The pancreas performs both digestive (these are alpha cells) and endocrine functions. Elements of internal secretion - beta cells of the pancreas. They secrete the hormone insulin, which affects all types of metabolism. This is a hormone that promotes the absorption of glucose by cells of organs and tissues, the biosynthesis of glucose reserves in the liver - glycogen, fats and proteins. With insulin deficiency, this whole process is disrupted - the uptake of glucose by tissues, the glucose content in the blood rises, which is called hyperglycemia. This is the main symptom of diabetes.

There is an absolute deficiency of insulin, when there is a defect in the beta cells and they produce insufficient amounts of the hormone or do not produce it at all. There is also relative insulin deficiency, when insulin is produced in a normal amount, but the tissues of the body are immune to it.

The prevalence of diabetes mellitus (DM) is 0.5% of the total number of births. But this figure is growing every year, which is due to the increase in the number of diabetes in other population groups. Approximately 7% of all pregnancies are complicated by gestational diabetes (more than 200 thousand), gestational diabetes is diagnosed (gestational pregnancy). Before the invention of artificial insulin, childbirth in women with diabetes mellitus was a rarity, pregnancy occurred in only 5% of all patients, threatened the life of a woman, the mortality of fetuses and newborns reached 60%. And the deaths of pregnant women and puerperas were not so rare! Now the death of women is still high - 1-2%, but the mortality of fetuses and newborns has been reduced to 20. With rational tactics for managing pregnancy and childbirth in women with diabetes, when only severe malformations remain the cause of death of the fetus and newborn, mortality will be reduced. reduce to 1-2%.

The problem of managing pregnancy and childbirth in women with diabetes is relevant all over the world, since with diabetes the frequency of threatened miscarriage, preeclampsia, polyhydramnios, genital infections is 5-10 times higher than normal. In fetuses, excess weight is observed even with intrauterine hypoxia, placental insufficiency, therefore, birth injuries of newborns and mothers increase. The frequency of fetuses with increased weight, but affected by hypoxia, injured in childbirth, reaches 94-100%. Complications in the postpartum period - in 80% of newborns, about 12% of children require resuscitation; malformations are found 2-3 times more often than in other pregnant women. Mortality of fetuses and newborns, even in specialized maternity hospitals, is 4-5 times higher than this value among normal children.

Therefore, it is important to compensate for diabetes (until blood glucose levels normalize) within three months before conception and maintain this compensation throughout pregnancy, childbirth and the postpartum period. Women with diabetes who are preparing for pregnancy must go through the so-called diabetes schools in the area of ​​​​residence, have their phone number. In such schools, they are taught methods of self-control, the use of rational doses of insulin.

The risk of developing gestational diabetes should be calculated to further optimize pregnancy management.

Low risk groupdiabetes mellitus:

• under 30 years old;
• with normal weight and body mass index;
• there are no indications of the hereditary factor of DM in relatives;
• there were no cases of violations of carbohydrate metabolism (including glucose was also not detected in the urine);
• there was no polyhydramnios, stillbirth, no children with malformations, or this is the first pregnancy.

To classify a woman at low risk for diabetes, a combination of all these features is needed.

Medium risk groupdiabetes mellitus:

• a slight excess of mass;
• in childbirth there was polyhydramnios or a large fetus was born, there was a child with a developmental defect, there was a miscarriage, preeclampsia, stillbirth.

To a high-risk groupdiabetes mellitus include women:

• over 35 years old;
• with severe obesity;
• with gestational diabetes in a previous birth;
• with heredity burdened by diabetes (had or have relatives);
• with cases of impaired carbohydrate metabolism.

To classify a woman as a high-risk group for developing diabetes, 1-2 of these signs are enough.

There are 3 main typesdiabetes mellitus:

1. Type I diabetes mellitus - insulin dependent (IDDM);
2. Diabetes mellitus type II - insulin independent (NIDDM);
3. Pregnancy diabetes is gestational diabetes (GD) that develops after 28 weeks of pregnancy and is manifested by a transient disorder of carbohydrate metabolism during pregnancy.

Type I diabetes is an autoimmune disease in which antibodies destroy pancreatic B cells. It manifests itself in children or adolescents with a corresponding absolute deficiency of insulin, a tendency to accumulate acidic metabolic products and peroxidize glucose to acetone (called ketoacidosis), with rapid damage to the small vessels of the retina, which can result in blindness, and kidney tissue. In their blood auto-antibodies to pancreatic beta cells are detected.

The risk of developing diabetes in offspring with a disease of the mother is 2-3%, the father is 6%, and both parents are 20%. The average life expectancy of such patients who developed IDDM in childhood does not exceed 40-45 years.

Type II diabetes mellitus develops after the age of 35, most often against the background of obesity. Insulin deficiency is relative, but the tissues do not respond to their own insulin, and the response to the input is weak, which is why it is called NIDDM - insulin resistance (tissues are immune to insulin) and hyperinsulinemia - an increased amount of insulin in the blood. At the same time, late onset diabetes with mild disturbances in the vessels and metabolism, the state of the reproductive system is almost not disturbed. But the risk of inheriting diabetes in offspring is very high - genetic overwhelming inheritance.

There are three degrees of severity of diabetes:

• Grade I (mild) - fasting glucose<7,7 ммоль/л, не возникает кетоз. Нормализация глюкозы может быть достигнута одной только диетой;
• II degree (medium) - fasting glucose< 12,7 ммоль/л. Нет признаков кетоза. Нормализация уровня глюкозы может быть достигнута с помощью диеты и инсулина в дозе до 60 ед./сут.;
• III degree (severe) - fasting glucose> 12.7 mmol / l. Severe ketoacidosis, violation of small vessels in the retina and in the kidneys. Normalization of glucose levels can be achieved with doses of insulin in excess of 60 units/day.

With IDDM, there is a moderate or severe form of diabetes mellitus. And with NIDDM - mild or moderate severity of diabetes.

Pregnancy diabetes (GD) is a transient disorder of blood glucose, first diagnosed during pregnancy. In the first trimester, HD is detected in 2%; in the II trimester - in 5.6%; in the III trimester, HD is detected in 3% of pregnant women.

The main consequence of HD is diabetic fetopathy (foetus - fetus; pathia - disease), i.e. violations of the formation of the fetus, which includes increased body weight (4-6 kg), with the immaturity of lung tissue for independent breathing - a high frequency of malformations, impaired adaptation to extrauterine life, in the neonatal period - high mortality of fetuses and newborns.

There are 2 main forms of fetopathy, which is formed in 94-100% of the fetuses of patientsmaternal diabetes mellitus:

• hypertrophic - high body weight with normal body length, large and thick placenta;
• hypoplastic - feto-placental insufficiency and IUGR (intrauterine growth retardation) of the fetus, the placenta is thin and smaller. More severe course of intrauterine hypoxia and birth asphyxia.

Symptoms and signs of diabetes during pregnancy

During normal pregnancy, there are significant changes in the content of glucose in the blood, as well as the levels of insulin secretion, which has a diverse effect on several metabolic factors. Glucose is a source of energy for the development of the fetus. The need for glucose is provided by the glucose in the mother's blood. Fasting blood glucose levels decrease as the pregnancy progresses. The reason is the increased uptake of glucose by the placenta. In the first half of pregnancy, due to a decrease in blood glucose, the sensitivity of maternal tissues to insulin increases.

In the second half of pregnancy, the level of placental hormones increases significantly, which suppress the uptake of glucose by maternal tissues, which ensures a sufficient level of glucose supply to the fetus. Therefore, pregnant women have higher postprandial blood glucose levels than non-pregnant women. A constantly slightly elevated blood glucose level in pregnant women leads to an increase in the amount of insulin secreted. In parallel, tissue insensitivity to insulin is formed, due to placental hormones, as mentioned above. And such insensitivity of maternal tissues and cells to insulin increases its amount in the blood.

An increase in blood glucose inhibits the formation of a store of glucose in the liver - glycogen. As a result, a significant part of glucose passes into soluble fats - triglycerides - this is an easy depot of fat, its reserve for the development of the brain and nervous system of the fetus. By the 10-12th week of pregnancy, formed beta cells appear in the pancreas of the fetus, capable of releasing full-fledged insulin. Elevated levels of glucose in the mother's blood also increase the amount in the blood of the fetus, which stimulates the release of insulin.

In the third trimester of pregnancy, under the action of placental lactogen, which prepares the mammary glands of the mother for future lactation (milk production), the breakdown of fats increases. Drops of soluble fats are the basis of milk. Therefore, the amount of glycerol and free fatty acids in the mother's blood increases.

As a result, the level of so-called ketone bodies, oxidized fatty acid residues, rises. Maternal liver cells also take part in the formation of these ketone bodies. These ketones are needed by the fetus for the formation of the liver and brain, as a source of energy.

This is a description of the physiological picture of changes in the amounts of glucose and insulin in a pregnant woman and fetus during pregnancy, although it may seem that this is a picture of diabetes mellitus. Therefore, many researchers regard pregnancy as a diabetogenic factor. Pregnant women may even have glucose in their urine, which is caused by a decrease in kidney function rather than a disorder in blood glucose.

Complications of pregnancy in diabetes mellitus begin from the earliest stages of embryo development. It is possible to transmit chromosomal mutations that subsequently cause diabetes in the fetus and newborn. A genetic mutation leads to the death of the zygote (the earliest stage in the division of a fertilized egg), and the already mentioned menstrual abortion occurs.

Diabetes mellitus in a pregnant woman with impaired metabolism and absorption of glucose in the organs and tissues of the body, with severe vascular disorders, especially in the small vessels of the liver, kidneys, retina, cannot but affect the processes of embryogenesis and embryo formation. A teratogenic effect is possible (see the chapter on the development of the embryo and fetus), incorrect laying of individual organs and systems (the occurrence of fetal malformations). In addition, an increased level of glucose in the blood of a pregnant woman causes the same increase in her fetus, which does not yet have its own insulin. As a result, the metabolism of the fetus is also disturbed, including increased lipid peroxidation with the formation of an increased amount of ketone bodies that freely penetrate into the blood of a pregnant woman. Ketones in the mother's blood can cause ketoacidosis - acidification of body fluids, which sharply worsens the condition of the pregnant woman, causing ketoacidotic shock that threatens the life of the pregnant woman. A shift to the acidic or alkaline side of the liquids and environments of the human body is a severe violation of cellular respiration (oxygen uptake in cells). Therefore, the death of a woman may follow.

The first half of pregnancy in patients with diabetes occurs only with the threat of abortion. If there is a high degree of damage to the vessels of the uterus and contact with the forming placenta is disturbed, a late miscarriage occurs, on the verge of premature birth, at 20-27 weeks in 15-30% of pregnant women.

In the second half of pregnancy, the frequency of preeclampsia is high; it develops in 30-70% of pregnant women with diabetes mellitus. The development of preeclampsia is associated with a pronounced violation of the vessels of the kidneys - nephropathy. Therefore, preeclampsia in diabetes is expressed by hypertension - increased blood pressure as a result of a violation of the blood supply to the kidneys and the involvement of the renin-angiotensin system of vasospasm. As a result, hypoxia of the kidneys increases even more, and circles of vascular and hypoxic disorders are winding up. The filtration of the kidneys is damaged, the second characteristic feature of diabetic gestosis occurs - edema, an increase in glucose in the urine. A tendency to accumulate tissue fluid can cause acute polyhydramnios. On the part of the fetus, urine output increases to "dilute" the high glucose in the amniotic fluid. Tissue edema and vasospasm in the placenta can cause intrauterine fetal death. The risk of stillbirth with preeclampsia reaches 18-45%. It is caused not only by hypoxia, but can occur due to malformations, mechanical compression by amniotic fluid, with polyhydramnios and a complete cessation of oxygen supply. Polyhydramnios is diagnosed in 20-60% of pregnant women with diabetes. Intrauterine fetal death in diabetes occurs most often at 36-38 weeks of gestation, with the highest permeability of the placenta for glucose - in particular, but also for ketones, peroxidized fats. Because of this, delivery of diabetic patients is often performed at 35-36 weeks. It is easier for a born child, although premature, to help by normalizing the level of glucose first of all.

Due to diabetic vascular disease in pregnant women with diabetes mellitus, chronic DIC is formed. Therefore, often combined preeclampsia has a severe course, up to eclampsia. The risk of maternal mortality is rising sharply. Large violations are also observed during the formation of the placenta: the so-called annular placenta is formed, underdeveloped by stripes, with additional lobules. Violations of the fundamental features of the placental circulation are possible: only one umbilical artery is formed instead of two. In the uterine arteries of mothers with diabetes, there are no changes characteristic of normal uteroplacental circulation. This causes insufficiency of uteroplacental circulation, germination of placental vessels into the uterine muscle, narrow vascular lumens, cannot provide a proper increase in uteroplacental circulation in the II and III trimesters of pregnancy. This is the cause of feto-placental insufficiency and chronic fetal hypoxia.

At the same time, an increased level of sugar in the blood of the fetus causes an increase in growth hormone, therefore, at the level of placental insufficiency, starting from the second trimester, bone tissue increases and muscle mass grows, and a large fetus can form. The frequency of birth of children weighing more than 4 kg in patients with diabetes mellitus is three times higher than the frequency of a large fetus in other women. Maternal diabetes mellitus causes the accumulation of adipose tissue with still normal bone thickness and muscle mass. The internal organs of the fetus (heart, liver, kidneys, pancreas) increase in proportion to the increase in the size of the fetus. There is a typical picture of hypertrophic diabetic fetopathy. Together with the growth of a large body weight and organs of the fetus, there is a significant insufficiency of the functions of these organs, a lack of enzymes.

But sometimes placental insufficiency overpowers, and a hypoplastic type of diabetic fetopathy occurs. With this form, the risk of death of an immature and hypotrophic fetus increases from insufficient production of surfactant, which straightens the lungs at the first breath of a newborn. This is also the reason for the syndrome of respiratory disorders (respiratory distress syndrome) in newborn diabetic children, large, but with immature hormonal and enzyme systems, their organs are not able to function normally, so more than 12% of newborns require resuscitation.

The clinical picture of diabetes mellitus is due to an increase in blood sugar. This explains dry mouth, increased thirst, drinking more than two liters of fluid per day, itching of the skin, especially in the genitals, in the anus, since glucose crystals irritate the mucous membranes and subcutaneous tissue. Violation of the vessels of the eyes causes periodic, transient changes in vision, weight loss. Violation of immunity explains the increased tendency to pustular skin lesions of pyoderma, furunculosis, and in the genital organs - to candidal colpitis (inflammation of the vagina).

The course of pregnancy in the first trimester, if it is possible to maintain it, proceeds without significant changes. Sometimes the blood sugar level even normalizes due to improved glucose tolerance, its absorption by tissues, as even some hypoglycemia occurs. Physicians should take this into account, as a reduction in insulin doses is required. The decrease in the amount of glucose in the mother is also explained by the increased absorption of glucose by the fetus. Strict control of glucose levels, ketones, acid-base balance is required to prevent the development of hypoglycemic or ketoacidotic coma.

In the II trimester, due to increased production of placental hormones that counteract insulin, glucose in the blood of a pregnant woman rises, typical diabetic complaints appear (dryness, thirst, itching), and glucose appears in the urine. Again, ketoacidosis threatens. Therefore, it is necessary to increase the dose of insulin.

In the III trimester, with the manifestation of placental insufficiency, the amount of hormones that counteract insulin decreases, the sugar level decreases again, this is due to the production of the fetus's own insulin. Therefore, the amount of insulin administered must be reduced.

In childbirth, there is a large lability (mobility, changes) in the sugar content. The stress of childbirth (fear and pain) generates an increase in glucose levels and the possibility of acidosis. But the work done on the birth of a large fetus, trauma and blood loss can quickly lead to a sharp decrease in glucose levels and hypoglycemic coma.

In the postpartum period, hypoglycemia (low glucose level) is also observed, by the 4-5th day the sugar level gradually increases. Doses of insulin should be increased or decreased accordingly. By the 7-10th day after birth, the glucose level reaches the level that was observed before pregnancy.

It can be said that diabetes and pregnancy mutually burden each other. Pregnancy requires increased functions, and organs and systems are significantly undermined by the existing disease. Therefore, vascular disorders progress significantly, vascular disorders of the retina are observed in 35% of pregnant women. Diabetic nephropathy leads to preeclampsia. There is a combination of vascular disorders in the kidneys and the addition of infections, in 6-30% of pregnant women - pyelonephritis and bacteriuria.

In childbirth, weakness of labor activity is often formed, due to overstretching of the uterus by a large fetus. Prolonged labor worsens the picture of fetal hypoxia, asphyxia may begin. Due to the large fetus, injuries to the mother and fetus increase. The fetus has a fracture of the clavicles or humerus, a skull injury is possible. And in the mother - ruptures of the cervix, vaginal walls, perineum, often make her dissection (lerineotomy).

The frequency of postpartum complications in diabetes mellitus is five times higher than in healthy puerperas. The number of infectious, wound, respiratory disorders is increased. Due to the decrease in placental lactogen, lactation of the mammary glands is reduced.

The course of pregnancy and childbirth, the severity of complications depend on the type of diabetes.

Management of pregnancy in diabetic patients

Observation of pregnant women with diabetes mellitus is carried out in the conditions of both an outpatient clinic and a hospital, departments of specialized maternity hospitals. Women with a diagnosis of diabetes mellitus before pregnancy, when planning it, should undergo an examination, which specifies the type of diabetes and the degree of its compensation, the presence of vascular damage characteristic of diabetes.

Antibodies to beta-cells of the pancreas, antibodies to insulin are being investigated. The "School of Diabetes" provides training in the method of self-control of insulin therapy. During pregnancy, regardless of the type of diabetes, everyone is switched to the introduction of appropriate doses of insulin to compensate for the increased level of glycemia (high blood sugar). Hypoglycemic drugs taken orally should be canceled due to the presence of these drugs in embryotoxic and teratogenic effects. After a detailed examination, the issue of the admissibility of pregnancy, the risk of carrying it is decided.

Pregnancy is contraindicated in:

• the presence of rapidly progressive or existing severe vascular disorders of the retina, threatening blindness, or nephropathy, which can pose a threat to life, with severe preeclampsia;
• insulin resistance, the presence of antibodies to insulin. Labile (changeable) course of diabetes;
• the presence of diabetes in both parents, which dramatically increases the risk of fetal disease;
• a combination of diabetes mellitus and Rh sensitization in a future mother, significantly worsening the prognosis for the fetus;
• a combination of diabetes mellitus and active pulmonary tuberculosis, which during pregnancy threatens with a severe exacerbation of the process.

The question of the possibility of prolonging pregnancy is decided by a board of doctors - an obstetrician-gynecologist, an endocrinologist, a therapist, and sometimes a phthisiatrician.

Case from practice. Pregnant M.O., 35 years old, with type II diabetes, 8 weeks pregnant, threatened recurrent miscarriage. Before the existing pregnancy, there were 3 miscarriages in the first trimester and a stillbirth at 25 weeks of pregnancy. The diagnosis revealed severe microcirculation disorders, the threat of blindness and nephropathy. The board of doctors recommended M.O. terminate the pregnancy due to severe prognosis for herself and the fetus.

But not only M.O., but also many women with diseases of internal organs that threaten to worsen their condition or even die during pregnancy, neglect the advice of doctors and prolong pregnancy with the manic idea of ​​giving birth to a child, even at the cost of their own lives.

Accordingly, M.O. refused to terminate the pregnancy and began to bear it.

The pregnancy was saved. However, a deterioration in the state of the vessels of the retina was revealed. From 22 weeks, combined preeclampsia with nephropathy, edema and hypertension began. M.O. was urgently hospitalized. Long-term intravenous treatment of preeclampsia and placental insufficiency, administration of corticoid hormones to accelerate the maturation of surfactant in the lungs of the fetus were started.

This was done due to the insufficient effect of the treatment. There was a sharp deterioration in the patient's vision, she was almost blind. Destabilization of blood glucose levels began, hypoglycemic states began to occur.

Therefore, premature delivery at 28-29 weeks was undertaken.

Due to chronic fetal hypoxia, a caesarean section was performed. A girl with a weight of 3000 g, signs of prematurity and functional immaturity of organs (and this at 29 weeks) was extracted - a hypertrophic form of diabetic fetopathy. The mother sacrificed her eyesight for the birth of her daughter.

Treatment of diabetes during pregnancy

The severity of pregnancy complications in diabetes necessitates the consideration of repeated hospitalizations as the pregnancy progresses. The purpose of these hospitalizations is to prevent possible complications of pregnancy and diabetes.

The first hospitalization is carried out at the first visit of the pregnant woman to the antenatal clinic. The tasks of this hospitalization are the exact determination of the gestational age, genetic counseling with, according to indications, amniocentesis, cordocentesis, chorionic biopsy. Ultrasound is performed to detect diabetic embryopathy. Doses of insulin are adjusted. Information is given on the control of not only the level of glycemia, but also glucosuria (the appearance of glucose in the urine), acetonuria - the appearance of ketones in the urine. The features of the diet required regardless of the type of diabetes are explained. An in-depth examination of urogenital infection and treatment of detected infections are carried out. The only possible type of correction of the immune system for pregnant women is the introduction of rectal suppositories Viferon or Kipferon.

The second hospitalization - at a period of 8-12 weeks. At this time, correction of insulin doses is required due to the onset of relative hypoglycemia (lowering blood sugar). Repeated ultrasound is carried out, control of the size of the fetus, detection of malformations, the amount of amniotic fluid. An examination by an ophthalmologist, identification of the state of the vessels of the retina is necessary. Symptoms of a threatened miscarriage are identified, and treatment is prescribed if necessary.

The third hospitalization - at 20-24 weeks. Another correction of insulin doses.

Monitoring the presence or development of small vessel lesions characteristic of diabetes. Signs of the development of combined gestosis are revealed. Ultrasound control - clarification of the state of the placenta, the correspondence of the size of the fetus to the gestational age, signs of diabetic fetopathy, the amount of amniotic fluid. A course of metabolic therapy (metabolism - metabolism) is carried out for three weeks to prevent placental insufficiency - fetal hypoxia.

The next hospitalization is at the 30th-32nd week of pregnancy. Another correction of insulin doses, determination of the presence or occurrence of damage to small vessels. Assessment of the condition of the fetus and placenta using ultrasound, Doppler study of blood flow in the placenta and in the fetus. A study of the fetal heartbeat is also carried out - a CTG recording. Control of blood clotting, placental hormones. Prevention of insufficiency in the production of surfoctant in the lungs of the fetus. The timing and method of delivery are determined

Childbirth is carried out as close as possible to a full-term pregnancy, but the risk of intrauterine death of the fetus, loss of the fetus during childbirth is taken into account. In case of violation of the presentation of the fetus, severe diabetes, a high risk of fetal loss in childbirth, a caesarean section is performed at 36-37 weeks of pregnancy. Perhaps delivery and in earlier terms of pregnancy. It all depends on the compensation of diabetes, the severity of complications, the condition of the pregnant woman and the fetus. It is necessary to take into account the sharp drops in blood glucose levels during childbirth and the early postpartum period.

Case from practice. Patient O.N., 32 years old. Diabetes mellitus type I, congenital, the presence of antibodies to pancreatic beta cells. Admitted for delivery at 34 weeks of gestation with severe preeclampsia, hypertension and acute polyhydramnios. Intravenous administration of antihypoxants (drugs for the treatment of hypoxia) and micronized heparin was started, this was the prevention of DIC.

When compensating for the level of blood pressure, blood glucose, a careful amniotomy (opening of the fetal bladder) was performed with a gradual release of fluid.

CTG monitoring revealed severe fetal hypoxia, a hypoplastic form of diabetic fetopathy.

According to the sum of severe diabetic and obstetric risks, the birth plan was changed to operational. A caesarean section was performed - a live, premature, malnourished boy was removed, with asphyxia, weighing 1300 g. Subsequently, the child was found to have a congenital heart disease, fusion of the fingers. The postoperative period on the 2nd day was complicated by severe hypoglycemia, ketoacidosis, hypoglycemic coma. An immediate jet injection of 40% glucose was started, but this did not help, death occurred. An autopsy revealed cerebral edema with wedging of the cerebellum into the foramen magnum - the cause of death. It was the automatism of the actions of physicians. After the operation, a zero table is assigned - only water, a weak broth. And the doses of insulin were not adjusted on time. The sugar-lowering action of insulin, fasting, and early postoperative (fear, blood loss) hypoglycemia converged. The sugar level dropped to zero. Therefore, even intravenous jet administration of 250 ml of 40% glucose did not help.

The predisposition of women to diabetes can be thought of in the following cases:

• if both parents of a woman have diabetes,
• if her identical twin is diabetic,
• if a woman previously had children weighing more than 4500 g,
• if the woman is obese,
• if she had habitual miscarriages,
• with polyhydramnios,
• with glucosuria (detection of sugar in the urine).

The fact that a woman suffers from diabetes is most often known even before pregnancy, but diabetes can first appear during the bearing of the baby.

Symptoms of the disease

Insulin affects all types of metabolism. With a lack of this hormone, the absorption of glucose is disturbed, its decay increases, resulting in an increase in blood glucose levels (hyperglycemia) - the main symptom of diabetes mellitus.

Patients with diabetes complain of dry mouth, thirst, increased fluid intake (more than 2 liters), excessive urination, increased or decreased appetite, weakness, weight loss, skin itching, especially in the perineum, sleep disturbance. They have a tendency to pustular skin diseases, furunculosis.

Diagnosis of diabetes mellitus requires laboratory tests, primarily the determination of the amount of sugar in the blood. The diagnosis of "diabetes mellitus" can be made when the level of glucose in blood taken on an empty stomach from a vein is above 7.0 mmol/l or in blood taken from a finger is above 6.1 mmol/l. This level is called hyperglycemia.

Suspicion of the presence of diabetes occurs when the level of glucose in the blood on an empty stomach is in the range of 4.8-6.0 mmol / l. Then it is necessary to conduct a more complex glucose tolerance test - this test allows you to explore the body's response to the introduction of an additional amount of glucose. With initial hyperglycemia, the diagnosis is clear and no test is needed. It is necessary to determine blood sugar at the beginning of pregnancy weekly, and by the end of pregnancy - 2-3 times a week.

The second important indicator of diabetes is the detection of sugar in the urine (glucosuria), but with the simultaneous presence of hyperglycemia (increased blood sugar levels). Glucosuria without hyperglycemia is often found in healthy women and is called "glycosuria of pregnancy." This condition is not a sign of illness.

Severe diabetes mellitus disrupts not only carbohydrate, but also fat metabolism. With decompensation of diabetes mellitus, ketonemia appears (an increase in the amount of fat metabolism products in the blood - ketone bodies, including acetone), and acetone is found in the urine.

With a stable normal blood sugar level and normalization of the glucose tolerance test, it is believed that diabetes mellitus is in a state of compensation.

Diabetes mellitus occurs with damage to many organs and systems of the body: small vessels of the eyes, kidneys, skin, muscles, nervous system, and gastrointestinal tract suffer.

Especially dangerous eye disease - diabetic retinopathy, accompanied by a progressive decline in visual acuity, retinal hemorrhage and threatening blindness. Kidney damage is manifested by an increase in blood pressure, the presence of protein in the urine, edema, visual impairment, chronic renal failure (a violation of the internal environment of the body caused by the irreversible death of kidney tissue), which in this case develops earlier than in other kidney diseases. Diabetes mellitus also contributes to the appearance of other renal pathologies, especially those associated with infection: pyelonephritis, cystitis. In diabetes mellitus, there is a weakening of the immune system, which may be one of the reasons for frequent bacterial complications.

Diabetes also affects the genitals. Women have spontaneous abortions, premature births, intrauterine fetal death.

Coma is a dangerous complication of pregnancy. Ketonemic (another name is diabetic) and hypoglycemic coma can develop, in which the patient loses consciousness. The causes of coma may be dietary disorders (excessive or insufficient consumption of carbohydrates) and an inadequate dose of insulin in the blood glucose level - overestimated or insufficient.

There are 3 degrees of severity of diabetes:

1 degree (mild): fasting hyperglycemia less than 7.7 mmol/l; normalization of blood sugar levels can be achieved with a single diet.

2nd degree (medium): fasting hyperglycemia less than 12.7 mmol/l; diet is not enough to normalize blood sugar levels, insulin treatment is needed.

3 degree (severe): hyperglycemia on an empty stomach is more than 12.7 mmol / l, vascular lesions of organs are expressed, there is acetone in the urine.

Features of the course of the disease in pregnant women

During pregnancy, the course of diabetes changes significantly. There are several stages of these changes.

1. V I trimester of pregnancy there is an improvement in the course of the disease, the level of glucose in the blood decreases, and this can lead to the development of hypoglycemia. Therefore, the dose of insulin is reduced by 1/3.
2. WITH 13 weeks pregnant there is a deterioration in the course of the disease, an increase in hyperglycemia, which can lead to coma. The dose of insulin must be increased.
3. WITH 32 weeks of pregnancy and before childbirth it is possible to improve the course of diabetes again and the appearance of hypoglycemia. Therefore, the dose of insulin is reduced by 20-30%.
4. There are significant fluctuations in blood sugar levels during childbirth; hyperglycemia may develop under the influence of emotional influences (pain, fear) or hypoglycemia as a result of the physical work done, the woman's fatigue.
5. After childbirth, blood sugar quickly decreases and then gradually rises, reaching the level that it was before pregnancy by the 7-10th day of the postpartum period.

In connection with such dynamics of the pathological process, a woman is hospitalized for correction of insulin doses in the following periods of pregnancy:

1. in the first weeks, as soon as pregnancy is diagnosed, to assess the severity of the course of the disease and carefully compensate for diabetes;
2. 20-24 weeks, when the course of the disease worsens;
3. at 32 weeks to compensate for diabetes mellitus and resolve the issue of the timing and method of delivery.

Pregnancy adversely affects the course of diabetes. Vascular diseases progress, in particular, diabetic retinopathy is diagnosed in 35% of patients, diabetic kidney damage contributes to the addition of gestosis, a complication of pregnancy, manifested by an increase in blood pressure, the appearance of edema, protein in the urine, and a recurrence of exacerbations of pyelonephritis.

Pregnancy in women with diabetes mellitus occurs with a large number of serious complications. Preeclampsia develops in 30-70% of women. It is manifested mainly by an increase in blood pressure and edema, but severe forms of preeclampsia are not uncommon, up to eclampsia (convulsive seizures with loss of consciousness). With a combination of preeclampsia and diabetic kidney damage, the danger to the life of the mother increases dramatically, as renal failure may develop due to a significant deterioration in kidney function. The stillbirth rate in preeclampsia in patients with diabetes is 18-46%.

Spontaneous termination of pregnancy occurs in 15-31% of women at 20-27 weeks of pregnancy or earlier. But with careful monitoring and treatment, the risk of spontaneous miscarriage does not exceed that of healthy women. Preterm births are common, and diabetic women rarely carry to term. 20-60% of pregnant women may have polyhydramnios. With polyhydramnios, fetal malformations and stillbirth are often diagnosed (in 29%). Intrauterine fetal death usually occurs at 36-38 weeks of gestation. More often this happens with a large fetus, manifestations of diabetes and preeclampsia. If polyhydramnios and fetal malformations are diagnosed during pregnancy, then perhaps doctors will raise the issue of labor induction at 38 weeks.

Childbirth does not always proceed safely for the mother and fetus due to the large size of the latter, causing injuries - both maternal and child.

The frequency of postpartum infectious complications in patients with diabetes is significantly higher than in healthy women. There is insufficient lactation.

Due to the worsening of the course of the disease during pregnancy and the increase in the frequency of pregnancy complications, not all women with diabetes can safely endure pregnancy and childbirth. Pregnancy is contraindicated:

1. with diabetic micrangiopathies (damage to small vessels of various organs),
2. with insulin resistant forms of the disease (when insulin treatment does not help),
3. with diabetes of both spouses (there is a high risk of a hereditary disease of the child),
4. with a combination of diabetes and Rh conflict (a condition in which the red blood cells of a Rh-positive fetus are destroyed by antibodies produced in the body of an Rh-negative mother),
5. with a combination of diabetes and active tuberculosis,
6. if a woman has repeated stillbirths or children born with malformations in the past.

If the pregnancy proceeds safely, diabetes mellitus is compensated, childbirth should be timely and carried out through the natural birth canal. With insufficiently compensated diabetes or with a complicated course of pregnancy, premature delivery is performed at 37 weeks. Often in patients with diabetes, there is a need for operative delivery by caesarean section.

Children in women with diabetes mellitus are born large due to adipose tissue (weight more than 4500 g, height 55-60 cm). They are characterized by diabetic fetopathy: puffiness, cyanosis (bluish discoloration of the skin), moon face (rounded face due to the features of fat deposition), excessive fat deposition, immaturity. These children adapt much worse in the early postpartum period, which is manifested by the development of jaundice, a significant loss of body weight and its slow recovery. The other extreme - fetal malnutrition (low body weight) - occurs in diabetes mellitus in 20% of cases.

Congenital malformations are observed 2-4 times more often than in normal pregnancy. Risk factors for their occurrence in diabetes mellitus are poor control of diabetes before conception, disease duration over 10 years, and diabetic vascular disease. Genetic causes cannot be ruled out. It is assumed that already in the very early stages of pregnancy, hyperglycemia disrupts the formation of organs. 5 times more often than in healthy women, children are born with heart defects, often with damage to the kidneys, brain and intestinal anomalies. Malformations incompatible with life occur in 2.6% of cases.

Prenatal developmental disorders can be identified through special studies.

The risk of developing diabetes in offspring with diabetes of one of the parents is 2 - 6%, both - 20%.

Treatment

A woman with diabetes should, even before pregnancy, under the supervision of a doctor, achieve complete compensation for diabetes and maintain this condition throughout the pregnancy.

The main principle of the treatment of diabetes during pregnancy is the desire to fully compensate for the disease through adequate insulin therapy in combination with a balanced diet.

The diet of pregnant women with diabetes must be agreed with an endocrinologist. It contains a reduced amount of carbohydrates (200-250 g), fats (60-70 g) and a normal or even increased amount of proteins (1-2 g per 1 kg of body weight); energy value - 2000-2200 kcal. Obesity requires a subcaloric diet: 1600-1900 kcal. It is very important to consume the same amount of carbohydrates every day. Meals should coincide in time with the onset and maximum action of insulin, so patients taking combined insulin preparations (long-acting and simple insulin) should receive carbohydrate-rich foods one and a half and 5 hours after insulin administration, as well as before bedtime and upon awakening . It is forbidden to use fast-absorbing carbohydrates: sugar, sweets, jam, honey, ice cream, chocolate, cakes, sugary drinks, grape juice, semolina and rice porridge. In pregnant women with diabetes without obesity, such a diet helps to normalize the body weight of newborns. Nutrition of a pregnant woman suffering from diabetes should be fractional, preferably 8 times a day. During pregnancy, a patient with diabetes should gain no more than 10-12 kg in weight.

In the diet of pregnant women with diabetes, vitamins A, groups B, C, and D, folic acid (400 mcg per day) and potassium iodide (200 mcg per day) are needed.

If after 2 weeks of treatment with a diet at least twice the glucose numbers are elevated, they switch to insulin therapy. Too rapid fetal growth even with normal blood sugar levels is also an indication for insulin treatment. The dose of insulin, the number of injections and the time of administration of the drug are prescribed and controlled by the doctor. In order to avoid lipodystrophy (absence of subcutaneous tissue at the injection sites), insulin should be injected into the same place no more than 1 time in 7 days.

In mild forms of diabetes, the use of herbal medicine is acceptable. A number of plants have hypoglycemic properties. For example, you can brew blueberry leaves (60 g) in a liter of boiling water, leave for 20 minutes, strain; drink 100 ml 4-5 times a day, for a long time, under the control of blood sugar. You can use the following collection: 5 g of bean pods without seeds, 5 g of blueberry leaves, 5 g of chopped oat straw, 3 g of linseed, 2 g of chopped burdock root mix, pour 600 ml of boiling water, boil for 5 minutes, leave for 20 minutes, strain. Drink 50 ml 6 times a day for 4-6 months.

In addition to diet and insulin, diabetic patients benefit from physical activity in this case, working muscles consume glucose and blood sugar decreases. Hiking is recommended for pregnant women as exercise.

Patients with diabetes mellitus should use a glucometer and diagnostic strips for self-monitoring, but it is impossible to diagnose diabetes mellitus based on these studies, because they are not accurate enough.

All of the above applies to type 1 diabetes mellitus - this is diabetes that occurs at a young age, with it the formation of insulin in the pancreas is always impaired. Type 2 diabetes and gestational diabetes are much less common in pregnant women.

Type 2 diabetes occurs in people over the age of 30, often with obesity. With this form of diabetes mellitus, the state of the reproductive organs is almost not disturbed. However, the risk of developing diabetes in offspring is very high. Women with type 2 diabetes usually give birth at term.

Antidiabetic drugs (not insulin) in the form of tablets that treat type 2 diabetes are contraindicated in pregnant women: they pass through the placenta and have a damaging effect on the fetus (causing the formation of fetal malformations), therefore, in type 2 diabetes, insulin is also prescribed to pregnant women .

Diabetes mellitus in pregnancy occurs in 4% of women. This form of diabetes develops during pregnancy and disappears shortly after it ends. It develops in obese women in the presence of diabetes in relatives. A burdened obstetric history (spontaneous miscarriage, stillbirth, polyhydramnios, birth of large children in the past) may indicate its presence. This form of diabetes is detected with the help of a special test for glucose tolerance, more often at 27-32 weeks of pregnancy. Pregnancy diabetes disappears 2-12 weeks after delivery. Over the next 10-20 years, these women often develop diabetes as a chronic disease. Pregnancy with gestational diabetes proceeds in the same way as with type 2 diabetes.

Approximately 25% of women with gestational diabetes require insulin therapy.

Pregnancy is a serious test for the health of a woman with diabetes. For its successful completion, scrupulous implementation of all the recommendations of an endocrinologist is required.

Relatively recently, doctors were categorically opposed to women with diabetes becoming pregnant and giving birth to children. It was believed that in this case the probability of a healthy baby is too small.

Today, the situation in the cortex has changed: in any pharmacy you can buy a pocket glucometer, which will allow you to control blood sugar levels daily, and if necessary, several times a day. Most clinics and maternity hospitals have all the necessary equipment to manage pregnancy and childbirth in diabetics, as well as to nurse children born in such conditions.

Thanks to this, it became clear that pregnancy and diabetes are quite compatible things. A diabetic woman is just as likely to give birth to a perfectly healthy baby as a healthy woman. However, during pregnancy, the risks of complications in diabetic patients are extremely high, the main condition for such a pregnancy is constant monitoring by a specialist.

Types of diabetes

Medicine distinguishes three types of diabetes:

1. insulin dependent diabetes also called type 1 diabetes. It usually develops during adolescence;
2. non-insulin dependent diabetes respectively, type 2 diabetes. Occurs in people over 40 who are overweight;
3. Gestational diabetes during pregnancy.

Type 1 is the most common among pregnant women, for the simple reason that it affects women of childbearing age. Type 2 diabetes, although more common in itself, is much less common in pregnant women. The fact is that women encounter this type of diabetes much later, already before the menopause itself, and even after its onset. Gestational diabetes is extremely rare and causes far fewer problems than any other form of the disease.

Gestational diabetes mellitus

This type of diabetes develops only during pregnancy and disappears without a trace after childbirth. Its reason is the increasing load on the pancreas due to the release of hormones into the blood, the action of which is opposite to insulin. Usually the pancreas copes with this situation, however, in some cases, blood sugar levels jump noticeably.

Although gestational diabetes is extremely rare, it is advisable to know the risk factors and symptoms in order to rule out this diagnosis in yourself.

Risk factors are:

• obesity;
• polycystic ovary syndrome;
• sugar in the urine before pregnancy or at its beginning;
• the presence of diabetes in one or more relatives;
• diabetes in previous pregnancies.

The more factors there are in a particular case, the greater the risk of developing the disease.

Symptoms diabetes mellitus during pregnancy, as a rule, is not pronounced, and in some cases it is completely asymptomatic. However, even if the symptoms are quite pronounced, it is difficult to suspect diabetes in oneself. Judge for yourself:

• strong thirst;
• hunger;
• frequent urination;
• blurred vision.

As you can see, almost all of these symptoms are common in normal pregnancies. Therefore, it is so necessary to regularly and timely take a blood test for sugar. With an increase in the level, doctors prescribe additional studies.

diabetes and pregnancy

So, it was decided to be pregnant. However, before proceeding with the implementation of the plan, it would not be a bad idea to understand the topic in order to imagine what awaits you. As a rule, this problem is relevant for patients with type 1 diabetes during pregnancy. As mentioned above, women with type 2 diabetes usually no longer want, and often cannot, give birth.

Pregnancy planning

Remember once and for all, with any form of diabetes, only a planned pregnancy is possible. Why? Everything is pretty obvious. If the pregnancy is accidental, the woman will know about it only a few weeks after conception. During these few weeks, all the main systems and organs of the future person are already being formed.

And if during this period at least once the level of sugar in the blood jumps strongly, developmental pathologies can no longer be avoided. In addition, ideally, there should not be sharp jumps in sugar levels in the last few months before pregnancy, as this can also affect the development of the fetus.

Many people with mild diabetes do not regularly measure their blood sugar, and therefore do not remember the exact numbers that are considered normal. They don’t need it, just take a blood test and listen to the doctor’s verdict. However, during planning, you will have to track these indicators yourself, so now you need to know them.

The normal level is 3.3-5.5 mmol. The amount of sugar from 5.5 to 7.1 mmol is called the pre-diabetic state. If the sugar level exceeds the figure of 7.1 mol., then they are already talking about one or another stage of diabetes.

It turns out that preparation for pregnancy must begin 3-4 months in advance. Get a pocket glucometer so that you can check your sugar levels at any time. Then visit your gynecologist and endocrinologist and let them know that you are planning a pregnancy.

The gynecologist examines the woman for the presence of concomitant urinary tract infections, and will help to treat them if necessary. The endocrinologist will help you choose the dose of insulin to compensate. Communication with an endocrinologist is mandatory throughout the entire pregnancy.

No less mandatory ophthalmologist consultation. His task is to examine the vessels of the fundus and assess their condition. If any of them look unreliable, in order to avoid breaks, they are cauterized. Repeated consultation with an ophthalmologist is also necessary before childbirth. Problems with the vessels of the eye day may well become indications for a caesarean section.

You may be advised to visit other specialists in order to assess the risks during pregnancy and prepare for possible consequences. Only after all experts give the go-ahead for pregnancy, it will be possible to cancel contraception.

From this point on, it is necessary to monitor the amount of sugar in the blood especially carefully. A lot often depends on how successfully this is done, including the health of the child, his life, as well as the health of the mother.

Contraindications for pregnancy in diabetes mellitus

Unfortunately, in some cases, a woman with diabetes is still contraindicated in giving birth. In particular, the combination of diabetes with the following diseases and pathologies is absolutely incompatible with pregnancy:

• ischemia;
• kidney failure;
• gastroenteropathy;
• negative Rh factor in the mother.

Features of the course of pregnancy

At the beginning of pregnancy, under the influence of the hormone estrogen in pregnant women with diabetes, an improvement in carbohydrate tolerance is observed. As a result, insulin synthesis increases. During this period, the daily dose of insulin, quite naturally, should be reduced.

Starting at 4 months, when the placenta is finally formed, it begins to produce contra-insulin hormones, such as prolactin and glycogen. Their action is opposite to the action of insulin, as a result of which the volume of injections will again have to be increased.

In addition, starting from 13 weeks it is necessary to strengthen control over the level of sugar in the blood, because this period the baby's pancreas begins its work. She begins to react to the mother's blood, and if there is too much sugar in it, the pancreas responds by injecting insulin. As a result, glucose breaks down and is processed into fat, that is, the fetus is actively gaining fat mass.

In addition, if during the entire pregnancy the child often encountered "sweetened" maternal blood, it is likely that in the future he will also encounter diabetes. Of course, during this period, compensation for diabetes is simply necessary.

Please note that at any time the dose of insulin should be selected by the endocrinologist. Only an experienced specialist can do this quickly and accurately. While independent experiments can lead to disastrous results.

Near the end of pregnancy the intensity of the production of contra-insulin hormones decreases again, which forces a decrease in the dosage of insulin. With regard to childbirth, it is almost impossible to predict what the level of glucose in the blood will be, so blood tests are carried out every few hours.

Principles of pregnancy management in diabetes mellitus

It is quite natural that the management of pregnancy in such patients will be fundamentally different from the management of pregnancy in any other situation. Diabetes mellitus during pregnancy quite predictably creates additional problems for a woman. As can be seen from the beginning of the article, the problems associated with the disease will begin to bother the woman at the planning stage.

At first, you will have to visit the gynecologist every week, and in case of any complications, visits will become daily, or the woman will be hospitalized. However, even if everything goes well, you still have to lie in the hospital several times.

The first time hospitalization is prescribed in the early stages, up to 12 weeks. During this period, a complete examination of the woman is carried out. Identification of risk factors and contraindications for pregnancy. Based on the results of the examination, it is decided whether to keep the pregnancy or terminate it.

The second time a woman needs to go to the hospital at 21-25 weeks. At this time, a re-examination is necessary, during which possible complications and pathologies are identified, and treatment is also prescribed. In the same period, a woman is sent for an ultrasound scan, and after that she undergoes this study weekly. This is necessary to monitor the condition of the fetus.

The third hospitalization falls on a period of 34-35 weeks. Moreover, the woman remains in the hospital until the birth. And again, the case will not do without examination. Its purpose is to assess the condition of the child and decide when and how the birth will occur.

Since diabetes itself does not interfere with natural childbirth, this option always remains the most desirable. However, sometimes diabetes leads to complications, due to which it is impossible to wait for a full-term pregnancy. In this case, the onset of labor is stimulated.

There are a number of situations that force doctors to initially stop at the option of caesarean section, such situations include:

• pronounced diabetic complications in the mother or fetus, including ophthalmic.

Childbirth with diabetes

During childbirth also has its own characteristics. First of all, you need to pre-prepare the birth canal. If this can be done, then childbirth usually begins with piercing the amniotic sac. In addition, to enhance labor activity, the necessary hormones can be introduced. An obligatory component in this case is anesthesia.

It is mandatory to monitor the blood sugar level and the fetal heart rate with the help of KGT. With the attenuation of labor activity, the pregnant woman is intravenously injected with oxytocin, and with a sharp jump in sugar - insulin.

By the way, in some cases, glucose can also be administered in parallel with insulin. There is nothing seditious and dangerous in this, so there is no need to resist such a course of doctors.

If, after the introduction of oxytocin and the opening of the cervix, labor activity begins to fade again or acute fetal hypoxia occurs, obstetricians may resort to forceps. If hypoxia begins even before the cervix opens, then, most likely, delivery will occur by caesarean section.

However, regardless of whether the birth will take place naturally or by caesarean section, the chance of having a healthy baby is quite high. The main thing is to be attentive to your body, and respond in time to all negative changes, as well as strictly follow the doctor's prescriptions.

diabetes mellitus in pregnant women

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Gestational diabetes mellitus (GDM): danger of "sweet" pregnancy. Consequences for the child, diet, signs

According to the World Health Organization, there are more than 422 million people with diabetes in the world. Their number is growing every year. Increasingly, the disease affects young people.

Complications of diabetes lead to serious vascular pathologies, kidneys, retina, are affected. But this disease is controllable. With properly prescribed therapy, severe consequences are delayed in time. no exception and gestational diabetes that developed during gestation. This disease is called gestational diabetes mellitus.

• Can pregnancy cause diabetes?
• What are the types of diabetes during pregnancy
• Risk group
• What is gestational diabetes during pregnancy
• Consequences for the child
• What is the danger for a woman
• Symptoms and signs of gestational diabetes in pregnancy
• Analyzes and timing
• Treatment
• Insulin therapy: who is indicated and how it is carried out
• Diet: allowed and prohibited foods, basic principles of nutrition for pregnant women with GDM
• Sample menu for the week
• ethnoscience
• How to give birth: natural childbirth or caesarean section?
• Prevention of gestational diabetes in pregnant women

Pregnancy - a provocateur?

The American Diabetes Association reports that 7% of pregnant women develop gestational diabetes. In some of them, after childbirth, glucosemia returns to normal. But in 60%, type 2 diabetes (DM2) manifests in 10-15 years.

Gestation acts as a provocateur of impaired glucose metabolism. The mechanism of development of the gestational form of diabetes is closer to type 2 diabetes. A pregnant woman develops insulin resistance due to the following factors:

• synthesis in the placenta of steroid hormones: estrogen, placental lactogen;
• an increase in the formation of cortisol in the adrenal cortex;
• violation of insulin metabolism and a decrease in its effects in tissues;
• increased excretion of insulin through the kidneys;
• activation of insulinase in the placenta (an enzyme that breaks down the hormone).

The condition worsens in those women who have physiological resistance (immunity) to insulin, which did not manifest itself clinically. These factors increase the need for the hormone, pancreatic beta cells synthesize it in increased quantities. Gradually, this leads to their depletion and persistent hyperglycemia - an increase in the level of glucose in the blood plasma.

What are the types of diabetes during pregnancy?

Pregnancy can be accompanied by different types of diabetes. The classification of pathology according to the time of occurrence implies two forms:

1. diabetes that existed before pregnancy (DM 1 and DM type 2) - pregestational;
2. gestational diabetes (GDM) in pregnancy.

Depending on the treatment needed for GDM, there are:

• compensated by diet;
• compensated by diet therapy and insulin.

Diabetes can be in the stage of compensation and decompensation. The severity of pregestational diabetes depends on the need for various treatments and the severity of complications.

Hyperglycemia that develops during pregnancy is not always gestational diabetes. In some cases, this may be a manifestation of type 2 diabetes.

Who is at risk for developing diabetes during pregnancy?

Hormonal changes that can disrupt insulin and glucose metabolism occur in all pregnant women. But the transition to diabetes is not for everyone. This requires predisposing factors:

• overweight or obesity;
• existing impaired glucose tolerance;
• episodes of rising sugar before pregnancy;
• Type 2 diabetes in parents of a pregnant woman;
• age over 35;
• a history of miscarriages, stillbirths;
• birth in the past of children weighing more than 4 kg, as well as with malformations.

Actual video

Diagnosis of latent diabetes in pregnant women

But which of these causes affects the development of pathology to a greater extent is not fully known.

What is gestational diabetes

GDM is considered to be the pathology that has developed after - bearing a child. If hyperglycemia is diagnosed earlier, then there is latent diabetes mellitus that existed before pregnancy. But the peak incidence is observed in the 3rd trimester. A synonym for this condition is gestational diabetes.

It differs from gestational overt diabetes in pregnancy in that after one episode of hyperglycemia, sugar gradually increases and does not tend to stabilize. This form of the disease is more likely to progress to type 1 or type 2 diabetes after childbirth.

To determine the further tactics, all puerperas with GDM in the postpartum period determine the level of glucose. If it does not normalize, then it can be considered that type 1 or type 2 diabetes has developed.

Impact on the fetus and consequences for the child

The danger to the developing child depends on the degree of compensation of the pathology. The most severe consequences are observed in the uncompensated form. The effect on the fetus is expressed as follows:

1. Malformations of the fetus with an increased level of glucose in the early stages. Their formation occurs due to energy deficiency. In the early stages, the child's pancreas has not yet been formed, so the mother's organ must work for two. Violation of work leads to energy starvation of cells, disruption of their division and the formation of defects. This condition can be suspected by the presence of polyhydramnios. Insufficient intake of glucose into cells is manifested by intrauterine growth retardation, low weight of the child.
2. Uncontrolled sugar levels in a pregnant woman with gestational diabetes in the 2nd and 3rd trimester leads to diabetic fetopathy. Glucose crosses the placenta in unlimited quantities, the excess is deposited as fat. If there is an excess of own insulin, accelerated growth of the fetus occurs, but there is a disproportion of body parts: a large abdomen, shoulder girdle, small limbs. It also enlarges the heart and liver.
3. A high concentration of insulin disrupts the production of surfactant, a substance that coats the alveoli of the lungs. Therefore, after birth, respiratory disorders may occur.
4. Tying the umbilical cord of a newborn disrupts the supply of excess glucose, the child's glucose concentration drops sharply. Hypoglycemia after childbirth leads to neurological disorders, impaired mental development.

Also, in children born to mothers with gestational diabetes, the risk of birth trauma, perinatal death, cardiovascular diseases, pathology of the respiratory system, disorders of calcium and magnesium metabolism, and neurological complications increase.

Why high sugar is dangerous for a pregnant woman

GDM or pre-existing diabetes increases the possibility of late toxicosis (), it manifests itself in various forms:

• dropsy of pregnant women;
• nephropathy 1-3 degree;
• preeclampsia;
• eclampsia.

The last two conditions require hospitalization in the intensive care unit, resuscitation and early delivery.

Immune disorders that accompany diabetes lead to infections of the genitourinary system - cystitis, pyelonephritis, as well as recurrent vulvovaginal candidiasis. Any infection can lead to infection of the child in utero or during childbirth.

The main signs of gestational diabetes during pregnancy

Symptoms of gestational diabetes are not expressed, the disease develops gradually. Some signs of a woman are taken for normal changes in the condition during pregnancy:

• increased fatigue, weakness;
• thirst;
• frequent urination;
• insufficient weight gain with pronounced appetite.

Hyperglycemia is often an incidental finding during a mandatory blood glucose screening test. This serves as an indication for further in-depth examination.

Grounds for diagnosis, tests for latent diabetes

The Ministry of Health has determined the deadlines for a mandatory blood test for sugar:

• when registering;

In the presence of risk factors in - a glucose tolerance test is performed. If symptoms of diabetes appear during pregnancy, then a glucose test is performed according to indications.

One analysis, which revealed hyperglycemia, is not enough to make a diagnosis. You need to check after a few days. Further, with repeated hyperglycemia, an endocrinologist consultation is prescribed. The doctor determines the need and timing of the glucose tolerance test. Usually it is at least 1 week after the recorded hyperglycemia. The test is also repeated to confirm the diagnosis.

The following test results speak about GSD:

• fasting glucose more than 5.8 mmol / l;
• an hour after taking glucose - above 10 mmol / l;
• after two hours - above 8 mmol / l.

Additionally, according to indications, research is carried out:

• glycosylated hemoglobin;
• urinalysis for sugar;
• cholesterol and lipid profile;
• coagulogram;
• blood hormones: estrogen, placental lactogen, cortisol, alpha-fetoprotein;
• urinalysis according to Nechiporenko, Zimnitsky, Reberg's test.

Pregnant women with pregestational and gestational diabetes undergo fetal ultrasound from the 2nd trimester, doplerometry of the vessels of the placenta and umbilical cord, regular CTG.

Management of pregnant women with diabetes mellitus and treatment

The course of pregnancy with existing diabetes depends on the level of self-control on the part of the woman and the correction of hyperglycemia. Those who had diabetes before conception must go through the "School of Diabetes" - special classes that teach proper eating behavior, self-control of glucose levels.

Regardless of the type of pathology, pregnant women need the following observations:

• visiting a gynecologist every 2 weeks at the beginning of gestation, weekly - from the second half;
• consultations with an endocrinologist once every 2 weeks, in a decompensated state - once a week;
• observation of the therapist - every trimester, as well as when extragenital pathology is detected;
• ophthalmologist - once a trimester and after childbirth;
• neurologist - twice during pregnancy.

Mandatory hospitalization is provided for examination and correction of therapy for a pregnant woman with GDM:

• 1 time - in the first trimester or when diagnosing a pathology;
• 2 times - in - to correct the condition, determine the need to change the treatment regimen;
• 3 times - with type 1 and type 2 diabetes - in, GDM - in to prepare for childbirth and the choice of the method of delivery.

In a hospital, the frequency of studies, the list of analyzes and the frequency of the study is determined individually. Daily monitoring requires a urine test for sugar, blood glucose, blood pressure control.

Insulin

The need for insulin injections is determined individually. Not every case of GDM requires this approach; for some, a therapeutic diet is sufficient.

Indications for starting insulin therapy are the following blood sugar levels:

• fasting blood glucose on the background of a diet of more than 5.0 mmol / l;
• one hour after eating above 7.8 mmol / l;
• 2 hours after a meal, glycemia is above 6.7 mmol / l.

Attention! In pregnant and lactating women, the use of any hypoglycemic drugs, except for insulin, is prohibited! Long-acting insulins are not used.

The basis of therapy is short- and ultrashort-acting insulin preparations. In type 1 diabetes, basal bolus therapy is performed. For type 2 diabetes and GDM, it is also possible to use the traditional scheme, but with some individual adjustments that are determined by the endocrinologist.

In pregnant women with poor hypoglycemic control, insulin pumps can be used to facilitate hormone administration.

Diet for gestational diabetes during pregnancy

Nutrition of a pregnant woman with GDM should comply with the following principles:

• Little and often. It is better to have 3 main meals and 2-3 small snacks.
• The amount of complex carbohydrates is about 40%, protein - 30-60%, fats up to 30%.
• Drink at least 1.5 liters of liquid.
• Increase the amount of fiber - it is able to adsorb glucose from the intestines and remove it.

Actual video

Diet for gestational diabetes in pregnancy

Products can be divided into three conditional groups presented in Table 1.

Table 1

It is forbidden to use	Limit Quantity	You can eat
Sugar sweet pastries Honey, sweets, jam Fruit juices from the store Carbonated sweet drinks Semolina and rice porridge Grapes, bananas, melon, persimmon, dates Sausages, sausages, any fast food Sweeteners	Durum wheat pasta Potato Animal fats (butter, lard), fatty Margarine	All kinds of vegetables, including Jerusalem artichoke Beans, peas and other legumes Wholemeal bread Buckwheat, oatmeal, barley, millet Lean meat, poultry, fish Low fat dairy products Fruits, except prohibited Vegetable fats

Sample menu for a pregnant woman with gestational diabetes

The menu for the week (table 2) may look something like this (table No. 9).

Table 2.

Day of the week	Breakfast	2 breakfast	Dinner	afternoon tea	Dinner
Monday	Millet porridge with milk, bread with unsweetened tea	Apple or pear or banana	Fresh vegetable salad with vegetable oil; Chicken broth with noodles; Boiled meat with stewed vegetables	Cottage cheese, unsweetened cracker, tea	Braised cabbage with meat, tomato juice. Before going to bed - a glass of kefir
Tuesday	Omelette for a couple with, Coffee/tea, bread	Any fruit	Vinaigrette with butter; milk soup; barley porridge with boiled chicken; dried fruits compote	Unsweetened yogurt	Steamed fish with vegetable garnish, tea or compote
Wednesday	Cottage cheese casserole, tea with cheese sandwich	Fruit	Vegetable salad with vegetable oil; low-fat borscht; mashed potatoes with beef goulash; dried fruits compote	Low fat milk with crackers	Buckwheat porridge with milk, egg, tea with bread
Thursday	Oatmeal in milk with raisins or fresh berries, tea with bread and cheese	Yogurt without sugar	Cabbage and carrot salad; pea soup; Mashed potatoes with boiled meat; tea or compote	Any fruit	Stewed vegetables, boiled fish, tea
Friday	Millet porridge, boiled egg, tea or coffee	Any fruit	Vinaigrette in vegetable oil; milk soup; baked zucchini with meat;	Yogurt	Vegetable casserole, kefir
Saturday	Milk porridge, tea or coffee with bread and cheese	Any permitted fruit	Vegetable salad with low-fat sour cream; buckwheat soup with chicken broth; boiled pasta with chicken;	Milk with crackers	Cottage cheese casserole, tea
Sunday	Oatmeal with milk, tea with a sandwich	Yogurt or kefir	Bean and tomato salad; cabbage soup; boiled potatoes with stew;	Fruit	Grilled vegetables, chicken fillet, tea

ethnoscience

Traditional medicine methods offer many recipes for using herbal remedies to reduce blood sugar and replace sugary foods. For example, stevia and its extracts are used as a sweetener.

For diabetics, this plant is not dangerous, but use in pregnant women and lactating women is not recommended. Studies on the effect on the course of pregnancy and the formation of the fetus have not been conducted. In addition, the plant can cause an allergic reaction, which is highly undesirable during pregnancy against the background of gestational diabetes.

Natural birth or caesarean?

How the delivery will take place depends on the condition of the mother and child. Hospitalization of pregnant women with gestational diabetes is carried out in -. To avoid birth trauma, they try to induce labor with a full-term baby during this period.

In a serious condition of a woman or fetal pathology, the issue of a caesarean section is decided. If, according to the results of ultrasound, a large fetus is determined, the correspondence of the size of the woman's pelvis and the possibility of childbirth are determined.

With a sharp deterioration in the condition of the fetus, the development of severe preeclampsia, retinopathy and nephropathy of the pregnant woman, a decision can be made on early delivery.

Prevention methods

It is not always possible to avoid the disease, but it is possible to reduce the risk of its occurrence. Women who are overweight or obese should start planning their pregnancy with diet and weight loss.

Everyone else should adhere to the principles of a healthy diet, control weight gain, reduce the consumption of sweet and starchy, fatty foods. We must not forget about sufficient physical activity. Pregnancy is not a disease. Therefore, in its normal course, it is recommended to perform special sets of exercises.

Women with hyperglycemia should take into account the recommendations of the doctor, be hospitalized at the scheduled time for examination and correction of treatment. This will help prevent the development of complications of gestational diabetes. Those who had GDM in a previous pregnancy have a significantly increased risk of developing diabetes when they re-gestate.

The problem of pregnancy management in women with diabetes is relevant throughout the world. The course of pregnancy and childbirth in diabetes mellitus has an extremely unfavorable effect on the intrauterine development of the fetus, the frequency of malformations increases, and perinatal morbidity and mortality are high.

In clinical practice, there are three main types of diabetes mellitus:

Type I diabetes mellitus - insulin dependent(IDSD);

Type II diabetes mellitus - non-insulin dependent(INSD);

Type III diabetes mellitus - gestational diabetes(HD), which develops after 28 weeks. pregnancy and is a transient impairment of glucose utilization in women during pregnancy.

The most common is IDDM. The disease, as a rule, is found in girls in childhood, during puberty. NIDDM occurs in older women (after 30 years) and is less severe. HD is rarely diagnosed.

IDDM in pregnant women is characterized by significant lability and undulating course of the disease. A characteristic feature of IDDM in pregnant women is an increase in the symptoms of diabetes mellitus, early development of angiopathy (in almost half of pregnant women), and a tendency to ketoacidosis.

First weeks of pregnancy. The course of diabetes mellitus in most pregnant women remains unchanged, or an improvement in carbohydrate (estrogen) tolerance is observed, which stimulates the secretion of insulin by the pancreas. In turn, improved peripheral glucose uptake. This is accompanied by a decrease the level of glycemia, the appearance of hypoglycemia in pregnant women, which requires a reduction in the dose of insulin.

second half of pregnancy. Due to the increased activity of contrainsular hormones (glucagon, placental lactogen, prolactin), carbohydrate tolerance worsens, diabetic complaints increase, glycemia increases, glucosuria increases, and ketoacidosis may develop. At this time, an increase in insulin is needed.

By the end of pregnancy due to a decrease in the level of contra-insular hormones, carbohydrate tolerance improves again, the level of glycemia and the dose of insulin administered decrease.

In childbirth in pregnant women with diabetes mellitus, both high hyperglycemia, a state of acidosis, and a hypoglycemic state are possible.

In the first days of the postpartum period the level of glycemia falls, then increases by 4-5 days.

The first half of pregnancy in most diabetic patients proceeds without any special complications. The exception is the threat of spontaneous miscarriage.

In the second half of pregnancy, such obstetric complications as late preeclampsia, polyhydramnios, the threat of premature birth, fetal hypoxia, and urinary tract infections are more likely to occur.

The course of childbirth is complicated by the presence of a large fetus, which is the cause of a number of further complications in childbirth: weakness of the labor force, untimely discharge of amniotic fluid, increased fetal hypoxia, development of a functionally narrow pelvis, difficult birth of the shoulder girdle, development of endometritis during childbirth, birth trauma of the mother and fetus.

Maternal diabetes has a major impact on the development of the fetus and newborn. There are a number of features that distinguish children born to diabetic women from the offspring of healthy mothers. These include a characteristic appearance (round, moon-shaped face, overly subcutaneous fatty tissue is developed), a large number of hemorrhages on the skin of the face and extremities, swelling, cyanosis; large mass, significant frequency of malformations, functional immaturity of organs and systems. The most severe manifestation of diabetic fetopathy is the high perinatal mortality of children. In untreated women during pregnancy, it reaches 70-80%. Under the condition of specialized monitoring of pregnant women suffering from diabetes mellitus, perinatal mortality in children sharply decreases and reaches 15%. Today, in many clinics, this figure does not exceed 7-8%.

The neonatal period in the offspring of patients with diabetes mellitus is distinguished by a slowdown and inferiority of the processes of adaptation to the conditions of extrauterine existence, which is manifested by lethargy, hypotension and hyporeflexia of the child, instability of his hemodynamic parameters, delayed weight recovery, increased susceptibility to severe respiratory disorders. One of the main conditions for the management of pregnant women with diabetes is the compensation of diabetes. Insulin therapy during pregnancy is mandatory even with the mildest forms of diabetes.

Early detection among pregnant women of latent and clinically obvious forms of diabetes mellitus.

Family planning in diabetic patients:

timely determination of the degree of risk to resolve the issue of the advisability of maintaining pregnancy;
pregnancy planning in diabetic women;
strict compensation of diabetes mellitus before pregnancy, during pregnancy, during childbirth and in the postpartum period;
prevention and treatment of pregnancy complications;
choice of term and method of delivery;
carrying out adequate resuscitation and careful nursing of newborns;
further monitoring of the offspring of diabetic mothers.
Pregnancy management in patients with diabetes mellitus is carried out on an outpatient and inpatient basis. In pregnant women with diabetes, three planned hospitalizations in a hospital are advisable:

I hospitalization - in the early stages of pregnancy for examination, solving the issue of maintaining pregnancy, conducting preventive treatment, compensating for diabetes mellitus.

Contraindications for pregnancy in diabetes mellitus

The presence of rapidly progressive vascular complications, which are usually found in severe disease (retinopathy, nephropathy), complicate the course of pregnancy and significantly worsen the prognosis for the mother and fetus.

The presence of insulin-resistant and labile forms of diabetes mellitus.

The presence of diabetes mellitus in both parents, which dramatically increases the possibility of the disease in children.

The combination of diabetes mellitus and Rh sensitization of the mother, which significantly worsens the prognosis for the fetus

The combination of diabetes mellitus and active pulmonary tuberculosis, in which pregnancy often leads to a severe exacerbation of the process.

The question of the possibility of pregnancy, its preservation or the need for interruption is decided consultatively with the participation of obstetrician-gynecologists, a therapist, an endocrinologist up to a period of 12 weeks.

II hospitalization to the hospital at a period of 21-25 weeks due to the worsening of the course of diabetes mellitus and the appearance of pregnancy complications, which requires appropriate treatment and careful adjustment of the insulin dose.

III hospitalization at a period of 34-35 weeks for careful monitoring of the fetus, treatment of obstetric and diabetic complications, choice of the term and method of delivery.

Basic principles of pregnancy management in diabetes mellitus:

Strict, stable compensation of diabetes mellitus, which primarily involves the normalization of carbohydrate metabolism (in pregnant women with diabetes, the level of fasting glycemia should be in the range of 3.3-4.4 mmol / l, and 2 hours after eating - no more than 6, 7 mmol/l);

Careful metabolic control;

Compliance with the diet - on average, the daily calorie content of food is 1600-2000 kcal, and 55% of the total calorie content of food is covered by carbohydrates, 30% by fat, 15% by protein, a sufficient amount of vitamins and minerals;

Careful prevention and timely treatment of obstetric complications.

It should be remembered that the increased tendency of pregnant women with diabetes mellitus to develop severe forms of late preeclampsia and other complications of pregnancy dictates the need for strict monitoring of the dynamics of weight, blood pressure, urine and blood tests, as well as meticulous adherence to the regimen of the pregnant woman herself.

The term of delivery in pregnant women with diabetes is determined individually, taking into account the severity of diabetes, the degree of compensation for the disease, the functional state of the fetus, and the presence of obstetric complications.

With diabetes, delayed maturation of the functional system of the fetus is possible, so timely delivery is optimal. However, the increase in various complications by the end of pregnancy (feto-placental insufficiency, late preeclampsia, etc.) dictates the need for delivery of patients at 37-38 weeks.

When planning delivery in fetuses from diabetic mothers, an assessment of the degree of maturity should be carried out. The best method of delivery for mothers with diabetes mellitus and their fetuses is vaginal delivery. Delivery through the natural birth canal is carried out under constant monitoring of the level of glycemia (every 2 hours), thorough anesthesia, therapy of feto-placental insufficiency, adequate insulin therapy.

Given the characteristics of the birth act, characteristic of diabetes mellitus, it is necessary:

Careful preparation of the birth canal.

With the prepared birth canal, it is advisable to start labor induction with an amniotomy, followed by the creation of a hormonal background. With effective labor activity, childbirth should be continued through the natural birth canal with the widespread use of antispasmodics.

To prevent secondary weakness of the labor forces when the cervix is ​​dilated by 7-8 cm, start IV administration of oxytocin and continue its administration according to indications until the birth of the child.

Prevention of fetal hypoxia, monitoring of maternal hemodynamic parameters.

Prevention of decompensation of diabetes mellitus in childbirth. To do this, after 1-2 hours, determine the level of glycemia in a woman in labor.

To prevent weakness of attempts and ensure active labor activity by the time of the birth of a massive shoulder girdle of the fetus, it is necessary to continue the activation of labor forces with oxytocin.

In case of detection of fetal hypoxia or secondary weakness of labor forces - operative delivery - obstetric forceps with preliminary episiotomy.

In case of unprepared birth canal, the absence of the effect of labor induction, or the appearance of symptoms of increasing fetal hypoxia, childbirth must be completed by a caesarean section.

To date, there are no absolute indications for a planned caesarean section in diabetes mellitus. However, the following can be distinguished (except for those generally accepted in obstetrics):

Severe or progressive complications of diabetes and pregnancy.

Breech presentation of the fetus.

The presence of a large fruit.

Progressive fetal hypoxia.

The main principle of resuscitation of newborns from mothers with diabetes mellitus is the choice of resuscitation measures depending on the condition of the newborn, its degree of maturity and the method of delivery. A feature of the management of newborns from diabetic mothers is the introduction of 10% glucose into the umbilical cord vein immediately after birth. Further administration of glucose in these newborns is carried out at the rate of the daily fluid requirement, depending on the level of glycemia, which is checked 2, 3, 6 hours after birth, then according to indications.