Timing of delivery
1.Pregnant women with GDM who do not need insulin treatment and whose blood sugar control is up to standard, without maternal or pediatric complications, can wait until the expected date of delivery under close monitoring, and take measures to terminate the pregnancy if they are still not in natural labor.
2, pre-pregnancy diabetes and the application of insulin treatment of GDM, if good glycemic control, without maternal and pediatric complications, under close monitoring, termination of pregnancy after 39 weeks of pregnancy; unsatisfactory glycemic control or the emergence of maternal and pediatric complications, timely hospitalization of close maternal and pediatric complications, termination of pregnancy timing to take individualized treatment.
3. In cases of diabetes mellitus with microangiopathy, or those with a history of previous bad deliveries, the timing of termination of pregnancy should be individualized under close monitoring.
Mode of delivery
Diabetes itself is not an indication for cesarean delivery. Those who decide to deliver vaginally should make a delivery plan during labor and closely monitor maternal blood glucose, contractions and fetal heart changes during labor to avoid prolonged labor.
Indications for elective cesarean section are diabetes mellitus with severe microangiopathy and other obstetric indications. The indications for cesarean delivery should be relaxed if the glucose is not well controlled during pregnancy, if the fetus is large, especially if the estimated fetal weight is above 4250g, or if there is a history of stillbirth or stillbirth in the past.
Principles of insulin use during labor and perioperative period
Principle of use
Stop all subcutaneous insulin injections before and after surgery, during labor and delivery, and during the postpartum period when the diet is not normal, and switch to insulin intravenous drip to avoid hyperglycemia or hypoglycemia. Supply sufficient glucose to meet basal metabolic needs and energy expenditure during stressful conditions. Supply insulin to prevent the occurrence of DKA, control hyperglycemia and facilitate glucose utilization. Maintain proper blood volume and electrolyte metabolic balance.
Examination during labor or before surgery
Blood glucose and urinary ketone bodies must be measured. Electrolytes, blood gas, liver and kidney function tests are also performed for elective surgery.
Insulin administration
Monitor blood glucose every 1~2h, and maintain small dose of insulin intravenously according to blood glucose value. When insulin is used to control blood glucose during pregnancy and delivery is planned, medium-acting insulin is used normally before bedtime the day before induction of labor; insulin before breakfast is stopped on the day of induction of labor; saline is given intravenously; once labor is officially approaching or blood glucose level decreases to below 3.9 mmol/L, intravenous drip is changed from saline to 5% glucose solution and infused at a rate of 100~150 ml/h to maintain blood glucose level Around 5.6 mmol/L; if the blood glucose level exceeds 5.6 mmol/L, 5% glucose solution with short-acting insulin is used and infused intravenously at a rate of 1~4 U/h; the blood glucose level is monitored once an hour using a rapid glucose meter and the rate of insulin or glucose infusion is adjusted. Blood glucose can also be regulated according to the following table.
Management of combined DKA in pregnancy
Clinical manifestations and diagnosis
Nausea, vomiting, weakness, thirst, polyhydramnios, polyuria, a few with abdominal pain; dry skin mucosa, sunken eyes, ketone odor in exhalation, consciousness impairment or coma in severe cases; laboratory tests show hyperglycemia (>13.9mmol/L), positive urine ketone bodies, blood PH<7.35, CO2CP<13.8mmol/L, blood ketone bodies>5mmol/L, electrolyte disturbance.
Causes of morbidity
Diabetes mellitus was missed during pregnancy, not diagnosed and treated in time; irregular insulin treatment during pregnancy; unreasonable dietary control during pregnancy; emergency state during labor and before and after surgery; co-infection; use of glucocorticoids, etc.
Treatment principles
Insulin should be given to lower blood sugar, correct metabolic and electrolyte disorders, improve circulation, and remove causative factors.
Specific measures
(1) In case of high blood glucose (>16.6mmol/L), insulin 0.2~0.4U/kg should be injected intravenously at once.
(2) Insulin continuous intravenous drip: 0.9% NS+RI, input at the rate of insulin 0.1U/kg/h or 4~6U/h.
(3) Monitor blood glucose, monitor blood glucose every 1h from the beginning of insulin use and adjust according to the blood glucose drop, requiring an average blood glucose drop of 3.9~5.6 mmol/L per hour or more than 30% of the level before intravenous drip. Those who fail to reach this standard may have insulin resistance and the RI should be doubled.
(4) When blood glucose drops to 13.9mmol/L, change 0.9% NS to 5% glucose solution or glucose saline, and add 1U insulin for every 2~4g glucose until blood glucose drops below 11.1mmol/L, urine ketone body is negative, and can be smoothly transitioned to preprandial subcutaneous injection therapy when rehydration is stopped.
Precautions
The principle of rehydration is fast and then slow, salt first and then sugar; pay attention to the balance of in and out volume. After starting intravenous insulin therapy and after the patient has urine, potassium should be recharged in time to avoid the occurrence of severe hypokalemia. When PH<7.1, CO2CP<10mmol/L, HCO3-<10mmol/L, alkali can be replenished, usually with 5% NaHCO3 100ml + 400ml of water for injection, at a rate of 200ml/h intravenously until PH≥7.2 or CO2CP>15mmol/L, stop alkali replenishment.
Postpartum management
Postpartum insulin application
The target of postpartum glycemic control and the application of insulin are referred to the standard of non-pregnancy glycemic control.
(1) Application of insulin during pregnancy During the period of fasting or failure to resume normal diet after cesarean section, intravenous infusion is given, and the ratio of insulin to glucose is 1:4-6, and blood glucose level and urinary ketone body are monitored at the same time, and whether to apply and adjust the dosage of insulin is decided according to the test results.
(2) For those who apply insulin during pregnancy, once normal diet is resumed, and blood glucose monitoring is performed in a timely manner. If the blood glucose is obviously abnormal, insulin should be injected subcutaneously and the dose should be adjusted according to the blood glucose level, and the dose of insulin needed is often significantly reduced compared with that during pregnancy. Postpartum blood glucose return to normal without continuing insulin therapy.
(3) For those who do not need insulin therapy for GDM during pregnancy, they should resume normal diet after delivery and avoid high sugar and high fat diet.
Referral
If FPG is repeatedly ≥7.0mmol/L after delivery, it should be regarded as diabetes combined with pregnancy, and should be referred to endocrine specialist for treatment.
Breastfeeding
Postpartum breastfeeding can reduce insulin application, and at the same time, the risk of diabetes in offspring decreases.
Neonatal management
(1) Newborns are prone to hypoglycemia after birth, and dynamic monitoring of blood glucose changes allows timely detection of hypoglycemia. It is recommended that end-point glucose measurement be performed 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 water and milk early, and if necessary, 10% glucose should be given slowly.
(4) Routinely check hemoglobin, potassium, calcium, magnesium and bilirubin.
(5) Pay close attention to the occurrence of neonatal respiratory distress syndrome.
Postnatal follow-up of GDM
GDM patients and their offspring are recognized as a high-risk group for diabetes mellitus, and GDM patients have a significantly increased risk of developing type 2 DM after delivery. Meanwhile, a study by the Diabetes Prevention Program (DPP) showed that lifestyle changes and medication can reduce the incidence of DM by more than 50% in women with a history of GDM. Therefore, postpartum follow-up is regulated by existing standards for the diagnosis and treatment of GDM.
It is recommended that all patients with GDM be followed up at 6 to 12 weeks postpartum.
The significance of postpartum follow-up should be explained to the mother; she should be guided to change her lifestyle, eat a reasonable diet and exercise appropriately, and encourage breastfeeding.
Physical measurements, including height, weight, BMI, waist circumference and hip circumference, are recommended at the follow-up visit. It is also recommended to understand the recovery of maternal blood glucose after delivery, and all GDM are recommended to perform 75g OGTT after delivery, measure fasting and 2 hours after taking sugar, and clarify whether there are abnormalities of glucose metabolism and types according to the 2014 ADA standards. It is recommended to test lipid and insulin levels if available. Follow-up is recommended at least every 3 years for those who are able to do so.
Follow-up visits and healthy lifestyle guidance are recommended for future generations of diabetic patients. Length, weight, head circumference and abdominal circumference measurements can be performed, and blood pressure and glucose testing can be performed when necessary.