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

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

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

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

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

The risk of developing diabetes in pregnancy must be calculated to further optimize pregnancy management.

Low risk groupdiabetes mellitus:

• under 30 years of age;
• with normal weight and body mass index;
• there is no indication of the hereditary factor of diabetes in relatives;
• there were no cases of violation of carbohydrate metabolism (including glucose was not detected in the urine);
• there was no polyhydramnios, stillbirth, no children with developmental defects, or this is the first pregnancy.

To classify a woman as a low-risk group for diabetes requires a combination of all of these characteristics.

Medium risk groupdiabetes mellitus:

• slight excess mass;
• in childbirth there was polyhydramnios or a large fetus was born, there was a child with a malformation, there was a miscarriage, gestosis, stillbirth.

High risk groupdiabetes mellitus include women:

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

To classify a woman as a high-risk group for the development of diabetes mellitus, 1-2 of these signs are sufficient.

There are 3 main typesdiabetes mellitus:

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

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

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

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

There are three degrees of diabetes severity:

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

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

Pregnancy diabetes (HD) is a transient abnormality in blood glucose that was first identified during pregnancy. In the first trimester, HD is detected in 2%; in the second trimester - 5.6%; in the third trimester, HD is detected in 3% of pregnant women.

The main consequence of HD is diabetic fetopathy (fetus - fetus; patia - disease), i.e. fetal malformations, which include increased body weight (4-6 kg), with immaturity of lung tissue for spontaneous breathing - a high frequency of malformations, impaired adaptation to extrauterine life, in the neonatal period - high fetal and newborn mortality.

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

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

Symptoms and signs of diabetes during pregnancy

During normal pregnancy, significant shifts occur in blood glucose levels, and insulin secretion levels also change, which has a manifold effect on several metabolic factors. Glucose is a source of energy for fetal development. The need for glucose is provided by glucose in the mother's blood. Fasting blood glucose decreases as pregnancy progresses. The reason is the increased absorption of glucose by the placenta. In the first half of pregnancy, due to a decrease in blood glucose, the sensitivity of maternal tissues to insulin increases.

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

An increase in blood glucose inhibits the formation of a store of glucose in the liver - glycogen. As a result, a significant part of glucose passes into soluble fats - triglycerides - this is a light depot of fat, its reserve for the development of the brain and nervous system of the fetus. An increased level of glucose in the mother's blood also increases the amount in the fetal blood, which stimulates the release of insulin.

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

As a result, the level of so-called ketone bodies - oxidized residues of fatty acids - increases. The cells of the maternal liver also take part in the formation of these ketone bodies. These ketones are needed by the fetus to form the liver and brain, as a source of energy.

This is a description of the physiological picture of changes in the amounts of glucose and insulin in a pregnant woman and a fetus during pregnancy, although it may seem that this is a picture of diabetes mellitus. Therefore, many researchers regard pregnancy as a diabetogenic factor. In pregnant women, urinary glucose may even be detected, which is caused by decreased kidney function rather than abnormal blood glucose.

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

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

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

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

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

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

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

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

The course of pregnancy in the first trimester, if it is possible to maintain it, proceeds without significant changes. Sometimes even the blood sugar level is normalized due to an improvement in glucose tolerance, its absorption by tissues, since even some hypoglycemia occurs. This should be taken into account by doctors, since a decrease in insulin doses is required. The decrease in the amount of glucose in the mother is also explained by the increased absorption of glucose by the fetus. Strict control of levels of glucose, ketones, acid-base balance is required to prevent the development of hypoglycemic or ketoacidosis coma.

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

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

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

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

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

In childbirth, weakness of labor is often formed, due to overstretching of the uterus with a large fetus. Prolonged labor worsen the picture of fetal hypoxia, asphyxia may begin. Due to a large fetus, injuries to the mother and the fetus increase. The fetus has a fracture of the collarbones or humerus bones, possibly a skull injury. And the mother has ruptures of the cervix, the walls of the vagina, the perineum, often making her dissection (lerineotomy).

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

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

Pregnancy management in patients with diabetes mellitus

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

Antibodies to beta cells of the pancreas, antibodies to insulin are being investigated. The “School of Diabetes” provides training in self-control techniques for insulin therapy. During pregnancy, regardless of the type of diabetes, everyone is transferred to the introduction of appropriate doses of insulin to compensate for the increased level of glycemia (high blood sugar). Oral sugar-lowering drugs should be discontinued due to the embryotoxic and teratogenic effects of these drugs. After a detailed examination, the question of the admissibility of the onset of pregnancy, the risk of carrying it, is decided.

Pregnancy is contraindicated when:

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

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

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

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

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

We managed to keep the pregnancy. But a deterioration in the state of the vessels of the retina of the eyes was revealed. At 22 weeks, combined preeclampsia with nephropathy, edema and hypertension began. M.O. was urgently hospitalized. Long-term intravenous treatment of preeclampsia and placental insufficiency, the introduction of corticoid hormones to accelerate the maturation of surfactant in the fetal lungs was started.

This was done due to insufficient treatment effect. There was a sharp deterioration in the patient's vision, she was practically blind. The destabilization of the blood glucose level began, and hypoglycemic states began to appear.

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

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

Diabetes mellitus treatment during pregnancy

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

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

The second hospitalization is at a period of 8-12 weeks. At this time, a correction of insulin doses is required due to the onset of relative hypoglycemia (a decrease in blood sugar). A repeated ultrasound scan is performed, fetal size control, identification of malformations, the amount of amniotic fluid. An examination by an ophthalmologist, revealing the state of the retinal vessels is required. Symptoms of the threat of termination of pregnancy are identified, and treatment is prescribed if necessary.

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

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

The next hospitalization is at 30-32 weeks of pregnancy. The next correction of insulin doses, determination of the presence or occurrence of lesions of small vessels. Assessment of the condition of the fetus and placenta using ultrasound, Doppler study of blood flow in the placenta and in the fetus. A study of the fetal heart rate is also carried out - CTG recording. Control of blood clotting, placental hormones. Prevention of insufficient production of surfactant in the lungs of the fetus. The timing and method of delivery are determined

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

A case from practice. Patient O.N., 32 years old. Type I diabetes mellitus, congenital, the presence of antibodies to the beta cells of the pancreas. Was admitted for delivery at 34 weeks of gestation with severe gestosis, hypertension and acute polyhydramnios. Intravenous administration of antihypoxants (drugs for the treatment of hypoxia) and micronized heparin was started, this was the prevention of DIC.

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

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

According to the sum of severe diabetic and obstetric risks, the delivery plan was changed to an operative one. A cesarean section was performed - a living, premature, hypotrophic boy with asphyxia, weighing 1300 g was extracted. Subsequently, the child was found to have a congenital heart defect, fusion of the fingers. The postoperative period on the 2nd day was complicated by severe hypoglycemia, ketoacidosis, hypoglycemic coma. An immediate jet injection of 40% glucose was started, but this did not help, death occurred. Autopsy revealed cerebral edema with wedging of the cerebellum into the foramen magnum - the cause of death. It was about the automation of the actions of the doctors. After the operation, a zero table is assigned - only water, a weak broth. And insulin doses were not adjusted on time. The sugar-lowering effect of insulin, starvation, and early postoperative (fear, blood loss) hypoglycemia converged. The sugar level dropped to zero. Therefore, even an intravenous jet injection of 250 ml of 40% glucose did not help.

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

Read in this article

Reasons for the development of diabetes in pregnant women

Experts cannot name the obvious culprit for the violation of tissue response to glucose in expectant mothers. Undoubtedly, hormonal changes are not the least important factor in the development of diabetes. But they are common for all pregnant women, and, fortunately, not everyone is diagnosed with the disease in this position. Those who transferred it noted:

• Hereditary tendency. If there are cases of diabetes in the family, there is also a higher probability of its occurrence in a pregnant woman compared to others.
• Autoimmune diseases that, due to their characteristics, disrupt the function of the insulin-producing pancreas.
• Frequent viral infections. They can also upset the function of the pancreas.
• Passive lifestyle and high-calorie food. They lead to excess weight, and if it existed before conception, the woman is at risk. This also includes those whose body weight increased by 5-10 kg in adolescence in a short time, and its index became above 25.
• Age from 35 years old. Those who are under 30 at the time of pregnancy are less likely to get gestational diabetes than others.
• Past birth of an infant weighing more than 4.5 kg or a stillborn child for unknown reasons.

Women of Asian or African descent are more prone to diabetes during pregnancy than European women.

Signs for Suspecting Gestational Diabetes

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

With the development of malaise, a woman may feel:

• The need for a large amount of fluid. Despite her satisfaction, dry mouth worries.
• The need to urinate more often, while the fluid comes out much more than usual.
• Increased fatigue. Pregnancy already takes a lot of energy, and now a woman's desire to take a break arises faster than before, with diabetes her self-awareness does not correspond to the load received.
• Deterioration in the quality of vision. Clouding may periodically appear in the eyes.
• Itchy skin, mucous membranes can also itch.
• A significant increase in the need for food and a rapid increase in weight.

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

How to get rid of diabetes during pregnancy

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

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

Diet and physical activity are key at this stage.

Nutrition for gestational diabetes

it is impossible for a pregnant woman, the fetus must have everything it needs, and sugar grows from lack of food. The expectant mother will have to adhere to healthy eating principles:

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

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

Medicines

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

Insulin is given intravenously, usually in two divided doses. The first is injected before breakfast, the second before dinner. The diet with drug therapy is maintained, as is the regular monitoring of the concentration of glucose in the blood.

Physical exercise

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

The movement should not be to the point of exhaustion, it is necessary to exclude the possibility of injury. Walking, exercise in the gym (except for swinging the press), swimming are suitable.

Prevention of gestational diabetes

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

• Early in life increases the likelihood. With gestational diabetes, a conflict is created between her body and the fetus. He seeks to reject the embryo.
• Thickening of the placental vessels due to gestational diabetes leads to circulatory disorders in this area, therefore, a decrease in the supply of oxygen and nutrients to the fetus.
• Having arisen from 16 to 20 weeks, the ailment can lead to defective formation of the cardiovascular system and the fetal brain, stimulate its excessive growth.
• Childbirth may start ahead of time. And the large size of the fetus forces a cesarean section. If the birth is natural, it will create a risk of injury to the mother and baby.
• A newborn baby may be at risk of jaundice, respiratory distress, hypoglycemia, and increased blood clotting. These are signs of diabetic fetopathy, which causes other pathologies in a child in the postnatal period.
• A woman is more likely to develop preeclampsia and eclampsia. Both problems are dangerous with high blood pressure, seizures, which during childbirth can kill both the mother and the baby.
• Subsequently, the woman has an increased risk of developing diabetes mellitus.

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

• Regular. It is important to register early, do all the necessary tests, especially when you are in a risk group.
• Maintaining optimal body weight. If she was more than normal before pregnancy, it is best to lose weight first and plan later.
• ... High blood pressure can indicate a tendency to increase sugar and stimulate it.
• To give up smoking. Habit affects the function of many organs, including the pancreas.

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

Pregnancy diabetes or gestational diabetes mellitus (GDM) Is a violation tolerance(from Latin tolerantia - tolerance, that is, the maximum amount of a substance introduced into the body that can be assimilated without detectable pathological manifestations) to carbohydrates (glucose) of varying degrees, which occurs or is first detected during pregnancy. At the same time, fasting glucose levels can remain normal, glucose is not detected in the urine, and there are no clinical symptoms of diabetes. The frequency of occurrence among pregnant women is 2-3%.

dangerous Often, this pathology remains undiagnosed and manifests itself either as complications during pregnancy and childbirth, or in the onset of diabetes mellitus in the long term.

Risk factors

1. Diabetes mellitus in close relatives;
2. GDM in a previous pregnancy;
3. Violation of fat metabolism in a pregnant woman;
4. Previous birth of children weighing more than 4 kg;
5. Stillbirth, miscarriage, polyhydramnios in previous pregnancies;
6. (4 kg or more);
7. Congenital malformations of the fetus;
8. Pathological weight gain;
9. Elevated blood glucose ( hyperglycemia) on an empty stomach - more than 4.5 mmol / l;
10. Detection of glucose in urine 2 or more times.

With a physiologically ongoing pregnancy, the fasting glucose level in the first trimester is 3.3 - 4.4 mmol / l.

In the presence of risk factors, pregnant women undergo oral(from Latin per os - through the mouth) glucose tolerance test(GTT) no later than 16 weeks of pregnancy. Then, if necessary, GTT is carried out for about 24 weeks, and then at 32-34.

GTT options:

1. Fingersticks are taken on an empty stomach to determine glucose levels ( glycemia). The woman then drinks 100 grams of glucose dissolved in a glass of water. Further, a study of glycemia is carried out after 1, 2 and 3 hours.
2. A more simplified version with 75 grams of glucose and fasting blood sampling, as well as 2 hours after glucose load. Normal glycemic parameters during the glucose tolerance test in pregnant women (mmol / l) are shown in the table.

On an empty stomach	After 1 hour	In 2 hours	After 3 hours
75 gram	Less than 5.3		Less than 7.6
100g	Less than 5.3	Less than 9.4	Less than 8.6	Less than 7.7

For the diagnosis of gestational diabetes mellitus, it is necessary to exceed 2 indicators. With changes on the part of GTT, it is possible to conduct daily monitoring of glucose levels in an endocrinological hospital, as well as to conduct special additional studies (for example, determination of the level of glycated hemoglobin - a biochemical blood index reflecting the average blood sugar content over a long period (up to three months).

Important Clinically, GDM is usually not present. Most often, the lack of treatment leads to complications of the course of pregnancy, which respond to therapy much worse than usual.

Complications of gestational diabetes

1. ... Features of the course in pregnant women with GDM: early onset, more severe course, rapid increase in symptoms, low effectiveness of therapy.
2. Gestational pyelonephritis(inflammation of the pyelocaliceal system and renal parenchyma)
3. Diabetic fetopathy (fetal complications), which is manifested by:

• Macrosomia(large fruit sizes),
• Hypoglycemia(reduced glucose level) in the postpartum period (the fetus's body tries to compensate for the increased glucose level in the mother, and after childbirth, insulin production remains elevated, so the glucose level drops sharply up to hypoglycemic coma);
• Hypocalcemia(decreased blood calcium levels);
• Hyperbilirubinemia (increased serum bilirubin levels and associated jaundice);
• Thrombocytopenia(decreased blood platelet count);
• Respiratory distress syndrome of the newborn(the lungs of the newborn are not ready for extrauterine life);
• Hypertrophic cardiomyopathy(changes in the heart with possible disruption of its work)

• Intrauterine fetal death.

Treatment of pregnancy diabetes

1. Conducted in conjunction with an endocrinologist;
2. Continuous monitoring of blood glucose levels;
3. Diet No. 9: frequent, fractional meals up to 6-7 times a day with restriction of easily digestible carbohydrates (confectionery, fruits, honey, sweet, sugar), no more than 30-35 kcal / kg of body weight;
4. If the diet does not allow compensation for gestational diabetes mellitus, then insulin therapy is indicated for the woman. The multiplicity and dosage of drugs are determined by the attending physician together with the endocrinologist!

Important Tableted antihyperglycemic drugs are contraindicated during pregnancy.

Criteria for compensation of diabetes mellitus in pregnant women:

• Fasting glucose level 3.5 - 5.5 mmol / L;
• The glucose level 2 hours after a meal is not more than 6.7 mmol / l.

With compensated gestational diabetes mellitus, a satisfactory condition of the pregnant woman and the absence of fetal abnormalities, delivery can be performed at 39-40 weeks. The optimal way is programmed labor through the vaginal birth canal with glucose control during and after childbirth.

Information In the presence of complications that cannot be corrected, an early delivery is performed. The method depends on the obstetric situation.

In the postpartum period, glucose control is mandatory. If GDM was compensated, then GTT is performed 1.5 months after childbirth. If the pregnant woman was on insulin therapy, then after delivery, insulin is canceled and glucose levels are monitored. For hyperglycemia, treatment is prescribed by an endocrinologist. At normal glucose levels, GTT is performed after 1.5, 6 months, and then once a year. Planning for the next pregnancy no earlier than 1.5 years later.

Additionally After childbirth, 2/3 develop type 1 diabetes and 30-50% develop type 2 diabetes. The risk of developing diabetes mellitus in children also increases.

Thus, gestational diabetes mellitus is a serious pathology, since a large number of women develop diabetes mellitus in the future. And in the absence of treatment during pregnancy, it often leads to complications from both the pregnant woman and the fetus.

Diabetes mellitus during pregnancy, also called gestational diabetes mellitus, is diabetes that is first diagnosed during pregnancy and in most cases goes away without a trace shortly after the baby is born.

According to various sources, gestational diabetes mellitus develops in 2-14 women out of a hundred (that is, in 2-14%). This is one of the most common complications of pregnancy.

Who is at increased risk of diabetes in pregnancy?

Gestational diabetes is more likely to develop if:

• Pregnant over 35 years old;
• The woman had it before pregnancy;
• The woman has already given birth to a child whose birth weight was more than 4000 grams;
• The woman is taking corticosteroid hormones;
• Close relatives of the pregnant woman (parents, brothers or sisters) have type 2 diabetes mellitus;
• Before pregnancy, the woman was diagnosed.

Reasons for the development of diabetes mellitus in pregnant women

Diabetes mellitus develops if the pancreas does not produce enough of the hormone insulin, or if there is enough insulin, but it loses its ability to affect the cells of the body.

As a result of a decrease in the level of insulin (or its ineffectiveness) in the blood, the level of glucose rises. Constantly high blood glucose levels affect not only the course of pregnancy, but also the growth and development of the unborn child.

How does gestational diabetes affect pregnancy?

In most pregnant women, gestational diabetes mellitus progresses well and is well controlled with diet and, if necessary, medication.

However, if diabetes mellitus was not detected on time, or if the pregnant woman does not follow the doctor's recommendations, this disease can lead to serious consequences in the form of increased blood pressure and preeclampsia, which is considered one of the most dangerous complications of pregnancy, threatening the life of both the pregnant woman and her unborn child.

Is diabetes mellitus during pregnancy dangerous for an unborn child?

The presence of diabetes mellitus in a pregnant woman can adversely affect the growth and development of her unborn child:

• High birth weight

Pregnant women with gestational diabetes mellitus have an increased risk of having a baby weighing more than 4000 grams. The large size of the fetus can impede its movement along the birth canal, increase the risk of fetal stuck in the birth canal and emergency.

• Premature birth and breathing problems

Elevated blood glucose levels can be the reason when the lungs of the fetus are not yet ripe and ready to breathe spontaneously.

• Low blood glucose (hypoglycemia) soon after birth

Due to the increased level of glucose in the mother's blood, the body of the fetus produces more insulin than necessary. Soon after a baby is born, when the mother’s blood glucose is no longer available and insulin levels are still high, the baby’s blood sugar drops sharply, which can lead to seizures.

• Increased risk of developing diabetes in the future

Children born to mothers with gestational diabetes are more likely to experience obesity and type 2 diabetes in adulthood.

Untreated diabetes mellitus during pregnancy can cause fetal death or the death of a baby shortly after birth. Fortunately, due to the timely diagnosis and treatment of diabetes in pregnant women, such complications are extremely rare in our time.

Symptoms and signs of pregnancy diabetes

Gestational diabetes mellitus is very often asymptomatic and is detected by chance, during a routine examination in the second trimester of pregnancy. This type of diabetes is often referred to as "latent" diabetes, as it can only be found out with the help of a special examination.

However, the following symptoms and signs of the disease may indicate diabetes mellitus in pregnancy:

• Excessive thirst
• Very frequent urination
• Blurred vision
• Excessive fatigue

But even the presence of all these symptoms does not necessarily mean that a pregnant woman has diabetes. Therefore, for the timely diagnosis of this disease, doctors prescribe an analysis for gestational diabetes mellitus.

Analysis for diabetes mellitus in pregnant women

Most health care providers offer all pregnant women between 24 and 28 weeks to be screened for gestational diabetes. If a pregnant woman has risk factors for gestational diabetes mellitus (listed above), then an analysis for diabetes mellitus can be prescribed already at the first visit of a pregnant woman to a doctor (in the first trimester of pregnancy).

If screening for diabetes mellitus in pregnant women revealed an increase in fasting blood glucose levels, then the pregnant woman is recommended to undergo a second test.

Treatment of diabetes mellitus in pregnant women

Typically, diabetes mellitus during pregnancy can be successfully controlled with diet, but in some cases, the pregnant woman may require medication in the form of insulin injections.

Nutrition for diabetes mellitus in pregnant women

Eating well is one of the most effective treatments for gestational diabetes.

The menu of a pregnant woman with gestational diabetes should include vegetables, fruits and whole grains (whole grain breads, pasta and cereals). At the same time, you need to avoid fast carbohydrates, which include any sweets, sugary drinks, honey, fruit juices based on concentrates, etc.

Note also that there is no special diet for diabetes that would suit all pregnant women. If necessary, the doctor will prescribe you a consultation with an endocrinologist or nutritionist, who will make a menu that is right for you (depending on your weight before pregnancy and current weight, blood sugar level, your degree of physical activity, your eating habits, etc.) ...

Exercise in the treatment of pregnancy diabetes

Regular physical activity during pregnancy not only allows better control of blood glucose levels, but also has a beneficial effect on the well-being of the pregnant woman and her unborn child. If your doctor has not recommended bed rest for you, try to remain moderately active throughout your pregnancy. Go swimming, yoga, Pilates, maternity fitness, or just go out more often.

Insulin injections for diabetes mellitus in pregnant women

If blood glucose levels remain high despite diet and exercise, the pregnant woman may be advised to receive insulin injections until delivery. Insulin shots will help you maintain normal blood sugar levels, which will be beneficial for your health and that of your unborn baby.

The expectant mother should not worry that insulin can harm the unborn child in any way: insulin practically does not penetrate the placenta, therefore it does not have a negative effect on the fetus. Thus, the risk of taking insulin during pregnancy is much less than the risk of complications if the pregnant woman refuses treatment.

What are the features of pregnancy management in gestational diabetes mellitus?

You will likely need to visit your doctor a little more often to monitor your blood glucose levels. You can monitor your glucose yourself with a home glucometer (a device that measures your blood sugar at home).

In the third trimester of pregnancy, the doctor may recommend several examinations aimed at finding out the condition and well-being of the unborn child. These examinations include ultrasound examining the biophysical profile as well as the size of the fetus.

If the ultrasound shows that the fetus is large, you may be asked to induce labor a little ahead of time (before the 40th week of pregnancy), or, if the fetus is very large, the doctor may insist on a planned delivery.

What are the consequences of pregnancy diabetes?

As a rule, gestational diabetes mellitus disappears without a trace for both the woman and her baby immediately after childbirth. However, women with pregnancy diabetes are at increased risk of developing type 2 diabetes in the future. However, diabetes can be avoided by adjusting your diet, physical activity, and normalizing your weight.

How to reduce the risk of developing diabetes during pregnancy?

Prevention of gestational diabetes mellitus includes the following recommendations:

• If you are overweight, try to normalize it even before pregnancy;
• Control;
• Avoid eating fast carbohydrates (sweets, chocolates, pastries, etc.);
• Take care of quality;
• Stay physically active throughout your pregnancy (unless your doctor has advised you otherwise): Go swimming, do yoga, Pilates, or just walk a lot;
• Stop smoking. is not only very harmful to the unborn child, but also increases the risk of gestational diabetes mellitus.

If a woman had no suspicion of diabetes mellitus before pregnancy, and after that all the prerequisites for the disease appeared, then this indicates gestational diabetes mellitus. What are the symptoms of diabetes during pregnancy? Unlike chronic diabetes mellitus, during pregnancy, the symptoms of this type of disease disappear immediately after childbirth.

During pregnancy, a woman should carefully consider her health and carefully monitor any changes in the body, so that, on occasion, in time to identify a potential threat to the development of the baby. Diabetes mellitus can do a lot of harm to both the fetus and its mother.

High sugar levels can cause the baby to grow faster, making a large fetus difficult to deliver. In this case, hypoxia can also develop, that is, oxygen starvation of the baby. But if you diagnose diabetes mellitus, which occurred during pregnancy, in time, you can cure it and give birth to a healthy child on your own.

Why does diabetes mellitus develop in the female body during such an important process? As you know, progesterone is the main hormone that ensures the favorable development of the baby in the womb. So the increased release of the hormone into the blood has its side effects, which are expressed in the release of a large amount of glucose in the body.

The problem is that there is an increased load on the pancreas, which often does not cope with sugar processing, which leads to diabetes. The main trouble that comes with this disease is the direction of all oxygen to participate in chemical reactions to process glucose.

This situation suggests that the child develops an oxygen deficiency, which leads to hypoxia, and as a result, a violation in the development of the baby. How to define diabetes mellitus in a pregnant woman? What symptoms can indicate the development of this pathology?

The development of diabetes mellitus during gestation increases tenfold the likelihood of termination of pregnancy at different periods, the development of genital infections and gestosis, and an increase in the amount of amniotic fluid and the size of the baby, which can lead to injury to both during labor.

Gestational diabetes mellitus, which can occur during pregnancy, has, although not obvious signs, it is possible to determine it. The problem should be looked for where the following symptoms occur:

A woman needs to pay attention to the fact that her vision has deteriorated somewhat;

When you have to find out that the urine excreted by the body is more than usual, and the frequency of going to the toilet has become a little more frequent.

Usually, with diabetes mellitus, the expectant mother may face impotence and intense thirst, and a constant feeling of hunger accompanies this unpleasant diagnosis. If you suddenly had to deal with such manifestations, it is immediately necessary to donate urine and blood for laboratory research.

There is also a risk group of women, the likelihood of developing diabetes mellitus in whose case increases. It is necessary to constantly monitor blood sugar indicators for women who suffer from overweight, as well as for women whose previous child was born more than four kilograms.

Of course, heredity is not an unlikely risk factor and gestational diabetes in previous pregnancy: if a woman observes a constantly elevated blood glucose level before pregnancy, but which does not exceed the norm.

Diabetes mellitus should not cause panic in a woman, because these two phenomena are quite compatible. In this case, it is important to follow the diet prescribed by the attending endocrinologist. If you are overweight, you will have to monitor the calorie content of your menu. For constant monitoring of sugar, rapid tests can be purchased that will keep a woman aware of changes in glucose values.

The birth of a child makes all the symptoms of the disease disappear after a few days. However, after such a postponed problem, care should be taken to planning repeated pregnancies in order to avoid relapse.

Among the complications that can occur with diabetes during pregnancy, there is pronounced hypolekimia in a newborn, which can provide a slowed down formation of lung tissue, as a result of which, after birth, the baby has difficulty breathing.