Diabetes and Pregnancy: Gestational diabetes Diabetes combined with pregnancy
Classification
Pregnancy in Pregnancy Diabetes:Pregnancy in Type 1 and Type 2 Diabetes
Gestational diabetes mellitus (GDM)
Gestational hypoglycemia (GIGT): a high risk factor for later conversion to GDM (about 1/3 GIGT)
Gestational diabetes mellitus
Higher fasting and postprandial glucose than in normal pregnancy, with increased insulin resistance and decreased insulin sensitivity
Higher lipid and amino acid concentrations than in normal pregnancy, especially triglyceride levels
Type 1 diabetes combined with pregnancy
Hyperglycemia, hyperinsulinism and hyperlipidemia during fasting and postprandial periods due to insulin deficiency or lack of insulin
Increased rate of hypoglycemia during insulin therapy compared to non-pregnant type 1 diabetic women, which is associated with a further impairment in the ability of pregnant women with type 1 diabetes to counteract and regulate the hypoglycemic response
Normal metabolic changes in pregnancy have a tendency to cause diabetes
The combination of diabetes mellitus and pregnancy can lead to further disturbances in the metabolism of various substances, resulting in adverse effects on the mother and child.
Normalization of metabolic status reduces maternal and child complications
Study of the mechanism of increased insulin resistance during pregnancy
As pregnancy increases, the amount of each hormone in the blood of pregnant women: cortisol, progesterone, placental lactogen (or chorionic lactogen, HPL or HCS), pituitary lactogen (PRL) and estrogen, increases gradually and parallels the gradual increase in anti-insulin power; the increase in the amount of these hormones reduces the sensitivity of target cells to insulin.
Administration of these hormones to non-pregnant women induces metabolic changes similar to those caused by impaired insulin action
The rate of insulin-mediated glucose uptake is significantly reduced in adipose and skeletal muscle tissue in the above hormonal environment; this reduction is more pronounced in an environment where multiple hormones are combined
Study on the mechanism of enhanced insulin resistance during pregnancy
After delivery of the fetus and placenta, the above hormones are no longer secreted, and the insulin resistance phenomenon is rapidly eliminated, leading to maternal and child complications.
Pregnancy with uncontrolled diabetes can lead to diabetic nephropathy, retinopathy, myocardial infarction, cerebral thrombosis, hypertension, amniotic fluid overload and urinary tract infection.
The prognosis of pregnant women with diabetes mellitus is related to their diabetes mellitus, and the prognosis is worse as the diabetes mellitus progresses, especially when it is complicated by renal, cardiovascular and other vascular complications.
Effect of pregnancy on diabetic nephropathy
Pregnancy can accelerate the deterioration of the disease: increased glomerular filtration rate; increased protein uptake; accelerated development and aggravation of hypertensive complications
Diabetic nephropathy itself is a progressive disease, and renal function will gradually deteriorate even in the absence of pregnancy
Although good metabolic control of diabetes can slow the progression of nephropathy, most opinions do not support pregnancy in women with this disease
Diabetic retinopathy
Nearly one third of pregnant women with type 1 diabetes have occult or proliferative retinopathy; approximately 4% of non-progressive retinopathy diagnosed at the beginning of pregnancy progresses to the proliferative form
Risk factors of pregnancy that accelerate the progression of the disease: hypercoagulable state during pregnancy; increased systemic small artery spasm and peripheral vascular resistance due to preeclampsia; increased diabetic microangiopathy; increased placental secretion of various anti-insulin hormones and renin and angiotensin secretion.
Treatment
Pregnant women with proliferative retinopathy may have adverse maternal and child outcomes and should not conceive or should terminate their pregnancies.
Early pregnancy planning can reduce the incidence of this complication; occult lesions are not a contraindication to pregnancy
Careful ophthalmic examination before pregnancy and fluorescein angiography if necessary, but contraindicated during pregnancy
If photocoagulation has been performed before pregnancy for proliferative lesions, the rate of vision loss can be reduced by 50% in those affected during pregnancy, and if there is no progression after pregnancy, pregnancy can be carried out or continued
Perinatal complications
Perinatal complications are most common in pregnant women with pre-pregnancy diabetes; in addition to congenital malformations, the incidence of perinatal complications is also more common in GDM and GIGT
The prognosis of the perinatal infant is related to the degree of metabolic control from preconception to pregnancy; moreover, it is related to the complication of vascular disease, which is worse if it has already occurred
With advances in diabetes treatment and prenatal monitoring, the mortality rate of recent pregnancies and perinatal infants (except for prenatal malformations) has approached that of normal pregnancies; however, perinatal morbidity is still common.
Perinatal complications
congenital malformations
huge babies
Stillbirth
increased incidence of neonatal hypoglycemia, hypocalcemia, magnesiumemia, hyperbilirubinemia and erythrocytosis, pulmonary hyaline membrane changes
Smaller babies, increased incidence of neonatal hypertrophic heart disease, spontaneous abortion and preterm birth, and later obesity, diabetes and impaired intellectual and behavioral development
Gestational diabetes mellitus (GDM)
A type of temporary diabetes mellitus that occurs for the first time after pregnancy or is diagnosed with varying degrees of poor carbohydrate tolerance
GDM occurs in a small number of pregnant women only when the islet ß-cells are severely damaged and there is severe insulin resistance.
Most GDM is reversible and disappears rapidly after delivery, with the ability to metabolize carbohydrates returning to pre-pregnancy status
GDM should not be included in cases of pre-pregnancy hypoglycemia that are exposed only after pregnancy, but it is extremely difficult to identify them.
Those who fail to return to normal one year after delivery should be reclassified
High risk factors for GDM
Family history of diabetes, especially first-degree relatives, mainly the mother
Gestational age 30 years
Obesity: actual weight above 120% of standard weight or BMI ≥ 27 kg/m2
History of unexplained recurrent miscarriage, stillbirth, or stillbirth
excessive amniotic fluid and large fetus in the current pregnancy
Symptoms of polyhydramnios, polyuria and polyphagia
Skin infection and mycosis vaginalis with recurrent episodes
Positive fasting morning urine glucose, especially if detected at 24-28 weeks of gestation
Screening for GDM Most people prefer universal screening
Screening period: 24-28 weeks of gestation for primary screening, 32-34 weeks of gestation for repeat screening
Judgment criteria: 1 hour after fasting oral glucose 50g, blood glucose value <7.2 (130mg/dl) can exclude GDM; 7.2mmol/L, then need to do 75g or 100g glucose 3 hours OGTT; for emergency cases, can be done at any time
GDM diagnosis
GDM screening measures (GCT) to identify the presence or absence of postprandial hyperglycemia ability is lower than OGTT. Because the relatively short cycle of 50g glucose load is difficult to reflect the changes in islet function after provocation
75g and 100g glucose 3-hour OGTT have similar rates of correctly diagnosing GDM, and both can be used as a basis for diagnosis
The OGTT should be preceded by an overnight fast of 8-14 hours, with no restriction on diet or exercise for the previous 3 days, sitting still, not smoking, and drinking water during the test
OGTT diagnostic criteria for GDM
Treatment of gestational diabetes
The aim of treatment is to ensure maternal health and normal fetal development
Blood sugar should be maintained at normal level, fasting blood sugar
≤5.8 mmol/L
2 hours postprandial blood glucose ≤6.7mmol/L, HbA1c<6%;
Each region should set its own normal level of OGTT
During treatment, hypoglycemia and ketosis should be avoided
Nutritional treatment (I)
In order to supply pregnant women and fetuses with adequate nutrition, it is necessary to reasonably
control the total calories.
The whole pregnancy is divided into three periods, the first period is from 1 to 3 months, and the second period is from 4 to 4 months.
The first period is from 1 to 3 months, the second period is from 4 to 6 months, and the third period is from 7 to 9 months.
The calorie intake in the first period is the same as before pregnancy. Starting from the second trimester
The calorie intake should be 38 Kcal/kg/day according to the pre-pregnancy ideal weight.
Even if gestational diabetes occurs in obese women, it is not considered
Weight loss during pregnancy. Weight gain during pregnancy should not
The weight gain during pregnancy should not exceed 12 kg.
Nutritional treatment (II)
Carbohydrate intake should be 200-300g/day, too little carbohydrate is prone to ketosis.
Increase the protein intake by 15-25g/day (including at least 1/3 of high quality protein).
Pregnant women should be encouraged to eat more fresh green vegetables for vitamin supplementation and pig liver and pig blood products for iron supplementation, as well as iodine-containing foods.
Total calories should be divided into five to six meals throughout the day, and small and frequent meals will help to control blood sugar steadily and reduce the chance of postprandial hyperglycemia and preprandial hypoglycemia.
Exercise therapy
Moderate exercise, suitable for pregnant women with GDM and type 2 diabetes
Emphasize the safety of exercise
Attention to individualization
Insulin therapy
When pregnant women’s blood glucose cannot be maintained in the normal range
Insulin therapy should be given
The insulin preparation should be genetically recombinant human insulin.
Short-acting human insulin should be injected three to four times a day. If necessary
If necessary, medium-acting insulin should be added once before bedtime to control the morning hyperglycemia.
Morning hyperglycemia
Oral hypoglycemic drugs should not be used
The principles of insulin therapy for GDM are different from those for non-pregnant diabetes
Postprandial hyperglycemia is much more common in GDM than in FPG, so it is advisable to treat with a combination of medium and short-acting agents.
Before 30 weeks of pregnancy, the metabolism is still unstable, insulin secretion and sensitivity to insulin are decreased, so the insulin requirement increases, and frequent blood glucose measurement is necessary to correct the dose; after 30 weeks of pregnancy, the glucose metabolism becomes stable, and the insulin requirement is relatively consistent.
Stop using medium-acting insulin preparations 3-7 days after delivery
After delivery, insulin dosage should be reduced to no use
Long-acting insulin should not be used during pregnancy
Blood glucose monitoring
Since the renal glucose threshold is lower in women during pregnancy, even
urine glucose can be positive even in the presence of normal blood glucose.
Therefore, urine glucose test cannot be used as an observation indicator, but should be tested
Blood glucose should be tested to understand the condition and adjust the treatment in time.
Blood glucose test can be checked at the hospital, or the patient can use the blood glucose meter to check and record by himself.
Monitoring the blood glucose value one hour after meal is better than before meal
Outpatient follow-up
Pregnant women with gestational diabetes must visit the obstetrics clinic regularly for checkups.
This includes checking for gestational hypertension and ultrasound in the third trimester.
Fetal size to determine the need to prepare for cesarean delivery
Pregnant women with gestational diabetes must also visit the diabetes clinic every one to two weeks to check their blood glucose and adjust their insulin levels.
The glucose should be checked at the diabetes clinic every 1 to 2 weeks, the insulin dose should be adjusted, and dietary guidance should be given.
Postpartum observation
The majority of gestational diabetes can stop insulin after delivery, only a few patients still need a small amount of insulin.
A 75g glucose tolerance test is performed 6 to 8 weeks after delivery to clarify the diagnosis of diabetes.
About 2% have type 2 diabetes, 8% have low glucose tolerance, and 60-70% have normal glucose tolerance.
More type 2 diabetes will be found after long-term observation
The Department of Endocrinology of Peking Union Medical College Hospital has followed up 30 cases of gestational diabetes for 20 years.
Among them, 25 cases had type 2 diabetes, 3 cases had normal OGTT and 2 cases were lost to follow-up.
Appropriate postpartum diet control and avoidance of obesity are the basic measures to prevent or delay the onset of type 2 diabetes mellitus.
Postpartum education of GDM
Explain the importance of maintaining proper weight and measuring OGTT once a year
Seek medical attention in case of hyperglycemia
Maintain the diet plan implemented in late pregnancy to meet the needs of breastfeeding
Encourage breastfeeding
Low-dose oral contraceptives are safe and effective for people with a history of GDM
Use adverse glucose metabolism medications with caution
Pre-conception planning for women with diabetes
Comprehensive assessment for vascular complications
Switch from oral hypoglycemic agents to insulin therapy
Adjustment of diet control
Knowledge and practice of self-monitoring and management of diabetes mellitus
Terminate contraception if well controlled and take BBT to determine conception date
Stop taking contraceptive pills 3 months before planned conception and replace them with instrumental contraception
Avoid ultrasound in early pregnancy without special indications
Fertility and spontaneous abortion
Normal fertility in diabetic women with well-controlled metabolism and no complications
The rate of spontaneous abortion in diabetic pregnant women with well-controlled blood glucose is similar to that of non-diabetic pregnant women
The rate of spontaneous abortion is significantly higher in early pregnancy when HbA1c levels are significantly elevated
Genetic predisposition to diabetes
Parents with type 1 diabetes have a 2% to 6% chance of passing the disease on to their offspring.
The incidence of diabetes in the offspring of pregnant women with type 2 diabetes is unclear and is associated with race, obesity, etc.
Pregnancy is not prohibited in women with diabetes
Congenital malformations
Good glycemic control before pregnancy and during early pregnancy can significantly reduce the rate of congenital malformations; however, it cannot absolutely guarantee the birth of a completely healthy child.
If the blood glucose control is poor, such as HbA1C is significantly increased in early pregnancy, the rate of congenital malformation is 10-25%.
For suspected congenital malformations, blood and amniotic fluid AFP and amniotic fluid AChE analysis should be performed to determine whether there are congenital open defects.
Ultrasound and color ultrasound can detect bone, central nervous system, cardiovascular and renal malformations; there is no measure for 100% diagnostic compliance
The participation of every diabetic woman of childbearing age in counseling, training and guidance before and throughout pregnancy is an important measure to reduce the rate of maternal and child complications in the near and long term after pregnancy
The importance of joint multidisciplinary guidance, education, awareness and training
The importance of mobilizing patients to actively participate and cooperate in various treatment plans before and after pregnancy, labor and delivery, postpartum, and long-term follow-up