free T4 + antibodies 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;
. ganglion blockers;
. antibiotics (aminoglycosides, tetracyclines, macrolides, etc.);
. statins.
Antihypertensive therapy during pregnancy:
. The drug of choice is methyldopa.
. If the effectiveness of methyldopa is insufficient, the following may be prescribed:
- calcium channel blockers;
- β1-selective adrenergic blockers.
. Diuretics - for health reasons (oliguria, pulmonary edema, heart failure).
Appendix 5
Replacement of products using the XE system
1 XE - amount of product containing 15 g carbohydrates
| Milk and liquid dairy products | ||
| Milk | 250 ml | 1 glass |
| Kefir | 250 ml | 1 glass |
| Cream | 250 ml | 1 glass |
| Kumis | 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 tbsp. spoon |
| Pasta | ||
|
Vermicelli, noodles, horns, pasta, juice |
2-4 tbsp. spoons depending on the shape of the product | |
| Cereals, flour | ||
| Any cereal, boiled | 2 tbsp. with a slide | |
| Semolina | 2 tbsp. | |
| Flour | 1 tbsp. | |
| Potatoes, corn | ||
| Corn | 100 g | ½ cob |
| Raw potatoes | 270 g||
Content
Pregnancy is a period of increased stress on a woman’s internal organs. 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 if left untreated, it negatively affects the intrauterine development of the child and increases the risk of early infant mortality.
What is gestational diabetes mellitus
Due to hormonal imbalances during pregnancy, a special form of diabetes mellitus, gestational diabetes, can develop. This pathology in obstetrics is diagnosed in approximately 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 appear in the 2nd–3rd trimester of pregnancy. The symptoms of the disease completely disappear on their own after the birth of the child. Sometimes the pathology remains in women after childbirth, causing 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 impaired glucose tolerance of the body begins due to hormones blocking the production of the required amount of insulin. In most cases, the pancreas releases additional amounts of insulin into the blood during pregnancy. If a woman’s body does not produce the required amount, then glycogen synthesis decreases, which becomes the main factor in the development of gestational diabetes.
Patients who are addicted to smoking, using drugs and alcoholic beverages are at risk of developing pathology. Aggravating factors are: history of polyhydramnios, stillbirth, large fetus, excess body weight before pregnancy. Other causes of the disease:
- heredity;
- polycystic ovary syndrome;
- autoimmune diseases;
- viral infections suffered in early pregnancy.
Symptoms
Diabetes mellitus in pregnant women is expressed moderately, appearing in the 2nd or 3rd trimester. Excessive increase in a woman’s body weight, skin itching, feeling of thirst, and increased daily diuresis occur not only with the gestational type of the disease, so laboratory tests are required to make a diagnosis. The main sign of pathology is an increase in the concentration of glucose in the blood. In addition to the above symptoms, patients complain of rapid fatigue and loss of appetite.
A sign of the development of GDM on the part of the fetus is a rapid increase in its weight, excessive deposition of fatty tissue, and 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;
- relapse of previously suffered infectious diseases;
- copious and frequent urination.
Consequences of diabetes during pregnancy
For a woman, gestational diabetes mellitus is dangerous due to 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:
- pancreatic β-cell hypertrophy;
- intrauterine fetal death;
- carbohydrate metabolism disorders;
- fetal macrosomia;
- dysplastic obesity;
- hepatomegaly;
- premature birth;
- damage to the birth canal;
- recurrent urinary tract infections;
- gestosis;
- preeclampsia and eclampsia;
- fungal infections of the mucous membranes.
Clinical observations indicate that in the vast majority of GDM resolves immediately after childbirth. When the placenta, which is the most hormone-producing organ, departs, the pregnant woman’s blood sugar normalizes. While the woman is in the hospital, doctors continue to monitor glucose levels. 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 compensation of GDM. The most serious complications are observed with uncompensated diabetes mellitus. The impact on the child is expressed as follows:
- Fetal malformations in early pregnancy. Since at a short term the baby’s pancreas is not yet formed, the maternal organ has a double load. Violation of its functionality due to high glucose levels leads to immaturity of the baby’s respiratory, cardiovascular and digestive systems, and intrauterine hypoxia.
- Uncontrolled sugar levels lead to diabetic fetopathy. Excess glucose, which penetrates the placenta in unlimited quantities, is deposited as fat. Because of this, accelerated growth of the fetus occurs, and there is a disproportion of parts of its body: small limbs, large belly, enlarged heart, liver.
- After tying the umbilical cord in a newborn, the supply of excess glucose is disrupted, its concentration sharply decreases, and hypoglycemia occurs. This leads to impaired mental development and 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
When visiting a doctor for the first time, a pregnant woman must undergo a blood sugar test. If the fasting glucose level is above 7 mmol/l, and glycated hemoglobin exceeds 6.5%, then the woman has a high probability of diabetes mellitus. 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 from 24 to 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 60 and 120 minutes later. The carbohydrates used are 82.5 g of glucose monohydrate and 75 g of glucose anhydrite, which are dissolved in a glass of warm water, and then given to the pregnant woman to drink. 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 fasting blood glucose concentration is less than 5.1, after 1 hour – 10.0, and after 2 hours no higher than 8.5 mmol/liter – this is normal. 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;
- Gastrointestinal pathologies that impair glucose absorption.
How to reduce sugar during pregnancy
Diagnosing GDM while expecting a baby is not a reason to panic. If you start treatment on time, visit your doctor regularly, and follow the prescribed therapy, you can avoid complications for the mother and baby and prevent the development of diabetes in the future. The patient is monitored simultaneously by a gynecologist and an endocrinologist. A pregnant woman with GDM needs to visit doctors 2 times a month until the 29th week, then weekly. To normalize glucose, moderate physical activity and diet are prescribed. In some cases, insulin therapy is used.
Antihyperglycemic drugs are prohibited during pregnancy, so insulin is prescribed by injection. The doctor selects the insulin therapy regimen according to the self-monitoring diary, which the patient with GDM keeps independently: daily 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.
For GDM, only short or ultra-short peptide hormone is injected. Insulin injections are administered subcutaneously with special dispensers or disposable pen syringes. As an auxiliary treatment, doctors may prescribe drugs for microcirculation of fetoplacental insufficiency and vitamin and mineral complexes. After childbirth, insulin therapy is immediately discontinued; it does not cause addiction.
Diet
The main treatment for gestational diabetes mellitus in pregnant women is a diet, the prescription of which takes into account the woman’s weight and physical activity. Diet therapy includes correction of nutrition, composition and calorie content of food. The menu of a patient with GDM should ensure the supply of essential vitamins and nutrients and improve the functioning of the gastrointestinal tract. Dietary rules for a pregnant woman:
- eat little and often (3 main meals and 3 snacks);
- drink more than 1.5 liters of liquid 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.
A pregnant woman's menu must include vegetables, fruits, fish, meat, and herbs. Authorized products:
- all types of cabbage;
- all greens;
- cucumbers;
- zucchini;
- radish;
- eggplant;
- raw carrots;
- grapefruits;
- strawberry;
- cherry;
- apples;
- lemons;
- avocado.
You should not delay or skip the scheduled meal time for too long. For a woman with GDM, there is a complete ban on sugar, baked goods, sugar-containing desserts, and fast food products. If you have diabetes in pregnant women, you should not resort to complete fasting and bring yourself to the point of exhaustion. To lower your blood glucose levels, you should limit your saturated fat intake to 10%. To do this, you need to cook exclusively with vegetable oil and switch to lean varieties of meat 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 exercise
Regular exercise will help reduce insulin resistance and prevent excess 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 include water aerobics, swimming, and brisk walking. It is not allowed to perform movements while lying on your stomach or back, or to raise your legs or torso. Sports that can cause injury are not suitable: horse riding, cycling, roller skating, skating.
The minimum time for exercise for gestational diabetes is 150 minutes per week. If you feel unwell, the exercise should be stopped; if you feel well, you should resume it. Examples of exercises for pregnant women with this endocrine pathology:
- Sit on the floor, rest your hands on your back. Turn your torso and 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, extend both arms in front of you, place them on top of each other. Slowly raise your right arm and move it back as far as possible without turning your head or body. Hold for a few seconds, then return back. Do 4 exercises, then turn onto your right side and repeat the same.
- Sit on the floor, press your hips and knees together, place your heels under your buttocks, and stretch your arms in front of you. Tilt your body and head slowly, trying to touch your forehead to the floor. Then go back. If your stomach is in the way, then spread your knees a little. Do 3 to 5 inclines.
Gestational diabetes and childbirth
Delivery in diabetes mellitus can be natural or by caesarean section. Tactics are prescribed depending on the parameters of the woman’s pelvis, the weight of the fetus, and the degree of compensation for the disease. During spontaneous 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 about its use during childbirth is made in accordance with the current level of glycemia. During a cesarean section, glucose levels are monitored before surgery, then immediately before the baby is delivered, then after the fetus is removed, and then every 2 hours. If a diagnosis is made in a timely manner and stable disease compensation is achieved during pregnancy, the prognosis for mother and child is favorable.
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Currently, there are various special tools for self-measurement of blood sugar levels. If, as a result of diagnostic tests, GDM is detected in a pregnant woman, 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. Constant self-monitoring of blood glucose will help determine whether diet and physical activity alone are 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, by comparing the color of the test strip with the standard scale, you can only approximately determine the sugar level (± 2-3 mmol/l). This is completely unacceptable during pregnancy, since to prevent the development of complications in the fetus, maximum compensation of carbohydrate metabolism is required. 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
Blood sugar levels exceeding the above figures are called hyperglycemia.
Special automatic devices for piercing the skin of the fingers help ensure a painless examination.
Your doctor will help you choose the right self-control products and tell you where to buy them.
You should test 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 main meals (the time for self-monitoring will be determined by your doctor). If you receive insulin injections, then monitoring must be carried out 8 times a day: on an empty stomach, before and 1 or 2 hours after main meals, before bed and at 3 am.
Compensation of carbohydrate metabolism significantly reduces the risk of developing late toxicosis of pregnancy and diabetic fetopathy (DF). This is why it is so important to regularly self-monitor your blood glucose 4-8 times a day. If you are on diet therapy, then monitoring your sugar after meals will allow you to assess the effectiveness of the diet and determine the effect of various foods on your glycemic level. As the placenta grows, the amount of pregnancy hormones increases, which reduce the sensitivity of the mother's body cells to insulin. Regular self-monitoring of blood sugar levels allows you to prescribe insulin therapy in a timely manner if hyperglycemia persists.
Be sure to keep a self-monitoring diary, where you should note your blood sugar levels, the amount of carbohydrates eaten, the dose of insulin, blood pressure and weight. Regular self-monitoring will help you correctly assess the changes occurring in your body, fearlessly make independent decisions in changing insulin therapy tactics, reduce the risk of pregnancy complications and diabetes, and give birth to a healthy baby. Be sure to bring your diary with you to every visit to your endocrinologist.
The effectiveness of diet therapy, insulin therapy and self-control is assessed by examining the level of fructosamine (a combination of the protein albumin and glucose). Fructosamine can be considered the average of blood glucose levels over the 2 weeks preceding the test. The study of fructosamine makes it possible to quickly respond to decompensation of carbohydrate metabolism. The fructosamine content is considered normal within the range of 235-285 µmol/l.
In addition to monitoring blood sugar levels, it is necessary to monitor the presence of ketone bodies in the urine. We have already discussed that ketone bodies are products of the breakdown of cellular fat. They can appear when restricting carbohydrates in the diet. Their significant concentration during inadequate insulin therapy or during fasting (for example, “fasting days”!) can have a detrimental effect on the fetus, since the delivery of oxygen to its organs and tissues is reduced. Therefore, firstly, fasting days during pregnancy are excluded! Second, monitor ketone bodies in the following situations:
· in the morning on an empty stomach to assess the adequacy of carbohydrate intake,
· if glycemia is above 13 mmol/l during two or three studies in a row,
· if you ate less carbohydrates than usual.
To determine ketone bodies in urine, special test strips are used that are coated with a chemical composition that reacts with ketone bodies in urine. This test strip can be placed under a stream of urine or lowered into a container with urine for a few seconds. In the presence of ketone bodies, the test field of the strip changes its color. The intensity of the color depends on their concentration, which can be determined by comparing the color of the test strip with the standard scale.
You should inform your doctor about the presence of ketone bodies in your urine. He will help you understand the reason for their appearance and give appropriate recommendations.
At home, you can also monitor your blood pressure and weight gain yourself.
The upper limit of normal blood pressure for a pregnant woman is 130/85 mmHg. Art. However, if your blood pressure before pregnancy and in the first trimester was, for example, 90/60 mmHg, then the pressure is 120-130/80-85 mmHg. Art in the third trimester of pregnancy should be the reason for you to make 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: Should fit your hand size. If the shoulder girth 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 needle should be at zero, the divisions should be clearly visible.
Bulb and valve: The valve regulates the rate of pressure drop in the cuff. Inflation and deflation of air must occur freely.
Phonendoscope: Used to listen to noises produced by blood movement.
· Before taking measurements, rest for 5 minutes in a sitting position.
· Apply the cuff so tightly that you can fit your finger under it.
· Before the first measurement, find the place of pulsation of the artery in the cubital fossa, apply the phonendoscope membrane to this place.
· Place the “olives” of the phonendoscope in your ears so that they tightly cover the ear canal.
· Place the tonometer scale so that the divisions are clearly visible.
· The arm on which the measurement will be taken must be freed from clothing, placed on the table, straightened and relaxed.
· Take the bulb with your other hand, screw on the valve with your thumb and index finger, and quickly pump air into the cuff to a value of approximately 30 mmHg. above your estimated systolic (“upper”) pressure.
· Open the valve slightly and release the air slowly. The rate of pressure drop should be no more than 2 mmHg. per second.
· The value of systolic pressure corresponds to the first beat of at least two consecutive beats.
The value of diastolic (“lower”) pressure is the number at which beats stop being heard
· After the blows have stopped completely, open the valve.
· Record your results in your self-monitoring diary.
Weight control should be carried out weekly in the morning, on an empty stomach, without clothes, after bowel movements and bladder. Only if these conditions are met will you 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 hidden edema. For symptoms of obvious edema, as well as other symptoms of late toxicosis of pregnancy that require urgent medical attention, see the article “How GDM affects the course of pregnancy.”
For timely prevention and identification 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 urine test contains many leukocytes.
How to monitor the development and condition of your baby.
Ultrasound examination (ultrasound)
This is a study using a machine that emits ultrasound waves and creates an image of the organs and tissues of the mother and fetus on a screen. The study is safe for the health of mother and child. Using 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 Doplerometry.
CTG - cardiotocography .
The test is used to confirm that the baby is in good condition and is based on the principle that the fetal heart rate increases during physical activity. To do this, special sensors are placed on the pregnant woman's stomach to record uterine contractions and the fetal heartbeat. Every time the fetus moves, the woman must press a special button on the recording device. The baby's movements can be spontaneous or caused by external influence, for example, stroking the mother's belly. The fetal heartbeat is recorded while it moves. If the heart rate increases, the test is considered normal.
Fetal movements.
The activity of the fetus reflects its condition. If you feel the fetal movements well and 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 it may be in danger. Your doctor will ask you to count your baby's movements during the last trimester of pregnancy. The lower limit of normal is considered to be 10 strong tremors in the last 12 hours or 10 movements in 1 hour. If you do not feel the fetus moving or the number of movements was less than usual, consult a doctor immediately!
How does GDM affect labor and breastfeeding?
If your diabetes is well controlled, your condition is satisfactory, your obstetric history is not burdensome (the size of the fetus and pelvis is appropriate, the fetus is in cephalic presentation, etc.), and the baby is of normal size, then you can give birth through the vaginal birth canal. Indications for cesarean section will be the presence of signs of diabetic fetopathy in the fetus, disruption of its vital functions, complications of pregnancy, such as arterial hypertension, impaired renal function, etc.
During childbirth, the need for insulin changes significantly. The level of counter-insulin pregnancy hormones sharply decreases (since the placenta stops producing them), and cell sensitivity to insulin is restored. During labor, you may even be given an intravenous glucose solution to prevent hypoglycemia. After giving birth, you most likely will not need insulin; your blood sugar levels will return to normal.
Breastfeeding is not contraindicated. This helps to quickly regain shape and 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 birth, and even a little more in the next 3 months.
Of course, your baby receives the greatest benefit from breastfeeding. Breast milk provides him with protection (immunity) from infections and all the necessary nutrients in ideal proportions.
How will gestational diabetes affect your future health?
For most women, GDM disappears after childbirth. 6-8 weeks after the birth of your baby, you need to do a stress test with 75 g of glucose to rule out type 2 diabetes. If the need for insulin continues after birth, it is possible that you developed type 1 diabetes during pregnancy. Be sure to contact 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 levels annually. Regular exercise and maintaining a normal body weight can help reduce your risk of diabetes.
How will GDM affect your child's future health?
Most often, women with GDM are concerned with the question: “Will my baby develop diabetes mellitus after birth?” Answer: “Probably not.” However, such children most often suffer from excess body weight and metabolic disorders. They are at risk for developing type 2 diabetes in later life. Prevention of these diseases is proper nutrition, physical activity and maintaining normal body weight.
Planning a pregnancy
You should be aware of the increased risk of developing GDM in your 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 other specialists if necessary.
Diabetes mellitus is a pathology that requires regular daily monitoring. It is precisely in the precise frequency of performing the necessary therapeutic and preventive measures that a favorable outcome and the possibility of achieving compensation for the disease lie. As you know, diabetes requires constant measurement of blood sugar, the level of acetone bodies in the urine, blood pressure and a number of other indicators. Based on the data obtained over time, the entire treatment is corrected.
In order to lead a full life and control endocrine pathology, experts recommend that patients keep a diabetic diary, which over time becomes an indispensable assistant.
Such a self-monitoring diary allows you to record the following data daily:
- blood sugar levels;
- taking oral medications that lower blood glucose;
- insulin doses administered and injection times;
- number of bread units that were consumed during the day;
- general state;
- level of physical activity and set of exercises performed;
- other indicators.
Purpose of the diary
A diabetic self-monitoring diary is especially important to have in case of an insulin-dependent form of the disease. Its regular filling allows you to determine the body’s reaction to the injection of a hormonal drug, analyze changes in blood sugar levels and the time of jumps to the highest numbers.
Blood sugar levels are an important indicator recorded in a personal diary
A self-monitoring diary for diabetes mellitus allows you to clarify the individual dosage of administered medications based on glycemic indicators, identify unfavorable factors and atypical manifestations, and monitor body weight and blood pressure over time.
Important! Information recorded in a personal diary will allow the treating specialist to adjust therapy, add or replace medications used, change the patient’s physical activity regimen and, as a result, evaluate the effectiveness of the measures taken.
Types of diaries
The diabetes diary is quite easy to use. Self-monitoring for diabetes can be carried out using a manually lined document or a ready-made document printed from the Internet (PDF document). The printed diary is valid for 1 month. Once completed, you can print the same new document and attach it to the old one.
If it is not possible to print such a diary, diabetes can be kept under control using a manually lined notebook or diary notebook. Table columns must include the following columns:
- year and month;
- the patient’s body weight and glycated hemoglobin levels (determined in laboratory conditions);
- date and time of diagnosis;
- sugar readings using a glucometer, determined at least 3 times a day;
- doses of glucose-lowering tablets and insulin;
- the volume of bread units consumed for each meal;
- note (health, blood pressure, ketone bodies in urine, level of physical activity are recorded here).
An example of a personal diary of self-control for diabetes
Internet applications for self-monitoring
Some may find using pen and paper a more reliable means of storing data, but many young people prefer to use specially designed gadget applications. There are programs that can be installed on a personal computer, smartphone or tablet, and services that operate online are also offered.
Social Diabetes
A program that received an award from UNESCO for Mobile Health in 2012. Can be used for any type of diabetes, including gestational. For type 1 disease, the application will help you choose the correct dose of insulin for injection based on the amount of carbohydrates ingested and the glycemic level. With type 2, it will help to early identify any abnormalities in the body that indicate the development of complications of the disease.
Important! The application is developed for a platform running on the Android system.
Diabetes-glucose diary
Main features of the application:
- accessible and easy to use interface;
- tracking data on date and time, glycemic level;
- comments and descriptions for the entered data;
- the ability to create accounts for multiple users;
- sending data to other users (for example, to the attending physician);
- ability to export information to calculation applications.
The ability to communicate information is an important aspect of modern applications for disease control
Diabetes Connect
Designed for Android. It has nice, clear graphics that allow you to get a complete overview of the clinical situation. The program is suitable for types 1 and 2 of the disease, maintains blood glucose levels in mmol/l and mg/dl. Diabetes Connect tracks the patient's diet, the amount of bread units and carbohydrates consumed.
It is possible to synchronize with other Internet programs. After entering personal data, the patient receives valuable medical instructions directly in the application.
Diabetes magazine
The application allows you to track personal data on glucose levels, blood pressure, glycated hemoglobin and other indicators. Features of the Diabetes Journal are as follows:
- the ability to create several profiles simultaneously;
- calendar for viewing information for certain days;
- reports and graphs based on the data received;
- the ability to export information to the attending physician;
- a calculator that allows you to convert one unit of measurement to another.
SiDiary
Electronic diary of self-control for diabetes, which is installed on mobile devices, computers, tablets. It is possible to transfer data with their further processing from glucometers and other devices. In the personal profile, the patient establishes basic information about the disease, on the basis of which the analysis is carried out.
Smileys and arrows are an indicative moment of data changes in dynamics
For patients using pumps to administer insulin, there is a personal page where you can visually manage your basal levels. It is possible to enter data on medications, on the basis of which the required dosage is calculated.
Important! Based on the results of the day, emoticons appear that visually determine the dynamics of the patient’s condition and arrows showing the directions of glycemic indicators.
DiaLife
This is an online diary of self-monitoring of blood sugar compensation and adherence to diet therapy. The mobile application includes the following points:
- glycemic index of foods;
- calorie consumption and calculator for counting them;
- body weight tracking;
- consumption diary - allows you to see statistics of calories, carbohydrates, lipids and proteins entering the body of patients;
- For each product there is a card that describes the chemical composition and nutritional value.
A sample diary can be found on the manufacturer's website.
D-Expert
An example of a self-monitoring diary for diabetes. The daily table records data on blood sugar levels, and below – factors that influence glycemic indicators (bread units, insulin administration and duration of its action, the presence of morning dawn). The user can independently add factors to the list.
The last column of the table is called “Forecast”. It provides hints on what actions need to be taken (for example, how many units of the hormone need to be administered or the required number of grain units to enter the body).
Diabetes: M
The program is capable of monitoring almost all aspects of diabetes therapy, generating reports and graphs with data, and sending results by email. The tools allow you to record blood sugar levels and calculate the amount of insulin required for administration of varying durations of action.
The application is capable of receiving and processing data from glucometers and insulin pumps. Development for the Android operating system.
It must be remembered that treatment of diabetes mellitus and constant control over this disease is a set of interrelated measures, the purpose of which is to maintain the condition of the patient’s body at the required level. First of all, this complex is aimed at correcting the functioning of pancreatic cells, which allows you to keep blood sugar levels within acceptable limits. If the goal is achieved, the disease is compensated.
Last updated: April 18, 2018
Gestational diabetes mellitus during pregnancy is a fairly common disease in Russia and the world in general. The frequency of occurrence varies according to different countries from 7 to 25%. The number of women with this disease is steadily growing every year, which is associated with an increase in the incidence of diabetes mellitus (mainly type 2) in the general population.
Today, in the era of high development of information technology and, thereby, active popularization of knowledge about various diseases of the population, incl. During pregnancy, improving family planning methods, it is relevant to increase the knowledge of women planning pregnancy about the risk of developing gestational diabetes mellitus in order to timely seek medical help in highly qualified medical institutions, where this problem is dealt with by doctors with extensive clinical experience in managing such patients.
basic information
Gestational diabetes mellitus developed during pregnancy is characterized by hyperglycemia (increased blood glucose levels). In some cases, this disorder of carbohydrate metabolism may precede pregnancy and be first identified (diagnosed) only during the development of this pregnancy.
During pregnancy, physiological (natural) metabolic changes occur in the mother's body, aimed at the normal development of the fetus - in particular, the constant supply of nutrients through the placenta.
The main source of energy for the development of the fetus and the functioning of the cells of its body is glucose, which freely (through facilitated diffusion) penetrates the placenta; the fetus cannot synthesize it on its own. The role of the conductor of glucose into the cell is played by the hormone “insulin”, which is produced in the β-cells of the pancreas. Insulin also promotes the “storage” of glucose in the fetal liver.
Amino acids - the main building material for protein synthesis in the fetus, necessary for cell growth and division - are supplied in an energy-dependent manner, i.e. through active transfer across the placenta.
In the mother’s body, in order to maintain energy balance, a protective mechanism is formed (“rapid starvation phenomenon”), which implies an immediate restructuring of metabolism - preferential breakdown (lipolysis) of adipose tissue, instead of the breakdown of carbohydrates with the slightest restriction in the supply of glucose to the fetus - ketone bodies (products) increase in the blood fat metabolism are toxic to the fetus), which also easily penetrate the placenta.
From the first days of physiological pregnancy, all women experience a decrease in fasting blood glucose levels due to accelerated excretion in the urine, decreased glucose synthesis in the liver, and glucose consumption by the fetoplacental complex.
Normally, during pregnancy, fasting blood glucose does not exceed 3.3-5.1 mmol/l. The blood glucose level 1 hour after eating in pregnant women is higher than in non-pregnant women, but does not exceed 6.6 mmol/l, which is associated with a decrease in motor activity of the gastrointestinal tract and an increase in the absorption time of carbohydrates supplied with food.
In general, in healthy pregnant women, fluctuations in blood glucose occur within very narrow limits: on an empty stomach on average 4.1 ± 0.6 mmol/l, after meals - 6.1 ± 0.7 mmol/l.
In the second half of pregnancy (starting from the 16-20th week), the fetal need for nutrients remains highly relevant against the backdrop of even faster growth rates. The placenta plays a leading role in changes in a woman’s metabolism during this period of pregnancy. As the placenta matures, active synthesis of hormones of the fetoplacental complex occurs, which maintain pregnancy (primarily placental lactogen, progesterone).
As the duration of pregnancy increases, for its normal development in the mother’s body, the production of hormones such as estrogens, progesterone, prolactin, cortisol- they reduce the sensitivity of cells to insulin. All these factors, combined with decreased physical activity of the pregnant woman, weight gain, decreased thermogenesis, and decreased insulin excretion by the kidneys, lead to development of physiological insulin resistance(poor tissue sensitivity to its own (endogenous) insulin) is a biological adaptive mechanism for creating energy reserves in the form of adipose tissue in the mother’s body in order to provide the fetus with nutrition in case of starvation.
In a healthy woman, a compensatory increase in insulin secretion by the pancreas occurs approximately three times (the mass of beta cells increases by 10-15%) to overcome such physiological insulin resistance and maintain blood glucose levels normal for pregnancy. Thus, there will be an increased level of insulin in the blood of any pregnant woman, which is the absolute norm during pregnancy!
However, if the pregnant woman has a hereditary predisposition to diabetes mellitus, obesity (BMI more than 30 kg/m2), etc. The existing secretion of insulin does not allow one to overcome the physiological insulin resistance that develops in the second half of pregnancy - glucose cannot penetrate the cells, which leads to an increase in blood sugar and the development of gestational diabetes mellitus. With the bloodstream, glucose is immediately and unhinderedly transferred through the placenta to the fetus, facilitating its production of its own insulin. Fetal insulin, having a “growth-like” effect, leads to stimulation of the growth of its internal organs against the background of a slowdown in their functional development, and the entire flow of glucose coming from the mother to the fetus through its insulin is deposited in the subcutaneous depot in the form of fat.
As a result, chronic maternal hyperglycemia harms the development of the fetus and leads to the formation of the so-called diabetic fetopathy- fetal diseases occurring from the 12th week of intrauterine life until the onset of labor: high fetal weight; violation of body proportions - large belly, wide shoulder girdle and small limbs; advance of intrauterine development - with ultrasound, an increase in the main dimensions of the fetus in comparison with gestational age; swelling of the tissues and subcutaneous fat of the fetus; chronic fetal hypoxia (impaired blood flow in the placenta as a result of prolonged uncompensated hyperglycemia in a pregnant woman); delayed formation of lung tissue; trauma during childbirth.
Diabetic fetopathy
Diabetic fetopathy is one of the main reasons for the high risk of losing a child during pregnancy and childbirth! After birth, diabetic fetopathy causes the development of neonatal (after birth) diseases of the child and requires staged observation and treatment by a neonatologist (a specialist in the physiological management of newborns/infants and pathological conditions).
Child health problems with gestational diabetes mellitus
Thus, at the birth of children with fetopathy, there is a violation of their adaptation to extrauterine life, which is manifested by the immaturity of the newborn even with a full-term pregnancy and its large size: macrosomia (child weight more than 4000 g), respiratory disorders up to asphyxia (suffocation), organomegaly (enlarged spleen, liver, heart, pancreas), heart pathology (primary damage to the heart muscle), obesity, jaundice, disorders in the blood coagulation system, the content of erythrocytes (red blood cells) in the blood increases, as well as metabolic disorders (low values of glucose, calcium , potassium, magnesium blood).
Children born to mothers with uncompensated gestational diabetes mellitus are more likely to have neurological diseases (cerebral palsy, epilepsy), during puberty and beyond, the risk of developing obesity, metabolic disorders (in particular, carbohydrate metabolism), and cardiovascular diseases is increased.
On the part of a pregnant woman with gestational diabetes mellitus, polyhydramnios, early toxicosis, urinary tract infections, and late toxicosis are more common (a pathological condition that is manifested by the appearance of edema, high blood pressure and proteinuria (protein in the urine), develops in the second and third trimester up to preeclampsia - a disorder of cerebral circulation, which can lead to cerebral edema, increased intracranial pressure, functional disorders of the nervous system), premature birth, spontaneous termination of pregnancy, delivery by cesarean section, anomalies of labor, and trauma during childbirth are more often observed.
Disorders of carbohydrate metabolism can develop in any pregnant woman, taking into account the hormonal and metabolic changes that consistently occur at different stages of pregnancy. But the highest risk of developing gestational diabetes is in women who are overweight/obese and over 25 years of age; presence of diabetes in close relatives; with disorders of carbohydrate metabolism identified before the current pregnancy (impaired glucose tolerance, impaired fasting glucose, gestational diabetes in previous pregnancies); glucosuria during pregnancy (the appearance of glucose in the urine).
Gestational diabetes mellitus, which first developed during pregnancy, often does not have clinical manifestations associated with hyperglycemia (dry mouth, thirst, increased volume of urine excreted per day, itching, etc.) and requires active detection (screening) during pregnancy !
Necessary tests
All pregnant women must have their fasting venous blood plasma glucose tested in a laboratory (cannot be tested using portable glucose self-monitoring devices - glucometers!) - against the background of a normal diet and physical activity - at the first visit to the antenatal clinic or perinatal center (as possible earlier!), but no later than 24 weeks of pregnancy. It should be remembered that during pregnancy the blood glucose level on an empty stomach is lower, and after eating it is higher than outside pregnancy!
Pregnant women whose blood glucose levels, according to WHO recommendations, meet the diagnostic criteria for diabetes mellitus or impaired glucose tolerance are diagnosed with gestational diabetes mellitus. If the results of the study correspond to normal indicators during pregnancy, then an oral glucose tolerance test - OGTT ("stress test" with 75 g of glucose) is mandatory at 24-28 weeks of pregnancy in order to actively identify possible disorders of carbohydrate metabolism. All over the world, OGTT with 75 g of glucose is a safe and the only diagnostic test for detecting disorders of carbohydrate metabolism during pregnancy!
| Research time | Venous plasma glucose | ||
|---|---|---|---|
| On an empty stomach | > 7.0 mmol/l (>126mg/dl) | > 5,1 < 7,0 ммоль/л (>92<126мг/дл) | < 5,1 ммоль/л (<92 мг/дл) |
| At any time of the day if there are symptoms of hyperglycemia (dry mouth, thirst, increased volume of urine excreted per day, itching, etc.) | > 11.1 mmol/l | - | - |
| Glycated hemoglobin (HbA1C) | > 6,5% | - | - |
| OGTT with 75 g anhydrous glucose h/w 1 hour after meals | - | > 10 mmol/l (>180mg/dl) | < 10 ммоль/л (<180мг/дл) |
| OGTT with 75 g anhydrous glucose h/w 2 hours after meals | - | > 8.5 mmol/l (>153mg/dl) | < 8,5 ммоль/л (<153мг/дл) |
| Diagnosis | diabetes mellitus type 1 or 2 during pregnancy | Gestational diabetes mellitus | Physiological blood glucose levels during pregnancy |
Remember that normalizing carbohydrate metabolism in a pregnant woman allows you to avoid complications from both the course of pregnancy itself and the condition of the fetus!
After a diagnosis of gestational diabetes mellitus is made, all women require constant monitoring by an endocrinologist together with an obstetrician-gynecologist. Pregnant women should be trained in the principles of rational nutrition, self-control and behavior in conditions of a new pathological condition (i.e., timely testing and visits to specialists - at least once every 2 weeks).
A pregnant woman's diet should be sufficiently high in calories and balanced in basic food ingredients to provide the developing fetus with all the necessary nutrients. At the same time, in women with gestational diabetes mellitus, taking into account the characteristics of the pathological condition, nutrition should be adjusted. The basic principles of diet therapy include ensuring stable normoglycemia(maintaining blood glucose levels corresponding to those for physiological pregnancy), and preventing ketonemia(appearance of fat breakdown products - “hungry” ketones - in the urine), as mentioned above in the text.
Increased postprandial blood glucose levels (above 6.7 mmol/L) are associated with an increased incidence of fetal macrosomia. Therefore, a pregnant woman should exclude easily digestible carbohydrates from food (which lead to a rapid uncontrollable rise in blood glucose) and give preference in the diet to difficult-to-digest carbohydrates high in dietary fiber - carbohydrates protected by dietary fiber (for example, many vegetables, legumes) have a low glycemic index. The glycemic index (GI) is a factor in the rate of absorption of carbohydrates.
Diet for gestational diabetes mellitus
| Hard-to-digest carbohydrates | Low glycemic index product |
|---|---|
| Vegetables | Any cabbage (white cabbage, broccoli, cauliflower, Brussels sprouts, collards, kohlrabi), salads, greens (onions, dill, parsley, cilantro, tarragon, sorrel, mint), eggplant, zucchini, peppers, radishes, radishes, cucumbers, tomatoes, artichoke , asparagus, green beans, leeks, garlic, onions, spinach, mushrooms |
| Fruits and berries | Grapefruit, lemon, lime, kiwi, orange, chokeberry, lingonberry, blueberry, blueberry, blackberry, feijoa, currant, strawberry, strawberry, raspberry, gooseberry, cranberry, cherry. |
| Cereals (porridge), flour and pasta products | Buckwheat, barley; coarse flour bread; Italian durum wheat pasta |
| Milk and dairy products | Cottage cheese, low-fat cheeses |
Products containing carbohydrates with a high amount of dietary fiber should make up no more than 45% of the daily calorie intake, they should be evenly distributed throughout the day (3 main meals and 2-3 snacks) with a minimum carbohydrate content in breakfast, because. the counter-insular effect of increased levels of maternal hormones and the feto-placental complex in the morning increases tissue insulin resistance. Daily walks after meals in the second half of pregnancy help normalize blood glucose levels.
Pregnant women regularly need to monitor ketone bodies in urine (or blood) to identify insufficient carbohydrate intake from food, because. the mechanism of “rapid fasting” with a predominance of fat breakdown can immediately start (see comments above in the text). If ketone bodies appear in the urine (blood), then it is necessary to additionally eat ~ 12-15 g of carbohydrates and ~ 10 g of protein (a glass of milk/kefir or a sandwich with cheese) before going to bed or at night to reduce the long period of fasting at night.
Pregnant women with gestational diabetes mellitus should conduct regular self-monitoring - measuring glycemia using self-monitoring devices (glucometer) - on an empty stomach and 1 hour after each main meal, recording the measurements in a personal self-monitoring diary. Also, the diary should reflect in detail: dietary habits (the number of foods eaten) at each meal, the level of ketones in the urine (using test urine strips for ketones), weight and blood pressure values measured once a week, the amount of fluid drunk and excreted.
Target self-control indicators for pregnant women with GDM are less than 5.0 mmol/l on an empty stomach, less than 7.0 mmol/l 1 hour after a meal, less than 5.5 mmol/l before bedtime and at night!
If, against the background of diet therapy, it is not possible to achieve target blood glucose values within 1-2 weeks, then the pregnant woman is prescribed insulin therapy (tablet glucose-lowering drugs are contraindicated during pregnancy!). For therapy, insulin preparations that have passed all stages of clinical trials and are approved for use during pregnancy are used. Insulin does not penetrate the placenta and has no effect on the fetus, but excess glucose in the mother’s blood immediately goes to the fetus and contributes to the development of those pathological conditions mentioned above (perinatal losses, diabetic fetopathy, neonatal diseases of newborns).
Gestational diabetes mellitus itself during pregnancy - is not an indication for caesarean section or early delivery(until the 38th week of pregnancy). If the pregnancy proceeded against the background of compensation of carbohydrate metabolism (maintaining blood glucose levels corresponding to those for a physiological pregnancy) and complied with all the instructions of your attending physician, then the prognosis for the mother and the unborn child is favorable and does not differ from that of a physiological full-term pregnancy!
In pregnant women with gestational diabetes mellitus, after delivery and expulsion of the placenta, hormones return to normal levels, and, consequently, cell sensitivity to insulin is restored, which leads to normalization of carbohydrate metabolism. However, women with gestational diabetes remain at high risk of developing diabetes in later life.
Therefore, all women with a disorder of carbohydrate metabolism that developed during pregnancy, 6-8 weeks after birth or after the end of lactation, undergo an oral glucose tolerance test (“load test” with 75 g of glucose) in order to reclassify the condition and actively identify disorders of carbohydrate metabolism. exchange.
All women who have had gestational diabetes mellitus are recommended to change their lifestyle (diet and physical activity) in order to maintain normal body weight, and undergo mandatory regular (once every 3 years) blood glucose testing.
Children born to mothers with gestational diabetes mellitus during pregnancy should be observed by appropriate specialists (endocrinologist, therapist, nutritionist, if necessary) to prevent the development of obesity and/or carbohydrate metabolism disorders (impaired glucose tolerance).
Timely seeking qualified medical help, possibly even at the stage of pregnancy planning, will allow timely identification of carbohydrate metabolism disorders or a high risk of their development during the upcoming pregnancy, receive recommendations for prevention or begin treatment as early as possible in order to preserve the health of the woman and her future offspring!
Author of the article Tatyana Yurievna Golitsyna, endocrinologist at the REMEDI Institute of Reproductive Medicine
