Pregnancy after a diagnosis of diabetes is a combined pregnancy with diabetes. The first occurrence or detection of reduced glucose tolerance or diabetes during pregnancy is called gestational diabetes or diabetes during pregnancy. Patients with gestational diabetes may include a subset of patients with preexisting hypoglycemia or diabetes who are first diagnosed during pregnancy. The main risks of hyperglycemia during pregnancy are poor perinatal maternal and infant clinical outcomes and increased mortality, including development of type 2 diabetes in the mother, abnormal intrauterine fetal development, neonatal malformations, macrosomia (increased risk of comorbidities and trauma to the mother and infant during delivery) and increased risk of neonatal hypoglycemia. Generally speaking, the blood glucose level fluctuates a lot in diabetic patients with combined pregnancy, and blood glucose is more difficult to control, and most patients need to use insulin to control their blood glucose. On the contrary, gestational diabetes patients have relatively mild blood glucose fluctuations. Blood sugar is easy to control, and most patients can get satisfactory control of blood sugar through strict diet plan and exercise, only some patients need to use insulin to control blood sugar.
I. Screening for gestational diabetes
1. Pregnant women with high risk of diabetes mellitus: those with history of gestational diabetes mellitus, history of delivery of huge children, obesity, PCOS, family history of diabetes mellitus, positive fasting urine glucose in early pregnancy and history of multiple spontaneous abortions without obvious reasons, history of fetal malformation and stillbirth, history of delivery of neonatal respiratory distress syndrome, etc. should monitor blood glucose as early as possible if fasting blood glucose ≥7.0 mmoL/L and (or) random blood glucose If the fasting blood glucose is ≥11.1 mmol/L, the measurement should be repeated within 2 weeks. If the blood glucose remains so, diabetes during pregnancy can be diagnosed.
2. All pregnant women should have their blood glucose measured by 75g?OGTT at 24-28 weeks of gestation.
3.Diagnostic criteria of gestational diabetes: In 2013, WHO published “Diagnostic criteria and classification of hyperglycemia newly diagnosed during pregnancy”. The hyperglycemia found during pregnancy was divided into two categories: diabetes mellitus in pregnancy (diabetes mellitus in pregnancy) and gestational diabetes mellitus (gestational diabetes mellitus).
The diagnostic criteria for diabetes mellitus in pregnancy are consistent with the 1999 WHO diagnostic criteria for diabetes mellitus in the non-pregnant population, i.e. fasting blood glucose ≥ 7.0 mmol/L, or 2 h after OGTT blood glucose ≥ 11.1 mmo]/L. or random blood glucose ≥ 11.1 mmol/L at the time of obvious diabetic symptoms.
Pre-pregnancy preparation for diabetic women with planned pregnancy
1. Women with diabetes mellitus should plan pregnancy and take contraceptive measures before diabetes mellitus is satisfactorily controlled. Pregnant diabetic women should be informed of the importance of intensive glycemic control during pregnancy and the possible risks of hyperglycemia to mother and child.
2. Before planning a pregnancy, the following medical history should be carefully reviewed.
(1) Course of diabetes mellitus.
(2) Acute complications, including history of infection, ketoacidosis, and hypoglycemia.
(3) Chronic complications, including large and small vessel lesions and neurological lesions.
(4) Details of the treatment of diabetes mellitus.
(5) Other concomitant diseases and treatment.
(6) Menstrual history, reproductive history, and birth control history
(7) Support from family and workplace.
(3) Assessment of suitability for pregnancy by the diabetologist and obstetrician-gynecologist.
4. If pregnancy is planned, the following preparations should be made before conception.
(1) Comprehensive examination, including blood pressure, electrocardiogram, fundus, renal function, HbA1c.
(2) Stop using oral hypoglycemic drugs and switch to insulin for blood glucose control.
(3) Strictly control blood sugar and strengthen blood sugar monitoring. (3) Strictly control blood glucose and strengthen blood glucose monitoring. Control preprandial blood glucose at 3.9-6.5 mmol/L, postprandial blood glucose at 8.5 mmol/L or less, HbA1c at 7.0% or less (for those treated with insulin), and try to control it at 6.5% or less under the condition of avoiding hypoglycemia.
(4) Strictly control blood pressure below 130/80 mmHg. (5) Discontinue ACEI and ARB and replace with methyldopa or calcium antagonists.
(5) Discontinue statins and fibrate lipid-regulating drugs.
(6) Increase diabetes education.
(7) Quit smoking.
Management of diabetes mellitus during pregnancy
The diagnosis of diabetes mellitus during pregnancy should be made as early as possible, and after the diagnosis is confirmed, the management of diabetes mellitus combined with pregnancy should be carried out as soon as possible. 1 to 2 weeks for a consultation.
2.Targeted diabetes education according to the cultural background of pregnant women.
3.Diet control standard during pregnancy: it can ensure the energy needs of pregnant women and fetus, but also maintain blood sugar in the normal range, and no starvation ketosis. Choose carbohydrates with low glycemic index as much as possible. For those who use insulin, the type and quantity of carbohydrates should be selected according to the dosage and form of insulin. A small number of meals should be implemented, divided into 5 to 6 meals per day.
4. Encourage to check fasting and pre-meal glucose, 1-2 h post-meal glucose and urinary ketone bodies by SMBG as much as possible. If possible, fasting and postprandial blood glucose should be measured 4 to 6 times a day. The goal of blood glucose control is fasting, pre-meal or bedtime blood glucose 3.3-5.3 mmol/L, 1 h after meal ≤ 7.8 mmoL/L; or 2 h after meal blood glucose ≤ 6.7 mmol/L; HbA1c should be controlled below 6.0% as much as possible.
5. Avoid using oral hypoglycemic drugs, and use insulin therapy when blood sugar cannot be controlled through diet therapy. Human insulin is better than animal insulin. Preliminary clinical evidence
shows that the fast-acting insulin analogs lysergic insulin, menthol insulin and detergent insulin are safe and effective for use during pregnancy.
6. When urine is positive for ketones, blood glucose should be checked (because the renal glucose threshold of pregnant women has decreased, urine glucose cannot accurately reflect the blood glucose level of pregnant women), if blood glucose is normal, consider starvation ketosis, increase food intake in a timely manner, and if necessary, administer an appropriate amount of glucose intravenously under the condition of monitoring blood glucose. If ketoacidosis occurs, treat according to the principles of ketoacidosis treatment.
7.Blood pressure should be controlled below 130/80 mmHg.
8.Renal function, fundus and lipid testing should be performed every 3 months.
9.Strengthen the monitoring of fetal development and routine ultrasound examination to understand the fetal development.
10.Method of delivery: Diabetes is not an indication for cesarean delivery, and vaginal delivery is possible without special circumstances. However, if other high-risk factors are combined, elective cesarean delivery should be performed or the indication for cesarean delivery should be relaxed.
11.Strengthen blood glucose monitoring during and after delivery to maintain good blood glucose control.
Management of diabetes mellitus after delivery
1. The need for insulin will be significantly reduced after delivery for those with diabetes combined with pregnancy. Attention should be paid to blood glucose monitoring, reducing the amount of insulin at the appropriate time to avoid hypoglycemia. The management of diabetes mellitus is the same as that of general diabetic patients.
2. Most of those who use insulin in gestational diabetes can stop using insulin after delivery and continue to monitor blood glucose. Those with normal blood glucose after delivery should have a 75 g?OGTT 6 weeks after delivery to re-evaluate glucose metabolism and have a lifelong follow-up.
V. Special problems in combined diabetes mellitus and pregnancy
1. Retinopathy: Diabetic retinopathy can be aggravated by pregnancy. Gradual glycemic control and prophylactic fundus photocoagulation prior to pregnancy (for those with indications) may reduce the risk of exacerbation of diabetic retinopathy.
Hypertension: Both preexisting hypertension and hypertension complicated by pregnancy can aggravate the existing diabetic complications in pregnant women. Blood pressure should be strictly controlled during pregnancy. ACEI, ARB, B-blockers and diuretics should be avoided.
3. Diabetic nephropathy: Pregnancy can aggravate existing kidney damage. In patients with mild nephropathy, pregnancy can cause temporary renal decompensation; in patients who already have more severe renal insufficiency [serum creatinine >265umol/L (3 mg/d1), or creatinine clearance <50ml/min], pregnancy can cause permanent damage to renal function in some patients. Renal insufficiency has adverse effects on the development of the fetus.
4. Neuropathy: Gastroparesis, urinary retention, poor defensive response to hypoglycemia and upright hypotension associated with diabetic neuropathy can further increase the difficulty of managing diabetes during pregnancy.
5. Cardiovascular pathology: Pregnancy increases the risk of death if underlying cardiovascular disease is not detected and managed. Evidence of cardiovascular disease should be carefully examined prior to pregnancy.
The evidence should be carefully examined and managed before pregnancy. Diabetic women with a desire to become pregnant should have cardiac function at a level that can tolerate exercise testing.
The above special circumstances require consultation with an obstetrician/gynecologist about termination of pregnancy.