Gestational diabetes treatment routine
I. Diabetes mellitus combined with pregnancy (DM).
1. Diabetes mellitus has been diagnosed before pregnancy.
2, never had a blood glucose test before pregnancy, the presence of high-risk factors for diabetes mellitus, one of the following conditions can be diagnosed as pre-pregnancy diabetes mellitus.
(1) GHbAlc≥6.5%;
(2) Fasting blood glucose (FBG) ≥7.0mmol/L;
(3) OGTT 2-hour glucose level ≥11.1mmol/L;
(4) With typical symptoms of hyperglycemia or hyperglycemic crisis, along with random blood glucose ≥11.1mmol/L.
Note: If there are no obvious hyperglycemic symptoms, (1)-(3) need to be retested on another day to verify.
II. Gestational diabetes mellitus (GDM)
1. One-step method: OGTT fasting, 1 hour and 2 hour cut-off values are 5.1mmol/L, 10.mmol/L and 8.5 mmol/L respectively. One of the three is diagnosed when the cut-off value is reached or exceeded;
2. Two-step method: 1) Fasting blood glucose ≥5.1mmol/L, that is, the diagnosis;
2) Fasting blood glucose: 4.4-5.1mmol/L, further OGTT should be performed;
3) Fasting blood glucose ≤4.4mmol/L is normal, and GDM is excluded.
Treatment during pregnancy.
I. Dietary treatment.
The ideal goal of dietary control: to ensure and provide the caloric and nutritional needs during pregnancy, but also to avoid the appearance of postprandial hyperglycemia or starvation ketosis, and to ensure normal fetal growth and development. (Note that excessive dietary control should be avoided, as this can lead to maternal starvation ketosis and fetal growth restriction).
Dietary control standards during pregnancy: total daily calories during pregnancy: 1800-2200 kcal, of which carbohydrates account for 50%-55%, protein 20-25% and fat 25-30%. Small amount and multiple meals system should be implemented, divided into 5-6 meals per day.
GDM patients after 3-5 days of dietary treatment, blood glucose and the corresponding urine ketone body test indicates that the results do not reach the standard, especially after the emergence of hunger ketosis after dietary control, increase the calorie blood glucose and exceed the standard, insulin therapy should be added in a timely manner.
II. Insulin therapy.
According to the results of blood glucose profile test, combined with the insulin sensitivity of individual pregnant women, insulin should be applied reasonably.
(i) Calculation formula.
1) More sugar in the body (mg) = (fasting blood glucose mg/dl-100)*10*weight kg*0.6
2) Ordinary insulin used = excess sugar in the body (g)/2
3) Method: Subcutaneously injected 30min before three meals, the dosage is 1/2, 1/4 and 1/4 in the morning, midday and evening respectively, and the insulin dosage is adjusted according to the blood glucose results 2 hours after three meals after the dosage.
(B) Glycemic control criteria for gestational diabetes patients : 1) Fasting blood glucose control at 3
1) Fasting blood sugar control at 3.3~5.6mmol/L
2) 30 minutes before meal: 3.3~5.8 mmol/L
3) 2h after meal: 4.4 ~ 6.7mmol/L
4) Nighttime: 4.4 to 6.7 mmol/L
5) Urinary ketone bodies(-)
Third, ketosis treatment.
Advocate the application of small dose regular insulin 0.1u/kg・h intravenous.
1. Blood glucose > 13.9 mmol/L: add insulin to saline;
2.Glucose ≤13.9mmol/L: add insulin to 5% glucose or 5% glucose saline (add 1U insulin by 2-3g glucose);
3. Monitor blood glucose once every 1 to 2 hours;
4.After the ketone body turns negative, it can be changed to subcutaneous insulin injection.
After the treatment of rehydration and static insulin, attention should be paid to detecting blood potassium. In patients with severe ketosis, blood gas should be checked for the presence of ketoacidosis.
Choice of delivery timing.
1. In principle, while strictly controlling maternal blood sugar, strengthen fetal monitoring and try to terminate pregnancy after 38-39 weeks.
2. Indications for early termination of pregnancy: unsatisfactory glycemic control, with vascular lesions, combined with severe gestational hypertensive disease, severe infection, fetal growth restriction, fetal distress.
3, amniocentesis; late diagnosis of GDM or unsatisfactory glycemic control and other reasons for early termination of pregnancy should be performed 48 hours before the planned termination of pregnancy, amniocentesis to understand the maturation of fetal lung and intra-amniotic injection of dexamethasone 10mg to promote fetal lung maturation.
Choice of delivery mode.
Diabetes mellitus itself is not an absolute indication for cesarean delivery.
1. If you decide to deliver vaginally, you should make a delivery plan during labor and closely monitor maternal blood sugar, contractions and fetal heart changes during labor to avoid prolonged labor.
2.Surgical indications for cesarean delivery.
1) Caesarean section should be performed for huge fetus (estimated fetal weight is over 4000g), placental dysfunction, abnormal fetal position or other obstetric indications
2) Indications for cesarean delivery should be relaxed for pregnant women with diabetes mellitus >10 years, with retinopathy and renal impairment, severe pre-eclampsia, and history of stillbirth or stillbirth.
Management during labor and delivery.
Discontinue the medium-acting insulin at 10:00 p.m. the day before induction of labor; after elective cesarean delivery or prodromal delivery, all subcutaneous insulin should be discontinued, closely monitor blood glucose during labor, measure blood glucose and urinary routine every 2 hours, and maintain blood glucose at 4.4-6.7 mmoL/L. According to blood glucose level, decide the dosage of intravenous drip insulin.
Continuous intravenous drip of small-dose short-acting insulin during labor
Blood glucose (mg/d1) Blood glucose (mmol/1) Insulin volume (u/h) IV fluid drip (125 ml/hr)
<100 <5.6 0 5% glucose lactate Ringer's solution
100-140 5.6-7.8 1.0 5% glucose lactate Ringer’s solution
140-180 7.8-10 1.5 Physiological saline
181-220 10-12.2 2.0 Physiological saline
>220 12.2 2.5 Physiological saline
Postpartum insulin application.
The insulin dosage is reduced by 1/2~2/3 after delivery for pre-pregnancy diabetes, and the insulin dosage is adjusted in combination with the blood glucose level after delivery. (Postpartum infusion can be added to IU insulin ratio for every 3~4g of glucose), and dynamically monitor blood glucose level during the infusion.
Neonatal management.
1. newborns are prone to hypoglycemia after birth, measure blood glucose within 30 minutes after birth. 2. newborns are treated as high-risk infants, pay attention to warmth and oxygenation, etc. 3. feed sugar water and open milk early, monitor blood glucose changes dynamically. 4. routinely check hemoglobin, blood potassium, blood calcium and magnesium, bilirubin. 5. pay close attention to the occurrence of neonatal respiratory distress syndrome. 6. examine newborns carefully to detect neonatal malformations in time.
Postpartum follow-up of GDM.
All pregnant women with GDM should check fasting glucose after delivery, and those with normal fasting glucose should undergo oral 75 grams glucose tolerance test (check fasting and glucose 2 hours after taking sugar) 6~12 weeks after delivery, and those who still have abnormal glucose at this time can be diagnosed with combined diabetes mellitus pregnancy.