Gestational diabetes in pregnancy. Diabetes mellitus and pregnancy (planning, management, monitoring and nutrition) Nutrition diary for GDM
With gestational diabetes and avoid even the slightest deviation.
Why is GDM dangerous for a pregnant woman and fetus?
During the gestation of the embryo, antagonists of the insulin substance are activated in the body. They contribute to the saturation of plasma with glucose, which is not enough to neutralize insulin.
This condition is called by doctors. After delivery, the pathology in most cases recedes. But, despite this, a woman in a state of pregnancy needs to control the amount of sugar in the serum.
Gestational diabetes is an endocrinological disorder that negatively affects the health of a woman and her child. But with normal compensation, the pregnant woman manages to endure and give birth to a baby without any problems.
Without treatment, GDM can lead to a number of:
- fetal death in utero or in the first 7-9 days after birth;
- the birth of a baby with malformations;
- the appearance of a large baby with various complications (injuries to the limbs, skulls during childbirth);
- the development of the second form of diabetes mellitus in the near future;
- high risk of infectious diseases.
For the mother, GDM is dangerous for the following:
- polyhydramnios;
- the risk of transition from GDM to diabetes of the second form;
- development of intrauterine infection;
- complication of pregnancy (, preeclampsia, edematous syndrome, eclampsia);
- kidney failure.
It is important for a pregnant woman with GDM to keep her sugar levels under control.
The norm of blood sugar in gestational diabetes during pregnancy
In women in position, the level of glucose substance differs from the generally accepted standard. The optimal values are up to 4.6 mmol / l, up to 6.9 mmol / l after an hour and up to 6.2 mmol / l two hours after consumption.
At the same time, for diabetics with a gestational form of the disease, the norm is at this level:
- up to 5.3 mmol / l 8-12 hours after dinner;
- up to 7.7 60 minutes after eating;
- up to 6.7 a couple of hours after eating.
Checking blood sugar with a glucometer at home
Pregnant women with GDM are advised to purchase a special for self-monitoring of sugar levels.. This one is easy to use.
Electronic models are accurate and do not take much time for testing. The frequency of the analysis is agreed with the attending doctor.
In GDM, sugar should be checked at least twice a day, especially in the second period of pregnancy. With instability of glycemia, endocrinologists advise testing in the morning, before bedtime, before and after eating.
The results of the analysis will help to understand what measures should be taken by a pregnant woman. So, if the test showed a value below the norm, then it is recommended to drink sweet compote or.
If glucose exceeds the optimal value, then you should take a sugar-lowering drug, reconsider your lifestyle,.
The algorithm for performing a test for the concentration of sugar with a home glucometer:
- wash your hands with laundry soap. Perform disinfection with an alcohol-containing agent;
- warm fingers, massage hands to improve blood circulation;
- turn on the glucometer;
- install, enter the code;
- make a puncture in the finger;
- put a couple of drops of blood on the test strip;
- wait for the information to appear on the screen.
If you suspect a false glucose result, you should retest. Home glucometers sometimes have a high error. In this case, they need to or check the validity of the test strips.
In case of improper storage (too high or low temperature, not completely closed container), the strips for glucose analysis deteriorate earlier than the period established by the manufacturer.
Related videos
About gestational diabetes in the video:
Thus, knowing the blood sugar rate for GDM, a pregnant woman can control her condition and avoid the onset of diabetes after delivery and.
For control, you should periodically visit the laboratory and. The test is easy to carry out at home with an electronic glucometer.
The diary of self-control in diabetes mellitus is a source of necessary information directly for the patient, the people caring for him, as well as for the doctor. It has long been proven that people with this disease live quite comfortably, since diabetes can be controlled.
What is a diary for?
Learning how to properly correct therapy, including physical activity, diet, dosage of insulin preparations, as well as correctly assess one's condition, is the task of self-control. Of course, the leading role in this process belongs to the doctor, but the patient who consciously manages his disease achieves good results, always controls the situation and feels more confident.
Accurately filling out a diabetic diary or self-control diary will be taught in special schools that are in every clinic in the city. It is useful for patients with any type of disease. When filling it out, it should be remembered that this is not a routine job that takes time, but a way to prevent serious complications. There are no uniform standards for writing in it, however, there are some wishes for its maintenance. It is recommended to keep a diary immediately after the diagnosis is made.
What to write in a diary?
It is necessary to fix the information, the analysis of which will reduce the risks of complications or improve the patient's condition. The following points are considered the most important:
Types of diaries
There are several options for keeping self-monitoring diaries for diabetes:
Internet applications for self-management in diabetes mellitus
Currently, there is a large selection of programs for this category of patients. They differ in functionality and can be both paid and free. Modern technologies make it possible to simplify the maintenance of a self-control diary for diabetes mellitus, and also, if necessary, consult with the attending doctor by sending him information from the diary in electronic form. Programs are installed on a smartphone, tablet or personal computer. Let's consider some of them.
DiaLife
It is an online self-monitoring diary for dieting and hypoglycemia. The mobile application contains the following parameters:
- body weight and its index;
- calorie consumption, as well as their calculation using a calculator;
- glycemic index of food;
- for any product, the nutritional value is derived and the chemical composition is indicated;
- a diary that makes it possible to see the amount of proteins, lipids, carbohydrates entering the body, as well as count calories.
A sample diary of self-control in diabetes mellitus can be found on the manufacturer's website.
Social Diabetes
This universal program provides an opportunity to use it for any type of diabetes:
- at the first, it helps to determine the dose of insulin, which is calculated based on the level of glycemia and the amount of carbohydrates ingested;
- at the second - to reveal deviations at an early stage.
Self-monitoring diary for gestational diabetes
If a pregnant woman has this disease, then she needs constant self-monitoring, which will help to identify the following points:
- whether physical activity and diet are sufficient to control glycemia;
- whether there is a need to administer insulin preparations to protect the fetus from high blood glucose levels.
The following parameters should be noted in the diary:
- the amount of carbohydrates consumed;
- dosage of injected insulin;
- blood sugar concentration;
- body weight;
- blood pressure numbers;
- ketone bodies in urine. They are found with limited carbohydrate intake, improper insulin therapy, or fasting. You can determine them using medical devices (special test strips). The appearance of ketone bodies reduces the delivery of oxygen to tissues and organs, which adversely affects the fetus.
For many women, gestational diabetes resolves after delivery. If after childbirth the need for insulin preparations persists, then most likely during the period of bearing the baby, type 1 diabetes developed. Some women are diagnosed with type 2 diabetes a few years after the birth of their baby. Physical activity, diet, and blood glucose monitoring at least once a year will help reduce the risk of developing it.
Self-monitoring diary for type 2 diabetes
The main task in this disease is stable normalization of blood glucose. The patient is not able to feel its fluctuations, so only careful self-control will allow you to track the dynamics of this serious pathology.
The frequency of glucose level studies directly depends on the hypoglycemic drug therapy that is prescribed to the patient and the level of glycemia during the day. At values close to normal, blood sugar is determined at different times of the day, several days a week. When changing the habitual lifestyle, for example, increasing physical activity, stressful situations, exacerbation of a concomitant disease or the occurrence of an acute pathology, the frequency of glucose self-monitoring is carried out in consultation with the doctor. If diabetes mellitus is combined with overweight, then the following information must be recorded in the diary:
- weight changes;
- the energy value of the diet;
- blood pressure readings at least twice a day;
- and other parameters recommended by the doctor.
The information contained in the diary of self-control in diabetes mellitus will allow the doctor to objectively assess the quality of treatment and timely correct therapy or give appropriate nutritional recommendations, prescribe physiotherapy. Constant monitoring of the disease and regular therapy of this disease will help maintain the individual's body at the required level, and, if necessary, take urgent measures to normalize the condition.
Diabetes diagnosed during pregnancy
Gestational diabetes (GD) - develops only during pregnancy, more often after 20 weeks.
This is a special form of diabetes mellitus that develops in pregnant women whose blood sugar never increased before pregnancy.
During pregnancy, the placenta produces hormones necessary for the development of the fetus. If these hormones block the action of maternal insulin, gestational diabetes occurs. In this case, a condition called insulin resistance (insensitivity of cells to insulin) occurs, and blood sugar levels rise.
Gestational diabetes most often goes away on its own after childbirth, but 25-50% of women with gestational diabetes eventually develop true type II diabetes.
In some women, gestational diabetes recurs with repeated pregnancies. In 30-85 women, HD occurs again.
In the ICD (International Classification of Diseases), GD is distinguished as a separate diagnostic unit
ICD-10 code: Pregnancy diabetes 024.4.
Manifestations of HD can be different: from a slight increase in blood sugar on an empty stomach (in the absence of pregnancy, a diagnosis would be made: Violation of fasting glycemia)
or after a meal (In the absence of pregnancy, the diagnosis would be: Impaired glucose tolerance),
or the classic clinical picture of diabetes mellitus with high blood sugar levels develops.
In Russia, according to the State Registry of Diabetes Mellitus, the prevalence of HD is 4.5%.
According to international studies, about 7% of all pregnancies are complicated by HD, and there is an upward trend in the incidence.
High risk of developing HD in pregnant women:
with heredity burdened by diabetes mellitus;
with a history of gestational diabetes mellitus;
with glucosuria or clinical symptoms of diabetes mellitus during a previous or current pregnancy;
with the level of glucose in capillary blood on an empty stomach before pregnancy above 5.5 mmol / l or 2 hours after eating more than 7.8 mmol / l;
with obesity;
if the body weight of the previous child at birth is more than 4000 g;
with a history of habitual non-carrying, unexplained fetal death or congenital anomalies in its development;
with polyhydramnios and / or the presence of a large fetus;
over 35 years of age;
with arterial hypertension;
with severe forms of preeclampsia in history;
with recurrent colpitis.
If you have the above risk factors for GDM, or at least one of them, then it is necessary to examine the level of sugar in the blood at the first visit to the antenatal clinic (for example, on a glucometer - screening) on an empty stomach against the background of a normal diet and physical activity. That is, you should eat all the foods that you usually eat, without excluding anything from your diet!
If during screening (mass determination of blood sugar in all pregnant women, for example, using a glucometer), an increase in blood sugar is detected, additional laboratory examinations are necessary.
Raise fear!
Blood sugar taken from a finger, on an empty stomach from 4.8 to 6.0 mmol / l
(N.Yu. Arbatskaya, PhD, endocrinologist, City Clinical Hospital No. 1 named after N.I. Pirogov,
Assistant of the Department of Endocrinology and Diabetology of the Federal University of Education and Science of the Russian State Medical University)
If such indicators are detected, stress tests are carried out (determination of blood sugar after taking 75 g of glucose) to make a diagnosis only by laboratory methods, and it is necessary to confirm the increase in blood sugar at least twice (once elevated blood sugar cannot be the basis for the diagnosis)
The most important criterion for making a diagnosis is the definition glycated hemoglobin (HbA1c) : average blood sugar for 3 months. It is determined in the laboratory of a medical institution.
With an HbA1c level of more than 6.5%, the diagnosis is considered confirmed.
With questionable results, a special test with a glucose load is prescribed to detect a violation of carbohydrate metabolism.
Test rules:
1. 3 days before the examination, you eat your usual diet and follow your usual physical activity.
2. The test is carried out in the morning on an empty stomach (after overnight fasting for at least 8-14 hours)
3. After taking a fasting blood sample, you should drink a glucose solution consisting of 75 grams of dry glucose dissolved in 250-300 ml of water within 5 minutes. A repeat blood sample to determine the blood sugar level is taken 2 hours after the glucose load.
The diagnosis of GDM is based on the following criteria
blood glucose taken from a finger on an empty stomach is more than 6.1 mmol / l or
blood glucose taken from a vein on an empty stomach 7 mmol / l or
blood glucose taken from a finger or from a vein 2 hours after a load of 75 g of glucose is more than 7.8 mmol / l.
(N.Yu. Arbatskaya, Candidate of Medical Sciences, endocrinologist of the City Clinical Hospital No. 1 named after N.I. Pirogov, assistant of the Department of Endocrinology and Diabetology of the Federal University of Education and Science of the Russian State Medical University)
If the results of the study are normal, then the test is repeated at 24-28 weeks of pregnancy, when the level of pregnancy hormones increases.
Why is gestational diabetes dangerous for a child?
In uncompensated diabetes mellitus, including gestational diabetes, there are high risks of various fetal malformations, especially in the early stages of development. This happens due to the fact that the fetus receives nutrition from the mother in the form of glucose, but does not receive enough insulin, and the fetus does not yet have its own pancreas. Constant hyperglycemia (high blood sugar) causes a lack of energy for the normal development of the fetus and contributes to the abnormal development of organs and systems (2-3 weeks behind peers).
In the second trimester, the fetus develops its own pancreas, which, in addition to utilizing glucose in the child's body, is forced to normalize the glucose level in the mother's body. This causes the production of a large amount of insulin, hyperinsulinemia develops. The development of hyperinsulinemia threatens with hypoglycemic conditions in newborns (since the pancreas is used to working for two), respiratory disorders and the development of asphyxia.
For the fetus, not only high sugar is dangerous, but also low. Frequent hypoglycemia causes malnutrition of the brain, which threatens to slow down the mental development of the child.
Why is gestational diabetes dangerous for a mother?
Uncompensated gestational diabetes poses a threat to the normal course of pregnancy. There is a high risk of developing gestosis (a complication in which the functions of various organ systems, especially the vascular system, are disrupted). This leads to malnutrition of the fetus.
Polyhydramnios often develops.
The risk of missed pregnancies increases.
With persistent hyperglycemia, infections of the genital tract often develop, which causes infection of the fetus.
Often such a pregnancy is accompanied by ketoacidosis, which causes poisoning of the body.
Uncompensated diabetes is very dangerous because it causes the development of complications of diabetes, such as impaired functioning of the kidneys and organs of vision.
Most often, with poor compensation for diabetes, a very large fetus develops, which makes natural childbirth impossible. In such cases, resort to caesarean section. In special cases, childbirth is prescribed at 37-38 weeks - due to the risks of the mother and the large development of the fetus.
Large-scale clinical studies have shown that diabetes mellitus is not an absolute obstacle to the birth of a healthy child. Your baby's health is negatively affected by high blood sugar, not the disease itself.
For a healthy baby
IT IS IMPORTANT TO CONTROL BLOOD SUGAR USING A GLUCOMETER and, if necessary, consult a doctor in a timely manner to correct treatment
Self-monitoring includes the determination of blood sugar using portable devices (glucometers) on an empty stomach, before and 1 hour after the main meals
(From the recommendations: RUSSIAN NATIONAL CONSENSUS "GESTATIONAL DIABETES MELLITUS: DIAGNOSTICS, TREATMENT, POSTNATAL OBSERVATION", FSBI Endocrinological Research Center (ESC), Director of the FSBI ENTS, Academician of the Russian Academy of Sciences and the Russian Academy of Medical Sciences Dedov Ivan Ivanovich, Chief Freelance Endocrinologist of the Ministry of Health of the Russian Federation)
Treatment
Treatment goals - COMPENSATION (achievement of normal blood sugar levels against the background of regular monitoring)
Stable compensation of carbohydrate metabolism (NORMAL BLOOD SUGAR) is required throughout pregnancy.
Compensation criteria: fasting capillary blood glucose< 5,0-5,5 ммоль/л, через 1 ч после еды < 7,8 ммоль/л, через 2 ч после еды < 6,7-7,2 ммоль/л, нормальный (или ниже нормы) уровень гликированного гемоглобина.
The ideal sugar curve should look like this:
on an empty stomach - 5.3 mmol / l;
before meals - 5.8 mmol / l;
one hour after eating - 7.8 mmol / l;
two hours after eating - 6.7 mmol / l.
Non-drug treatment
Very often, diet and blood sugar control are sufficient to compensate for HD.
It is impossible to sharply reduce the energy value of food.
During pregnancy, easily digestible carbohydrates (sugar, pastries, sweets) should be excluded, as they cause a sharp rise in blood sugar.
It is necessary to limit the consumption of fats (cream, fatty meat, butter), since in conditions of lack of insulin they are sources of ketone bodies, which causes intoxication.
Increase the intake of foods containing a large amount of fiber (vegetables, herbs, fruits). Bananas, grapes, melons should be excluded from fruits.
About 50% should be allocated to carbohydrates in the daily diet, about 20% to proteins, and about 30% to fats.
Complete fasting during pregnancy is contraindicated!
If the target glycemic values are not achieved on the diet for 1-2 weeks (two or more non-target glycemic values), insulin therapy is prescribed.
The optimal scheme (determined by the endocrinologist) is intensified insulin therapy: only short-acting insulin before the main meals 3 times a day or in combination with intermediate-acting insulin in the morning and / or evening. It should be especially noted that if the diet is ineffective, it is absolutely unacceptable to prescribe oral hypoglycemic drugs to pregnant women! Signs of macrosomia in fetal ultrasound biometrics may serve as an indication for the appointment of insulin therapy for a pregnant woman.
Pregnant women with HD who are on insulin therapy need to keep a diary, where they record: the results of self-monitoring of blood glucose levels (6-8 times a day), the amount of carbohydrates per meal, calculated according to the system of bread units (XE), insulin doses, body weight (weekly), notes (episodes of hypoglycemia, acetonuria, blood pressure, etc.). Once a trimester, the level of glycated hemoglobin is examined [Dedov I.I., Fadeev V.
If you have had gestational diabetes before, your doctor will recommend a glucose tolerance test (GTT) at 16-18 weeks of pregnancy, and then again at 28 if the first test showed no problems.
What to do with HD after childbirth?
At 6–12 weeks postpartum, all women with fasting plasma venous glucose< 7,0 ммоль/л проводится пероральный глюкозотолерантный тест с 75 г глюкозы (исследование глюкозы натощак и через 2 ч после нагрузки) для реклассификации степени нарушения углеводного обмена
RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical Protocols of the Ministry of Health of the Republic of Kazakhstan - 2014
Diabetes mellitus in pregnancy, unspecified (O24.9)
Endocrinology
general information
Short description
Approved
at the Expert Commission on Health Development
Ministry of Health of the Republic of Kazakhstan
Protocol No. 10 dated July 04, 2014
Diabetes mellitus (DM) is a group of metabolic (exchange) diseases characterized by chronic hyperglycemia, which is the result of a violation of insulin secretion, insulin action, or both of these factors. Chronic hyperglycemia in diabetes is accompanied by damage, dysfunction and failure of various organs, especially the eyes, kidneys, nerves, heart and blood vessels (WHO, 1999, 2006 with additions) .
This is a disease characterized by hyperglycemia, first diagnosed during pregnancy, but not meeting the criteria for "manifest" diabetes mellitus. GDM is a disorder of glucose tolerance of varying severity that occurs or is first diagnosed during pregnancy.
I. INTRODUCTION
Protocol name: Diabetes during pregnancy
Protocol code:
Code (codes) according to ICD-10:
E 10 Insulin-dependent diabetes mellitus
E 11 Non-insulin dependent diabetes mellitus
O24 Diabetes mellitus in pregnancy
O24.0 Pre-existing diabetes mellitus, insulin-dependent
O24.1 Pre-existing diabetes mellitus, non-insulin dependent
O24.3 Pre-existing diabetes mellitus, unspecified
O24.4 Diabetes mellitus during pregnancy
O24.9 Diabetes mellitus of pregnancy, unspecified
Abbreviations used in the protocol:
AH - arterial hypertension
BP - blood pressure
GDM - gestational diabetes mellitus
DKA - diabetic ketoacidosis
IIT - intensified insulin therapy
IR - insulin resistance
IRI - immunoreactive insulin
BMI - body mass index
MAU - microalbuminuria
ITG - impaired glucose tolerance
IGN - impaired fasting glycemia
LMWH - Continuous Glucose Monitoring
CSII - continuous subcutaneous insulin infusion (insulin pump)
OGTT - oral glucose tolerance test
PDM - pregestational diabetes mellitus
DM - diabetes mellitus
Type 2 diabetes - type 2 diabetes
Type 1 diabetes - type 1 diabetes
CCT - hypoglycemic therapy
FA - physical activity
XE - bread units
ECG - electrocardiogram
HbAlc - glycosylated (glycated) hemoglobin
Protocol development date: year 2014.
Protocol Users: endocrinologists, general practitioners, internists, obstetrician-gynecologists, emergency physicians.
Classification
Classification
Table 1 Clinical classification of SD:
| type 1 diabetes | Destruction of pancreatic β-cells, usually resulting in absolute insulin deficiency |
| type 2 diabetes | Progressive impairment of insulin secretion against the background of insulin resistance |
| Other specific types of DM |
Genetic defects in β-cell function; Genetic defects in insulin action; Diseases of the exocrine part of the pancreas; - induced by drugs or chemicals (in the treatment of HIV / AIDS or after organ transplantation); Endocrinopathy; infections; Other genetic syndromes associated with DM |
| Gestational diabetes | occurs during pregnancy |
Types of diabetes in pregnant women :
1) "true" GDM, which occurred during this pregnancy and is limited to the period of pregnancy (Appendix 6);
2) type 2 diabetes, manifested during pregnancy;
3) type 1 diabetes that manifested during pregnancy;
4) Pregestational diabetes type 2;
5) Pregestational diabetes type 1.
Diagnostics
II. METHODS, APPROACHES AND PROCEDURES FOR DIAGNOSIS AND TREATMENT
List of basic and additional diagnostic measures
Basic diagnostic measures at the outpatient level(Appendix 1 and 2)
To detect hidden SD(on first visit):
- Determination of glucose on an empty stomach;
- Determination of glucose, regardless of the time of day;
- Glucose tolerance test with 75 grams of glucose (pregnant women with BMI ≥25 kg/m2 and risk factor);
To detect GDM (at 24-28 weeks gestation):
- Glucose tolerance test with 75 grams of glucose (all pregnant women);
All pregnant women with PDM and GDM
- Determination of glucose before meals, 1 hour after meals, at 3 am (glucometer) for pregnant women with PDM and GDM;
- Determination of ketone bodies in urine;
Additional diagnostic measures at the outpatient stage:
- ELISA - determination of TSH, free T4, antibodies to TPO and TG;
- LMWH (in accordance with Appendix 3);
- determination of glycosylated hemoglobin (HbAlc);
- Ultrasound of the abdominal cavity, thyroid gland;
The minimum list of examinations for referral to planned hospitalization:
- determination of glycemia: on an empty stomach and 1 hour after breakfast, before lunch and 1 hour after lunch, before dinner and 1 hour after dinner, at 22:00 and at 3:00 in the morning (glucometer);
- determination of ketone bodies in urine;
- UAC;
- OAM;
- ECG
Basic (mandatory) diagnostic examinations carried out at the hospital level(in case of emergency hospitalization, diagnostic examinations are performed that are not performed at the outpatient level):
- determination of glycemia: on an empty stomach and 1 hour after breakfast, before lunch and 1 hour after lunch, before dinner and 1 hour after dinner, at 22-00 and at 3 am
- biochemical blood test: determination of total protein, bilirubin, AST, ALT, creatinine, potassium, calcium, sodium, calculation of GFR;
- determination of activated partial thromboplastin time in blood plasma;
- determination of the international normalized ratio of the prothrombin complex in blood plasma;
- determination of soluble fibrinomonomer complexes in blood plasma;
- determination of thrombin time in blood plasma;
- determination of fibrinogen in blood plasma;
- determination of protein in urine (quantitatively);
- Ultrasound of the fetus;
- ECG (in 12 leads);
- determination of glycosylated hemoglobin in the blood;
- determination of the Rh factor;
- determination of the blood group according to the ABO system with tsoliklones;
- Ultrasound of the abdominal organs.
Additional diagnostic examinations carried out at the hospital level(in case of emergency hospitalization, diagnostic examinations are performed that were not performed at the outpatient level):
- LMWH (in accordance with Appendix 3)
- biochemical blood test (total cholesterol, lipoprotein fractions, triglycerides).
Diagnostic measures taken at the stage of emergency care:
- Determination of glucose in blood serum with a glucometer;
- determination of ketone bodies in urine with test strips.
Diagnostic criteria
Complaints and anamnesis
Complaints:
- when compensating SD are absent;
- with decompensated diabetes, pregnant women are concerned about polyuria, polydipsia, dry mucous membranes, and skin.
Anamnesis:
- SD duration;
- the presence of vascular late complications of diabetes;
- BMI at the time of pregnancy;
- pathological weight gain (more than 15 kg during pregnancy);
- burdened obstetric history (birth of children weighing more than 4000.0 grams).
Physical examination:
Type 2 diabetes and GDM are asymptomatic (Appendix 6)
SD type 1:
- dry skin and mucous membranes, decreased skin turgor, "diabetic" blush, enlarged liver;
- in the presence of signs of ketoacidosis, there are: deep Kussmaul breathing, stupor, coma, nausea, vomiting of "coffee grounds", a positive symptom of Shchetkin-Blumberg, defense of the muscles of the anterior abdominal wall;
- signs of hypokalemia (extrasystoles, muscle weakness, intestinal atony).
Laboratory research(Appendix 1 and 2)
table 2
1 If abnormal values were obtained for the first time and no symptoms hyperglycemia, the preliminary diagnosis of overt diabetes during pregnancy should be confirmed by fasting venous plasma glucose or HbA1c using standardized tests. In the presence of symptoms hyperglycemia one determination in the diabetic range (glycemia or HbA1c) is sufficient to establish the diagnosis of DM. If overt DM is detected, it should be qualified as soon as possible into any diagnostic category according to the current WHO classification, for example, type 1 DM, type 2 DM, etc.
2 HbA1c using the method of determination, certified in accordance with the National Glycohemoglobin Standardization Program (NGSP) and standardized in accordance with the reference values adopted in the DCCT (Diabetes Control and Complications Study).
If the HbA1c level<6,5% или случайно определенный уровень глюкозы плазмы <11,1 ммоль/л (в любое время суток), то проводится определение глюкозы венозной плазмы натощак: при уровне глюкозы венозной плазмы натощак ≥5,1 ммоль/л, но <7,0 ммоль/л устанавливается диагноз ГСД.
Table 3 Threshold values of venous plasma glucose for the diagnosis of GDM at the initial visit
Table 4 Threshold values of venous plasma glucose for the diagnosis of GDM during OGTT
1 Only the level of glucose in venous plasma is examined. The use of capillary whole blood samples is not recommended.
2 At any stage of pregnancy (one abnormal measurement of venous plasma glucose is sufficient).
Instrumental Research
Table 5 Instrumental studies in pregnant women with diabetes *
Revealing Ultrasound signs of diabetic fetopathy requires immediate correction of nutrition and LMWH:
. large fetus (diameter of the abdomen ≥75 percentile);
. hepatosplenomegaly;
. cardiomegaly/cardiopathy;
. bypass of the fetal head;
. swelling and thickening of the subcutaneous fat layer;
. thickening of the neck fold;
. newly diagnosed or increasing polyhydramnios with an established diagnosis of GDM (in case of exclusion of other causes of polyhydramnios).
Indications for specialist consultations
Table 6 Indications for specialist consultations in pregnant women with DM*
| Specialist | Goals of the consultation |
| Ophthalmologist's consultation | For the diagnosis and treatment of diabetic retinopathy: ophthalmoscopy with a wide pupil. With the development of proliferative diabetic retinopathy or a pronounced worsening of preproliferative diabetic retinopathy, immediate laser coagulation |
| Obstetrician-gynecologist consultation | For the diagnosis of obstetric pathology: up to 34 weeks of pregnancy - every 2 weeks, after 34 weeks - weekly |
| Endocrinologist's consultation | To achieve compensation for diabetes: up to 34 weeks of pregnancy - every 2 weeks, after 34 weeks - weekly |
| Therapist's consultation | To detect extragenital pathology every trimester |
| Nephrologist's consultation | For the diagnosis and treatment of nephropathy - according to indications |
| Cardiologist's consultation | For the diagnosis and treatment of complications of diabetes - according to indications |
| Neurologist's consultation | 2 times during pregnancy |
*If there are signs of chronic complications of diabetes, the addition of concomitant diseases, the appearance of additional risk factors, the question of the frequency of examinations is decided individually.
Antenatal management of pregnant women with diabetes is presented in Annex 4.
Differential Diagnosis
Differential Diagnosis
Table 7 Differential diagnosis of diabetes in pregnant women
| Pregestational SD | Manifest diabetes during pregnancy | GSD (Appendix 6) |
| Anamnesis | ||
| DM diagnosed before pregnancy | Detected during pregnancy | |
| Venous plasma glucose and HbA1c values for diagnosing DM | ||
| Achievement of target parameters |
Fasting glucose ≥7.0 mmol/L HbA1c ≥6.5% Glucose regardless of time of day ≥11.1 mmol/l |
Fasting glucose ≥5.1<7,0 ммоль/л 1 hour after PHGT ≥10.0 mmol/l 2 hours after PHGT ≥8.5 mmol/l |
| Timing of diagnosis | ||
| Before pregnancy | At any stage of pregnancy | At 24-28 weeks of pregnancy |
| Carrying out PGGT | ||
| Not carried out | Carried out at the first visit of a pregnant woman at risk | It is carried out for 24-28 weeks to all pregnant women who did not have a violation of carbohydrate metabolism in the early stages of pregnancy |
| Treatment | ||
| Insulin therapy with multiple injections of insulin or continuous subcutaneous infusion (pump) | Insulin therapy or diet therapy (for type 2 diabetes) | Diet therapy, if necessary, insulin therapy |
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Treatment
Treatment goals:
The goal of treating diabetes in pregnant women is to achieve normoglycemia, normalize blood pressure, prevent complications of diabetes, reduce complications of pregnancy, childbirth and the postpartum period, and improve perinatal outcomes.
Table 8 Carbohydrate Targets During Pregnancy
Treatment tactics :
. Diet therapy;
. physical activity;
. learning and self-control;
. hypoglycemic drugs.
Non-drug treatment
diet therapy
In type 1 diabetes, an adequate diet is recommended: eating with enough carbohydrates to prevent "hungry" ketosis.
In GDM and type 2 diabetes, diet therapy is carried out with the complete exclusion of easily digestible carbohydrates and restriction of fats; uniform distribution of the daily volume of food for 4-6 receptions. Carbohydrates with a high content of dietary fiber should be no more than 38-45% of the daily caloric intake of food, proteins - 20-25% (1.3 g / kg), fats - up to 30%. For women with a normal BMI (18-25 kg/m2), a daily caloric intake of 30 kcal/kg is recommended; with excess (BMI 25-30 kg/m2) 25 kcal/kg; with obesity (BMI ≥30 kg / m2) - 12-15 kcal / kg.
Physical activity
For DM and GDM, dosed aerobic exercise is recommended in the form of walking for at least 150 minutes a week, swimming in the pool; self-monitoring is performed by the patient, the results are provided to the doctor. It is necessary to avoid exercises that can cause an increase in blood pressure and uterine hypertonicity.
. Patient education should provide patients with the knowledge and skills to help achieve specific therapeutic goals.
. Women who are planning a pregnancy, and pregnant women who have not been trained (primary cycle), or patients who have already been trained (for repeated cycles) are referred to the school of diabetes to maintain the level of knowledge and motivation or when new therapeutic goals appear, transfer to insulin therapy.
self control b includes the determination of glycemia using portable devices (glucometers) on an empty stomach, before and 1 hour after the main meals; ketonuria or ketonemia in the morning on an empty stomach; blood pressure; fetal movements; body weight; keeping a self-control diary and a food diary.
NMG system
Medical treatment
Treatment of pregnant women with diabetes
. If pregnancy occurs against the background of the use of metformin, glibenclamide, prolongation of pregnancy is possible. All other hypoglycemic drugs should be stopped until pregnancy and replaced with insulin.
Use only short-acting and intermediate-acting human insulin preparations, ultra-short-acting and long-acting insulin analogs permitted under Category B
Table 9 Insulin products approved for use in pregnant women (List B)
| Insulin preparation | Method of administration |
| Genetically engineered short-acting human insulins | Syringe, syringe pen, pump |
| Syringe, syringe pen, pump | |
| Syringe, syringe pen, pump | |
| Intermediate-acting human insulins | Syringe, syringe pen |
| Syringe, syringe pen | |
| Syringe, syringe pen | |
| Rapid acting insulin analogues | Syringe, syringe pen, pump |
| Syringe, syringe pen, pump | |
| Long-acting insulin analogues | Syringe, syringe pen |
During pregnancy, it is forbidden to use biosimilar insulin preparations that have not passed the full procedure for registration of medicines and pre-registration clinical trials in pregnant women.
All insulin preparations should be prescribed to pregnant women with the obligatory indication of the international non-proprietary name and trade name.
Insulin pumps with continuous glucose monitoring are the optimal means of administering insulin.
The daily requirement for insulin in the second half of pregnancy can increase dramatically, up to 2-3 times, in comparison with the initial requirement before pregnancy.
Folic acid 500 mcg per day up to the 12th week inclusive; potassium iodide 250 mcg per day throughout pregnancy - in the absence of contraindications.
Antibiotic therapy for detecting urinary tract infections (penicillins in the first trimester, penicillins or cephalosporins in the second or third trimesters).
Features of insulin therapy in pregnant women with type 1 diabetes
First 12 weeks in women with type 1 diabetes, due to the “hypoglycemic” effect of the fetus (i.e., due to the transfer of glucose from the mother’s bloodstream to the fetal bloodstream), they are accompanied by an “improvement” in the course of diabetes, the need for daily insulin use decreases, which can be manifested by hypoglycemic conditions with Somoji phenomenon and subsequent decompensation.
Women with diabetes on insulin therapy should be warned about the increased risk of hypoglycemia and its difficulty in recognizing during pregnancy, especially in the first trimester. Pregnant women with type 1 diabetes should be provided with glucagon supplies.
From 13 weeks hyperglycemia and glucosuria increase, the need for insulin increases (by an average of 30-100% of the pregestational level) and the risk of developing ketoacidosis, especially in the period of 28-30 weeks. This is due to the high hormonal activity of the placenta, which produces contra-insular agents such as chorionic somatomammatropin, progesterone, and estrogens.
Their excess leads to:
. insulin resistance;
. decrease in the sensitivity of the patient's body to exogenous insulin;
. an increase in the need for a daily dose of insulin;
. pronounced "dawn" syndrome with a maximum increase in glucose levels in the early morning hours.
With morning hyperglycemia, an increase in the evening dose of prolonged insulin is not desirable, due to the high risk of nocturnal hypoglycemia. Therefore, in these women with morning hyperglycemia, it is recommended to administer the morning dose of prolonged insulin and an additional dose of short / ultra-short-acting insulin or switching to insulin pump therapy.
Features of insulin therapy in the prevention of fetal respiratory distress syndrome: when prescribing dexamethasone 6 mg 2 times a day for 2 days, the dose of prolonged insulin is doubled for the period of dexamethasone administration. Glycemic control is prescribed at 06.00, before and after meals, at bedtime and at 03.00. to adjust the dose of short-acting insulin. Correction of water-salt metabolism is carried out.
After 37 weeks In pregnancy, the need for insulin may decrease again, which leads to an average decrease in the dose of insulin by 4-8 units / day. It is believed that the insulin-synthesizing activity of the β cellular apparatus of the pancreas of the fetus by this moment is so high that it provides a significant consumption of glucose from the mother's blood. With a sharp decrease in glycemia, it is desirable to strengthen control over the condition of the fetus due to the possible inhibition of the fetoplacental complex against the background of placental insufficiency.
In childbirth there are significant fluctuations in the level of glucose in the blood, hyperglycemia and acidosis may develop under the influence of emotional influences or hypoglycemia, as a result of the physical work done, the woman's fatigue.
After childbirth blood glucose drops rapidly (against the background of a drop in the level of placental hormones after birth). At the same time, the need for insulin for a short time (2-4 days) becomes less than before pregnancy. Then gradually blood glucose rises. By the 7-21st day of the postpartum period, it reaches the level observed before pregnancy.
Early toxicosis of pregnant women with ketoacidosis
Pregnant women need rehydration with saline solutions in the amount of 1.5-2.5 l / day, as well as orally 2-4 l / day with water without gas (slowly, in small sips). In the nutrition of a pregnant woman for the entire period of treatment, mashed food is recommended, mainly carbohydrate (cereals, juices, jelly), with additional salting, with the exception of visible fats. When glycemia is less than 14.0 mmol / l, insulin is administered against the background of 5% glucose solution.
Birth management
Planned hospitalization:
. the optimal term of delivery is 38-40 weeks;
. the optimal method of delivery is vaginal delivery with careful glycemic control during (hourly) and after childbirth.
Indications for caesarean section:
. obstetric indications for operative delivery (scheduled / emergency);
. the presence of severe or progressive complications of diabetes.
The term of delivery in pregnant women with diabetes is determined individually, taking into account the severity of the course of the disease, the degree of its compensation, the functional state of the fetus and the presence of obstetric complications.
When planning childbirth in patients with type 1 diabetes, it is necessary to assess the degree of fetal maturity, since delayed maturation of its functional systems is possible.
Pregnant women with DM and fetal macrosomia should be informed about the possible risks of complications from normal vaginal delivery, induction of labor and caesarean section.
With any form of fetopathy, unstable glucose levels, progression of late complications of diabetes, especially in pregnant women of the “high obstetric risk” group, it is necessary to resolve the issue of early delivery.
Insulin therapy during childbirth
For natural childbirth:
. glycemic levels must be maintained within 4.0-7.0 mmol/L. Continue infusion of extended insulin.
. When eating during childbirth, the introduction of short insulin should cover the amount of XE consumed (Appendix 5).
. Glycemic control every 2 hours.
. With glycemia less than 3.5 mmol / l, intravenous administration of a 5% glucose solution of 200 ml is indicated. With glycemia below 5.0 mmol / l, an additional 10 g of glucose (dissolve in the oral cavity). With glycemia more than 8.0-9.0 mmol / l intramuscular injection of 1 unit of simple insulin, at 10.0-12.0 mmol / l 2 units, at 13.0-15.0 mmol / l -3 units. , with glycemia more than 16.0 mmol / l - 4 units.
. With symptoms of dehydration, intravenous administration of saline;
. In pregnant women with type 2 diabetes with a low need for insulin (up to 14 units / day), insulin administration during labor is not required.
For operative childbirth:
. on the day of surgery, a morning dose of prolonged insulin is administered (with normoglycemia, the dose is reduced by 10-20%, with hyperglycemia, the dose of extended insulin is administered without correction, as well as an additional 1-4 units of short insulin).
. in the case of general anesthesia during childbirth in women with diabetes, regular monitoring of blood glucose levels (every 30 minutes) should be carried out from the moment of induction until the birth of the fetus and the woman's full recovery from general anesthesia.
. Further tactics of hypoglycemic therapy are similar to those for natural delivery.
. On the second day after the operation, with limited food intake, the dose of prolonged insulin is reduced by 50% (mainly administered in the morning) and short insulin 2-4 units before meals with glycemia more than 6.0 mmol/l.
Features of the management of childbirth in DM
. permanent cardiotographic control;
. thorough anesthesia.
Management of the postpartum period in diabetes
In women with type 1 diabetes after childbirth and with the onset of lactation, the dose of prolonged insulin can be reduced by 80-90%, the dose of short insulin usually does not exceed 2-4 units before meals in terms of glycemia (for a period of 1-3 days after birth). Gradually, within 1-3 weeks, the need for insulin increases and the dose of insulin reaches the pregestational level. That's why:
. adapt insulin doses, taking into account the rapid decrease in demand already on the first day after delivery from the moment the placenta is born (by 50% or more, returning to the original doses before pregnancy);
. recommend breastfeeding (warn about the possible development of hypoglycemia in the mother!);
. effective contraception for at least 1.5 years.
Benefits of insulin pump therapy in pregnant women with diabetes
. Women using CSII (insulin pump) are easier to reach target levels of HbAlc<6.0%.
. insulin pump therapy reduces the risk of hypoglycemia, especially in the first trimester of pregnancy, when the risk of hypoglycemia increases.
. in late pregnancy, when peaks in maternal blood glucose levels lead to fetal hyperinsulinemia, reducing glucose fluctuations in women using CSII reduces macrosomia and neonatal hypoglycemia.
. The use of CSII is effective in controlling blood glucose levels during delivery and reduces the incidence of neonatal hypoglycemia.
The combination of CSII and continuous glucose monitoring (CGM) achieves glycemic control throughout pregnancy and reduces the incidence of macrosomia (Appendix 3).
Requirements for CSII in pregnant women:
. start using CSII before conception to reduce the risk of spontaneous miscarriage and birth defects in the fetus;
. if pump therapy is started during pregnancy, reduce the total daily insulin dose to 85% of the total dose on syringe therapy, and in case of hypoglycemia, to 80% of the original dose.
. in the 1st trimester, the basal dose of insulin is 0.1-0.2 units / h, at a later date 0.3-0.6 units / h. Increase the ratio of insulin:carbohydrates by 50-100%.
. given the high risk of ketoacidosis in pregnant women, check for ketones in the urine if the blood glucose level exceeds 10 mmol/l and change infusion sets every 2 days.
. during delivery, continue using the pump. Set your temp basal rate to 50% of your maximum rate.
. When breastfeeding, reduce the basal rate by another 10-20%.
Medical treatment provided on an outpatient basis
Medical treatment provided at the inpatient level
List of Essential Medicines(100% chance of use)
. Short acting insulins
. Ultrashort-acting insulins (human insulin analogues)
. Intermediate-acting insulins
. Long-term, peakless insulin
. Sodium chloride 0.9%
List of additional medicines(less than 100% chance of application)
. Dextrose 10% (50%)
. Dextrose 40% (10%)
. Potassium chloride 7.5% (30%)
Drug treatment provided at the stage of emergency emergency care
. Sodium chloride 0.9%
. Dextrose 40%
Preventive actions(Annex 6)
. In persons with prediabetes, carry out annual monitoring of carbohydrate metabolism for early detection of diabetes;
. screening and treatment of modifiable risk factors for cardiovascular disease;
. to reduce the risk of developing GDM, conduct therapeutic measures among women with modifiable risk factors before pregnancy;
. all pregnant women, in order to prevent carbohydrate metabolism disorders during pregnancy, are advised to follow a balanced diet with the exception of foods with a high carbohydrate index, such as sugar-containing foods, juices, sweet carbonated drinks, foods with flavor enhancers, with the restriction of sweet fruits (raisins, apricots, dates , melon, bananas, persimmon).
Further management
Table 15 List of laboratory parameters requiring dynamic monitoring in patients with diabetes
| Laboratory indicators | Examination frequency |
| Self-monitoring of glycemia | At least 4 times daily |
| HbAlc | 1 time in 3 months |
| Biochemical blood test (total protein, bilirubin, AST, ALT, creatinine, calculation of GFR, electrolytes K, Na,) | 1 time per year (in the absence of changes) |
| General blood analysis | 1 time per year |
| General urine analysis | 1 time per year |
| Determination of albumin to creatinine ratio in urine | Once a year after 5 years from the moment of diagnosis of type 1 diabetes |
| Determination of ketone bodies in urine and blood | According to indications |
Table 16 List of instrumental examinations required for dynamic control in DM patients *
| Instrumental examinations | Examination frequency |
| Continuous Glucose Monitoring (CGM) | 1 time per quarter, according to indications - more often |
| BP control | Every visit to the doctor |
| Examination of the legs and evaluation of foot sensitivity | Every visit to the doctor |
| Neuromyography of the lower extremities | 1 time per year |
| ECG | 1 time per year |
| Checking equipment and examining injection sites | Every visit to the doctor |
| Chest X-ray | 1 time per year |
| Ultrasound of the vessels of the lower extremities and kidneys | 1 time per year |
| Ultrasound of the abdominal organs | 1 time per year |
*If there are signs of chronic complications of diabetes, the addition of concomitant diseases, the appearance of additional risk factors, the question of the frequency of examinations is decided individually.
. 6-12 weeks postpartum all women with GDM undergo OGTT with 75 g of glucose to reclassify the degree of carbohydrate metabolism disorder (Appendix 2);
It is necessary to inform pediatricians and GPs about the need to monitor the state of carbohydrate metabolism and prevent type 2 diabetes in a child whose mother has had GDM (Appendix 6).
Indicators of treatment efficacy and safety of diagnostic and treatment methods described in the protocol:
. achievement of the level of carbohydrate and lipid metabolism as close as possible to the normal state, normalization of blood pressure in a pregnant woman;
. development of motivation for self-control;
. prevention of specific complications of diabetes mellitus;
. absence of complications during pregnancy and childbirth, the birth of a live healthy full-term baby.
Table 17 Glycemic targets in patients with GDM
Hospitalization
Indications for hospitalization of patients with PSD *
Indications for emergency hospitalization:
- onset of diabetes during pregnancy;
- hyper/hypoglycemic precoma/coma
- ketoacidotic precoma and coma;
- progression of vascular complications of diabetes (retinopathy, nephropathy);
- infections, intoxications;
- accession of obstetric complications requiring emergency measures.
Indications for planned hospitalization*:
- All pregnant women are subject to hospitalization if they have diabetes.
- Women with pregestational diabetes are hospitalized routinely at the following gestational ages:
First hospitalization is carried out in the gestation period up to 12 weeks in a hospital of an endocrinological / therapeutic profile due to a decrease in the need for insulin and the risk of developing hypoglycemic conditions.
Purpose of hospitalization:
- addressing the issue of the possibility of prolonging pregnancy;
- detection and correction of metabolic and microcirculatory disorders of DM and concomitant extragenital pathology, training at the "School of Diabetes" (with prolongation of pregnancy).
Second hospitalization in the period of 24-28 weeks of pregnancy to the hospital of the endocrinological / therapeutic profile.
The purpose of hospitalization: correction and control of the dynamics of metabolic and microcirculatory disorders of DM.
Third hospitalization is carried out in the department of pathology of pregnant organizations of obstetrics of the 2nd-3rd level of regionalization of perinatal care:
- with type 1 and 2 diabetes in the period of 36-38 weeks of pregnancy;
- with GDM - in the period of 38-39 weeks of pregnancy.
The purpose of hospitalization is to assess the condition of the fetus, correct insulin therapy, choose the method and term of delivery.
*It is possible to manage pregnant women with DM in a satisfactory condition on an outpatient basis, if DM is compensated and all necessary examinations are performed
Information
Sources and literature
- Minutes of the meetings of the Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan, 2014
- 1. World Health Organization. Definition, Diagnosis, and Classification of Diabetes Mellitus and its Complicatios: Report of a WHO consultation. Part 1: Diagnosis and Classification of Diabetes Mellitus. Geneva, World Health Organization, 1999 (WHO/NCD/NCS/99.2). 2 American Diabetes Association. Standards of medical care in diabetes-2014. Diabetes Care, 2014; 37(1). 3. Algorithms of specialized medical care for patients with diabetes mellitus. Ed. I.I. Dedova, M.V. Shestakova. 6th edition. M., 2013. 4. World Health Organization. Use of Glycated Haemoglobin (HbAlc) in the Diagnosis of Diabetes Mellitus. Abbreviated Report of a WHO Consultation. World Health Organization, 2011 (WHO/NMH/CHP/CPM/11.1). 5. Russian national consensus "Gestational diabetes mellitus: diagnosis, treatment, postpartum care" / Dedov I.I., Krasnopolsky V.I., Sukhikh G.T. On behalf of the working group//Diabetes mellitus. - 2012. - No. 4. - P.4-10. 6. Nurbekova A.A. Diabetes mellitus (diagnosis, complications, treatment). Textbook - Almaty. - 2011. - 80 p. 7. Bazarbekova R.B., Zeltser M.E., Abubakirova Sh.S. Consensus on the diagnosis and treatment of diabetes mellitus. Almaty, 2011. 8. Selected issues of perinatology. Edited by Prof. R.J. Nadishauskienė. Publishing house Lithuania. 2012 652 p. 9. National Guideline "Obstetrics", edited by E.K. Ailamazyan, M., 2009. 10. NICE Protocol for Diabetes Mellitus During Pregnancy, 2008. 11. Insulin Pump Therapy and Continuous Glucose Monitoring. Edited by John Pickup. OXFORD, UNIVERSITY PRESS, 2009. 12.I. Blumer, E. Hadar, D. Hadden, L. Jovanovic, J. Mestman, M. HassMurad, Y. Yogev. Diabetes and Pregnancy: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab, November 2-13, 98(11):4227-4249.
Information
III. ORGANIZATIONAL ASPECTS OF PROTOCOL IMPLEMENTATION
List of protocol developers with qualification data:
1. Nurbekova A.A., Doctor of Medical Sciences, Professor of the Department of Endocrinology of KazNMU
2. Doshchanova A.M. - Doctor of Medical Sciences, Professor, Doctor of the Highest Category, Head of the Department of Obstetrics and Gynecology on internship at JSC "MUA";
3. Sadybekova G.T. - Candidate of Medical Sciences, Associate Professor, Endocrinologist of the highest category, Associate Professor of the Department of Internal Diseases for Internship at JSC "MUA".
4. Akhmadyar N.S., Doctor of Medical Sciences, Senior Clinical Pharmacologist of JSC NSCMD
Indication of no conflict of interest: no.
Reviewers:
Kosenko Tatyana Frantsevna, Candidate of Medical Sciences, Associate Professor of the Department of Endocrinology, AGIUV
Indication of the conditions for revising the protocol: revision of the protocol after 3 years and / or when new diagnostic / treatment methods with a higher level of evidence appear.
Attachment 1
In pregnant women, the diagnosis of diabetes is based on laboratory determinations of venous plasma glucose levels only.
Interpretation of test results is carried out by obstetrician-gynecologists, therapists, general practitioners. A special consultation with an endocrinologist to establish the fact of a violation of carbohydrate metabolism during pregnancy is not required.
Diagnosis of disorders of carbohydrate metabolism during pregnancy carried out in 2 phases.
1 PHASE. At the first visit of a pregnant woman to a doctor of any specialty for up to 24 weeks, one of the following studies is mandatory:
- Glucose of venous plasma on an empty stomach (determination of glucose of venous plasma is carried out after preliminary fasting for at least 8 hours and not more than 14 hours);
- HbA1c using a method of determination certified in accordance with the National Glycohemoglobin Standardization Program (NGSP) and standardized in accordance with the reference values adopted in the DCCT (Diabetes Control and Complications Study);
- venous plasma glucose at any time of the day, regardless of food intake.
table 2 Threshold values of venous plasma glucose for the diagnosis of overt (newly detected) DM during pregnancy
1 If abnormal values are obtained for the first time and there are no symptoms of hyperglycemia, then the provisional diagnosis of overt diabetes during pregnancy should be confirmed by fasting venous plasma glucose or HbA1c using standardized tests. In the presence of symptoms of hyperglycemia, a single determination in the diabetic range (glycemia or HbA1c) is sufficient to establish the diagnosis of diabetes. If overt DM is detected, it should be qualified as soon as possible into any diagnostic category according to the current WHO classification, for example, type 1 DM, type 2 DM, etc.
2 HbA1c using a method certified by the National Glycohemoglobin Standardization Program (NGSP) and standardized according to the DCCT (Diabetes Control and Complications Study) reference values.
In the event that the result of the study corresponds to the category of manifest (first detected) DM, its type is specified and the patient is immediately transferred for further management to an endocrinologist.
If the HbA1c level<6,5% или случайно определенный уровень глюкозы плазмы <11,1 ммоль/л (в любое время суток), то проводится определение глюкозы венозной плазмы натощак: при уровне глюкозы венозной плазмы натощак ≥5,1 ммоль/л, но <7,0 ммоль/л устанавливается диагноз ГСД.
Table 3
1 Only the level of glucose in venous plasma is examined. The use of capillary whole blood samples is not recommended.
2 At any stage of pregnancy (one abnormal measurement of venous plasma glucose is sufficient).
When first contacting pregnant women with BMI ≥25 kg/m2 and having the following risk factors held PGGT for the detection of latent type 2 diabetes(table 2):
. sedentary lifestyle
. 1st-line relatives with diabetes
. women with a history of large fetuses (more than 4000g), stillbirth, or established gestational diabetes
. hypertension (≥140/90 mmHg or on antihypertensive therapy)
. HDL 0.9 mmol/L (or 35 mg/dL) and/or triglycerides 2.82 mmol/L (250 mg/dL)
. the presence of HbAlc ≥ 5.7%, preceding impaired glucose tolerance or impaired fasting glycemia
. history of cardiovascular disease
. other clinical conditions associated with insulin resistance (including severe obesity, acanthosis nigricans)
. polycystic ovary syndrome
PHASE 2- is carried out at the 24-28th week of pregnancy.
To all women who did not have DM in early pregnancy, OGTT with 75 g of glucose is performed to diagnose GDM (Appendix 2).
Table 4 Threshold values of venous plasma glucose for the diagnosis of GDM
1 Only the level of glucose in venous plasma is examined. The use of capillary whole blood samples is not recommended.
2 At any stage of pregnancy (one abnormal measurement of venous plasma glucose is sufficient).
3 According to the results of OGTT with 75 g of glucose, at least one of the three venous plasma glucose values that would be equal to or above the threshold is sufficient to establish the diagnosis of GDM. If abnormal values are obtained in the initial measurement, glucose loading is not carried out; when receiving abnormal values at the second point, the third measurement is not required.
Fasting glucose, random meter blood glucose, and urine glucose (urine litmus test) are not recommended tests for diagnosing GDM.
Appendix 2
Rules for conducting OGTT
PGTT with 75g of glucose is a safe exercise diagnostic test for the detection of carbohydrate metabolism disorders during pregnancy.
Interpretation of OGTT results can be carried out by a doctor of any specialty: obstetrician, gynecologist, internist, general practitioner, endocrinologist.
The test is performed on a normal diet (at least 150 g of carbohydrates per day) for at least 3 days prior to the study. The test is performed in the morning on an empty stomach after an 8-14-hour overnight fast. The last meal must necessarily contain 30-50 g of carbohydrates. Drinking water is not prohibited. The patient must be seated during the test. Smoking is prohibited until the end of the test. Drugs that affect blood glucose levels (multivitamins and iron preparations containing carbohydrates, glucocorticoids, β-blockers, β-agonists), if possible, should be taken after the end of the test.
PGTT is not carried out:
- with early toxicosis of pregnant women (vomiting, nausea);
- if it is necessary to comply with strict bed rest (the test is not carried out until the expansion of the motor regimen);
- against the background of an acute inflammatory or infectious disease;
- with exacerbation of chronic pancreatitis or the presence of dumping syndrome (syndrome of the resected stomach).
Determination of venous plasma glucose performed only in the laboratory on biochemical analyzers or on glucose analyzers.
The use of portable self-monitoring devices (glucometers) for testing is prohibited.
Blood sampling is carried out in a cold tube (preferably vacuum) containing preservatives: sodium fluoride (6 mg per 1 ml of whole blood) as an enolase inhibitor to prevent spontaneous glycolysis, as well as EDTA or sodium citrate as anticoagulants. The test tube is placed in water with ice. Then immediately (no later than the next 30 minutes) the blood is centrifuged to separate plasma and formed elements. The plasma is transferred to another plastic tube. In this biological fluid, the glucose level is determined.
Test execution steps
1st stage. After taking the first fasting venous blood plasma sample, the glucose level is measured immediately, because. upon receipt of results indicating overt (newly diagnosed) DM or GDM, no further glucose loading is performed and the test is terminated. If it is impossible to quickly determine the level of glucose, the test continues and is brought to an end.
2nd stage. When continuing the test, the patient should drink a glucose solution within 5 minutes, consisting of 75 g of dry (anhydrite or anhydrous) glucose dissolved in 250-300 ml of warm (37-40 ° C) non-carbonated (or distilled) drinking water. If glucose monohydrate is used, 82.5 g of the substance is needed to perform the test. The start of taking a glucose solution is considered the beginning of the test.
3rd stage. The next blood samples to determine the level of venous plasma glucose are taken 1 and 2 hours after the glucose load. If results are obtained indicating GDM after the 2nd blood draw, the test is terminated.
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
| Gestational age | Management plan for a pregnant woman with diabetes |
| First consultation (together with an endocrinologist and an obstetrician-gynecologist) |
- Providing information and advice on optimizing glycemic control - Collection of a complete medical history to determine the complications of diabetes - Evaluation of all medications taken and their side effects - Passing an examination of the state of the retina and kidney function in case of a history of their violation |
| 7-9 weeks | Confirmation of pregnancy and gestational age |
| Full antenatal registration | Providing comprehensive information on diabetes during pregnancy and its impact on pregnancy, delivery and the early postpartum period and motherhood (breastfeeding and initial child care) |
| 16 weeks | Retinal examinations at 16-20 weeks in women with pregestational diabetes in case of detection of dibetic retinopathy during the first consultation of an ophthalmologist |
| 20 weeks | Ultrasound of the fetal heart in a four-chamber view and vascular cardiac outflow at 18-20 weeks |
| 28 weeks |
Ultrasound of the fetus to assess its growth and volume of amniotic fluid. Retinal examinations in women with pregestational DM in the absence of signs of dibetic retinopathy at the first consultation |
| 32 weeks | Ultrasound of the fetus to assess its growth and amniotic fluid volume |
| 36 weeks |
Ultrasound of the fetus to assess its growth and amniotic fluid volume Decision about: - timing and method of delivery - anesthesia during childbirth - correction of insulin therapy during childbirth and lactation - postpartum care - breastfeeding and its effect on glycemia - contraception and repeated postpartum 25 examination |
Conception is not recommended :
- HbA1c level >7%;
- severe nephropathy with serum creatinine >120 µmol/l, GFR<60 мл/мин/1,73 м2 суточной протеинурии ≥3,0 г, неконтролируемой артериальной гипертензией;
- proliferative retinopathy and maculopathy before laser coagulation of the retina;
- the presence of acute and exacerbation of chronic infectious and inflammatory diseases (tuberculosis, pyelonephritis, etc.)
Pregnancy planning
When planning pregnancy, women with diabetes are encouraged to achieve target levels of glycemic control without the presence of hypoglycemia.
With diabetes, pregnancy should be planned:
. an effective method of contraception should be used until proper examination and preparation for pregnancy has been carried out:
. education in the “diabetes school”;
. informing the patient with diabetes about the possible risk to the mother and fetus;
. achieving ideal compensation 3-4 months before conception:
- plasma glucose on an empty stomach / before meals - up to 6.1 mmol / l;
- plasma glucose 2 hours after eating - up to 7.8 mmol / l;
- HbA ≤ 6.0%;
. control of blood pressure (no more than 130/80 mm Hg. Art.), with hypertension - antihypertensive therapy (cancellation of ACE inhibitors before stopping the use of contraception);
. determination of the level of TSH and free T4 + AT to TPO in patients with type 1 diabetes (increased risk of thyroid disease);
. folic acid 500 mcg per day; potassium iodide 150 mcg per day - in the absence of contraindications;
. treatment of retinopathy;
. treatment of nephropathy;
. to give up smoking.
CONTRAINDICATED during pregnancy:
. any tableted hypoglycemic drugs;
. ACE inhibitors and ARBs;
. ganglioblockers;
. antibiotics (aminoglycosides, tetracyclines, macrolides, etc.);
. statins.
Antihypertensive therapy during pregnancy:
. The drug of choice is methyldopa.
. With insufficient effectiveness of methyldopa, the following can be prescribed:
- calcium channel blockers;
- β1-selective blockers.
. Diuretics - for health reasons (oliguria, pulmonary edema, heart failure).
Annex 5
Replacement of products according to the XE system
1 XE - the amount of the product containing 15 g of carbohydrates
| Milk and Liquid Dairy Products | ||
| Milk | 250 ml | 1 glass |
| Kefir | 250 ml | 1 glass |
| Cream | 250 ml | 1 glass |
| Kumys | 250 ml | 1 glass |
| Shubat | 125 ml | ½ cup |
| Bread and bakery products | ||
| White bread | 25 g | 1 piece |
| Black bread | 30 g | 1 piece |
| crackers | 15 g | - |
| Breadcrumbs | 15 g | 1 st. a spoon |
| Pasta | ||
|
Vermicelli, noodles, horns, pasta, juicy |
2-4 st. spoons depending on the shape of the product | |
| Cereals, flour | ||
| Any cereal in boiled form | 2 tbsp with a slide | |
| Semolina | 2 tbsp | |
| Flour | 1 tbsp | |
| Potato, corn | ||
| Corn | 100 g | ½ cob |
| raw potatoes | 270 g||
A pregnant woman is sometimes diagnosed with gestational diabetes, which backfires on the baby. The disease occurs even in people with excellent health who have not previously experienced problems with high blood glucose. It is worth learning more about the signs of diseases, provoking factors and risks to the fetus. Treatment is prescribed by a doctor, and its results are carefully monitored until delivery.
What is gestational diabetes
Otherwise, diabetes mellitus in pregnancy is called gestational diabetes (GDM). It occurs during gestation, it is considered "prediabetes". This is not a full-fledged disease, but only a predisposition to intolerance to simple sugars. Gestational diabetes in pregnancy is considered to be an indicator of the risk of presenting type 2 disease. The disease may disappear after the birth of the baby, but sometimes it develops further. To prevent it, prescribe treatment and a thorough examination of the body.
The cause of the development of the disease is considered to be a weak reaction of the body to its own insulin produced by the pancreas. Violation appears due to a failure of the hormonal background. The risk factors for gestational diabetes are:
- overweight, metabolic disorders, pre-obesity;
- hereditary predisposition to general diabetes mellitus in the population;
- age after 25 years;
- previous births ended with the birth of a child from 4 kg in weight, with broad shoulders;
- had a history of GDM;
- chronic miscarriage;
- polyhydramnios, stillbirth.
Impact on pregnancy
The impact of diabetes on pregnancy is considered negative. A woman suffering from the disease is at risk of spontaneous abortion, late gestational toxicosis, infection of the fetus and polyhydramnios. GDM during pregnancy can affect the health of the mother in the following ways:
- development of hypoglycemic deficiency, ketoacidosis, preeclampsia;
- complication of vascular diseases - nephro-, neuro- and retinopathy, ischemia;
- after childbirth, in some cases, a full-fledged disease appears.
What is the danger of gestational diabetes for a child
No less dangerous are the consequences of gestational diabetes for the child. With an increase in sugars in the maternal blood, the growth of the child is observed. This phenomenon, coupled with excess weight is called macrosomia, occurs in the third trimester of pregnancy. The size of the head and brain remains normal, and large shoulders can cause problems with the natural passage through the birth canal. Violation of growth leads to early childbirth, trauma to the female organs and the child.
In addition to macrosomia, leading to immaturity of the fetus and even death, GDM has the following consequences for the child:
- congenital malformations of the body;
- complications in the first weeks of life;
- risk of first degree diabetes;
- morbid obesity;
- respiratory failure.
Sugar levels for gestational diabetes in pregnant women
Knowing the norms of sugar in gestational diabetes in pregnant women can help prevent the development of a dangerous disease. Doctors recommend that women at risk constantly monitor the concentration of glucose - before eating, after an hour after. Optimal concentration:
- on an empty stomach and at night - at least 5.1 mmol / liter;
- after an hour after eating - no more than 7 mmol / l;
- the percentage of glycated hemoglobin is up to 6.
Signs of diabetes in pregnancy
Gynecologists identify the following initial signs of diabetes in pregnant women:
- weight gain;
- frequent volumetric urination, the smell of acetone;
- strong thirst;
- fast fatiguability;
- lack of appetite.
If diabetes mellitus in pregnant women is not controlled, then the disease can cause complications with a negative prognosis:
- hyperglycemia - sharp jumps in sugars;
- confusion, fainting;
- high blood pressure, heart pain, stroke;
- kidney damage, ketonuria;
- decreased functionality of the retina;
- slow wound healing;
- tissue infections;
- leg numbness, loss of sensation.
Diagnosis of gestational diabetes
Having identified risk factors or symptoms of the disease, doctors conduct a prompt diagnosis of gestational diabetes. Blood is donated on an empty stomach. Optimal sugar levels range from:
- from a finger - 4.8-6 mmol / l;
- from a vein - 5.3-6.9 mmol / l.
Analysis for diabetes during pregnancy
When the previous indicators do not fit into the norm, a glucose tolerance test is performed for diabetes mellitus during pregnancy. The test includes two measurements and needs to follow the rules for examining the patient:
- three days before the analysis, do not change the diet, stick to normal physical activity;
- the night before the test, it is not recommended to eat anything, the analysis is done on an empty stomach;
- blood is taken;
- within five minutes the patient takes a solution of glucose and water;
- Two hours later, another blood sample is taken.
The diagnosis of manifest (manifested) GDM is made according to the established criteria for the concentration of glucose in the blood according to three laboratory samples:
- from a finger on an empty stomach - from 6.1 mmol / l;
- from a vein on an empty stomach - from 7 mmol / l;
- after taking a glucose solution - over 7.8 mmol / l.
Having determined that the indicators are normal or low, doctors prescribe the test again in the period of 24-28 weeks, because then the level of hormones increases. If the analysis is carried out earlier, GDM may not be detected, and later, complications in the fetus can no longer be prevented. Some doctors conduct a study with different amounts of glucose - 50, 75 and 100 g. Ideally, a glucose tolerance analysis should be done even when planning conception.
Treatment of gestational diabetes in pregnant women
When laboratory tests show GDM, treatment for diabetes mellitus during pregnancy is prescribed. The therapy is:
- proper nutrition, dosing of carbohydrate foods, increasing proteins in the diet;
- normal physical activity, it is recommended to increase it;
- constant glycemic control of blood sugars, ketone breakdown products in the urine, pressure;
- with chronic elevated sugar concentration, insulin therapy is prescribed in the form of injections, in addition to it, other drugs are not prescribed, because sugar-lowering pills negatively affect the development of the child
At what sugar is insulin prescribed during pregnancy
If gestational diabetes during pregnancy is prolonged, and sugar does not decrease, insulin therapy is prescribed to prevent the development of fetopathy. Insulin is also taken with normal sugar readings, but with the detection of excessive fetal growth, swelling of its soft tissues and polyhydramnios. Injections of the drug are prescribed at night and on an empty stomach. Find out the exact schedule of admission from the endocrinologist after consultation.
Diet for gestational diabetes in pregnancy
One of the points of treatment for the disease is a diet for gestational diabetes, which helps to maintain normal sugar. There are rules on how to reduce sugar during pregnancy:
- exclude sausages, smoked meats, fatty meat from the menu, give preference to lean poultry, beef, fish;
- culinary processing of food should include baking, boiling, using steam;
- eat dairy products with a minimum percentage of fat, give up butter, margarine, fatty sauces, nuts and seeds;
- without restrictions it is allowed to eat vegetables, herbs, mushrooms;
- eat often, but little, every three hours;
- daily calorie content should not exceed 1800 kcal.
