How Is Diabetes in Pregnancy Treated?

Patients who have had diabetes before pregnancy are pregnant and are called diabetes with pregnancy; the other is normal glucose metabolism or impaired glucose tolerance before pregnancy. Diabetes only occurs during pregnancy, also known as gestational diabetes (GDM). More than 80% of diabetic pregnant women are GDM, and less than 20% of diabetic pregnant women. Most of GDM patients' glucose metabolism can return to normal after delivery, but the chance of developing type 2 diabetes will increase in the future. The clinical course of diabetic pregnant women is complicated. It has great harm to the mother and child and must be paid attention to.

Basic Information

English name

gestational diabetes mellitus, GDM

Visiting department

Department of Endocrinology, Obstetrics and Gynecology

Common causes

Caused by a corresponding increase in insulin demand during pregnancy

Common symptoms

Polydipsia and polyuria during pregnancy, or candida vulva infection

Contagious

no

Gestational Diabetes Impact

1. The impact of pregnancy on diabetes

Pregnancy can make recessive diabetes explicit, make GDM occur in pregnant women without diabetes, and make the original diabetic patients worse. In early pregnancy, fasting blood glucose is low. If insulin treatment is not used to adjust the insulin dosage in time, some patients may have hypoglycemia.

2. The impact of diabetes on pregnancy

The effect and degree of pregnancy and diabetes on mothers and children depends on the condition of diabetes and blood glucose control. Those with a severe condition or poor blood glucose control have a great impact on the mother and child, and the near-term and long-term complications of the mother and child are still high.

3. Impact on pregnant women

(1) Hyperglycemia can cause abnormal embryo development and even death, and the incidence of miscarriage can reach 15% to 30%.

(2) The possibility of developing hypertension during pregnancy is 2 to 4 times higher than that of non-diabetic pregnant women. GDM complicated with hypertension in pregnancy may be related to the existence of severe insulin resistance and hyperinsulinemia.

(3) Infection is a major complication of diabetes. Pregnant women who fail to control their blood sugar are prone to infection. Infection can aggravate diabetes metabolic disorders and even induce acute complications such as ketoacidosis.

(4) The incidence of polyhydramnios is 10 times higher than that of non-diabetic pregnant women. The reason may be related to increased fetal urine excretion caused by fetal hyperglycemia and hypertonic diuresis.

(5) Due to the significant increase in the incidence of gigantic children, the incidence of dystocia, birth canal injury, and surgical births increased.

(6) Prone to diabetic ketoacidosis. Due to the complicated metabolic changes during pregnancy. In addition to the high or low blood sugar and the relative or absolute lack of insulin, the metabolic disorder has further developed to accelerate the decomposition of fat, the serum ketone body has increased sharply, and further developed into metabolic acidosis.

(7) When GDM pregnant women get pregnant again, the recurrence rate is as high as 33% to 69%. Long-term risk of developing diabetes increases, and 17% to 63% will develop type 2 diabetes.

4. Impact on the fetus

(1) The incidence of huge fetuses is as high as 25% to 42%. The reason is that pregnant women have high blood sugar, and the fetus has been in a hyperinsulinemia environment caused by maternal hyperglycemia for a long time. Promote protein and fat synthesis and inhibit lipolysis, leading to excessive trunk development.

(2) The incidence of fetal growth restriction (FGR) is 21%. Hyperglycemia in early pregnancy has the effect of inhibiting embryonic development, leading to embryonic development in early pregnancy.

(3) Prone to miscarriage and premature birth. The incidence of preterm birth is 10% to 25%.

(4) The fetal malformation rate is higher than that of non-diabetic pregnant women. The serious malformation rate is 7 to 10 times that of normal pregnancy. It is closely related to the high blood sugar level in the first few weeks after conception and is an important cause of perinatal death.

5. Impact on newborns

(1) The incidence of neonatal respiratory distress syndrome increases.

(2) Hypoglycemia of newborns After the newborns leave the mother's hyperglycemia environment, hyperinsulinemia still exists. If sugar is not added in time, hypoglycemia is prone to occur and endangers the life of the newborn in severe cases.

Clinical manifestations of gestational diabetes

During pregnancy, there are symptoms of polydipsia, polydipsia, polyuria, or repeated episodes of vulvovaginal candida infection. The weight of the pregnant woman is> 90kg. The pregnancy is complicated by polyhydramnios or a huge fetus.

Gestational diabetes examination

Urine glucose measurement

Those who are positive for urine glucose should not only consider physiological diabetes during pregnancy, but should further do fasting blood glucose test and sugar screening test.

2. Fasting blood glucose measurement

Two or more times of fasting blood glucose 5.1mmol / L can be diagnosed as diabetes.

3. Sugar screening test

It is recommended that GDM screening be performed at 24 to 28 weeks of pregnancy. 50 g of glucose powder is dissolved in 200 ml of water and taken within 5 minutes. After 1 hour, blood glucose level 7.8mmol / L is positive for sugar screening. Fasting blood glucose should be checked. Diabetes can be diagnosed, and those with normal fasting blood glucose should undergo glucose tolerance test (OGTT).

4.OGTT

Most use 75g sugar tolerance test. Means that after 12 hours of fasting, 75 g of glucose is orally administered. The normal upper limits are: 5.6 mmol / L on an empty stomach, 10.3 mmol / L for 1 hour, 8.6 mmo1 / L for 2 hours, and 6.7 mmol / L for 3 hours. Two or more of them reach or exceed normal values and can be diagnosed as gestational diabetes. Only one item was higher than normal, and abnormal glucose tolerance was diagnosed.

Gestational diabetes diagnosis

Family history of diabetes, age> 30 years, obesity, history of birth of giant children, history of unexplained recurrent abortion, stillbirth, stillbirth, birth history of term neonatal respiratory distress syndrome, birth history, etc.

Gestational diabetes stage

Staging (white classification) based on the age, course of the patient's diabetes, and the presence of vascular complications can help determine the severity and prognosis of the disease:

Grade A: After a controlled diet, fasting blood glucose is <5.8mmol / L, and 2 hours after a meal, blood glucose is <6.7mmol / L.

Grade B: Dominant diabetes, onset after 20 years of age, duration <10 years.

Grade C: The age of onset is 10-19 years, or the course of disease is 10-19 years.

Grade D: Onset before the age of 10, or duration of 20 years, or complicated with simple retinopathy.

Level F: diabetic. Kidney disease.

Grade R: Hypertrophic retinopathy or vitreous hemorrhage.

Grade H: Coronary atherosclerotic heart disease.

Grade T: History of kidney transplantation.

Gestational diabetes treatment

1. Conditions for pregnancy in diabetic patients

(1) Diabetics should determine the severity of diabetes before pregnancy. Once D, F, R diabetes is pregnant, the risk to the mother and child is greater, it is not suitable for pregnancy.

(2) Those with mild organic disease and good blood glucose control can be pregnant under active treatment and close monitoring.

(3) Strictly control blood glucose from the pre-pregnancy period with the assistance of a physician.

2. Treatment of pregnant women with abnormal glucose metabolism

(1) Satisfactory standard of blood glucose control during pregnancy. Pregnant women have no obvious hunger, fasting blood glucose is controlled at 3.3 5.6mmol / L; 30 minutes before meal: 3.3 5.8mmo1 / L; 2 hours after meal: 4.4 6.7mmol / L; At night: 4.4 to 6.7 mmol / L.

(2) Diet therapy Diet control is important. The ideal diet control goal: to ensure and provide calories and nutritional requirements during pregnancy, and to avoid the occurrence of postprandial hyperglycemia or hunger ketones, and ensure normal fetal growth and development.

(3) Drug therapy Insulin is the main treatment for diabetes that cannot be controlled by diet.

(4) Treatment of gestational diabetic ketoacidosis While monitoring blood gas, blood glucose, electrolytes and giving corresponding treatment, it is advisable to use a small dose of regular insulin O.1U / (kg · h) intravenous drip. Monitor blood glucose every 1 to 2 hours. For blood glucose> 13.9mmol / L, insulin should be added intravenously to 0.9% sodium chloride injection. For blood glucose 13.9mmo1 / L, insulin should be added to 5% glucose sodium chloride injection for intravenous infusion. Subcutaneous injection instead.

3. Maternal and child care during pregnancy

Check once a week until the 10th week of pregnancy. The second trimester of pregnancy should be checked every two weeks. Generally, insulin requirements begin to increase at 20 weeks of pregnancy and need to be adjusted in time. Renal function and glycated hemoglobin content were measured monthly, and fundus examination was performed at the same time. It should be checked weekly after 32 weeks of pregnancy. Pay attention to blood pressure, edema, and urine protein. Pay attention to the monitoring of fetal development, fetal maturity, fetal placental function, etc., and early hospitalization if necessary.

4. Timing of childbirth

The principle is to try to delay the termination of pregnancy. Glucose control is good, no complications in the third trimester, and the fetal condition is good. Wait until the pregnancy is 38 to 39 weeks to terminate the pregnancy. Unsatisfactory blood glucose control, with vascular disease, combined with severe preeclampsia, severe infection, fetal growth restriction, fetal distress, early amniotic fluid should be drawn and dexamethasone injection promotes fetal lung maturity, and pregnancy should be terminated immediately .

5. Delivery method

Pregnant women with diabetes, who have a large fetus, placental dysfunction, abnormal fetal position, or other obstetric indications should undergo cesarean section. For pregnant women with a course of diabetes> 10 years, with retinopathy and renal impairment, severe preeclampsia, and stillbirth history, the indications for cesarean section should be relaxed.

6. Management during delivery

(1) Closely observe the changes of blood sugar, urine glucose and ketone body, adjust insulin dosage in time, and strengthen fetal monitoring.

(2) Vaginal delivery, emotional tension and pain during labor can make blood sugar fluctuate. The amount of insulin is not easy to grasp, and strict control of the blood glucose level at birth is very important for both mothers and children. A diabetic diet is still used after labor. Subcutaneous injection of regular insulin should generally be discontinued during the delivery process. Intravenous infusion of 0.9% sodium chloride injection plus regular insulin should be used, and the intravenous infusion rate should be adjusted based on the blood glucose measured during the delivery process. Delivery should end within 12 hours, and the length of the labor increases the risk of ketoacidosis, fetal hypoxia, and infection.

(3) For cesarean section, the application of protamine zinc insulin before dinner is stopped on the day before surgery, and the subcutaneous injection of insulin is stopped on the surgery day. Generally, blood glucose, urine sugar and ketone body are monitored in the morning. According to his fasting blood glucose level and daily insulin dosage, he switched to a small-dose continuous insulin drip. Blood glucose was measured every 2 to 4 hours after the operation until the diet recovered.

(4) Postpartum treatment, after placental discharge during puerperium. Anti-insulin substances in the body decrease rapidly. Most GDM patients no longer need insulin after delivery, and only a few patients still need insulin treatment.

(5) Treatment at birth. The blood glucose, insulin, bilirubin, hematocrit, hemoglobin, calcium, phosphorus, and magnesium should be measured at birth. In particular, those who are not satisfied with the control of blood glucose during pregnancy need to be monitored to prevent hypoglycemia in the newborn. Glucose should be taken regularly at the same time as breastfeeding.