Gestosis diabetes mellitus during pregnancy. Gestational diabetes mellitus (reminder for patients). Gestational diabetes in pregnant women: symptoms

Gestational diabetes (GD) is detected during pregnancy when the patient's body is not able to cope with the additional need for insulin production, which leads to elevated levels blood glucose.

HD is controlled by monitoring glucose levels, changing the diet plan, and regular physical activity. Effective treatment gestational diabetes will reduce the risk of complications during pregnancy and childbirth.

Symptoms and signs of diabetes during pregnancy will be considered in our material.

In contact with

The exact pathophysiology of HD is unknown. One of the main aspects of the underlying pathology is insulin resistance, when the cells of the body do not respond to the hormone insulin in the usual way.

It is believed that some hormones that come into action during pregnancy interfere with the normal functioning of insulin, as they interfere with the body's response to it, most likely by interfering with cell signaling pathways.

Hormones that increase blood glucose levels or destroy insulin, and also come into action during pregnancy:

Insulin is the main hormone produced by beta cells in the pancreas and plays a key role in glucose regulation. Insulin stimulates cells in skeletal muscle and body fat to take up glucose from the bloodstream.

In the presence of insulin resistance, this absorption of glucose into the blood is prevented and blood sugar levels remain elevated. The body then compensates for this deficiency by producing more insulin to overcome the resistance and in gestational diabetes, insulin production can be up to 1.5 or 2 times higher than in a normal pregnancy.

The glucose present in the blood crosses the placenta to reach the fetus. If HD is not treated, the fetus is exposed to excess glucose, resulting in an increase in the amount of insulin produced by the unborn child.

Since insulin stimulates growth, this means that the baby can be born larger. As soon as the baby is born, the effect of excess glucose stops. However, the newborn still has increased production of insulin, i.e. the child is susceptible to low blood glucose levels.

The likelihood of developing HD during pregnancy is higher if:

Apart from gestational diabetes the occurrence and development of latent diabetes mellitus during pregnancy is possible, you can read about this.

When the doctor suspects such a diagnosis

Pregnant women are under the constant supervision of doctors - a gynecologist, an endocrinologist, an obstetrician. One of the listed doctors will check the patient for gestational diabetes between the 24th and 28th weeks of pregnancy.

If a pregnant woman is at risk (see "Who is at risk?"), the doctor may start doing checks well before the 24th week.

During the screening, the patient will be given a sugary liquid to drink and then asked for a blood test. If the blood sugar level is high, the patient will be referred.

Most women have gestational diabetes does not cause any noticeable signs or symptoms.

If you do experience symptoms (caused by high blood glucose), they may include:

These symptoms usually disappear after childbirth.

Possible complications of HD

If changes in diet and exercise do not help glucose stay within the target range for one to two weeks, you need to discuss possible options drug treatment with a doctor.

Important! Changes in diet and exercise activities are needed to control glucose levels even when treated with drugs.

Usually patients are given insulin injections.

Try one of these breakfast, lunch, and dinner ideas to get you started on healthy eating:

Breakfast

• Bowl of whole grain cereal, porridge (buckwheat/oatmeal), with semi-sweet milk or
• 2 toast with tomatoes and jam or
• Yogurt low in fat and sugar and fruits.

Dinner

Dinner

Your favorite recipes and meals can usually be adapted to be healthier.

Basically, three simple rules should be followed:

1. Reduce the amount of fat, sugar or salt in food;
2. Include more fruits and vegetables;
3. Reduce portion sizes.

More details about the rules for building a diet for HS are described. Making any of these changes will certainly help in the fight against HD.

Conclusion

Gestational diabetes usually goes away after delivery. Proper nutrition and exercise is still an important factor in maintaining your health after childbirth. Your child's lifestyle should also be correct.

Choose foods that are high in fiber and low in fat for both of you. You should also avoid sugary sweets and simple starches whenever possible. Adding sports to daily activities − great way support each other in your quest for healthy lifestyle life.

During pregnancy, chronic diseases may worsen or signs of previously unknown problems may appear. This problem can be gestational diabetes.

According to the classification of the World Health Organization, “gestational diabetes” is diabetes mellitus detected during pregnancy, as well as impaired glucose tolerance (the perception of glucose by the body), also detected during this period. Its cause is a reduced sensitivity of cells to their own insulin (insulin resistance), which is associated with a high content of pregnancy hormones in the blood. After childbirth, blood sugar levels often return to normal. However, the possibility of developing type 1 and type 2 diabetes during pregnancy cannot be ruled out. Diagnosis of these diseases is carried out after childbirth.

When analyzing data from multiple studies, doctors concluded that more than 50% of pregnant women with gestational diabetes develop true diabetes later in life.

Why is gestational diabetes dangerous?

Gestational diabetes in most clinical situations develops in the range up to. Early-detected carbohydrate metabolism disorders usually indicate previously unnoticed pregestational (“pre-pregnancy”) diabetes.

Of course, it is better to learn about chronic diseases before pregnancy, and then it will be possible to compensate for them as much as possible. It is for this reason that doctors strongly recommend planning a pregnancy. In preparation for pregnancy a woman will pass all basic examinations, including those for the detection of diabetes mellitus. If carbohydrate metabolism disorders are detected, the doctor will prescribe treatment, give recommendations, and future pregnancy will proceed safely, and the baby will be born healthy.

The main condition for managing a pregnancy complicated by diabetes (both gestational and its other forms) is maintaining blood glucose levels within the normal range (3.5-5.5 mmol / l). Otherwise, mother and baby find themselves in very difficult conditions.

What threatens mom? Premature births and stillbirths are possible. There is a high risk of development (in diabetes mellitus it develops more often and earlier - up to 30 weeks), hydramnios, and, consequently, fetal malnutrition. It is possible to develop diabetic ketoacidosis (a condition in which there is a sharp increase in glucose levels and the concentration of ketone bodies in the blood), genital tract infections, which are recorded 2 times more often and cause infection of the fetus and. It is also possible the progression of microangiopathies with an outcome in visual impairment, kidney function, blood flow disorders in the vessels of the placenta, and others. The woman may develop weakness labor activity, which in combination with a clinically narrow pelvis and large fruit make delivery inevitable caesarean section. In women with diabetes, infectious complications are more common in the postpartum period.

Pregnancy means a drastic change in the balance of hormones. And this natural feature can lead to the fact that the components secreted by the placenta will prevent the mother's body from taking insulin. A woman has an abnormal concentration of glucose in her blood. Gestational diabetes during pregnancy occurs more often from the middle of the term. But his earlier presence is also possible.

Experts cannot name a clear culprit for the violation of tissue response to glucose in expectant mothers. Undoubtedly, hormonal changes play a significant role in the appearance of diabetes. But they are common for all pregnant women, and, fortunately, not everyone is diagnosed in this position. Those who suffered it noted:

• hereditary tendency. If there is a history of diabetes in the family, there is also a higher probability of its occurrence in a pregnant woman compared to others.
• Autoimmune diseases that, due to their characteristics, disrupt the functions of the insulin-producing pancreas.
• Frequent viral infections. They are also capable of upsetting the functions of the pancreas.
• Passive lifestyle and high-calorie diet. They lead to overweight, and if it existed before conception, the woman is at risk. This also includes those whose body weight has increased by 5-10 kg in adolescence in a short time, and her index rose above 25.
• Age from 35 years. Those who are under 30 at the time of pregnancy are less likely to get gestational diabetes than others.
• Previous birth of an infant weighing more than 4.5 kg or stillbirth for unexplained reasons.

Women of Asian or African descent are more susceptible to gestational diabetes than those of European descent.

Signs that you might suspect you have gestational diabetes

At an early stage, diabetes mellitus during pregnancy practically does not show symptoms. That is why it is important for expectant mothers to control the concentration of sugar in the blood. Initially, they may notice that they began to drink a little more water, lost some weight, although there is no apparent reason for weight loss. Some find that it is more pleasant for them to lie or sit than to move.

With the development of malaise, a woman may feel:

• The need for a large amount of liquid. Despite her satisfaction, dry mouth worries.
• The need to urinate more often, the liquid comes out much more than usual.
• Increased fatigue. Pregnancy already takes a lot of energy, and now a woman’s desire to take a break arises faster than before, with diabetes, her self-awareness does not correspond to the received load.
• Deterioration in the quality of vision. Blurring may occasionally occur in the eyes.
• Skin itching, and mucous membranes can also itch.
• Significant increase in the need for food and rapid weight gain.

The first and last signs of diabetes during pregnancy are difficult to separate from the most. Indeed, in healthy women expecting babies, appetite and thirst often increase.

How to get rid of diabetes during pregnancy

At the first stage of development, gestational diabetes is treated by streamlining lifestyle and. Indispensable is the control of the quantitative content of glucose on an empty stomach, as well as 2 hours after each meal. Sometimes a blood sugar measurement may be required before it.

You will need to periodically do a urine test. This is necessary to make sure that there are no ketone components in the liquid, that is, the containment of pathological processes.

Diet and physical activity are key at this stage.

Diet for gestational diabetes

it is impossible for a pregnant woman, the fetus must have everything necessary, and sugar from a lack of food grows. Future mother will have to stick healthy principles in food:

• Portions should be small and meals should be frequent. If you eat 5-6 times a day, you can maintain optimal weight.
• The largest amount of slow carbohydrates (40 - 45% of the total food) should be for breakfast. These are cereals, rice, pasta, bread.
• It is important to pay attention to the composition of products, postponing sugary fruits, chocolate, pastries until better times. Fast food, and seeds are excluded. We need vegetables, cereals, poultry, rabbit meat. Fat must be removed, no more than 10% of the total amount of food should be eaten per day. Useful will not include a large number sugar fruits, berries, and greens.
• Do not eat instant food. Having the same names as natural ones, they contain more glucose. We are talking about freeze-dried cereals, mashed potatoes, noodles.
• Food must not be fried, only boiled or steamed. If stewed, then with a small amount of vegetable oil.
• You can fight morning sickness with dry, unsweetened biscuits. It is eaten in the morning without getting out of bed.
• Cucumbers, tomatoes, zucchini, lettuce, cabbage, beans, mushrooms can be eaten in large quantities. They are low in calories and have a low glycemic index.
• Vitamin-mineral complexes are taken only on the recommendation of a doctor. Many of them contain glucose, the excess of which is now harmful.

Water with this style of nutrition should be drunk up to 8 glasses a day.

Medications

If changes in diet do not work, that is, the glucose level remains elevated, or the urine test is poor with normal sugar, insulin will have to be injected. The dose in each case is determined by the doctor, based on the weight of the patient and the duration of pregnancy.

Insulin is administered intravenously, usually divided into 2 doses. The first prick before breakfast, the second - before dinner. The diet during drug therapy is maintained, as is regular monitoring of the concentration of glucose in the blood.

Physical exercise

Physical activity is needed regardless of whether the rest of the treatment was limited to diet or the pregnant woman injects insulin. Sport helps to spend excess energy, normalize the balance of substances, increase the effectiveness of the hormone missing in gestational diabetes.

The movement should not be to the point of exhaustion, the possibility of injury must be excluded. Walking, exercises in the gym (except for swinging the press), swimming are suitable.

Prevention of gestational diabetes

For women at risk, a specialist will explain how dangerous gestational diabetes is during pregnancy. Pathology in the mother creates many threats to her and the fetus:

• On the early term increases the likelihood. With gestational diabetes, a conflict is created between her body and the fetus. He seeks to reject the embryo.
• Thickening of the vessels of the placenta due to gestational diabetes leads to circulatory disorders in this area, therefore, a decrease in the supply of oxygen and nutrients to the fetus.
• Having arisen from 16 to 20 weeks, the disease can lead to defective formation of cardio-vascular system and the fetal brain, stimulate its excessive growth.
• Childbirth may begin prematurely. BUT big size The fetus is forced to carry out a caesarean section. If the birth is natural, it will create a risk of injury to the mother and baby.
• A newborn baby may be at risk of jaundice, respiratory distress, hypoglycemia, and increased blood clotting. These are signs of diabetic fetopathy, which also causes other pathologies in the child in the postnatal period.
• A woman is more likely to develop preeclampsia and eclampsia. Both problems are dangerous with high blood pressure, convulsions, which during childbirth can kill both mother and child.
• Subsequently, a woman has an increased risk of developing diabetes.

For these reasons, prevention of the disease is needed at an early stage, which includes:

• Regular. It is important to register early, to do all the necessary tests, especially when you are at risk.
• Maintain optimal body weight. If she was more normal before pregnancy, it is better to lose weight first and plan later.
• . High pressure may indicate a tendency to increase sugar and stimulate it.
• To give up smoking. The habit affects the functions of many organs, including the pancreas.

A woman with gestational diabetes is quite capable of giving birth to more than one healthy child. It is necessary to identify the pathology in time and make efforts to contain it.

After pregnancy, a woman is registered and undergoes many diagnostic procedures, including the detection of blood and urine sugar levels. Approximately 4% of all women in the position experience a moderately elevated and stable glucose level. This condition is called gestational diabetes during pregnancy. If elevated rates are detected and taken under the control of doctors on time, then nothing threatens the mother and child, and after childbirth, this form of diabetes disappears on its own. Although this pathology is quite rare, it is better to take note of the features of this disease. Therefore, we will consider the causes, symptoms and treatment options for GDM.

The main factor in triggering gestational diabetes mellitus is pathological glucose tolerance. The cause of such disorders is an overload of the pancreas. If in people outside of pregnancy such disruptions cause obesity and a sedentary lifestyle, then pregnant women have a completely different nature of insulin resistance. The placenta actively secretes hormones with the opposite effect of insulin, while increasing the amount of glucose in the body. If a woman has certain factors, such as low physical activity or excessive weight gain, transient diabetes develops. This happens between 28 and 36 weeks of gestation.
The uncontrolled course of gestational diabetes can affect the overall course of pregnancy and even affect the poor laying of the organs of the embryo. If the increase in sugar began in the first trimester, then the pregnancy will end in a miscarriage or numerous congenital anomalies. First of all, the brain and cardiovascular system can suffer.

On a note! Gestational diabetes mellitus during pregnancy affects the development of mental abilities and the usefulness of the bookmark nervous system only in the first trimester.

Insulin resistance in the 2nd and 3rd trimester provokes pathological feeding of the fetus and its intensive growth. The pancreas, which has not yet formed, begins to secrete a double dose of insulin in order to process all the sugar. But for a baby, a certain amount of glucose is needed, and all the excess settles in the form of a fatty layer on the organs and under the skin. The internal organs of the baby - the kidneys, liver, pancreas - begin to work in an enhanced mode, which in the future will have a bad effect on health. fruit, receiving great amount sugar from the mother (hyperinsulinemia), after childbirth begins to experience sugar hunger, and glucose levels begin to drop sharply. This condition is called diabetic fetopathy. This diagnosis can be made before the onset of labor according to the results ultrasound. If it is confirmed, then an unscheduled delivery is performed before the end of the gestational age.

Indirect signs of diabetic fetopathy:

1. Macrosomia (fetus over 4 kg).
2. Disproportion of the body (shortened limbs, abdominal circumference overtakes the volume of the head for several weeks, broad shoulders, swelling of the face).
3. Cardiomegaly (underdeveloped and greatly enlarged liver and kidneys).
4. Respiratory failure and reduced fetal activity.
5. A large number of developmental anomalies.
6. Excessive subcutaneous fat.

Important! Uncorrected diabetes can end premature birth, severe injuries to a woman, perinatal death.

What is the danger of gestational diabetes during pregnancy:

• Polyhydramnios progresses.
• The risk of pregnancy fading is doubled.
• Infections of the birth canal are often exacerbated, which are also transmitted to the baby.
• In the blood there are ketone bodies that provoke intoxication of the body of the mother and child.
• A large fetus causes a caesarean section or severe injuries in a woman after childbirth.
• Job disruption internal organs causes preeclampsia and fetal hypoxia.

Advice! The compensated amount of sugar during the gestation period excludes the development of pathologies in the fetus and complications in the woman.

What provokes gestational diabetes: determine the risk group

Even at the stage of pregnancy planning, a woman can independently or with the help of a therapist determine the likelihood of pathological glucose tolerance. Gestational diabetes mellitus during pregnancy occurs most often against the background of such diseases in history:

1. Excess weight (advanced forms of obesity).
2. Pregnancy planning for age category 30+.
3. Stable weight gain after 18 years and until pregnancy.
4. Patients with diabetes mellitus in the family line.
5. Hormonal imbalance (polycystic ovaries).
6. Pre-diabetic state (a slight increase in sugar above normal).
7. endocrine disorders.
8. Pregnancy with gestational diabetes in the past.
9. The first child was born weighing more than 4 kg.

Interesting! The chances of experiencing gestational diabetes are significantly higher in certain ethnic groups, such as Hispanics, Native Americans, and Asians.

Diagnosis of gestational diabetes: symptoms and laboratory values

Laboratory diagnostics for the detection of latent gestational diabetes is mandatory for all women in an “interesting” position between 24 and 28 weeks of gestation. This form of diabetes manifests itself in the same way as other types, but in most cases there are no symptoms at all. How to suspect the development of GDM before a routine study:

• The woman begins to experience a constant desire to drink.
• There is frequent urination.
• Appetite is disturbed (I want to eat all the time or vice versa, it is impossible to eat anything).
• The blood pressure rises.
• There is severe fatigue.
• There is clouding in the eyes.

The symptoms are quite superficial and may be present without an increase in glucose, but the presence of at least a few of them should be the reason for a visit to the gynecologist to clarify their nature.

Gestational diabetes is determined by a test called an oral glucose tolerance test. To get reliable test results, you need to properly prepare for blood donation. The material is taken first only on an empty stomach, then after taking 50 g of glucose (orally) after 1 hour and then after another 2 hours. The results obtained show how the body copes with the received glucose.

Standard sugar levels:

• 1st blood sampling - 5.49 mmol/l;
• 2nd sampling - 11.09 mmol/l;
• 3rd fence - 7.79 mmol/l.

Gestational diabetes mellitus during pregnancy is confirmed by indicators:

• 1st sampling - 5.49-6.69 mmol/l;
• 2nd sampling - less than 11.09 mmol/l;
• 3rd fence - more than 11.09 mmol / l.

The primary increase in sugar should not frighten a woman in anticipation of a baby, since the endocrinologist will refer her for re-diagnosis in 10-12 days. The fact is that the following factors can influence the result:

1. Eating a large amount of sugar-containing food on the eve of the diagnosis.
2. Experienced stress or anxiety.
3. Eating less than 8 hours before blood sampling.
4. Low or vice versa, strong physical activity.

A one-time rise in glucose is not a cause for panic. There is always a risk of error and non-compliance with the rules of blood donation. Only a double-confirmed increase can confirm the presence of diabetes.

Principles of treatment of GDM in pregnant women

Since gestational diabetes during pregnancy affects the fetus, it is necessary to properly treat a woman before childbirth, and sometimes after them. The essence of therapy is to eliminate adverse factors that affect blood sugar levels and constant monitoring of its amount. The condition of the fetus is also regularly checked.

1. Continuous monitoring of glucose levels. At least 4-6 times a day: on an empty stomach, 1.5 hours after a meal, sometimes a sugar check is required before meals.
2. Regular determination of ketone bodies in morning urine. Their presence indicates uncompensated diabetes.
3. Rigidly balanced diet.
4. Individually selected physical exercise taking into account the state of the pregnant woman.
5. Maintaining optimal body weight (calculated individually by body mass index).
6. Monitoring of indicators of arterial pressure.
7. In severe forms of GDM, insulin therapy is indicated. Sugar-reducing tablets are not prescribed.

Gestational diabetes during pregnancy: diet and daily routine

The primary cure for gestational diabetes in pregnancy is diet. Since weight loss is not the best treatment for pregnant women, you need to eat right. The menu for diabetes is compiled so that it is as nutritious as possible, and at the same time low in calories.

Making a rational menu

• Control carbohydrates. The amount of carbohydrates should be less than 45% of the total daily caloric intake. It is preferable to eat foods that are high in fiber (whole grains, legumes). Instead of eating starchy foods (bread, potatoes, cookies, spaghetti), it is better to replenish your carbohydrate reserve with vegetables (carrots, broccoli).
• Eat small portions of 200-250 g. You need to eat fractionally 5-6 times a day. Add a small portion of salad or vegetable juices to each meal. Choose green and yellow types of vegetables (pumpkin, carrots, lettuce, spinach, bell peppers, zucchini).
• Avoid fried foods that are high in fat. Eat boiled or baked foods without spicy and fatty sauces. Also avoid foods with a high glycemic index (buns, confectionery, pasta made from regular wheat varieties, sweet fruits).
• Tame morning sickness with crackers and biscuits while having breakfast in bed.
• Don't buy fast food. This category of products, in addition to the mountain of preservatives, contains fast carbohydrates. So enter the taboo in your kitchen for instant noodles and freeze-dried mashed potatoes.
• The amount of saturated fat should not exceed 10%. Cook only lean meats: poultry, rabbit, beef, lean pork, fish. Remove accessible fatty layers, and remove the skin from the bird.
• Drink 1.5 l clean water per day if there are no contraindications.

Such products are strictly prohibited.: margarine, spread, mayonnaise, sour cream, cream, butter, nuts and seeds (limited), sauces, sugary sodas, sweetened juices.

No restrictions allowed: cucumbers, ginger, zucchini, radishes, beans, lettuce, zucchini, all kinds of mushrooms, all leafy vegetables, cabbage, tomatoes, citrus fruits.

Advice! IN winter period to prevent beriberi, pregnant women are prescribed additional vitamin complexes.

Diabetes and exercise

Moderate exercise also helps keep sugar levels under control. To maintain weight, muscle tone and well-being, you can attend yoga classes or fitness training for pregnant women, or you can simply do light exercises at home. Naturally, there can be no talk of swinging the press, cycling or jumping rope. All classes should be carried out only at will and with excellent health. If you didn't exercise before pregnancy, swimming, walking, or running is fine. The optimal physical culture regimen involves 20 minutes of exercise three times a week.

On a note! If you are on insulin therapy, you should check your blood sugar levels before and after exercise. Physical activity helps lower blood sugar. Therefore, temporary hypoglycemia may occur.

Physical education for pregnant women helps to keep weight within normal limits. If a woman did not suffer from extra “kilos” before pregnancy, then a set of 10-16 kg for the entire gestation period is considered acceptable. In case of obvious obesity, weight gain is limited to 7 kg.

Gestational diabetes: the course of labor and postpartum control

During labor, glucose levels are monitored every 2-3 hours. If the level rises to a critical level, insulin is administered, and if it falls, glucose is administered. They also monitor the heartbeat and breathing rhythm of the fetus. In case of complications, an emergency caesarean section is performed.
The glucose index after childbirth in the baby is determined. The excess insulin produced does not immediately return to normal, so the baby has a reduced amount of sugar. To stabilize the child's condition, he is given a glucose solution intravenously.
Gestational diabetes indicates a woman's predisposition to type 2 diabetes. After childbirth, glucose levels fall to normal within a few hours, but it is recommended to check the amount after 6 weeks, and then every 3 months.

It is impossible to completely exclude the possibility of gestational diabetes in pregnant women. Therefore, if you are at an increased risk of developing insulin resistance, immediately inform your doctor about this and eliminate all provoking factors for this disease. Remember that GDM is not a sentence and if the recommendations are followed, it does not affect pregnancy.

Gestational diabetes mellitus in pregnancy. Video

RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols MH RK - 2014

Diabetes mellitus in pregnancy, unspecified (O24.9)

Endocrinology

general information

Short description

Approved
at the Expert Commission on Health Development
Ministry of Health of the Republic of Kazakhstan
Protocol No. 10 dated July 04, 2014

Diabetes mellitus (DM) is a group of metabolic (metabolic) diseases characterized by chronic hyperglycemia, which is the result of a violation of insulin secretion, insulin action, or both of these factors. Chronic hyperglycemia in diabetes is accompanied by damage, dysfunction and failure of various organs, especially the eyes, kidneys, nerves, heart and blood vessels (WHO, 1999, 2006 with additions) .

This is a disease characterized by hyperglycemia, first diagnosed during pregnancy, but not meeting the criteria for "manifest" diabetes mellitus. GDM is a disorder of glucose tolerance of varying severity that occurs or is first diagnosed during pregnancy.

I. INTRODUCTION

Protocol name: Diabetes during pregnancy
Protocol code:

Code (codes) according to ICD-10:
E 10 Insulin-dependent diabetes mellitus
E 11 Non-insulin dependent diabetes mellitus
O24 Diabetes mellitus in pregnancy
O24.0 Pre-existing diabetes mellitus, insulin-dependent
O24.1 Pre-existing diabetes mellitus, non-insulin dependent
O24.3 Pre-existing diabetes mellitus, unspecified
O24.4 Diabetes mellitus during pregnancy
O24.9 Diabetes mellitus of pregnancy, unspecified

Abbreviations used in the protocol:
AH - arterial hypertension
BP - blood pressure
GDM - gestational diabetes mellitus
DKA - diabetic ketoacidosis
IIT - intensified insulin therapy
IR - insulin resistance
IRI - immunoreactive insulin
BMI - body mass index
MAU - microalbuminuria
ITG - impaired glucose tolerance
IGN - impaired fasting glycemia
LMWH - Continuous Glucose Monitoring
CSII - continuous subcutaneous insulin infusion (insulin pump)
OGTT - oral glucose tolerance test
PDM - pregestational diabetes mellitus
DM - diabetes mellitus
Type 2 diabetes - type 2 diabetes
Type 1 diabetes - type 1 diabetes
CCT - hypoglycemic therapy
FA - physical activity
XE - bread units
ECG - electrocardiogram
HbAlc - glycosylated (glycated) hemoglobin

Protocol development date: year 2014.

Protocol Users: endocrinologists, general practitioners, internists, obstetrician-gynecologists, emergency physicians.

Classification

Classification

Table 1 Clinical classification of SD:

Types of diabetes in pregnant women :
1) "true" GDM, which occurred during this pregnancy and is limited to the period of pregnancy (Appendix 6);
2) type 2 diabetes, manifested during pregnancy;
3) type 1 diabetes that manifested during pregnancy;
4) Pregestational diabetes type 2;
5) Pregestational diabetes type 1.

Diagnostics

II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT

List of basic and additional diagnostic measures

Basic diagnostic measures at the outpatient level(Appendix 1 and 2)

To detect hidden SD(on first visit):
- Determination of glucose on an empty stomach;
- Determination of glucose, regardless of the time of day;
- Glucose tolerance test with 75 grams of glucose (pregnant women with BMI ≥25 kg/m2 and risk factor);

To detect GDM (at 24-28 weeks gestation):
- Glucose tolerance test with 75 grams of glucose (all pregnant women);

All pregnant women with PDM and GDM
- Determination of glucose before meals, 1 hour after meals, at 3 am (glucometer) for pregnant women with PDM and GDM;
- Determination of ketone bodies in urine;

Additional diagnostic measures at the outpatient stage:
- ELISA - determination of TSH, free T4, antibodies to TPO and TG;
- LMWH (in accordance with Appendix 3);
- determination of glycosylated hemoglobin (HbAlc);
- Ultrasound of the abdominal cavity, thyroid gland;

The minimum list of examinations for referral to planned hospitalization:
- determination of glycemia: on an empty stomach and 1 hour after breakfast, before lunch and 1 hour after lunch, before dinner and 1 hour after dinner, at 22:00 and at 3:00 in the morning (glucometer);
- determination of ketone bodies in urine;
- UAC;
- OAM;
- ECG

Basic (mandatory) diagnostic examinations carried out at the hospital level(in case of emergency hospitalization, diagnostic examinations are performed that are not performed at the outpatient level):
- determination of glycemia: on an empty stomach and 1 hour after breakfast, before lunch and 1 hour after lunch, before dinner and 1 hour after dinner, at 22-00 and at 3 am
- biochemical blood test: determination of total protein, bilirubin, AST, ALT, creatinine, potassium, calcium, sodium, calculation of GFR;
- determination of activated partial thromboplastin time in blood plasma;
- determination of the international normalized ratio of the prothrombin complex in blood plasma;
- determination of soluble fibrinomonomer complexes in blood plasma;
- determination of thrombin time in blood plasma;
- determination of fibrinogen in blood plasma;
- determination of protein in urine (quantitatively);
- Ultrasound of the fetus;
- ECG (in 12 leads);
- determination of glycosylated hemoglobin in the blood;
- determination of the Rh factor;
- determination of the blood group according to the ABO system with tsoliklones;
- Ultrasound of the abdominal organs.

Additional diagnostic examinations carried out at the hospital level(in case of emergency hospitalization, diagnostic examinations are performed that were not performed at the outpatient level):
- LMWH (in accordance with Appendix 3)
- biochemical blood test (total cholesterol, lipoprotein fractions, triglycerides).

Diagnostic measures carried out at the ambulance stage emergency care :
- Determination of glucose in blood serum with a glucometer;
- determination of ketone bodies in urine with test strips.

Diagnostic criteria

Complaints and anamnesis
Complaints:
- when compensating SD are absent;
- with decompensated diabetes, pregnant women are concerned about polyuria, polydipsia, dry mucous membranes, and skin.

Anamnesis:
- SD duration;
- the presence of vascular late complications of diabetes;
- BMI at the time of pregnancy;
- pathological weight gain (more than 15 kg during pregnancy);
- burdened obstetric history (birth of children weighing more than 4000.0 grams).

Physical examination:
Type 2 diabetes and GDM are asymptomatic (Appendix 6)

SD type 1:
- dry skin and mucous membranes, decreased skin turgor, "diabetic" blush, enlarged liver;
- in the presence of signs of ketoacidosis, there are: deep Kussmaul breathing, stupor, coma, nausea, vomiting " coffee grounds", a positive symptom of Shchetkin-Blumberg, defense of the muscles of the anterior abdominal wall;
- signs of hypokalemia (extrasystoles, muscle weakness, intestinal atony).

Laboratory research(Appendix 1 and 2)

table 2

1 If abnormal values ​​were obtained for the first time and no symptoms hyperglycemia, the preliminary diagnosis of overt diabetes during pregnancy should be confirmed by fasting venous plasma glucose or HbA1c using standardized tests. In the presence of symptoms hyperglycemia one determination in the diabetic range (glycemia or HbA1c) is sufficient to establish the diagnosis of DM. If overt DM is detected, it should be qualified as soon as possible into any diagnostic category according to the current WHO classification, for example, type 1 DM, type 2 DM, etc.
2 HbA1c using the method of determination, certified in accordance with the National Glycohemoglobin Standardization Program (NGSP) and standardized in accordance with the reference values ​​adopted in the DCCT (Diabetes Control and Complications Study).

If the HbA1c level<6,5% или случайно определенный уровень глюкозы плазмы <11,1 ммоль/л (в любое время суток), то проводится определение глюкозы венозной плазмы натощак: при уровне глюкозы венозной плазмы натощак ≥5,1 ммоль/л, но <7,0 ммоль/л устанавливается диагноз ГСД.

Table 3 Threshold values ​​of venous plasma glucose for the diagnosis of GDM at the initial visit

Table 4 Threshold values ​​of venous plasma glucose for the diagnosis of GDM during OGTT

1 Only the level of glucose in venous plasma is examined. The use of capillary whole blood samples is not recommended.
2 At any stage of pregnancy (one abnormal measurement of venous plasma glucose is sufficient).

Instrumental Research

Table 5 Instrumental studies in pregnant women with diabetes *

Revealing Ultrasound signs of diabetic fetopathy requires immediate correction of nutrition and LMWH:
. large fetus (diameter of the abdomen ≥75 percentile);
. hepatosplenomegaly;
. cardiomegaly/cardiopathy;
. bypass of the fetal head;
. swelling and thickening of the subcutaneous fat layer;
. thickening of the neck fold;
. newly diagnosed or increasing polyhydramnios with an established diagnosis of GDM (in case of exclusion of other causes of polyhydramnios).

Indications for specialist consultations

Table 6 Indications for specialist consultations in pregnant women with DM*

*If there are signs of chronic complications of diabetes, the addition of concomitant diseases, the appearance of additional risk factors, the question of the frequency of examinations is decided individually.

Antenatal management of pregnant women with diabetes is presented in Appendix 4.

Differential Diagnosis

Differential Diagnosis

Table 7 Differential diagnosis of diabetes in pregnant women

Treatment abroad

Get treatment in Korea, Israel, Germany, USA

Get advice on medical tourism

Treatment

Treatment goals:
The goal of treating diabetes in pregnant women is to achieve normoglycemia, normalize blood pressure, prevent complications of diabetes, reduce complications of pregnancy, childbirth and the postpartum period, and improve perinatal outcomes.

Table 8 Carbohydrate Targets During Pregnancy

Treatment tactics :
. Diet therapy;
. physical activity;
. learning and self-control;
. hypoglycemic drugs.

Non-drug treatment

diet therapy
In type 1 diabetes, an adequate diet is recommended: eating with enough carbohydrates to prevent "hungry" ketosis.
In GDM and type 2 diabetes, diet therapy is carried out with the complete exclusion of easily digestible carbohydrates and restriction of fats; uniform distribution of the daily volume of food for 4-6 receptions. Carbohydrates with a high content of dietary fiber should be no more than 38-45% of the daily caloric intake of food, proteins - 20-25% (1.3 g / kg), fats - up to 30%. For women with a normal BMI (18-25 kg/m2), a daily caloric intake of 30 kcal/kg is recommended; with excess (BMI 25-30 kg/m2) 25 kcal/kg; with obesity (BMI ≥30 kg / m2) - 12-15 kcal / kg.

Physical activity
For DM and GDM, dosed aerobic exercise is recommended in the form of walking for at least 150 minutes a week, swimming in the pool; self-monitoring is performed by the patient, the results are provided to the doctor. It is necessary to avoid exercises that can cause an increase in blood pressure and uterine hypertonicity.

. Patient education should provide patients with the knowledge and skills to help achieve specific therapeutic goals.
. Women who are planning a pregnancy, and pregnant women who have not been trained (primary cycle), or patients who have already been trained (for repeated cycles) are referred to the school of diabetes to maintain the level of knowledge and motivation or when new therapeutic goals appear, transfer to insulin therapy.
self control b includes the determination of glycemia using portable devices (glucometers) on an empty stomach, before and 1 hour after the main meals; ketonuria or ketonemia in the morning on an empty stomach; blood pressure; fetal movements; body weight; keeping a self-control diary and a food diary.
NMG system

Medical treatment

Treatment of pregnant women with diabetes
. If pregnancy occurs against the background of the use of metformin, glibenclamide, prolongation of pregnancy is possible. All other hypoglycemic drugs should be stopped until pregnancy and replaced with insulin.

Use only short-acting and intermediate-acting human insulin preparations, ultra-short-acting and long-acting insulin analogs permitted under Category B

Table 9 Insulin products approved for use in pregnant women (List B)

During pregnancy, it is forbidden to use biosimilar insulin preparations that have not passed the full procedure for registration of medicines and pre-registration clinical trials in pregnant women.

All insulin preparations should be prescribed to pregnant women with the obligatory indication of the international non-proprietary name and trade name.

Insulin pumps with continuous glucose monitoring are the optimal means of administering insulin.

The daily requirement for insulin in the second half of pregnancy can increase dramatically, up to 2-3 times, in comparison with the initial requirement before pregnancy.

Folic acid 500 mcg per day up to the 12th week inclusive; potassium iodide 250 mcg per day throughout pregnancy - in the absence of contraindications.

Antibiotic therapy for detecting urinary tract infections (penicillins in the first trimester, penicillins or cephalosporins in the second or third trimesters).

Features of insulin therapy in pregnant women with type 1 diabetes
First 12 weeks in women, type 1 diabetes due to the “hypoglycemic” effect of the fetus (i.e., due to the transfer of glucose from the mother’s bloodstream to the fetal bloodstream) is accompanied by an “improvement” in the course of diabetes, the need for daily insulin use decreases, which can be manifested by hypoglycemic conditions with Somoji phenomenon and subsequent decompensation.
Women with diabetes on insulin therapy should be warned about the increased risk of hypoglycemia and its difficulty in recognizing during pregnancy, especially in the first trimester. Pregnant women with type 1 diabetes should be provided with glucagon supplies.

From 13 weeks hyperglycemia and glucosuria increase, the need for insulin increases (by an average of 30-100% of the pregestational level) and the risk of developing ketoacidosis, especially in the period of 28-30 weeks. This is due to the high hormonal activity of the placenta, which produces contra-insular agents such as chorionic somatomammatropin, progesterone, and estrogens.
Their excess leads to:
. insulin resistance;
. decrease in the sensitivity of the patient's body to exogenous insulin;
. an increase in the need for a daily dose of insulin;
. pronounced "dawn" syndrome with a maximum increase in glucose levels in the early morning hours.

With morning hyperglycemia, an increase in the evening dose of prolonged insulin is not desirable, due to the high risk of nocturnal hypoglycemia. Therefore, in these women with morning hyperglycemia, it is recommended to administer the morning dose of prolonged insulin and an additional dose of short / ultra-short-acting insulin or switching to insulin pump therapy.

Features of insulin therapy in the prevention of fetal respiratory distress syndrome: when prescribing dexamethasone 6 mg 2 times a day for 2 days, the dose of prolonged insulin is doubled for the period of dexamethasone administration. Glycemic control is prescribed at 06.00, before and after meals, at bedtime and at 03.00. to adjust the dose of short-acting insulin. Correction of water-salt metabolism is carried out.

After 37 weeks In pregnancy, the need for insulin may decrease again, which leads to an average decrease in the dose of insulin by 4-8 units / day. It is believed that the insulin-synthesizing activity of the β cellular apparatus of the pancreas of the fetus by this moment is so high that it provides a significant consumption of glucose from the mother's blood. With a sharp decrease in glycemia, it is desirable to strengthen control over the condition of the fetus in connection with the possible inhibition of the fetoplacental complex against the background of placental insufficiency.

In childbirth there are significant fluctuations in the level of glucose in the blood, hyperglycemia and acidosis may develop under the influence of emotional influences or hypoglycemia, as a result of the physical work done, the woman's fatigue.

After childbirth blood glucose drops rapidly (against the background of a drop in the level of placental hormones after birth). At the same time, the need for insulin for a short time (2-4 days) becomes less than before pregnancy. Then gradually blood glucose rises. By the 7-21st day of the postpartum period, it reaches the level observed before pregnancy.

Early toxicosis of pregnant women with ketoacidosis
Pregnant women need rehydration with saline solutions in the amount of 1.5-2.5 l / day, as well as orally 2-4 l / day with water without gas (slowly, in small sips). In the diet of a pregnant woman for the entire period of treatment, pureed food is recommended, mainly carbohydrate (cereals, juices, jelly), with additional salting, with the exception of visible fats. When glycemia is less than 14.0 mmol / l, insulin is administered against the background of 5% glucose solution.

Birth management
Planned hospitalization:
. the optimal term of delivery is 38-40 weeks;
. the optimal method of delivery is vaginal delivery with careful glycemic control during (hourly) and after childbirth.

Indications for caesarean section:
. obstetric indications for operative delivery (scheduled / emergency);
. the presence of severe or progressive complications of diabetes.
The term of delivery in pregnant women with diabetes is determined individually, taking into account the severity of the course of the disease, the degree of its compensation, the functional state of the fetus and the presence of obstetric complications.

When planning childbirth in patients with type 1 diabetes, it is necessary to assess the degree of fetal maturity, since delayed maturation of its functional systems is possible.
Pregnant women with diabetes and fetal macrosomia should be informed about the possible risks of complications from normal vaginal delivery, induction of labor and caesarean section.
With any form of fetopathy, unstable glucose levels, progression of late complications of diabetes, especially in pregnant women of the “high obstetric risk” group, it is necessary to resolve the issue of early delivery.

Insulin therapy during childbirth

For natural childbirth:
. glycemic levels must be maintained within 4.0-7.0 mmol/L. Continue infusion of extended insulin.
. When eating during childbirth, the introduction of short insulin should cover the amount of XE consumed (Appendix 5).
. Glycemic control every 2 hours.
. With glycemia less than 3.5 mmol / l, intravenous administration of a 5% glucose solution of 200 ml is indicated. With glycemia below 5.0 mmol / l, an additional 10 g of glucose (dissolve in the oral cavity). With glycemia more than 8.0-9.0 mmol / l intramuscular injection of 1 unit of simple insulin, at 10.0-12.0 mmol / l 2 units, at 13.0-15.0 mmol / l -3 units. , with glycemia more than 16.0 mmol / l - 4 units.
. With symptoms of dehydration, intravenous administration of saline;
. In pregnant women with type 2 diabetes with a low need for insulin (up to 14 units / day), insulin administration during labor is not required.

For operative childbirth:
. on the day of surgery, a morning dose of extended insulin is administered (with normoglycemia, the dose is reduced by 10-20%, with hyperglycemia, the dose of extended insulin is administered without correction, as well as an additional 1-4 units of short insulin).
. in the case of general anesthesia during childbirth in women with diabetes, regular monitoring of blood glucose levels (every 30 minutes) should be carried out from the moment of induction until the fetus is born and the woman fully recovers from general anesthesia.
. Further tactics of hypoglycemic therapy are similar to those for natural delivery.
. On the second day after the operation, with limited food intake, the dose of prolonged insulin is reduced by 50% (mainly administered in the morning) and short insulin 2-4 units before meals with glycemia more than 6.0 mmol/l.

Features of the management of childbirth in DM
. permanent cardiotographic control;
. thorough anesthesia.

Management of the postpartum period in diabetes
In women with type 1 diabetes after childbirth and with the onset of lactation, the dose of prolonged insulin can be reduced by 80-90%, the dose of short insulin usually does not exceed 2-4 units before meals in terms of glycemia (for a period of 1-3 days after birth). Gradually, within 1-3 weeks, the need for insulin increases and the dose of insulin reaches the pregestational level. That's why:
. adapt insulin doses, taking into account the rapid decrease in demand already on the first day after delivery from the moment the placenta is born (by 50% or more, returning to the original doses before pregnancy);
. recommend breastfeeding (warn about the possible development of hypoglycemia in the mother!);
. effective contraception for at least 1.5 years.

Benefits of insulin pump therapy in pregnant women with diabetes
. Women using CSII (insulin pump) are easier to reach target levels of HbAlc<6.0%.
. insulin pump therapy reduces the risk of hypoglycemia, especially in the first trimester of pregnancy, when the risk of hypoglycemia increases.
. in late pregnancy, when maternal blood glucose peaks lead to fetal hyperinsulinemia, lowering glucose fluctuations in women using CSII reduces macrosomia and neonatal hypoglycemia.
. The use of CSII is effective in controlling blood glucose levels during delivery and reduces the incidence of neonatal hypoglycemia.
The combination of CSII and continuous glucose monitoring (CGM) achieves glycemic control throughout pregnancy and reduces the incidence of macrosomia (Appendix 3).

Requirements for CSII in pregnant women:
. start using CSII before conception to reduce the risk of spontaneous miscarriage and birth defects in the fetus;
. if pump therapy is started during pregnancy, reduce the total daily insulin dose to 85% of the total dose on syringe therapy, and in case of hypoglycemia, to 80% of the original dose.
. in the 1st trimester, the basal dose of insulin is 0.1-0.2 units / h, at a later date 0.3-0.6 units / h. Increase the ratio of insulin:carbohydrates by 50-100%.
. given the high risk of ketoacidosis in pregnant women, check the presence of ketones in the urine if the blood glucose level exceeds 10 mmol/l, and change infusion sets every 2 days.
. during delivery, continue using the pump. Set your temp basal rate to 50% of your maximum rate.
. When breastfeeding, reduce the basal rate by another 10-20%.

Medical treatment provided on an outpatient basis

Medical treatment provided at the inpatient level
List of Essential Medicines(100% chance of use)
. Short acting insulins
. Ultrashort-acting insulins (human insulin analogues)
. Intermediate-acting insulins
. Long-term, peakless insulin
. Sodium chloride 0.9%

List of additional medicines(less than 100% chance of application)
. Dextrose 10% (50%)
. Dextrose 40% (10%)
. Potassium chloride 7.5% (30%)

Drug treatment provided at the stage of emergency emergency care
. Sodium chloride 0.9%
. Dextrose 40%

Preventive actions(Annex 6)
. In persons with prediabetes, carry out annual monitoring of carbohydrate metabolism for early detection of diabetes;
. screening and treatment of modifiable risk factors for cardiovascular disease;
. to reduce the risk of developing GDM, conduct therapeutic measures among women with modifiable risk factors before pregnancy;
. To prevent carbohydrate metabolism disorders during pregnancy, all pregnant women are advised to follow a balanced diet with the exception of foods with a high carbohydrate index, such as sugar-containing foods, juices, sweet carbonated drinks, foods with flavor enhancers, with a restriction of sweet fruits (raisins, apricots, dates , melon, bananas, persimmon).

Further management

Table 15 List of laboratory parameters requiring dynamic monitoring in patients with diabetes

Table 16 List of instrumental examinations required for dynamic control in DM patients *

*If there are signs of chronic complications of diabetes, the addition of concomitant diseases, the appearance of additional risk factors, the question of the frequency of examinations is decided individually.

. 6-12 weeks postpartum all women with GDM undergo OGTT with 75 g of glucose to reclassify the degree of carbohydrate metabolism disorder (Appendix 2);

It is necessary to inform pediatricians and GPs about the need to monitor the state of carbohydrate metabolism and prevent type 2 diabetes in a child whose mother has had GDM (Appendix 6).

Indicators of treatment efficacy and safety of diagnostic and treatment methods described in the protocol:
. achievement of the level of carbohydrate and lipid metabolism as close as possible to the normal state, normalization of blood pressure in a pregnant woman;
. development of motivation for self-control;
. prevention of specific complications of diabetes mellitus;
. absence of complications during pregnancy and childbirth, the birth of a live healthy full-term baby.

Table 17 Glycemic targets in patients with GDM

Hospitalization

Indications for hospitalization of patients with PSD *

Indications for emergency hospitalization:
- onset of diabetes during pregnancy;
- hyper/hypoglycemic precoma/coma
- ketoacidotic precoma and coma;
- progression of vascular complications of diabetes (retinopathy, nephropathy);
- infections, intoxications;
- accession of obstetric complications requiring emergency measures.

Indications for planned hospitalization*:
- All pregnant women are subject to hospitalization if they have diabetes.
- Women with pregestational diabetes are hospitalized routinely at the following gestational ages:

First hospitalization is carried out in the gestation period up to 12 weeks in a hospital of an endocrinological / therapeutic profile due to a decrease in the need for insulin and the risk of developing hypoglycemic conditions.
Purpose of hospitalization:
- addressing the issue of the possibility of prolonging pregnancy;
- detection and correction of metabolic and microcirculatory disorders of DM and concomitant extragenital pathology, training at the "School of Diabetes" (with prolongation of pregnancy).

Second hospitalization in the period of 24-28 weeks of pregnancy to the hospital of the endocrinological / therapeutic profile.
The purpose of hospitalization: correction and control of the dynamics of metabolic and microcirculatory disorders of DM.

Third hospitalization is carried out in the department of pathology of pregnant organizations of obstetrics of the 2nd-3rd level of regionalization of perinatal care:
- with type 1 and 2 diabetes in the period of 36-38 weeks of pregnancy;
- with GDM - in the period of 38-39 weeks of pregnancy.
The purpose of hospitalization is to assess the condition of the fetus, correct insulin therapy, choose the method and term of delivery.

* It is possible to manage pregnant women with DM in a satisfactory condition on an outpatient basis, if DM is compensated and all necessary examinations are performed

Information

Sources and literature

1. Minutes of the meetings of the Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan, 2014
   1. 1. World Health Organization. Definition, Diagnosis, and Classification of Diabetes Mellitus and its Complicatios: Report of a WHO consultation. Part 1: Diagnosis and Classification of Diabetes Mellitus. Geneva, World Health Organization, 1999 (WHO/NCD/NCS/99.2). 2 American Diabetes Association. Standards of medical care in diabetes-2014. Diabetes Care, 2014; 37(1). 3. Algorithms of specialized medical care for patients with diabetes mellitus. Ed. I.I. Dedova, M.V. Shestakova. 6th edition. M., 2013. 4. World Health Organization. Use of Glycated Haemoglobin (HbAlc) in the Diagnosis of Diabetes Mellitus. Abbreviated Report of a WHO Consultation. World Health Organization, 2011 (WHO/NMH/CHP/CPM/11.1). 5. Russian national consensus "Gestational diabetes mellitus: diagnosis, treatment, postpartum care" / Dedov I.I., Krasnopolsky V.I., Sukhikh G.T. On behalf of the working group//Diabetes mellitus. - 2012. - No. 4. - P.4-10. 6. Nurbekova A.A. Diabetes mellitus (diagnosis, complications, treatment). Textbook - Almaty. - 2011. - 80 p. 7. Bazarbekova R.B., Zeltser M.E., Abubakirova Sh.S. Consensus on the diagnosis and treatment of diabetes mellitus. Almaty, 2011. 8. Selected issues of perinatology. Edited by Prof. R.J. Nadishauskienė. Publishing house Lithuania. 2012 652 p. 9. National Guideline "Obstetrics", edited by E.K. Ailamazyan, M., 2009. 10. NICE Protocol on Diabetes Mellitus During Pregnancy, 2008. 11. Insulin Pump Therapy and Continuous Glucose Monitoring. Edited by John Pickup. OXFORD, UNIVERSITY PRESS, 2009. 12.I. Blumer, E. Hadar, D. Hadden, L. Jovanovic, J. Mestman, M. HassMurad, Y. Yogev. Diabetes and Pregnancy: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab, November 2-13, 98(11):4227-4249.

Information

III. ORGANIZATIONAL ASPECTS OF PROTOCOL IMPLEMENTATION

List of protocol developers with qualification data:
1. Nurbekova A.A., Doctor of Medical Sciences, Professor of the Department of Endocrinology of KazNMU
2. Doshchanova A.M. - Doctor of Medical Sciences, Professor, Doctor of the Highest Category, Head of the Department of Obstetrics and Gynecology on internship at JSC "MUA";
3. Sadybekova G.T. - Candidate of Medical Sciences, Associate Professor, Endocrinologist of the highest category, Associate Professor of the Department of Internal Diseases for Internship at JSC "MUA".
4. Akhmadyar N.S., Doctor of Medical Sciences, Senior Clinical Pharmacologist of JSC NSCMD

Indication of no conflict of interest: no.

Reviewers:
Kosenko Tatyana Frantsevna, Candidate of Medical Sciences, Associate Professor of the Department of Endocrinology, AGIUV

Indication of the conditions for revising the protocol: revision of the protocol after 3 years and / or when new diagnostic / treatment methods with a higher level of evidence appear.

Attachment 1

In pregnant women, the diagnosis of diabetes is based on laboratory determinations of venous plasma glucose levels only.
Interpretation of test results is carried out by obstetrician-gynecologists, therapists, general practitioners. A special consultation with an endocrinologist to establish the fact of a violation of carbohydrate metabolism during pregnancy is not required.

Diagnosis of disorders of carbohydrate metabolism during pregnancy carried out in 2 phases.

1 PHASE. At the first visit of a pregnant woman to a doctor of any specialty for up to 24 weeks, one of the following studies is mandatory:
- Glucose of venous plasma on an empty stomach (determination of glucose of venous plasma is carried out after preliminary fasting for at least 8 hours and not more than 14 hours);
- HbA1c using a method of determination certified in accordance with the National Glycohemoglobin Standardization Program (NGSP) and standardized in accordance with the reference values ​​adopted in the DCCT (Diabetes Control and Complications Study);
- venous plasma glucose at any time of the day, regardless of food intake.

table 2 Threshold values ​​of venous plasma glucose for the diagnosis of overt (newly detected) DM during pregnancy

1 If abnormal values ​​are obtained for the first time and there are no symptoms of hyperglycemia, then the provisional diagnosis of overt diabetes during pregnancy should be confirmed by fasting venous plasma glucose or HbA1c using standardized tests. In the presence of symptoms of hyperglycemia, a single determination in the diabetic range (glycemia or HbA1c) is sufficient to establish the diagnosis of diabetes. If overt DM is detected, it should be qualified as soon as possible into any diagnostic category according to the current WHO classification, for example, type 1 DM, type 2 DM, etc.
2 HbA1c using a method certified by the National Glycohemoglobin Standardization Program (NGSP) and standardized according to the DCCT (Diabetes Control and Complications Study) reference values.

In the event that the result of the study corresponds to the category of manifest (first detected) DM, its type is specified and the patient is immediately transferred for further management to an endocrinologist.
If the HbA1c level<6,5% или случайно определенный уровень глюкозы плазмы <11,1 ммоль/л (в любое время суток), то проводится определение глюкозы венозной плазмы натощак: при уровне глюкозы венозной плазмы натощак ≥5,1 ммоль/л, но <7,0 ммоль/л устанавливается диагноз ГСД.

Table 3

1 Only the level of glucose in venous plasma is examined. The use of capillary whole blood samples is not recommended.
2 At any stage of pregnancy (one abnormal measurement of venous plasma glucose is sufficient).

When first contacting pregnant women with BMI ≥25 kg/m2 and having the following risk factors held PGGT for the detection of latent type 2 diabetes(table 2):
. sedentary lifestyle
. 1st-line relatives with diabetes
. women with a history of large fetuses (more than 4000g), stillbirth, or established gestational diabetes
. hypertension (≥140/90 mmHg or on antihypertensive therapy)
. HDL 0.9 mmol/L (or 35 mg/dL) and/or triglycerides 2.82 mmol/L (250 mg/dL)
. the presence of HbAlc ≥ 5.7%, preceding impaired glucose tolerance or impaired fasting glycemia
. history of cardiovascular disease
. other clinical conditions associated with insulin resistance (including severe obesity, acanthosis nigricans)
. polycystic ovary syndrome

PHASE 2- is carried out at the 24-28th week of pregnancy.
To all women who did not have DM in early pregnancy, OGTT with 75 g of glucose is performed to diagnose GDM (Appendix 2).

Table 4 Threshold values ​​of venous plasma glucose for the diagnosis of GDM

1 Only the level of glucose in venous plasma is examined. The use of capillary whole blood samples is not recommended.
2 At any stage of pregnancy (one abnormal measurement of venous plasma glucose is sufficient).
3 According to the results of OGTT with 75 g of glucose, at least one of three venous plasma glucose values ​​that would be equal to or above the threshold is sufficient to establish the diagnosis of GDM. If abnormal values ​​are obtained in the initial measurement, glucose loading is not carried out; when receiving abnormal values ​​at the second point, the third measurement is not required.

Fasting glucose, random meter blood glucose, and urine glucose (urine litmus test) are not recommended tests for diagnosing GDM.

Annex 2

Rules for conducting OGTT
PGTT with 75g of glucose is a safe exercise diagnostic test for the detection of carbohydrate metabolism disorders during pregnancy.
Interpretation of OGTT results can be carried out by a doctor of any specialty: an obstetrician, gynecologist, internist, general practitioner, endocrinologist.
The test is performed on a normal diet (at least 150 g of carbohydrates per day) for at least 3 days prior to the study. The test is performed in the morning on an empty stomach after an 8-14-hour overnight fast. The last meal must necessarily contain 30-50 g of carbohydrates. Drinking water is not prohibited. The patient must be seated during the test. Smoking is prohibited until the end of the test. Drugs that affect blood glucose levels (multivitamins and iron preparations containing carbohydrates, glucocorticoids, β-blockers, β-agonists), if possible, should be taken after the end of the test.

PGTT is not carried out:
- with early toxicosis of pregnant women (vomiting, nausea);
- if it is necessary to comply with strict bed rest (the test is not carried out until the expansion of the motor regimen);
- against the background of an acute inflammatory or infectious disease;
- with exacerbation of chronic pancreatitis or the presence of dumping syndrome (syndrome of the resected stomach).

Determination of venous plasma glucose performed only in the laboratory on biochemical analyzers or on glucose analyzers.
The use of portable self-monitoring devices (glucometers) for testing is prohibited.
Blood sampling is carried out in a cold tube (preferably vacuum) containing preservatives: sodium fluoride (6 mg per 1 ml of whole blood) as an enolase inhibitor to prevent spontaneous glycolysis, as well as EDTA or sodium citrate as anticoagulants. The test tube is placed in water with ice. Then immediately (no later than the next 30 minutes) the blood is centrifuged to separate plasma and formed elements. The plasma is transferred to another plastic tube. In this biological fluid, the glucose level is determined.

Test execution steps
1st stage. After taking the first fasting venous blood plasma sample, the glucose level is measured immediately, because. upon receipt of results indicating overt (newly diagnosed) diabetes or GDM, no further glucose loading is performed and the test is terminated. If it is impossible to quickly determine the level of glucose, the test continues and is brought to an end.

2nd stage. When continuing the test, the patient should drink a glucose solution within 5 minutes, consisting of 75 g of dry (anhydrite or anhydrous) glucose dissolved in 250-300 ml of warm (37-40 ° C) non-carbonated (or distilled) drinking water. If glucose monohydrate is used, 82.5 g of the substance is needed to perform the test. The start of taking a glucose solution is considered the beginning of the test.

3rd stage. The next blood samples to determine the level of venous plasma glucose are taken 1 and 2 hours after the glucose load. If results are obtained indicating GDM after the 2nd blood draw, the test is terminated.

Annex 3

The LMWH system is used as a modern method for diagnosing glycemic changes, identifying patterns and recurring trends, detecting hypoglycemia, correcting treatment and selecting hypoglycemic therapy; promotes patient education and participation in their care.

LMWH is a more modern and accurate approach than self-monitoring at home. LMWH measures glucose levels in the interstitial fluid every 5 minutes (288 measurements per day), providing the doctor and patient with detailed information regarding glucose levels and trends in its concentration, and also gives alarms in case of hypo- and hyperglycemia.

Indications for LMWH:
- patients with HbA1c levels above the target parameters;
- patients with a discrepancy between the level of HbA1c and the indicators recorded in the diary;
- patients with hypoglycemia or in cases of suspected insensitivity to the onset of hypoglycemia;
- Patients with fear of hypoglycemia, preventing the correction of treatment;
- children with high glycemic variability;
- pregnant women;
- patient education and involvement in their treatment;
- change in behavioral settings in patients who were not receptive to self-monitoring of glycemia.

Appendix 4

Special antenatal management of pregnant women with diabetes mellitus

Conception is not recommended :
- HbA1c level >7%;
- severe nephropathy with serum creatinine >120 µmol/l, GFR<60 мл/мин/1,73 м2 суточной протеинурии ≥3,0 г, неконтролируемой артериальной гипертензией;
- proliferative retinopathy and maculopathy before laser coagulation of the retina;
- the presence of acute and exacerbation of chronic infectious and inflammatory diseases (tuberculosis, pyelonephritis, etc.)

Pregnancy planning
When planning pregnancy, women with diabetes are encouraged to achieve target levels of glycemic control without the presence of hypoglycemia.
With diabetes, pregnancy should be planned:
. an effective method of contraception should be used until proper examination and preparation for pregnancy has been carried out:
. education in the “diabetes school”;
. informing the patient with diabetes about the possible risk to the mother and fetus;
. achieving ideal compensation 3-4 months before conception:
- plasma glucose on an empty stomach / before meals - up to 6.1 mmol / l;
- plasma glucose 2 hours after eating - up to 7.8 mmol / l;
- HbA ≤ 6.0%;
. control of blood pressure (no more than 130/80 mm Hg. Art.), with hypertension - antihypertensive therapy (cancellation of ACE inhibitors until contraception is discontinued);
. determination of the level of TSH and free T4 + AT to TPO in patients with type 1 diabetes (increased risk of thyroid diseases);
. folic acid 500 mcg per day; potassium iodide 150 mcg per day - in the absence of contraindications;
. treatment of retinopathy;
. treatment of nephropathy;
. to give up smoking.

CONTRAINDICATED during pregnancy:
. any tableted hypoglycemic drugs;
. ACE inhibitors and ARBs;
. ganglioblockers;
. antibiotics (aminoglycosides, tetracyclines, macrolides, etc.);
. statins.

Antihypertensive therapy during pregnancy:
. The drug of choice is methyldopa.
. With insufficient effectiveness of methyldopa, the following can be prescribed:
- calcium channel blockers;
- β1-selective blockers.
. Diuretics - for health reasons (oliguria, pulmonary edema, heart failure).

Annex 5

Replacement of products according to the XE system

1 XE - the amount of the product containing 15 g of carbohydrates

When calculating sweet flour products, the guideline is ½ a piece of bread.

When eating meat - the first 100g are not taken into account, each subsequent 100g corresponds to 1 XE.

Appendix 6

Pregnancy is a state of physiological insulin resistance, therefore, in itself is a significant risk factor for carbohydrate metabolism disorders.
Gestational diabetes mellitus (GDM)- a disease characterized by hyperglycemia, first detected during pregnancy, but not meeting the criteria for "manifest" diabetes.
GDM is a disorder of glucose tolerance of varying severity that occurs or is first diagnosed during pregnancy. It is one of the most common disorders in the endocrine system of a pregnant woman. Due to the fact that in most pregnant women GDM occurs without severe hyperglycemia and obvious clinical symptoms, one of the features of the disease is the difficulty of its diagnosis and late detection.
In some cases, GDM is established retrospectively after delivery on the basis of phenotypic signs of diabetic fetopathy in the newborn or is skipped altogether. That is why in many countries there is an active screening for the detection of GDM with OGTT with 75 g of glucose. This study is being carried out to all women at 24-28 weeks of gestation. Besides, women at risk(see section 12.3) OGTT with 75 g of glucose is carried out already at the first visit.

Tactics for the treatment of GDM
- diet therapy
- physical activity
- learning and self-control
- hypoglycemic drugs

diet therapy
With GDM, diet therapy is carried out with the complete exclusion of easily digestible carbohydrates (especially sweet carbonated drinks and fast foods) and restriction of fats; uniform distribution of the daily volume of food for 4-6 receptions. Carbohydrates with a high content of dietary fiber should be no more than 38-45% of the daily caloric intake of food, proteins - 20-25% (1.3 g / kg), fats - up to 30%. For women with a normal BMI (18-25 kg/m2), a daily caloric intake of 30 kcal/kg is recommended; with excess (BMI 25-30 kg/m2) 25 kcal/kg; with obesity (BMI ≥30 kg / m2) - 12-15 kcal / kg.

Physical activity
With GDM, dosed aerobic exercise is recommended in the form of walking for at least 150 minutes a week, swimming in the pool; self-monitoring is performed by the patient, the results are provided to the doctor. It is necessary to avoid exercises that can cause an increase in blood pressure and uterine hypertonicity.

Patient education and self-monitoring
Women who are planning a pregnancy, and pregnant women who have not been trained (primary cycle), or patients who have already been trained (for repeated cycles) are referred to the school of diabetes to maintain the level of knowledge and motivation or when new therapeutic goals appear, transfer to insulin therapy.
self control includes the definition:
- glycemia using portable devices (glucometers) on an empty stomach, before and 1 hour after the main meals;
- ketonuria or ketonemia in the morning on an empty stomach;
- blood pressure;
- fetal movements;
- body weight;
- keeping a diary of self-control and a food diary.

NMG system used as an adjunct to traditional self-monitoring in case of latent hypoglycemia or frequent hypoglycemic episodes (Appendix 3).

Medical treatment
For the treatment of GDM in most pregnant women, diet therapy and physical activity are sufficient. With the ineffectiveness of these measures, insulin therapy is prescribed.

Indications for insulin therapy in GDM
- the inability to achieve target levels of glycemia (two or more non-target glycemia values) within 1-2 weeks of self-monitoring;
- the presence of signs of diabetic fetopathy according to expert ultrasound, which is an indirect evidence of chronic hyperglycemia.

Ultrasound signs of diabetic fetopathy:
. Large fetus (diameter of the abdomen ≥75th percentile).
. Hepato-splenomegaly.
. Cardiomegaly/cardiopathy.
. Bicontour of the fetal head.
. Edema and thickening of the subcutaneous fat layer.
. Thickening of the neck fold.
. Newly diagnosed or increasing polyhydramnios with an established diagnosis of GDM (if other causes of polyhydramnios are excluded).

When prescribing insulin therapy, a pregnant woman is jointly led by an endocrinologist/therapist and an obstetrician-gynecologist. The regimen of insulin therapy and the type of insulin preparation are prescribed depending on the data of self-monitoring of glycemia. A patient on an intensified insulin therapy regimen should carry out self-monitoring of glycemia at least 8 times a day (on an empty stomach, before meals, 1 hour after meals, before bedtime, at 03.00 and if you feel unwell).

Oral antidiabetic drugs during pregnancy and breastfeeding contraindicated!
Hospitalization in the hospital when GDM is detected or when insulin therapy is initiated is not mandatory and depends only on the presence of obstetric complications. GDM by itself is not an indication for early delivery and planned caesarean section.

Tactics after childbirth in a patient with GDM:
. after delivery, insulin therapy is canceled in all patients with GDM;
. during the first three days after childbirth, it is necessary to measure the level of venous plasma glucose in order to identify a possible violation of carbohydrate metabolism;
. Patients who have undergone GDM are at high risk for its development in subsequent pregnancies and type 2 diabetes in the future. These women should be constantly monitored by an endocrinologist and an obstetrician-gynecologist;
. 6-12 weeks postpartum for all women with fasting venous plasma glucose< 7,0 ммоль/л проводится ПГТТ с 75 г глюкозы для реклассификации степени нарушения углеводного обмена;
. a diet aimed at reducing weight with its excess;
. increased physical activity;
. planning for future pregnancies.

Attached files

Attention!

• By self-medicating, you can cause irreparable harm to your health.
• The information posted on the MedElement website and in the mobile applications "MedElement (MedElement)", "Lekar Pro", "Dariger Pro", "Diseases: Therapist's Handbook" cannot and should not replace an in-person consultation with a doctor. Be sure to contact medical facilities if you have any diseases or symptoms that bother you.
• The choice of drugs and their dosage should be discussed with a specialist. Only a doctor can prescribe the right medicine and its dosage, taking into account the disease and the condition of the patient's body.
• The MedElement website and mobile applications "MedElement (MedElement)", "Lekar Pro", "Dariger Pro", "Diseases: Therapist's Handbook" are exclusively information and reference resources. The information posted on this site should not be used to arbitrarily change the doctor's prescriptions.
• The editors of MedElement are not responsible for any damage to health or material damage resulting from the use of this site.