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Diabetes mellitus is generally a serious diagnosis and is of particular importance in pregnancy as it affects both the mother’s body and the developing fetus.
From 0,2 – 0,3% of all complicated pregnancies are diabetes before pregnancy, and 1 – 6% – diabetes that occurs for the first time during pregnancy.
Classification of diabetes in pregnancy:
- GDM – gestational diabetes
- GDM 1 – impaired glucose tolerance with normoglycemia during diet
- GDM 2 – fasting hyperglycemia – for insulin
Diabetes diagnosed before pregnancy is divided into classes from A to T. We will not describe this classification in detail here, but for information purposes it divides patients into groups depending on the duration of the disease, age at which it appeared and the organ consequences it causes.
Carbohydrate metabolism in pregnancy
In healthy pregnant women, fasting glucose (serum sugar) is lower and amounts to about 60 – 80 mg% (3,3 – 4,3 mmol / l), its increase after a meal is greater in pregnant women. In pregnant women there is an increased secretion of spontaneous insulin and after a meal, and the transfer of glucose to the fetus depends on the level of glucose in the mother’s blood and on the needs of the placenta itself.
The deficiency of insulin produced by the pancreas results in hyperglycemia, glycosuria, ketonaemia, fatigue and dehydration. Additional factors that act as an anti-insulin appear during pregnancy: placental lactogen, estrogens and progesterone, prolactin, and placental insulinases. The amount of insulin decreases and thus the serum glucose level increases.
In the first trimester, there is an improvement in carbohydrate tolerance and a reduction in insulin requirements (the fetus takes in glucose and amino acids). In the second and third trimesters, carbohydrate metabolism deteriorates, and therefore the insulin requirement increases by 50 – 70%. Before delivery, the need for insulin may decrease as the fetus produces its own insulin. After delivery, the need for insulin decreases by approximately 30-50%.
Transport of glucose across the placenta is facilitated by facilitated diffusion – the higher the concentration of glucose in the mother’s serum, the more it passes through the placenta to the fetus.
Diabetes complications in pregnancy
The most common complications of diabetes in pregnancy are: miscarriage (in 10%), hypertension and pre-eclampsia, urinary tract infections, preterm labor and polyhydramnios. The increase in female mortality from this increases by about 1% (due to acidosis, pre-eclampsia or perinatal complications).
Also check out: What Happens at Week 39 of Pregnancy?
Complication may also be deaths perinatal newborns due to large birth defects (defects of the heart, nervous system, bone-joint-muscular system, kidneys and gastrointestinal tract). This applies to mothers with diabetes before pregnancy. Additionally, macrosomia (large fetus) or IUGR (inhibition of intrauterine growth of the fetus), prematurity, intrauterine deaths may occur. Fetal macrosomia is a body weight above the 90th percentile in relation to the gestational age, or a weight> 4000 – 4500 g. It results from hyperglycemia in a pregnant woman above 110 – 130 mg%.
As a consequence, it leads to intrauterine hypoxia, shoulder dystocia (a birth complication consisting in the inability to give birth to the shoulders of the fetus, and as a consequence, it may lead to rupture or paralysis of the shoulder plexus, which ends with paresis of the child’s upper limb), perinatal injury, obesity, glucose intolerance in the child. Intrauterine hypoxia is associated with changes in placental flow: vascular changes, metabolic acidosis with hypovolaemia (drop in blood pressure) and dehydration, preeclampsia and vasospasm.
That is why prophylaxis and sugar level testing are so important. It is important to control diabetes during the fertilization period (glycosylated Hb level <5%), using folic acid.
Management of women with diabetes
1.Before pregnancy, the following are necessary: insulin therapy and glycemic control (3-6 mmol / l, daily mean 10 mmol / l, HbA7C <2%), assessment of vascular complications in diabetes, thyroid parameters, folate supplementation - preparation for pregnancy takes about 1 months.
2nd trimester of pregnancy – visits every 1 week. Assessment of HbA1c, glycemia, acetone in urine, ultrasound.
3. II trimester of pregnancy – visits every 2 weeks, insulin therapy, glycemia, checking BMI and diet modification, ophthalmological tests, HbA1c and assessment of kidney function once a month, ultrasound examination for defects.
4.III trimester of pregnancy – visits every 1 week. Performing ultrasound examination – growth and AFI, fetal condition from 34 weeks. Biophysical profile, NST, KTG should be performed every 2 weeks. Insulin therapy.
Maternal acidosis causes fetal acidosis and intrauterine death in 50% of diabetic coma.
Childbirth in a woman with diabetes.
A woman with diabetes should never give birth after the 40th week of pregnancy. Early termination of pregnancy is recommended. The fetus is at risk in tests, by abnormal flows in ultrasound, lack of fetal movement for 12 hours, a sharp reduction in insulin requirements. Increased RR, acetonuria, and hyperglycemia despite intensive treatment are indications for immediate termination of pregnancy.
Vaginal delivery can take place if the weight of the fetus is below 4500 g, there are no additional complications in pregnancy, and glycemia control occurs every 1-2 hours. The condition is also that the pelvis and neck are correct. Maintaining blood glucose levels must be at the level of 70 – 90 mg%.
On the day of delivery, the following are performed:
-glycemia measurements, infusion of 5% glucose with short-acting insulin in the pump 0,25 – 2 units / hour. Blood glucose measurements are performed every hour and the dose is adjusted if necessary.
Diabetes compensation criteria:
– fasting blood glucose 3,3 – 5,0 mmol / l.
– an hour after a meal 3,9 – 7,8 mmol / l
– 2 hours after a meal 3,3 – 6,7 mmOI / l
– between 2-4.00 a.m.> 3,3 mmol / l
-HbA1c <6,5%, w okresie koncepcji <5,6 mmol/l
METABOLIC ACID
There is a much higher risk of its occurrence during pregnancy.
The causes of metabolic acidosis may include: infections, failure to take insulin, smoking, use of glucocorticosteroids and beta-agonists (these are drugs whose use is aimed at relaxing the uterine muscle in the event of preterm labor).
Other causes include hyperglycemia, osmotic diuresis, decrease in body fluid volume (4-10 l), decrease in electrolytes, decrease in minute volume, tachycardia, decrease in RR, decrease in arteriolar contractility and shock.
The most common diagnosis of acidosis is: malaise, headache, vomiting, high thirst, polyuria – polyuria, weakness, shortness of breath, acidic breathing, sensory disturbances, impaired consciousness, circulatory and kidney failure, pH <7, 3, alkaline deficiency <15 mmol / l, acetone in urine, serum glucose even below 200 mg%, usually> 300 mg%.
A patient with symptoms of metabolic acidosis must be in a hospital ward under intensive supervision. Measurements of glucose, ketone compounds, electrolytes and blood gas are performed every 1 – 2 hours. Insulin is administered at 0,2 – 0,4 U / kg body weight iv, and then 2 – 10 units per hour in the pump.
Polog
During the puerperium, the decrease in insulin requirement is about 50%, daily blood glucose <130 mg%, monitoring should be performed after 6 weeks. Breastfeeding is the primary prevention of diabetes in the newborn.
GDM
Risk factors:
– mother’s age> 35 years of age
– BMI> 27
– hypertension and kidney disease,
– history of glucose intolerance,
– other endocrine diseases,
– family history of diabetes
– GDM in a previous pregnancy,
– the occurrence of perinatal deaths in the previous pregnancy
– giving birth to a previous child weighing> 4000 g
Screening – screening test
During the first visit to the doctor, the level of fasting blood glucose is checked and, if indicated, a test with 75 g of glucose is performed. If the first sugar measurements are good, then between the 24-26 week of pregnancy a screening test is performed (it does not have to be on an empty stomach), 75 g of glucose, after an hour glycemia> 140 mg% <180 is an indication for a diagnostic test.
Fasting diagnostic test 75 g glucose, normal diet and exercise,> 180 mg% to diabetes center. If the screening test is incorrect and the diagnostic test is correct, the diagnostic test should be repeated at 32 weeks gestation.
When diagnosing diabetes from the 3rd to the 6th month of pregnancy, a diagnostic test should be performed after delivery.
A newborn of a diabetic mother may show: macrosomia, IUGR – delayed intrauterine development syndrome, perinatal injuries, hypoglycemia, hyperbilirubinemia, hypocalcemia, polycythemia, respiratory disorders, circulatory failure, cardiomyopathy.