Gestational diabetes mellitus (GDM), divided into two categories: PGDM (diabetes mellitus that was detected or did not occur before pregnancy) and GDM (diabetes mellitus that did not occur before pregnancy and occurred only during pregnancy).
Management of newborns with GDM: (1) check heel glucose within 30 minutes after birth; (2) pay attention to warmth and oxygen; (3) feed sugar water, open milk early, if blood glucose <2.2mM, intravenous infusion of 10% sugar water; (4) routinely check blood HB/blood potassium, calcium, magnesium, bilirubin; (5) pay attention to the occurrence of neonatal respiratory distress sign (NRDS), due to insufficient production of fetal lung surface active substance.
Timing of GDM termination: with low amniotic fluid, termination at 38-39 weeks is recommended, with OT for BIOSHOP score >6 and Pulbenecid for <6. < span="">
Elective cesarean delivery: 1 day before surgery without stopping with detergent insulin and discontinue all subcutaneous insulin on the day of surgery. Minimize preoperative starvation time, schedule morning surgery, and preoperative 10% sugar water sedation.
Vaginal trial of labor: stop all subcutaneous insulin after labor, measure blood glucose once every 2 hours during labor, maintain 4.4-9mM, and IV regular insulin according to the guidelines (increase 0.5U for every 2.2mM, 1U from 5.6, 2.5U from 12.2).
Admission criteria.
Personal management: diabetic diary, recording detailed types and portions of diet, exercise, number of fetal movements, special events (such as presence of contractions, bleeding, etc.)
I. PGDM criteria (1) Fasting plasma glucose (FPG) ≥7.0 mM during pregnancy (126). (2) 75 g oral glucose tolerance test (OGTT) with 2 h blood glucose ≥ 11.1 mmol/L (200 mg/dl). (3) Typical hyperglycemic symptoms or hyperglycemic crisis, along with random blood glucose ≥11.1 mM.(4) HbAlc ≥6.5%, specifically elevated by a variety of influences, HbAlc is not recommended for routine diabetes screening in pregnancy.
Risk factors for GDM include obesity (especially severe obesity), first-degree relative with type 2 diabetes mellitus (T2DM), history of GDM or delivery of a giant baby, polycystic ovary syndrome, and recurrent positive fasting urine glucose in early pregnancy. Fat sugar giant urinary bladder
FPG ≥5.1 mmol/L can be directly diagnosed and OGTT is not necessary; FPG <4.4 mmol/L (80 mg/dl) is very unlikely to occur and OGTT can not be performed temporarily; FPG ≥4.4 mmol/L and <5.1 mmol/L can not be performed temporarily. FPG≥4.4 mmol/L and <5.1 mmol/L, OGTT should be performed as soon as possible.
3, pregnant women with high risk factors for GDM, the first OGTT result is normal, if necessary, OGTT can be repeated in late pregnancy. 4, early and middle pregnancy with the increase of gestational weeks FPG level gradually decreases, especially in early pregnancy decreases significantly, therefore, early pregnancy FPG level can not be used as a basis for the diagnosis of GDM. If the first visit is after 28 weeks of gestation, it is recommended to have OGTT or FPG examination at the first visit or as soon as possible after the first visit if the person has not been examined regularly.
I. Blood glucose monitoring for pregnant women
1. Blood glucose monitoring methods: (1) Self-monitoring of blood glucose: Self-measurement of capillary whole blood glucose level by micro glucose meter. Newly diagnosed hyperglycemic pregnant women, those with poor or unstable glycemic control and those who apply insulin therapy during pregnancy should be monitored 7 times a day (large profile), i.e. 30 min before three meals, 2h after three meals and nocturnal blood glucose; 20150523 Prince Lotus Zhuhai lectures on the occurrence of hypoglycemia monitored by dynamic glucose meter, while reducing the insulin dosage of a certain PGDM (pre-serving insulin 56U per day) patient, 26- 26-26 (ultrashort)-28 (ditto) to 10-10-10-14.
2. For those with stable blood glucose (A2 level), the major profile test should be performed at least once a week, and the insulin dosage should be adjusted according to the blood glucose results; for those who do not use insulin therapy, it is recommended to monitor blood glucose at least once a week for the whole day, including the end fasting blood glucose and 2h after three meals, for a total of 4 times (for the minor profile) during the follow-up consultation. the number of times should be increased appropriately during the rapid fetal growth period from 28 to 34 weeks.
(2) Continuous ambulatory glucose monitoring: PGDM with unsatisfactory glycemic control or GDM pregnant women with obvious abnormal blood glucose requiring additional insulin.
Non-GDM pregnant women with some obstetric complications or obesity and tendency of huge baby, at what level of blood glucose control?
3. Measurement of HbAlc level: HbAlc reflects the average blood glucose level in the 2-3 months before blood sampling and is mostly used for the initial assessment of GDM. For pregnant women with diabetes mellitus treated with insulin, it is recommended to test once every 2 months.
Urine ketone body: timely detection of the lack of carbohydrate or energy intake of pregnant women, is also a sensitive indicator of early diabetic ketoacidosis, pregnant women with unexplained nausea, vomiting, fatigue and other discomfort or unsatisfactory blood glucose control should be monitored in a timely manner.
5. Urine glucose: urine glucose during pregnancy cannot really reflect the blood sugar level of pregnant women.
II. Monitoring of complications of pregnant women
The effect of diabetes mellitus: sugar ketone flu much high (pregnant women 7, sugar refers to postpartum T2DM up to 17-63%, re-pregnancy occurrence GDM 33-69%;), malignant flow distress low early size (distress low refers to neonatal) NRDS, neonatal jaundice, hypocalcemia, hypomagnesemia, hypertrophic cardiomyopathy.
Long-term effects on offspring: some suffer from type 2 diabetes, adolescent obesity, neuropsychological disorders. Neonatal cry distress jaundice, hypomagnesemia calcium sugar, cardiac hypertrophy sugar.
There are four types of diabetic coma: diabetic ketoacidosis coma, diabetic lactic acidosis, diabetic hyperosmolar coma, and insulin hypoglycemic coma
1, monitoring of hypertensive disorders in pregnancy: blood pressure and urine protein of pregnant women should be monitored during each pregnancy checkup.
2, monitoring of excessive amniotic fluid and its complications: pay attention to the uterine height curve and uterine tension of the pregnant woman, if the uterine height increases too fast or the uterine tension increases, promptly check the amount of amniotic fluid by B ultrasound.
3.Monitoring of DKA symptoms: If there is unexplained nausea, vomiting, weakness, headache or even coma during pregnancy, check the blood sugar and urine ketone body level, and perform blood gas analysis if necessary to clarify the diagnosis.
4, monitoring of infection: pay attention to whether pregnant women have increased leucorrhea vulvar itching, urinary urgency and frequency, painful urination and other manifestations, regular routine urine tests.
5.Thyroid function monitoring: perform thyroid function test if necessary to understand the thyroid function of pregnant women.
6.Other complications: In cases of diabetes mellitus with microangiopathy combined with pregnancy, renal function, fundus examination and lipid testing should be performed in the early, middle and late stages of pregnancy respectively.
Fetal monitoring
1. Monitoring of fetal development: prenatal screening of the fetus by ultrasound is applied in the middle of pregnancy. For pregnant women whose blood sugar is not controlled in the early stage of pregnancy, it is especially important to apply ultrasound to check the development of fetal central nervous system and heart, and fetal echocardiography is recommended if available.
2. Monitoring of fetal growth rate: Ultrasound examination should be performed every 4-6 weeks during late pregnancy to monitor fetal development, with special attention to monitoring changes in fetal abdominal circumference and amniotic fluid volume.
Evaluation of fetal intrauterine development: pregnant women in late pregnancy should pay attention to monitoring fetal movement. For those who need insulin or oral hypoglycemic drugs, non-stress test (NST) should be performed once a week from the 32nd week of pregnancy. The fetal growth restriction should be monitored closely especially if it is suspected.
4. Promote fetal lung maturation: If the glucose control during pregnancy is unsatisfactory and early termination of pregnancy is required, fetal lung maturation should be promoted 48 h before the planned termination of pregnancy. If possible, amniocentesis should be performed to extract amniotic fluid to understand the maturity of fetal lung, and intra-amniotic injection of dexamethasone 10 mg or intramuscular injection should be given, but the latter should be followed by monitoring the change of maternal blood glucose.
I. Pre-pregnancy (i) General recommendations
Pre-pregnancy counseling is recommended for all women with diabetes, impaired glucose tolerance (IGT) or impaired fasting glucose (IFG; i.e., prediabetes) who are planning to become pregnant. For example, diabetic retinopathy (DR), diabetic nephropathy (DN), neuropathy and cardiovascular disease. Chronic complications of diabetes may worsen during pregnancy and need to be re-evaluated during pregnancy screening.
The likelihood of GDM in a second pregnancy is 30%-50%, therefore, for those who plan to have a pregnancy more than 1 year after delivery, it is best to have OGTT before the planned pregnancy, or at least early in the pregnancy. if the blood glucose is normal, OGTT is still needed at 24-28 weeks of gestation (level B evidence).
In addition to hyperglycemia, abnormal feeding due to early pregnancy reactions (e.g. morning sickness) may also increase the risk of hypoglycemia.
(ii) Evaluation of diabetic complications
1. DR: Patients with diabetes should undergo an eye examination when pregnancy is planned or definite and be evaluated for risk factors that may aggravate or contribute to the progression of DR. When there is an indication, such as proliferative DR, taking laser treatment can reduce the risk of aggravation of DR lesions. Fundus changes should be closely followed during pregnancy until 1 year postpartum (Level B evidence. Good glycemic control before and during pregnancy may prevent progression of the disease.
2. DN: Pregnancy can cause temporary hyperalgesia in patients with mild DN. Renal insufficiency has adverse effects on fetal development; in patients with more severe renal insufficiency (serum creatinine >265 umol/L), or with creatinine clearance <50 ml/( min. 1.73 m2), pregnancy can cause permanent impairment of renal function in some patients. Therefore, pregnancy is not recommended for this group of patients. DN with normal renal function has less impact on renal function if glucose control is ideal during pregnancy.
3. other complications of diabetes mellitus: diabetic neurological related lesions including gastroparesis, urinary retention and postural hypotension can further increase the difficulty of diabetes mellitus management during pregnancy. If underlying cardiovascular disease is not identified and managed, pregnancy can increase the patient’s risk of death, and evidence of cardiovascular disease should be carefully examined and managed prior to pregnancy. Women with diabetes who are planning to become pregnant should have cardiac function at a level that can tolerate exercise testing.
(iii) Rational use of pre-pregnancy medications
Medications contraindicated during pregnancy, such as angiotensin-converting enzyme inhibitors (ACEI) and angiotensin II receptor antagonists, should be discontinued before pregnancy in women with PGDM. The use of ACEI drugs in early pregnancy does not increase the risk of fetal congenital heart disease, but ACEI and angiotensin II receptor antagonists are contraindicated in mid and late pregnancy (level Evidence).
In pregnant women with diabetes mellitus combined with chronic hypertension, the goal of blood pressure control during pregnancy is 110-129 mmHg systolic (1 mmHg=0.133kPa) and 65-79 mmHg diastolic. available evidence indicates that the application of labetalol and calcium channel blockers in early pregnancy does not significantly increase the risk of fetal teratogenesis and can be applied before and during pregnancy.
2.Multivitamin containing folic acid should be supplemented before pregnancy and early pregnancy in diabetic patients.
3.Patients with T2DM who apply metformin need to consider the possible benefits or adverse effects of the drug. If the patient is willing, the application can be continued under the guidance of the physician.
(iv) Blood sugar control before pregnancy
The risk of miscarriage and fetal malformation in early pregnancy is significantly increased in pregnant women with diabetes mellitus who have unsatisfactory blood glucose control; ideal blood glucose control before and after pregnancy can significantly reduce the above risk, but there is no definite blood glucose threshold standard to reduce the above risk.
Diabetic patients planning pregnancy should try to control their blood glucose so that HbAlc is <6.5%, and HbAlc can be <7% for those using insulin (level B evidence).
II. Pregnancy
(i) Medical nutrition therapy
The purpose of medical nutrition therapy is to keep the blood sugar of pregnant women with diabetes mellitus within the normal range, to ensure the reasonable nutritional intake of pregnant women and fetuses, and to reduce the occurrence of maternal and fetal complications. Once the diagnosis of GDM is confirmed, medical nutrition therapy and exercise instruction should be given to the patient immediately, and education on how to monitor blood glucose should be provided. After medical nutrition therapy and exercise instruction, if the FPG and 2h postprandial glucose are still abnormal, insulin is recommended to be applied promptly.
(B) Recommended nutritional intake
The total daily energy intake should be determined according to the body mass before pregnancy and the growth rate of body mass during pregnancy. Although it is necessary to control the total daily energy intake of pregnant women with diabetes, excessive energy restriction should be avoided, ensuring that it is not less than 1 500 kcal/d (1 kcal=4.184 kj) in early pregnancy and not less than 1 800 kcal/d in late pregnancy. insufficient carbohydrate intake may lead to the development of ketosis, which may have adverse effects on both the pregnant woman and the fetus.
2. Carbohydrates: The recommended dietary carbohydrate intake should account for 50%-60% of the total energy, with a daily carbohydrate intake of no less than 150 g. Avoid sucrose and other refined sugars, and give preference to low glycemic index foods when choosing equivalent carbohydrate foods. Monitoring the carbohydrate intake is a key strategy to achieve the glycemic control standard. When only total carbohydrates are considered, glycemic index and glycemic load may be more helpful for glycemic control (level B evidence).
3. Protein: The recommended dietary protein intake is 15%-20% of total energy, and metabolic waste is more harmful when excessive.
4. Fat: The recommended dietary fat intake is 25%-30% of total energy. However, foods with high saturated fatty acid content, such as animal fats, red meat, coconut milk, full-fat dairy products, etc., should be appropriately restricted, and the intake of saturated fatty acids for pregnant women with diabetes should not exceed 7% of the total energy intake; while monounsaturated fatty acids, such as olive oil and camellia oil, should account for more than 1/3 of the energy supplied by fat. Reducing the intake of trans fatty acids can lower LDL cholesterol and increase HDL cholesterol levels.
5, dietary fiber: is not energy-producing polysaccharides. Pectin in fruits, algae gum in kelp and nori, guanidine gum in some beans and konjac flour have the function of controlling the rise of blood sugar after meals, improving glucose tolerance and lowering blood cholesterol. The recommended daily intake is 25-30 g. The diet can be rich in dietary fiber such as oatmeal, wheat noodles and other coarse grains, as well as fresh vegetables, fruits, algae food, etc.
6, vitamins and minerals: during pregnancy, the need for iron, folic acid and vitamin D increases by a factor of one, the need for calcium, phosphorus, thiamine and vitamin B6 increases by 33%-50%, the need for zinc and riboflavin increases by 20%-25%, and the need for vitamin A, B12, C, selenium, potassium, biotin, niacin and total daily energy increases by about 18%.
Therefore, it is recommended that foods rich in vitamin B6, calcium, potassium, iron, zinc and copper, such as lean meat, poultry, fish, shrimp, dairy products, fresh fruits and vegetables, be increased systematically during pregnancy.
7. Use of non-nutritive sweeteners: The five FDA-approved non-nutritive sweeteners are potassium acetyl sulfonate, aspartame, neotame, edible saccharin and sucralose.
(iii) Reasonable arrangement of meals
Small and frequent meals, regular and quantitative meals are very important for blood sugar control. The energy of breakfast, lunch and dinner should be controlled at 10%-15%, 30% and 30% of the total daily energy intake, and the energy of each additional meal can account for 5%-10% to help prevent excessive hunger before meals.
The process of medical nutrition therapy should be closely coordinated with insulin application to prevent the occurrence of hypoglycemia. Meal plan must be individualized, and reasonable meal arrangement and corresponding nutrition education should be carried out according to cultural background, lifestyle, economic condition and education level.
( D ) exercise therapy of GDM
The role of exercise therapy: exercise therapy can reduce basal insulin resistance during pregnancy, and moderate intensity exercise after 30 min of each meal has no adverse effect on mother and child.
2, the method of exercise therapy: choose a low to moderate intensity aerobic exercise (also known as endurance exercise), mainly refers to the body’s large muscle groups to participate in continuous exercise. Walking is a simple aerobic exercise commonly used.
3, the duration of exercise: can start from 10 min, gradually extended to 30 min, which can be interspersed with the necessary intervals, it is recommended that the exercise after meals.
4, the frequency of exercise: the appropriate frequency is 3-4 times / week.
5, exercise treatment precautions: (1) exercise before the electrocardiogram to exclude cardiac disorders, and need to confirm the presence of macrovascular and microvascular complications. (2) Contraindications to exercise therapy for GDM: type 1 diabetes combined with pregnancy, heart disease, retinopathy, multiple pregnancy, cervical insufficiency, preterm labor or miscarriage, fetal growth restriction, placenta praevia, hypertensive disease during pregnancy, etc.
(3) Prevent hypoglycemic reaction and delayed hypoglycemia: eat for 30 min before exercising, limit the duration of exercise to 30-40 min each time, rest for 30 min after exercise, and stop exercising if the blood glucose level is <3.3>13.9 mmol/L. Carry cookies or candies with you when you exercise, so that you can eat them in time when there are signs of hypoglycemia.
(4) Seek medical attention if the following conditions occur during exercise: abdominal pain, vaginal bleeding or watering, breath-holding, dizziness, severe headache, chest pain, muscle weakness, etc. (5) Avoid exercising in the early morning on an empty stomach before insulin injection.
(5) Insulin therapy
1. Commonly used insulin preparations and their characteristics: (1) Ultra-short-acting human insulin analogues: Menthol insulin has a rapid onset of action and a short maintenance time. It has the strongest or best effect of lowering postprandial blood glucose, is not easy to occur hypoglycemia, and is used to control postprandial blood glucose levels.
(2) Short-acting insulin: fast-acting, easy to adjust the dose, and can be used subcutaneously, intramuscularly and intravenously. After intravenous injection of insulin, blood glucose can drop rapidly, and the half-life is 5-6 min, so it can be used to rescue DKA.(3) Medium-acting insulin: It is a suspension containing fisetin, short-acting insulin and zinc ion, and can only be injected subcutaneously but not intravenously. After injection, insulin must be separated from fisetin by the decomposition of protease in tissues to release insulin and then exert biological effects. The onset of action is slow, the duration is long, and its strength of lowering blood sugar is weaker than that of short-acting insulin.
(4) Long-acting insulin analogues: Dietary insulin is used to control nocturnal blood sugar and pre-meal blood sugar.
2. Timing of insulin application: After 3-5 d of diabetic pregnant women are treated with diet, the 24-h terminal blood glucose (blood glucose profile test) is measured, including nocturnal blood glucose, blood glucose 30 min before and 2 h after three meals, and urinary ketone bodies. If fasting or pre-meal glucose is ≥5.3 mmol/L 95 mg/dl), or 2h post-meal glucose is ≥6.7 mmol/L (120 mg/dl), or if starvation ketosis occurs after diet adjustment and glucose exceeds the pregnancy standard after increasing caloric intake, insulin therapy should be added promptly.
The 2010 Chinese guidelines for type 2 diabetes recommend starting basal insulin therapy immediately after the failure of oral medication (insulin therapy should be started after the maximum dose of oral hypoglycemic agents with HbA1c>7.0%. Basal insulin includes medium- and long-acting insulin. Method: Continue to take oral hypoglycemic drugs, combined with medium and long-acting ones injected at bedtime, starting dose 0.2U/Kg body weight, adjust the dosage according to FPG, every 3-4 d, adjust 1-4 U each time. if the blood sugar does not reach the standard during the day, change to multiple injections per day.
3.Insulin treatment plan: The insulin treatment plan that best meets the physiological requirements is: basal insulin combined with pre-meal ultra-short-acting or short-acting insulin. The replacement effect of basal insulin can last for 12-24 h, while pre-meal insulin has a fast onset and short duration, which is conducive to the control of postprandial blood glucose. Individualized insulin treatment plan should be selected according to the results of blood glucose monitoring. Evaluation of oral hypoglycemic agents + bedtime basal insulin combination therapy: small dose, slight elevation of plasma insulin, slight weight gain, reduction of FPG, enhancement of oral drug efficacy; improvement of beta cell function and insulin sensitivity, change from four injections to 1-2 injections.
(1) Basal insulin therapy: choose medium-acting insulin for subcutaneous injection before bedtime for pregnant women with high fasting glucose; for those whose fasting glucose has reached the standard after medium-acting insulin injection before bedtime but whose glucose is not well controlled before dinner, choose 2 injections before breakfast and before bedtime, or long-acting insulin injection before bedtime. The significance is to reduce hepatic glucose xenobiotic, reduce hepatic glucose output; control FPG, and then control PPG; effectively promote A1c to reach the standard.
(2) Pre-meal ultra-short-acting or short-acting insulin therapy: pregnant women with elevated postprandial glucose should be given ultra-short-acting or short-acting human insulin at mealtime or 30 min before meal.
(3) Insulin combination therapy: The combination of medium-acting insulin and ultra-short-acting or short-acting insulin is the most commonly used method, i.e. short-acting insulin is injected before three meals and medium-acting insulin is injected before bedtime. Due to the significant increase in postprandial glucose during pregnancy, the routine application of premixed insulin is generally not recommended.
4, insulin application precautions: (1) Start with a small dose, 0.3-0.8 U/(kg.d). Total daily insulin distribution principle: the most amount before breakfast, the least amount before Chinese food, and the middle amount before dinner. After each adjustment, the efficacy was judged by observation for 2-3 days, and it was appropriate to increase or decrease 2-4 U or < span=""> 20% of the total daily amount each time until the target of blood glucose control was reached, and the closer the target value was, the smaller the adjustment was. Xu Shijia adjusted the amount too carefully, in fact, it is not appropriate to stop metformin after 28 weeks.
(2) Treatment of early morning or fasting hyperglycemia during insulin therapy: Insufficient insulin action at night, dawn phenomenon and Somogyi phenomenon can all lead to hyperglycemia. In the first 2 cases, the amount of intermediate-acting insulin must be increased at bedtime, while the amount of intermediate-acting insulin at bedtime should be reduced in case of Somogyi phenomenon.
(3) Changes in the body’s insulin requirement during pregnancy: the insulin requirement increases to different degrees in the middle and late stages of pregnancy; the insulin requirement peaks during 32-36 weeks of gestation and decreases slightly after 36 weeks of gestation, and the insulin dosage should be adjusted continuously according to the results of individual blood glucose monitoring.
(vii) Zinc arginine insulin (long-acting)
1. Indications: This drug is preferred for mild to moderate diabetes mellitus, especially when blood glucose fluctuations are not easily controlled.
2. Usage: Generally 10-20u/day, the dosage of more than 40U a day is divided into two subcutaneous injections; product: injection 400u/ml
Second, the use of insulin precautions (a) calculation of insulin dose
1.According to the estimation of body weight, the general small dose starts at 0.3-0.4U/KG body weight.
2.According to the estimation of the severity of the disease, the daily physiological secretion of insulin is 40-50U, so medium-sized cases can start with 4-10U, heavy cases 16-20U, subcutaneous injection 30min before meal, 3 times a day.
3.In accordance with the estimation of urinary sugar excretion, 1U of insulin is used for every 2g of sugar
4.According to the estimation of blood glucose concentration, if the patient weighs 60KG, total body fluid = 60×60% = 36KG, if the blood glucose is 11.2mmol/L, the excess glucose in the body is about [(0.2-0.1)/100]×36×1000 = 36g, calculated by 1U insulin per 2g sugar, 18U insulin supplement is needed, 1/3-1/2 is given for the first time
5.The amount of insulin for three meals is generally morning “evening” in
6, each insulin dose adjustment, should be less than 20% of the original dose, and the observation of 3-4 days before adjustment, elderly patients generally every 3-6 days to adjust the dose.
(B) the role of different forms of insulin, 1, short-acting, mainly for the control of postprandial blood sugar.
2, medium-acting, long-acting to control the second post-prandial blood sugar; 3, long-acting, mainly to provide the basal level of insulin concentration.
(3) Insulin use should be started from small doses, paying attention to the highly individualized dose and the reflection of hypoglycemia (4) When switching from regular insulin to human insulin therapy, it is appropriate to start from 2/3 of the original dose
In order to reduce the number of injections, without affecting the efficacy and increasing the compliance of treatment, some simplified treatment plans have been developed. The main purpose is to take advantage of the difference in the onset of action of different insulin dosage forms and mix them for injection, which can produce a biphasic insulin that can control both postprandial and basal.
The most common is RN mixture, because R lasts for 8 hours, N starts for 1.5 hours, and the effect peaks at 4-12 hours. 4 – 5 hours after RN mixture R falling phase and N rising phase can combine to form another peak and can last for a certain period of time; R controls postprandial glucose 30 minutes after injection, and N controls postprandial glucose or fasting glucose. In this way the intensive treatment can be simplified to 2RN, so that some people who do not want to tie more needles, or do not have the condition of noon injection, can also get a more reasonable treatment. Pre-morning RN injection: breakfast at 30 minutes and lunch at 5 hours. If blood sugar control is too low after breakfast, hypoglycemia is likely to occur before lunch. The time of lunch varies from person to person, and there are differences in the structure of breakfast due to injection site, activity. Those who have the condition can measure blood sugar 2, 3, 4, 4.5, 5, 5.5 hours after breakfast to know your own blood sugar trough, this point is your noon insulin action peak, before 30 minutes as your meal time. In addition N as the main body of blood glucose control after lunch, the peak is smaller and longer, the amount of meals is not easy to be too large. If necessary, you can divide meals or add bactrim (drug divided meals) to facilitate blood sugar control.
RN injection before dinner: dinner is eaten after 30 minutes, and it is better to leave 1/4 of the dinner as a night snack before bedtime. This is because, as mentioned earlier, there can be another peak 4 – 5 hours after the injection that can easily produce hypoglycemia. Although the theoretical N peak lasts for 4 – 12 hours, its stronger effect time is about 8 hours.
For some people with heavy dawn phenomenon, fasting glucose control by this method is not effective. At this time, N can be changed to bedtime injection.
(VI) The application of oral hypoglycemic drugs in pregnant women with GDM
Most pregnant women with GDM can achieve the blood glucose standard through lifestyle intervention, and pregnant women with GDM who cannot achieve the standard should be recommended to apply insulin to control blood glucose first. At present, the safety and efficacy of oral hypoglycemic agents metformin and glibenclamide in pregnant women with GDM have been continuously confirmed, but there is a lack of relevant studies in China, and these two oral hypoglycemic agents are not included in the registration indications for the treatment of diabetes mellitus during pregnancy in China.
However, considering the potential risk of applying the above oral hypoglycemic agents in pregnant women with high insulin dosage or refusal to apply insulin is much less than the risk of uncontrolled gestational hyperglycemia itself to the fetus. Therefore, on the basis of informed consent, some pregnant women with GDM can be used with caution. The classification of oral hypoglycemic agents and their characteristics are shown in Table 4.
Glibenclamide: It is the most widely used oral hypoglycemic drug for the treatment of GDM, and its target organ is the pancreas. 99% of it exists in protein-bound form and rarely passes the placental barrier. The current clinical study shows that the efficacy of glibenclamide compared with insulin therapy in pregnant women with GDM in the middle and late stages of pregnancy is the same, but the former is convenient and cheap to use. However, the risk of preeclampsia and neonatal jaundice requiring phototherapy is increased, and a small number of pregnant women have nausea, headache and hypoglycemic reactions after the use of the drug.
2. Metformin: It can increase the sensitivity of insulin, and current data show that its application in early pregnancy is not teratogenic to the fetus, and has an important role in the maintenance of early pregnancy during the treatment of polycystic ovary syndrome. Since the drug can cross the placental barrier, the long-term safety of the drug for the fetus in the middle and late pregnancy has yet to be confirmed.
Timing and mode of delivery
(A) Timing of delivery
(1) Pregnant women with GDM who do not need insulin therapy and whose blood glucose control is up to standard, if there are no maternal and fetal complications, they can wait for the expected date of delivery under close monitoring, and those who are not in labor by the expected date of delivery can be induced to terminate the pregnancy.
2.Pregnant women with PGDM and insulin treated GDM, if they have good glycemic control and no maternal and child complications, the pregnancy can be terminated after 39 weeks of gestation under close monitoring; if the glycemic control is unsatisfactory or maternal and child complications occur, they should be admitted to hospital for observation in time and the timing of pregnancy termination should be decided according to their condition.
3. Those with diabetes mellitus with microangiopathy or previous history of adverse delivery should be closely monitored and the timing of termination of pregnancy should be individualized.
(ii) Mode of delivery
Diabetes mellitus itself is not an indication for cesarean delivery. For those who decide to deliver vaginally, a delivery plan should be made and the pregnant woman’s blood sugar, contractions and fetal heart rate changes should be closely monitored during labor to avoid prolonged labor.
Surgical indications for elective cesarean delivery are diabetes mellitus with severe microangiopathy or other obstetric indications. The indications for cesarean delivery should be relaxed in cases of poorly controlled glucose during pregnancy, large fetus (especially if the fetal mass is estimated to be ≥4,250 g) or previous history of stillbirth or stillbirth.
Treatment of special cases
I. Principles of insulin use during labor and perioperative period
1. Principles of use: All subcutaneous insulin injections should be stopped before and after surgery, during labor and delivery, and during the postpartum period when the diet is not normal, and intravenous insulin drips should be used instead to avoid hyperglycemia or hypoglycemia. The mother should be provided with sufficient glucose to meet the basal metabolic needs and energy consumption under stress; insulin should be supplied to prevent the occurrence of DKA, control hyperglycemia and facilitate the utilization of glucose; and proper blood volume and electrolyte metabolic balance should be maintained.
2. Examination during labor or before surgery: blood glucose and urinary ketone body levels must be detected. Electrolytes, blood gas analysis and liver and kidney function must also be checked for elective surgery.
3. Insulin use: monitor blood glucose every 1-2 hours and maintain small doses of insulin intravenously according to blood glucose values. When insulin is used to control blood glucose during pregnancy and delivery is planned, medium-acting insulin should be used normally at bedtime one d before induction of labor; insulin before breakfast should be stopped on the day of induction of labor and 0.9% sodium chloride injection should be given intravenously.
Formal labor or blood glucose level <3.9 100="" 100-150="" 5.6="15 mmol/L.
III. Postpartum treatment
1. Postpartum insulin application: The target of postpartum glucose control and insulin application should refer to the standard of non-pregnancy glucose control. (1) During the period of fasting or failure to resume normal diet after cesarean section in pregnant women applying insulin, intravenous infusion is given, and the ratio of insulin to glucose is 1: (4-6). (2) For those who apply insulin during pregnancy, once normal diet is resumed, blood glucose monitoring should be performed in a timely manner, and in case of significant abnormalities in blood glucose level, insulin subcutaneous injection should be applied, and the dose should be adjusted according to the blood glucose level, and the dose of insulin required is generally significantly reduced compared with that during pregnancy. (3) GDM women who do not need insulin treatment during pregnancy can resume normal diet after delivery, but should avoid high sugar and high fat diet.
2, postpartum review: postpartum FPG repeatedly ≥ 7.0 mmol/L, should be considered PGDM, recommended to refer to endocrine specialist treatment.
3, encourage breastfeeding: postpartum breastfeeding can reduce the application of maternal insulin, and the risk of diabetes in the offspring decreases.
4. Neonatal management: (1) Newborns are prone to hypoglycemia after birth, and close monitoring of their blood glucose changes can detect hypoglycemia in time. It is recommended that the newborn be tested for terminal blood glucose within 30 minutes after birth. (2) All newborns should be treated as high-risk infants, and attention should be paid to warmth and oxygenation. (3) Feed sugar and milk as early as possible, and if necessary, slowly infuse intravenous glucose solution with 10% glucose. (4) Routinely check hemoglobin, potassium, calcium, magnesium and bilirubin. (5) Pay close attention to the occurrence of neonatal respiratory distress syndrome.
Postpartum follow-up of pregnant women with GDM
Pregnant women with GDM and their offspring are at high risk for diabetes mellitus. A meta-analysis showed that the relative risk of postpartum T2DM in patients with GDM was 7.43 (95% CI: 4.79-11.51). A study by the Diabetes Prevention Program (DPP) showed that lifestyle changes and medications can reduce the incidence of diabetes in women with a history of GDM by more than 50%.
Therefore, the existing standards for the diagnosis and treatment of GDM regulate postpartum follow-up. Follow-up at 6-12 weeks postpartum is recommended for all women with GDM (Level E evidence).
During the postpartum follow-up visit, women should be educated about the significance of postpartum follow-up; they should be instructed to change their lifestyle, eat properly, and exercise appropriately to encourage breastfeeding. It is recommended to measure height, body mass, body mass index, waist circumference and hip circumference, and to understand the recovery of blood glucose in the postpartum period, and it is recommended that all women with GDM should undergo OGTT after delivery to measure fasting and 2-h blood glucose levels after taking sugar, and to identify any abnormalities in glucose metabolism and their types according to the 2014 ADA standards, as shown in Table 6. If available, lipid and insulin levels are recommended, with follow-up at least every 3 years (level E evidence). I. Limits of blood glucose levels
Normal: FPG 3.9-6.0mM, OGTT 2h<7.7mm< span="">.
Abnormal: Impaired fasting glucose regulation (IGF): 6.1-6.9 New requirement is FPG 5.6-6.9 mmol/L. Decreased glucose tolerance 2-h PG 7.8-11.0 mmol/L in OGTT test; C. HbA1c 5.7-6.4%.
2010 American Diabetes Association ADA diagnostic criteria for diabetes (any of the following): ①HbA1C ≥6.5%. ② Fasting plasma glucose (FPG) ≥ 7.0 mmol/L (126 mg/dl). ③Random blood glucose ≥ 11.1 mmol/L (200 mg/dl), with symptoms of hyperglycemia or hyperglycemic crisis; if no symptoms of hyperglycemia, recheck ① and ② the next day; symptoms of hyperglycemia refer to polyuria, irritable thirst and excessive drinking, and unexplained weight loss. ④OGTT 2h ≥ 11.1 (200 mg/dl) WHO 75 g of anhydrous glucose dissolved in water as sugar load.