Gestational diabetes. Gestational diabetes: modern diagnosis. Treatment of gestational diabetes mellitus

RCHR (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 Healthcare Development
Ministry of Health of the Republic of Kazakhstan
Protocol No. 10 dated July 04, 2014

Diabetes mellitus (DM) is a group of metabolic (metabolic) diseases characterized by chronic hyperglycemia, which is the result of impaired insulin secretion, insulin action, or both. 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 identified during pregnancy, but not meeting the criteria for “manifest” diabetes. GDM is a disorder of glucose tolerance of varying severity that arose or was first identified during pregnancy.

I. INTRODUCTORY PART

Protocol name: Diabetes mellitus during pregnancy
Protocol code:

ICD-10 code(s):
E 10 Insulin-dependent diabetes mellitus
E 11 Non-insulin-dependent diabetes mellitus
O24 Diabetes mellitus during pregnancy
O24.0 Pre-existing insulin-dependent diabetes mellitus
O24.1 Pre-existing non-insulin-dependent diabetes mellitus
O24.3 Pre-existing diabetes mellitus, unspecified
O24.4 Diabetes mellitus occurring during pregnancy
O24.9 Diabetes mellitus in pregnancy, unspecified

Abbreviations used in the protocol:
AH - arterial hypertension
BP - blood pressure
GDM - gestational diabetes mellitus
DKA - diabetic ketoacidosis
IIT - intensive insulin therapy
IR - insulin resistance
IRI - immunoreactive insulin
BMI - body mass index
MAU - microalbuminuria
IGT - impaired glucose tolerance
IFG - impaired fasting glucose
LMWH - continuous glucose monitoring
CSII - continuous subcutaneous infusion of insulin (insulin pump)
OGTT - oral glucose tolerance test
PSD - pregestational diabetes mellitus
DM - diabetes mellitus
Type 2 diabetes - type 2 diabetes mellitus
Type 1 diabetes - type 1 diabetes mellitus
SST - hypoglycemic therapy
PA - physical activity
XE - grain units
ECG - electrocardiogram
HbAlc - glycosylated (glycated) hemoglobin

Date of protocol development: year 2014.

Protocol users: endocrinologists, general practitioners, therapists, obstetricians-gynecologists, emergency medical services doctors.

Classification

Classification

Table 1 Clinical classification of diabetes:

Types of diabetes in pregnant women :
1) “true” GDM that occurred during a given pregnancy and is limited to the period of pregnancy (Appendix 6);
2) type 2 diabetes manifested during pregnancy;
3) type 1 diabetes 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 identify hidden diabetes(at first appearance):
- Determination of fasting glucose;
- 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 a risk factor);

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

To all pregnant women with PSD and GDM
- Determination of glucose before meals, 1 hour after meals, at 3 a.m. (with a 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;
- NMG (in accordance with Appendix 3);
- determination of glycosylated hemoglobin (HbAlc);
- Ultrasound of the abdominal organs, thyroid gland;

Minimum list of examinations for referral for 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 10 pm and 3 am (with a 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 carried out that were not carried out 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 10 pm and 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 (quantitative);
- Ultrasound of the fetus;
- ECG (12 leads);
- determination of glycosylated hemoglobin in the blood;
- determination of the Rh factor;
- determination of blood group according to the ABO system using cyclones;
- Ultrasound of the abdominal organs.

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

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

Diagnostic criteria

Complaints and anamnesis
Complaints:
- with compensation there are no SDs;
- with decompensation of diabetes, pregnant women are concerned about polyuria, polydipsia, dry mucous membranes and skin.

Anamnesis:
- duration of diabetes;
- presence of late vascular 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)

Type 1 diabetes:
- dry skin and mucous membranes, decreased skin turgor, “diabetic” blush, increased liver size;
- if there are signs of ketoacidosis, the following occur: deep Kussmaul breathing, stupor, coma, nausea, vomiting “coffee grounds”, positive Shchetkin-Blumberg sign, defence 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, then a 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 To establish a diagnosis of diabetes, one determination in the diabetic range (glycemia or HbA1c) is sufficient. If manifest diabetes is detected, it should be classified as soon as possible into any diagnostic category according to the current WHO classification, for example, type 1 diabetes, type 2 diabetes, etc.
2 HbA1c using the determination method, certified in accordance with the National Glycohemoglobin Standardization Program (NGSP) and standardized in accordance with the reference values ​​​​accepted 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 initial presentation

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

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

Instrumental studies

Table 5 Instrumental studies in pregnant women with diabetes *

Revealing Ultrasound signs of diabetic fetopathy requires immediate nutritional correction and LMWH:
. large fetus (abdominal diameter ≥75th percentile);
. hepatosplenomegaly;
. cardiomegaly/cardiopathy;
. double contour of the fetal head;
. swelling and thickening of the subcutaneous fat layer;
. thickening of the neck fold;
. newly identified or increasing polyhydramnios with an established diagnosis of GDM (if other causes of polyhydramnios are excluded).

Indications for specialist consultations

Table 6 Indications for pregnant women with diabetes for consultation with specialists*

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

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

Differential diagnosis

Differential diagnosis

Table 7 Differential diagnosis of diabetes in pregnant women

Treatment abroad

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Treatment

Treatment goals:
The goal of treatment of 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;
. training and self-control;
. hypoglycemic drugs.

Non-drug treatment

Diet therapy
For type 1 diabetes, it is recommended to follow an adequate diet: a diet with sufficient carbohydrates to prevent “hunger” ketosis.
For GDM and type 2 diabetes, diet therapy is carried out with the complete exclusion of easily digestible carbohydrates and the limitation of fats; uniform distribution of daily food volume into 4-6 meals. Carbohydrates with a high content of dietary fiber should make up no more than 38-45% of the daily calorie intake, proteins - 20-25% (1.3 g/kg), fats - up to 30%. For women with a normal BMI (18-25 kg/m2), a daily calorie 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 diabetes and GDM, dosed aerobic physical activity is recommended in the form of walking for at least 150 minutes per 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 increased blood pressure and uterine hypertonicity.

. Patient education should provide patients with the knowledge and skills to help them achieve specific therapeutic goals.
. Women planning a pregnancy and pregnant women who have not undergone training (initial cycle), or patients who have already completed training (for repeated cycles), are sent to the diabetes school to maintain the level of knowledge and motivation or when new therapeutic goals arise and transfer to insulin therapy.
Self-control b includes determination of glycemia using portable devices (glucometers) on an empty stomach, before and 1 hour after 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.
CMG system

Drug treatment

Treatment of pregnant women with diabetes
. If pregnancy occurs while using metformin or glibenclamide, pregnancy may be prolonged. All other glucose-lowering medications should be stopped before pregnancy and replaced with insulin.

Only short- and intermediate-acting human insulin preparations, ultra-short-acting and long-acting insulin analogues approved under category B are used

Table 9 Insulin preparations approved for use in pregnant women (list B)

During pregnancy, it is prohibited to use biosimilar insulin preparations that have not undergone the full procedure for drug registration and pre-registration clinical trials in pregnant women.

All insulin preparations must be prescribed to pregnant women with the obligatory indication of the international nonproprietary name and trade name.

The optimal means of administering insulin is insulin pumps with continuous glucose monitoring capabilities.

The daily need for insulin in the second half of pregnancy can increase sharply, up to 2-3 times, compared to the initial need before pregnancy.

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

Antibiotic therapy when a urinary tract infection is detected (penicillins in the first trimester, penicillins or cephalosporins in the second or third trimesters).

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

From 13 weeks hyperglycemia and glycosuria increase, the need for insulin increases (on average by 30-100% of the pregestational level) and the risk of developing ketoacidosis, especially at 28-30 weeks. This is due to the high hormonal activity of the placenta, producing counterinsular agents such as chorionic somatomammatropin, progesterone, and estrogens.
Their excess leads to:
. insulin resistance;
. reducing the sensitivity of the patient’s body to exogenous insulin;
. an increase in the need for a daily dose of insulin;
. pronounced “dawning” syndrome with a maximum increase in glucose levels in the early morning hours.

In case of morning hyperglycemia, increasing the evening dose of extended-release insulin is not advisable due to the high risk of nocturnal hypoglycemia. Therefore, in these women with morning hyperglycemia, it is recommended to administer a morning dose of long-acting insulin and an additional dose of short-acting/ultra-short-acting insulin or switching to pump insulin 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 extended-release insulin is doubled for the period of dexamethasone administration. Glycemic control is prescribed at 06.00, before and after meals, before bedtime and at 03.00. to adjust the dose of short-acting insulin. Correction of water-salt metabolism is carried out.

After 37 weeks During pregnancy, the need for insulin may decrease again, which leads to an average reduction in the insulin dose by 4-8 units/day. It is believed that the insulin-synthesizing activity of the β-cell apparatus of the fetal pancreas is so high at this point that it ensures 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 pheoplacental complex against the background of placental insufficiency.

During childbirth Significant fluctuations in blood glucose levels occur, hyperglycemia and acidosis may develop under the influence of emotional influences or hypoglycemia as a consequence of physical work done or the woman’s fatigue.

After childbirth blood glucose decreases rapidly (against the background of a drop in the level of placental hormones after birth). In this case, the need for insulin for a short time (2-4 days) becomes less than before pregnancy. Then gradually blood glucose increases. 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 a volume of 1.5-2.5 l/day, as well as orally 2-4 l/day with still water (slowly, in small sips). In the diet of a pregnant woman for the entire period of treatment, pureed food is recommended, mainly carbohydrate-rich (cereals, juices, jelly), with additional salting, excluding visible fats. When glycemia is less than 14.0 mmol/l, insulin is administered against the background of a 5% glucose solution.

Management of childbirth
Planned hospitalization:
. the optimal period of delivery is 38-40 weeks;
. The optimal method of delivery is vaginal delivery with careful glycemic control during (hourly) and after birth.

Indications for cesarean section:
. obstetric indications for surgical delivery (planned/emergency);
. the presence of severe or progressive complications of diabetes.
The timing of delivery in pregnant women with diabetes is determined individually, taking into account the severity 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 maturity of the fetus, since delayed maturation of its functional systems is possible.
Pregnant women with diabetes and fetal macrosomia should be informed about the possible risks of complications during normal vaginal delivery, induction of labor, and cesarean section.
In case of 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

During natural childbirth:
. Glycemic levels must be maintained within 4.0-7.0 mmol/l. Continue administration of extended-release insulin.
. When eating during childbirth, the administration of short-acting insulin should cover the amount of XE consumed (Appendix 5).
. Monitor glycemia every 2 hours.
. For glycemia less than 3.5 mmol/l, intravenous administration of a 5% glucose solution of 200 ml is indicated. For glycemia below 5.0 mmol/l, an additional 10 g of glucose (dissolve in the mouth). When glycemia is 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.
. For 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.

During operative delivery:
. on the day of surgery, a morning dose of extended-release insulin is administered (for normoglycemia, the dose is reduced by 10-20%; for hyperglycemia, the dose of extended-release insulin is administered without adjustment, as well as an additional 1-4 units of short-acting insulin).
. In the case of the use of general anesthesia during labor 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 complete recovery from general anesthesia.
. Further tactics of hypoglycemic therapy are similar to those for natural delivery.
. On the second day after surgery, with limited food intake, the dose of long-term insulin is reduced by 50% (mainly administered in the morning) and short-term insulin 2-4 units before meals with glycemia more than 6.0 mmol/l.

Features of childbirth management with diabetes
. constant cardiotographic monitoring;
. thorough pain relief.

Management of the postpartum period with diabetes
In women with type 1 diabetes after childbirth and with the onset of lactation, the dose of long-term insulin can be reduced by 80-90%; the dose of short-term insulin usually does not exceed 2-4 units before meals according to the glycemic level (for a period of 1-3 days after childbirth). Gradually, over 1-3 weeks, the need for insulin increases and the insulin dose reaches the pregestational level. That's why:
. adapt insulin doses taking into account the rapid decrease in need already in the first day after birth from the moment of birth of the placenta (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.

Advantages of insulin pump therapy in pregnant women with diabetes
. Women using CSII (insulin pump) have an easier time achieving target HbAlc levels<6.0%.
. Insulin pump therapy reduces the risk of hypoglycemia, especially in the first trimester of pregnancy, when the risk of hypoglycemia increases.
. During late pregnancy, when peaks in maternal blood glucose levels lead to fetal hyperinsulinemia, decreased glucose fluctuations in women using CSII reduce macrosomia and neonatal hypoglycemia.
. the use of CSII is effective in controlling blood glucose levels during labor and reduces the incidence of neonatal hypoglycemia.
The combination of CSII and continuous glucose monitoring (CGM) can achieve glycemic control at all stages of pregnancy and reduce the incidence of macrosomia (Appendix 3).

Requirements for CSII in pregnant women:
. initiate use of CSII before conception to reduce the risk of spontaneous miscarriage and congenital fetal defects;
. 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 initial dose.
. in the 1st trimester the basal dose of insulin is 0.1-0.2 units/hour, in later stages 0.3-0.6 units/hour. Increase the insulin:carbohydrate ratio by 50-100%.
. Given the high risk of ketoacidosis in pregnant women, check for ketones in the urine if blood glucose levels exceed 10 mmol/L and change infusion systems every 2 days.
. Continue using the pump during delivery. Set your temp basal to 50% of your maximum.
. If breastfeeding, reduce your basal rate by another 10-20%.

Drug treatment provided on an outpatient basis

Drug treatment provided at the inpatient level
List of essential medicines(100% chance of use)
. Short-acting insulins
. Ultra-short-acting insulins (analogs of human insulin)
. Intermediate-acting insulins
. Long-acting non-peak 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 emergency stage
. Sodium chloride 0.9%
. Dextrose 40%

Preventive actions(Appendix 6)
. In persons with prediabetes, conduct 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, carry out therapeutic measures among women with modifiable risk factors before pregnancy;
. In order to prevent carbohydrate metabolism disorders during pregnancy, all pregnant women are recommended to follow a balanced diet with the exclusion of foods with a high carbohydrate index, such as sugar-containing foods, juices, sweet carbonated drinks, foods with flavor enhancers, and limiting sweet fruits (raisins, apricots, dates , melon, bananas, persimmons).

Further management

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

Table 16 List of instrumental examinations necessary for dynamic monitoring in patients with diabetes *

*If signs of chronic complications of diabetes appear, concomitant diseases appear, or additional risk factors appear, the issue of the frequency of examinations is decided individually.

. 6-12 weeks after birth all women who have had 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 suffered from GDM (Appendix 6).

Indicators of treatment effectiveness and safety of diagnostic and treatment methods described in the protocol:
. achieving the level of carbohydrate and lipid metabolism as close as possible to the normal state, normalizing 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, 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:
- debut of diabetes during pregnancy;
- hyper/hypoglycemic precoma/coma
- ketoacidotic precoma and coma;
- progression of vascular complications of diabetes (retinopathy, nephropathy);
- infections, intoxications;
- addition of obstetric complications requiring emergency measures.

Indications for planned hospitalization*:
- All pregnant women are subject to hospitalization if they are diagnosed with diabetes.
- Women with pregestational diabetes are routinely hospitalized during the following periods of pregnancy:

First hospitalization carried out during pregnancy up to 12 weeks in an endocrinological/therapeutic hospital due to a decrease in the need for insulin and the risk of developing hypoglycemic conditions.
Purpose of hospitalization:
- resolving the issue of the possibility of prolonging pregnancy;
- identification and correction of metabolic and microcirculatory disorders of diabetes and concomitant extragenital pathology, training at the “School of Diabetes” (for prolongation of pregnancy).

Second hospitalization at 24-28 weeks of pregnancy to an endocrinological/therapeutic hospital.
The purpose of hospitalization: correction and control of the dynamics of metabolic and microcirculatory disorders of diabetes.

Third hospitalization carried out in the department of pathology of pregnant women of obstetrics organizations of 2-3 levels of regionalization of perinatal care:
- with diabetes types 1 and 2 at 36-38 weeks of pregnancy;
- for GDM - at 38-39 weeks of pregnancy.
The purpose of hospitalization is to assess the condition of the fetus, correct insulin therapy, and select the method and timing of delivery.

*It is possible to manage pregnant women with diabetes in satisfactory condition on an outpatient basis, if diabetes is compensated and all necessary examinations have been carried out

Information

Sources and literature

1. Minutes of meetings of the Expert Commission on Health Development of the Ministry of Health of the Republic of Kazakhstan, 2014
   1. 1. World Health Organization. Definition, Diagnosis, and Classification of Diabetes Mellitus and its Complications: 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 for specialized medical care for patients with diabetes mellitus. Ed. I.I. Dedova, M.V. Shestakova. 6th issue. 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 manual “Obstetrics”, edited by E.K Ailamazyan, M., 2009. 10. NICE Protocol on diabetes during pregnancy, 2008. 11. Pump insulin 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 information:
1. Nurbekova A.A., Doctor of Medical Sciences, Professor of the Department of Endocrinology of KazNMU
2. Doshchanova A.M. - MD, professor, doctor of the highest category, head of the department of obstetrics and gynecology for 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"

Disclosure of no conflict of interest: No.

Reviewers:
Kosenko Tatyana Frantsevna, Ph.D., Associate Professor, Department of Endocrinology, AGIUV

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

Annex 1

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

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

PHASE 1. When a pregnant woman first visits a doctor of any specialty for up to 24 weeks, one of the following studies is mandatory:
- fasting venous plasma glucose (venous plasma glucose determination is carried out after preliminary fasting for at least 8 hours and no more than 14 hours);
- HbA1c using a determination method certified in accordance with the National Glycohemoglobin Standardization Program (NGSP) and standardized in accordance with the reference values ​​​​accepted 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 manifest (newly diagnosed) diabetes during pregnancy

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

If the result of the study corresponds to the category of manifest (first detected) diabetes, its type is specified and the patient is immediately transferred to an endocrinologist for further management.
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 venous plasma glucose levels are examined. The use of capillary whole blood samples is not recommended.
2 At any stage of pregnancy (one abnormal value of venous plasma glucose measurement is sufficient).

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

PHASE 2- carried out at 24-28 weeks of pregnancy.
To all women, in whom diabetes was not detected in the early stages of pregnancy, an 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 venous plasma glucose levels are examined. The use of capillary whole blood samples is not recommended.
2 At any stage of pregnancy (one abnormal value of venous plasma glucose measurement is sufficient).
3 According to the results of an OGTT with 75 g of glucose, at least one value of venous plasma glucose level out of three, which would be equal to or above the threshold, is sufficient to establish a diagnosis of GDM. If abnormal values ​​are obtained in the initial measurement, a glucose load is not performed; If anomalous values ​​are obtained at the second point, a third measurement is not required.

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

Appendix 2

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

OGTT is not performed:
- 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 motor mode has expanded);
- against the background of an acute inflammatory or infectious disease;
- in case of exacerbation of chronic pancreatitis or the presence of dumping syndrome (resected stomach syndrome).

Determination of venous plasma glucose performed only in the laboratory on biochemical analyzers or glucose analyzers.
The use of portable self-monitoring devices (glucometers) for testing is prohibited.
Blood is drawn into 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 ice water. 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. It is in this biological fluid that the glucose level is determined.

Test execution steps
1st stage. After collecting the first fasting venous blood plasma sample, the glucose level is measured immediately, because If results are obtained indicating manifest (newly identified) diabetes or GDM, no further glucose loading is performed and the test is stopped. If it is impossible to quickly determine the glucose level, the test continues and is completed.

2nd stage. When continuing the test, the patient must 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) drinking still (or distilled) water. If glucose monohydrate is used, 82.5 g of the substance is needed to complete the test. The start of taking the glucose solution is considered the start of the test.

3rd stage. The following blood samples to determine venous plasma glucose levels are taken 1 and 2 hours after the glucose load. If results indicating GDM are received after the 2nd blood draw, the test is stopped.

Appendix 3

The LMWH system is used as a modern method for diagnosing changes in glycemia, identifying patterns and recurring trends, identifying hypoglycemia, adjusting treatment and selecting glucose-lowering therapy; promotes patient education and participation in their care.

CGM is a more modern and precise approach than home self-monitoring. CGM allows you to measure 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 alarm signals for hypo- and hyperglycemia.

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

Appendix 4

Special antenatal care for pregnant women with diabetes mellitus

Conception is not recommended :
- HbA1c level >7%;
- severe nephropathy with serum creatinine level >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.)

Planning a pregnancy
When planning pregnancy, women with diabetes are recommended to achieve target levels of glycemic control without the presence of hypoglycemia.
In case of diabetes, pregnancy should be planned:
. An effective method of contraception should be used until adequate evaluation and preparation for pregnancy has been made:
. training in “diabetes school”;
. informing a 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%;
. blood pressure control (no more than 130/80 mm Hg), for hypertension - antihypertensive therapy (withdrawal of ACE inhibitors before stopping the use of contraception);
. determination of the level of TSH and free T4 + antibodies to TPO in patients with type 1 diabetes (increased risk of thyroid diseases);
. folic acid 500 mcg per day; potassium iodide 150 mcg per day - in the absence of contraindications;
. treatment of retinopathy;
. treatment of nephropathy;
. to give up smoking.

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

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

Appendix 5

Replacement of products using the XE system

1 XE - amount of product containing 15 g of carbohydrates

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

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

Appendix 6

Pregnancy is a state of physiological insulin resistance, and therefore in itself is a significant risk factor for impaired carbohydrate metabolism.
Gestational diabetes mellitus (GDM) is a disease characterized by hyperglycemia, first identified during pregnancy, but not meeting the criteria for “manifest” diabetes.
GDM is a disorder of glucose tolerance of varying severity that arose or was first identified during pregnancy. It is one of the most common disorders in the endocrine system of a pregnant woman. Due to the fact that in most pregnant women GDM occurs without severe hyperglycemia and obvious clinical symptoms, one of the features of the disease is the difficulty of its diagnosis and late detection.
In some cases, GDM is diagnosed retrospectively after birth based on the phenotypic signs of diabetic fetopathy in the newborn or is completely missed. That is why many countries actively screen for GDM using an OGTT with 75 g of glucose. This study is being conducted to all women at 24-28 weeks of pregnancy. Besides, women from risk groups(see paragraph 12.3) OGTT with 75 g of glucose is carried out already at the first visit.

Treatment tactics for GDM
- diet therapy
- physical activity
- training and self-control
- hypoglycemic drugs

Diet therapy
For GDM, diet therapy is carried out with the complete exclusion of easily digestible carbohydrates (especially sweet carbonated drinks and fast foods) and the limitation of fats; uniform distribution of daily food volume into 4-6 meals. Carbohydrates with a high content of dietary fiber should make up no more than 38-45% of the daily calorie intake, proteins - 20-25% (1.3 g/kg), fats - up to 30%. For women with a normal BMI (18-25 kg/m2), a daily calorie 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 GDM, dosed aerobic physical activity is recommended in the form of walking for at least 150 minutes per 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 increased blood pressure and uterine hypertonicity.

Patient education and self-monitoring
Women planning a pregnancy and pregnant women who have not undergone training (initial cycle), or patients who have already completed training (for repeated cycles), are sent to the diabetes school to maintain the level of knowledge and motivation or when new therapeutic goals arise and transfer to insulin therapy.
Self-control includes definition:
- glycemia using portable devices (glucometers) on an empty stomach, before and 1 hour after 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.

CMG system used as an addition to traditional self-monitoring in case of hidden hypoglycemia or frequent hypoglycemic episodes (Appendix 3).

Drug treatment
To treat GDM, diet therapy and physical activity are sufficient for most pregnant women. If these measures are ineffective, insulin therapy is prescribed.

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

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

When prescribing insulin therapy, a pregnant woman is jointly managed by an endocrinologist/therapist and an obstetrician-gynecologist. The insulin therapy regimen and the type of insulin preparation are prescribed depending on the glycemic self-monitoring data. A patient on an intensive insulin therapy regimen should self-monitor glycemia at least 8 times a day (on an empty stomach, before meals, 1 hour after meals, before bed, at 03.00 and when feeling unwell).

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

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

Attached files

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In every woman’s mind, the period of waiting for a child seems to be something rosy, airy and serene, but it happens that this idyll is disrupted by serious health problems.
Gestational diabetes mellitus during pregnancy, why it is dangerous, what indicators and signs do pregnant women have, diet and menu, consequences for the child, analysis for hidden blood sugar is the topic of this article.
The material will be useful to any woman of fertile age who has risk factors and heredity for the disease.

Gestational diabetes in pregnant women: what is it?

Gestational or preeclampsia diabetes is a disease of increased blood sugar levels that occurs during pregnancy at any stage. Many people confuse the name and call it remote. Before pregnancy, the woman was completely healthy and showed no signs of illness. This disease is also called “diabetes mellitus in pregnancy.”


As a rule, this type of diabetes occurs in the second half of gestation, when the woman is at a decent age. After delivery, gestational diabetes may disappear, or it may develop into full-blown type 1 or type 2 diabetes.
However, there are studies that show a strong link between diabetes during pregnancy and type 2 diabetes later in life. In other words, if a woman had gestational diabetes at a young age, then in adulthood she has a greater risk of developing type 2 diabetes if there are risk factors in the form of obesity, poor nutrition and others.

The incidence of this type of diabetes is about 2.5 – 3.0%. There are certain risk factors that contribute to this, which I list below:

• overweight and obesity
• age over 30 years
• heredity for diabetes
• large baby from previous pregnancy
• detection of glucose in urine in a previous pregnancy
• gestational diabetes in the past
• polycystic ovary syndrome (PCOS)

Diabetes in pregnant women: dangers and consequences for the child

Diabetes is always a pathology and it cannot but influence the course of pregnancy and the health of the fetus. But with good compensation, it is possible to safely carry and give birth to a healthy baby. I’ll tell you what you need for good compensation below, but now I’ll list what the expectant mother can expect.

• high risk of fetal death in utero or in the first week of life after birth
• birth of a child with developmental defects
• high risk of various diseases of the newborn baby in the first month of life (for example, infections)
• the birth of a large fetus and the risk of complications associated with this (injuries to the child’s skull and limbs, maternal ruptures during childbirth, etc.)
• Your child's risk of developing diabetes in the future
• late complications of pregnancy (eclampsia and preeclampsia, arterial hypertension, edema syndrome)
• polyhydramnios
• intrauterine infection

What are the signs of diabetes during pregnancy?

Quite often, an increase in glucose levels is asymptomatic, and if there are any signs, they are usually attributed to the pregnancy itself. The symptoms of gestational diabetes are no different from those of any other type of diabetes. The severity of these manifestations depends on the level of sugar in the blood.

Symptoms of diabetes during pregnancy

• dry mouth
• frequent urination
• skin itching and perineal itching
• thrush
• rapid weight gain
• general weakness and drowsiness

As you can see, the manifestations are often a manifestation of pregnancy itself, and therefore every woman regularly undergoes blood and urine tests for early diagnosis of carbohydrate disorders.

Blood sugar levels in gestational diabetes

As I already said in the article, in order to make a diagnosis of Gestational Diabetes, you need to conduct a special analysis - an oral glucose tolerance test. Based on the results of this test, you can accurately diagnose and choose the right management tactics.


I also said there that during pregnancy not only gestational diabetes can occur, which is caused directly by the state of pregnancy, but also manifest diabetes mellitus, which is caused by other reasons, and pregnancy only provoked its development.
The difference between these types is that gestational diabetes is more sluggish and goes away after childbirth, and with overt diabetes, glycemic indicators are higher, the clinical picture is more pronounced, and it remains forever and does not disappear with childbirth.
Below you can see a table that displays diagnostic indicators for gestational diabetes. Anything that exceeds these indicators indicates manifest diabetes mellitus type 1 or 2. Click to make it larger.


So, you see that the diagnosis of “Gestational diabetes mellitus (GDM)” is made when fasting sugar is above 5.1 mmol/L, but less than 7.0 mmol/L.
After the glucose test, after 1 hour, blood glucose should not exceed 10.0 mmol/L, and after 2 hours - no more than 8.5 mmol/L.
What are the normal indicators for a pregnant woman I mentioned in the article. I recommend reading it.

How to properly take an analysis (test) for latent diabetes in pregnant women

The test is performed at 24-26 weeks of gestation. First of all, you need to wait for a 10-12 hour period of fasting and get a good night's sleep the night before. No smoking. For the procedure you will need 75 grams of glucose powder and 200 ml of warm water.

1. First, fasting blood sugar is tested
2. After this, dissolve the glucose powder in the brought water and drink it.
3. We sit down in a chair or on a couch in the laboratory reception area and don’t go anywhere.
4. After 1 and 2 hours we donate blood from a vein again.
5. After the third fence you can be free.

Treatment and diet for gestational diabetes in pregnant women

In some cases, nutrition and dieting are already powerful tools in the treatment of gestational diabetes. During pregnancy, all tablet medications are contraindicated, so the only way to lower blood sugar, besides diet, is insulin injections.


But in most cases, it is possible to do without it only by properly adjusting your diet, creating a rational menu, and also increasing feasible physical activity in the form of walking, for example.

Only a few are prescribed insulin and only in two cases:

• failure to achieve target glycemic values ​​within 1-2 weeks with diet alone
• presence of signs of fetal distress according to ultrasound data

What is the diet and nutrition of a woman with diabetes?

While a low-carbohydrate diet is an effective method to normalize blood sugar in a non-pregnant woman, this method is not suitable for a pregnant woman.


Such a woman should not completely deprive herself of carbohydrates, as this will lead to the formation of ketone bodies, which can negatively affect the development of the fetus. But there are still some restrictions. These restrictions are imposed on carbohydrates with a high glycemic index, namely any sweets, bread and flour, potatoes, cereals, sweet fruits (banana, persimmon, grapes).

What can you eat if you have gestational diabetes during pregnancy?

All types of meat and fish, any vegetables except potatoes, whole grains, seasonal local fruits and berries, nuts, mushrooms, and herbs are allowed. Maintain the following protein/fat/carbohydrate ratio. It is important to get high-quality proteins and healthy fats, both plant and animal in equal proportions.

• proteins 30 – 25%
• fats 30%
• carbohydrates 40 – 45%

Various cooking sites offer many recipes and menus, so I won’t go into more details. In addition, it is not always possible to satisfy the tastes of an audience of thousands of blog readers.

What should a pregnant woman's sugar level be (normal)

How do you know if you're doing everything right? Frequent monitoring of blood glucose will help you with this. Be sure to check your blood sugar before each meal, as well as 1 hour after eating; after 2 hours you don’t have to check it. If necessary, you will have to check your sugar at night at 2-3 o'clock.

• fasting sugar should be less than 5.1 mmol/l
• 1 hour after eating should not exceed the level of 7.0 mmol/l
• before going to bed and at night, sugar should be no more than 5.1 mmol/l
• the level of glycated hemoglobin should not be more than 6.0%

Tactics for managing women after childbirth

If a woman has received insulin therapy, then immediately after childbirth this insulin is discontinued. During the first three days, blood glucose is monitored to identify disturbances in carbohydrate metabolism. If your sugar is normal, then you can be calm.
All women who have had GDM should be monitored because they are at increased risk of recurrent GDM or developing type 2 diabetes in the future.

• after 6-12 weeks, a repeat glucose test is performed, only in its classic version (sugar is checked only on an empty stomach and 2 hours after exercise)
• It is recommended to adhere to a low-water diet (but not ketosis) in order to lose weight, if any.
• increased physical activity
• planning subsequent pregnancies

That's all for me. Good sugars and easy labor. Click on the social buttons. networks if you liked the article and found it useful. so as not to miss the release of new articles. See you again!

With warmth and care, endocrinologist Lebedeva Dilyara Ilgizovna

Gestational diabetes mellitus occurs rarely during pregnancy. Usually, a woman is already diabetic before conception or has hidden metabolic disorders with improper absorption of sugar and insulin.

But it happens that problems begin precisely with the onset of pregnancy. What to do if, according to test results, a pregnant woman’s glucose levels are exceeded for the first time in her life and repeated examinations only confirm the diagnosis?

What is gestational diabetes mellitus?

Diabetes mellitus is an endocrine disease in which the pancreas stops functioning properly. It insufficiently secretes the hormone insulin, which inevitably leads to an increase in blood sugar.

Why does such a “breakdown” occur in the body of a pregnant woman?

Hormones that help the placenta develop can reduce the effectiveness of insulin. Gestational diabetes appears when the body is no longer able to produce insulin itself and use it as much as necessary during the period of bearing a baby.

Glucose levels begin to rise.

True, the true cause of gestational diabetes mellitus in pregnant women has not yet been identified.

If a woman is over 40 years old, she smokes or her relatives are diabetics, there is a chance that gestational diabetes will not bypass her.

It is also surprising that African and Hispanic women, Indian and Asian women are more susceptible to the disease compared to white women.

What are the indicators of gestational diabetes during pregnancy?

If fasting glucose is 5.8 mmol/l and higher (blood from a finger), an hour after eating - 10 mmol/l, after 2 and 3 hours - 8,6 And 7,8 mmol/l, respectively, is at least a good reason to retake the test to eliminate the possibility of error.

If in a random study the indicator exceeds 10 mmol/l- a woman also automatically falls into the risk zone.

The examination should be carried out between 24 and 28 weeks, and if pathology is suspected, a special test is prescribed that will confirm or deny the presence of gestational diabetes mellitus in the pregnant woman.

The symptomatic picture of the disease is usually erased. Women may not feel any obvious signs of pathology, and only tests can reveal the presence of gestational diabetes.

How to treat?

If the diagnosis of gestational diabetes is confirmed, the doctor will prescribe treatment for the pregnant woman. In most cases, it comes down to adjusting your lifestyle and diet.

These measures are usually enough to successfully carry and give birth to a child.

• Healthy diet with gestational diabetes mellitus and reasonable physical activity(yoga for pregnant women, swimming, brisk walking) will help not only control blood glucose levels, but also reduce them.

• Physical activity will increase the flow of oxygen into the blood, which will have a beneficial effect on the child’s condition and metabolism. About the benefits of walking in the article Walking during pregnancy >>>

And you can say goodbye to extra pounds during training. The main thing is that the classes are fun and the loads are feasible.

Measurements are taken four times in a day. First on an empty stomach, and during the day - a couple of hours after each meal. Your doctor should determine your target blood sugar range.

If the treatment plan prescribed by the doctor does not bring results and the sugar level for gestational diabetes mellitus is still high, insulin tablets or injections may be prescribed.

As a rule, this happens only in rare cases.

It is important not to neglect the advice of a specialist, because if you let the pathology take its course, complications may arise and fetal abnormalities may develop.

Excess glucose will accumulate in the baby's body, turning into fat, which can cause damage to the humerus bones during the birth process.

In addition, glucose, which comes to the baby in large quantities from the mother, forces the baby’s pancreas to work hard to eliminate excess sugar.

Such children are often born with low glucose levels and high weight. They have breathing problems and are at greater risk of developing diabetes and becoming obese in the future.

A pregnant woman may develop preeclampsia, a serious complication of pregnancy.

In most cases, after childbirth there is no need to take antidiabetic drugs, and glucose levels return to normal.

Diet for gestational diabetes mellitus

Gestational diabetes mellitus during pregnancy can be easily corrected with a specially selected diet. Here are the basic principles of nutrition:

1. There should be more carbohydrates and fats in a pregnant woman’s diet than proteins: 40–45% and 30%, respectively. You shouldn’t suddenly give up carbohydrates after diagnosis.
2. We replace easily digestible carbohydrates with complex ones. A low-carbohydrate diet will only do harm: ketone bodies will begin to form in the blood, which is dangerous for the fetus.
3. 20–25% of the diet comes from proteins. Important article about meat during pregnancy >>>
4. The caloric content of food depends on the BMI of the pregnant woman.

With normal weight, women create a menu based on 30 kcal/kg. If you have an excess BMI, you will have to eat more modestly: 25 kcal/kg is acceptable. For obesity, it is recommended to create a diet so that you consume 15 kcal/kg.

1. You need to eat little by little, at intervals of 2-3 hours. Avoid long breaks between meals. Take care of a full breakfast, lunch, afternoon snack and dinner and a few light snacks.
2. Avoid:

• Sahara;
• jam;
• semolina;

Sweeteners are also prohibited, as they are harmful to the baby.

1. Exclude from your menu:

• margarine;
• mayonnaise;
• smoked meats and semi-finished products;
• fat meat;
• high fat dairy products.

1. You can diversify your menu for gestational diabetes with the following products:

• vegetables and herbs, raw, boiled, baked, stewed;
• berries;
• dried fruits;
• fruits, except grapes and dates.

1. You can allow yourself in reasonable quantities:

• pasta from durum wheat;
• low-fat dairy products (less than 4%), including cheese;
• lean meat and fish;
• boiled eggs;
• skinless chicken;
• legumes;
• bread with bran.

A pregnant woman should drink up to 1.5 liters of clean drinking water per day. For drinks, give preference to berry fruit drinks and freshly squeezed juices.

1. It is acceptable to drink several cups of tea and coffee a day without adding sugar.

Important! It is advisable to follow a diet for gestational diabetes mellitus in pregnant women for another 2 months after birth. This is necessary to prevent the development of full-blown type 2 diabetes.

Sample menu for the day

Having learned about food restrictions, many pregnant women get upset and exclaim, they say, what to eat then if almost everything from the usual diet is prohibited.

Here's what a sample daily menu looks like for a woman with gestational diabetes:

And in order to prevent pathology, try to lead a healthy lifestyle both before and during pregnancy. Proper nutrition, physical activity, adequate sleep and regular walks will reduce the risk of developing diabetes to zero.

Have a nice pregnancy and easy birth!

Gestational diabetes is a type of disease that occurs only in pregnant women. Its appearance is explained by the fact that a carbohydrate metabolism disorder occurs in the body of the expectant mother. Pathology is often diagnosed in the second half of the term.

How and why gestational diabetes occurs during pregnancy

The disease develops due to the fact that the female body reduces the perception of tissues and cells to its own insulin.

The reason for this phenomenon is said to be an increase in the level of hormones in the blood that are produced during pregnancy.

During this period, sugar decreases due to the fact that the fetus and placenta need it.

The pancreas begins to produce more insulin. If the body does not have enough of it, gestational diabetes mellitus develops during pregnancy.

In most cases, after the birth of a child, a woman's blood pressure returns to normal.

Studies in the United States show that this disease develops in 4% of pregnant women.

In Europe, this figure ranges from 1% to 14%.

It is worth noting that in 10% of cases, after the birth of a baby, signs of pathology develop into type 2 diabetes mellitus.

Consequences of GDM during pregnancy

The main danger of the disease is that the fruit is too large. It can be from 4.5 to 6 kilograms.

This can lead to a difficult birth, during which it will be necessary. Large children have an increased risk of obesity later in life.

Even more dangerous consequences of diabetes in pregnant women include an increased risk of developing diabetes.

This complication is characterized by high blood pressure, a large amount of blood, and swelling.

All this poses a threat to the life of mother and child. Sometimes doctors have to be called.

If the fetus is overweight, breathing problems may develop and muscle tone decreases. The sucking reflex is also suppressed, swelling and jaundice appear.

This condition is called diabetic fetopathy. It can lead in the future to heart failure and retardation in mental and physical development.

What causes gestational diabetes

This disease is more likely to occur in women with:

• extra pounds;
• carbohydrate metabolism disorders;
• diseases of the cardiovascular system;
• heavy;
• carrying twins or triplets;
• GDM in previous pregnancies.

The age of the expectant mother also influences the development of the disease. Most often it occurs in women giving birth over 30 years of age. The cause of the pathology can also be diabetes in one of the parents.

The birth of a previous child can also influence the formation of pathology. The fetus could be overweight or stillborn.

Chronic miscarriage from previous pregnancies may also be affected.

Diagnosis of the disease

A diagnosis of gestational diabetes mellitus during pregnancy indicates that blood glucose levels were normal before conception.

Symptoms

There are no main symptoms of gestational diabetes mellitus during pregnancy.

The disease can also manifest itself with frequent urination. But you shouldn't rely too much on these symptoms.

Laboratory readings

To perform a glucose tolerance test, blood is taken several times over a couple of hours. Next, a study is carried out using a solution of 50, 75 or 100 grams of glucose.

When carrying a child, a woman should have a fasting level of 5.1 mmol/l. An hour after eating - 10 mmol/l. And after two - 8.5 mmol/l.

If the indicator is higher, then a diagnosis is made - gestational diabetes mellitus during pregnancy.

Once the disease is detected, you will need to monitor your blood pressure and kidney function.

To check for violations, additional and are prescribed.

Your doctor may recommend purchasing a blood pressure monitor to measure your blood pressure at home.

Principle of treatment of GDM in pregnant women

At the first signs of gestational diabetes during pregnancy, the main treatment is prescribed - diet.

If necessary, it is supplemented with insulin injections. The dose is calculated individually.

For this disease, doctors mainly prescribe.

If a disease is detected, the patient should be monitored by an endocrinologist and a nutritionist. If she experiences psychological outbursts, it would be a good idea to consult with a psychologist.

It is important to remember that you should not take medications that lower your sugar.

Diet and daily routine during pregnancy with GDM

During the diet, the caloric content of the diet decreases.

You need to eat 5-6 times in small portions or eat main portions 3 times a day, making snacks 3-4 times between them.

Main courses include soups, salads, fish, meat, cereals, and snacks include vegetables, fruits, various desserts or low-fat dairy products.

When choosing food products, the expectant mother needs to ensure that her baby receives the microelements necessary for its development. Therefore, if a pregnant woman decides to create a menu herself, then she should study information about how people with type 1 and type 2 diabetes eat.

During the diet, carbohydrates should be replaced with proteins and healthy fats.

For the entire period of bearing the baby, it is necessary to exclude sweets, bread, buns, pasta and potatoes from the diet. You should also avoid rice and some types of fruits.

Dishes must be simple. This will help avoid overloading the pancreas.

Try to eat as little fried food, canned food, and everyone’s favorite fast foods as possible. It is worth giving up semi-finished products.

Calorie intake per day

Typically this is 35-40 calories per kilogram of a woman's weight. For example, if her weight is 70 kg, then the norm will be 2450-2800 kcal.

It is advisable to keep a food diary throughout the entire period. This can track at the end of the day whether the norm has been exceeded.

If you feel hungry between meals, you should drink water in small sips. Every day you should drink at least 2 liters of ordinary water.

Course of labor and postpartum control in GDM

Types 1 and 2 diabetes are not contraindications to labor; therefore, even with GDM, delivery occurs without problems.

The only risk is an overly large fetus, which may require a caesarean section.

Independent childbirth is allowed if the situation has not worsened over the past 24 hours.

Only if there are no natural ones or the pregnant woman is past her due date.

After birth, your baby may have low blood sugar. It is compensated by nutrition.

Medication treatment is often not required.

For some time the child will be under the supervision of doctors. This is necessary to identify whether there are any disorders due to glucose failure in the mother.

Usually, after the placenta is delivered, the woman’s condition returns to normal. There are no spikes in blood glucose levels. But still, during the first month, you need to stick to the diet that was before the birth of the child.

It is better to plan the next birth only after a couple of years. This will help the body recover and prevent the occurrence of serious pathologies.

Before conception, you should undergo an examination and tell your gynecologist about GDM during your first pregnancy.

The appearance of this disease during pregnancy indicates that the woman has poor sensitivity to insulin. This increases the risk of developing diabetes and vascular pathologies after childbirth. Therefore, it is important to prevent the disease.

After giving birth, at 6-12 weeks you need to take a sugar test again. Even if it is normal, it should be checked every 3 years in the future.

Video: gestational diabetes mellitus during pregnancy

Gestational diabetes (GD) is discovered during pregnancy when the patient's body is unable to cope with the additional demand for insulin production, resulting in elevated blood glucose levels.

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

We will consider the symptoms and signs of diabetes during pregnancy in our material.

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

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

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

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

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

Glucose present in the blood crosses the placenta to reach the fetus. If HD is left untreated, the fetus is exposed to excess glucose, resulting in an increase in the amount of insulin produced by the unborn baby.

Because insulin stimulates growth, this means the baby may be born larger. Once the baby is born, exposure to excess glucose stops. However, the newborn still has increased insulin production, i.e. baby is susceptible to low blood glucose levels.

The likelihood of developing HD during pregnancy is higher if:

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

When does the doctor suspect such a diagnosis?

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

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

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

For most women, gestational diabetes does not cause any noticeable signs or symptoms.

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

These symptoms usually disappear after childbirth.

Possible complications of HD

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

Important! Changes in diet and physical activity. activities are needed to control glucose levels even when treated with medications.

Usually Insulin injections are indicated for patients.

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

Breakfast

• A bowl of whole grain cereal, porridge (buckwheat/oatmeal), with semi-sweet milk or
• 2 toasts with tomatoes and jam or
• Low fat and sugar yogurt and fruit.

Dinner

Dinner

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

Basically, you should follow three simple rules:

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

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

Conclusion

Gestational diabetes usually goes away after delivery. Eating right and exercising are still important factors in maintaining your health after childbirth. Your child's lifestyle should also be correct.

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