I. What is diabetes mellitus combined with pregnancy? What is gestational diabetes?
Diabetes combined with pregnancy: refers to pre-existing diabetes and now pregnancy.
Gestational diabetes: It refers to the phenomenon of not having diabetes before pregnancy and having hyperglycemia only at the time of pregnancy.
Second, the characteristics of glucose metabolism during pregnancy.
1. The ratio of blood glucose and blood insulin decreases.
2. Pregnant women are in the state of insulin resistance.
3. Pregnant women are in a state of relative hypoglycemia. The cause of hypoglycemia is due to the large demand for glucose by the fetus and the excessive filtration by the kidneys of pregnant women due to the decrease of renal glucose threshold, so pregnant women often have hypoglycemia especially when they are hungry. Due to the decrease of renal sugar threshold, it can make urine sugar increase, if the blood sugar is normal, urine sugar is not significant.
4, pregnant women are in hypoglycemia, hypoglycemia can lead to a decrease in insulin secretion, and due to the increase in blood volume, hypoinsulinemia, hypoinsulinemia causes lipolysis, so that free fatty acids and ketone bodies are elevated, so pregnant women are prone to ketosis or ketoacidosis. And ketosis is extremely harmful to both the pregnant woman and the fetus.
5. As the weeks of pregnancy increase, the function of placenta gradually increases and the antagonistic effect of insulin gradually increases, hypoglycemia increases with the progress of pregnancy, and the blood glucose value during non-pregnancy is higher than that of early pregnancy, while early pregnancy is higher than that of late pregnancy.
III. What are the main causes of gestational diabetes?
In recent years, with the change of lifestyle, the trend of type 2 diabetes has increased and become younger; on the other hand, many pregnant women eat a lot and fine, while less active, which is an important reason for getting diabetes during pregnancy. Pregnancy can contribute to the change of recessive diabetes into dominant, and the special endocrine and metabolic changes during pregnancy are important factors in the occurrence of diabetes during pregnancy. For example, the hormones synthesized and secreted by the placenta are related to glucose metabolism, have an antagonistic effect on insulin, and can also accelerate insulin degradation.
The pathogenesis of gestational diabetes mellitus is currently considered to be mainly a relative decrease in insulin secretion and decreased insulin sensitivity
IV. 2012 Diagnostic criteria.
Oral glucose tolerance test is performed with 75g glucose load during pregnancy, and the diagnostic threshold of OGTT is as follows: fasting, 1-hour and 2-hour blood glucose values are 5.1, 10.0 and 8.5 mmol/L, respectively, and gestational diabetes is diagnosed when any of the blood glucose values reaches or exceeds the above threshold.
V. Hazards of gestational diabetes mellitus.
What are the hazards to pregnant women during pregnancy.
1, the chances of occurrence, preterm delivery and stillbirth are higher than normal mothers.
2, the chance of having excessive amniotic fluid increases.
3, resistance will be significantly reduced, and prone to co-infection.
4. The incidence of gestational hypertension in these patients is 4-8 times higher than that of normal pregnant women because of the thickening of the blood vessel wall and the narrowing of the uterine cavity.
5. Since patients with gestational diabetes tend to have huge fetuses, the chances of difficult labor and birth injuries during delivery will increase.
6, prone to ketosis, the disease if not corrected in time will make it develop into diabetic ketoacid, which will be extremely harmful to the mother and fetus. If ketosis occurs in the early stages of pregnancy, it can lead to fetal malformation, while in the middle and late stages of pregnancy, it can aggravate the degree of fetal hypoxia in the uterus.
What are the risks of gestational diabetes to the fetus?
1, can make the fetal mortality rate increase: research has concluded that the increase in fetal mortality is mainly related to the increased blood sugar level of pregnant women. If gestational diabetes patients can strictly control their blood sugar and strengthen the monitoring of the fetus in the late pregnancy, the fetal mortality rate can be reduced.
2, can form a huge fetus: gestational diabetes mostly occurs in the middle and late stages of pregnancy, when the fetal organs have been formed, so the impact on the fetus is mainly to cause its excessive development, thus forming a huge fetus.
3, can lead to fetal malformations: fetuses conceived by patients with gestational diabetes are prone to malformations of the nervous system and cardiovascular system, such as spina bifida, hydrocephalus, congenital, anal atresia, etc.
4, can lead to neonatal jaundice: the occurrence of diabetes in pregnant women can lead to fetal hypoxia in utero and increase the erythropoietin in the fetus, causing erythrocytosis. Newborns with erythrocytosis are prone to neonatal jaundice because of the destruction of a large number of red blood cells in their bodies.
5, can lead to neonatal respiratory distress syndrome: infants born to patients with gestational diabetes are six times more likely to suffer from neonatal respiratory distress syndrome than infants born to non-diabetic pregnant women. The occurrence of this syndrome is closely related to the failure of gestational diabetes patients to control blood sugar well, resulting in fetal hyperglycemia.
VI. Timing of glucose screening test.
As the placental secretion of placental lactogen, estrogen and progesterone and other hormones that antagonize insulin rise rapidly in the 24th-28th weeks of pregnancy and reach a peak in the 32nd-34th weeks of pregnancy, the need for insulin of pregnant women increases significantly at this time, which shows impaired glucose tolerance, and GDM is easily detected during this period; therefore, the time of routine glucose screening during pregnancy is set at the 24th-28th weeks of pregnancy; if the screening is normal but there are If the screening is normal but there are risk factors for diabetes, the screening should be repeated at 32-34 weeks of gestation. For those who have symptoms, glucose screening should be performed in early pregnancy to facilitate early diagnosis of diabetes mellitus that was missed before pregnancy.
VII. Treatment of gestational diabetes mellitus.
1. Diet therapy and exercise. Choose drug insulin when diet control + exercise is not effective.
2.Insulin therapy. Insulin is a relatively safe drug, first of all: insulin does not pass the placental barrier and has no effect on the fetus. The need for insulin increases in pregnant women (especially in the middle and late stages of pregnancy), but after delivery, with the delivery of the placenta, insulin resistance disappears rapidly and insulin dosage, rapidly decreases or even can be discontinued. The U.S. Food and Drug Administration has graded the safety of insulin in pregnancy as B. Insulin therapy for breastfeeding women is not dangerous to the baby.
Insulin is divided into short-acting and medium-acting. Short-acting is used for high postprandial glucose; medium-acting is used for high preprandial glucose.
VIII. Blood glucose control standard.
5.6 mmol/l before meal
7.8 mmol/l 1 hour after meal
6.7mmol/l 2 hours after meal
Prerequisite: urinary ketone body (-)
Some patients ask me if it is okay for me to monitor my blood glucose at home and control it at 5.6mmol/l before meals and 6.7mmol/l after meals.
It is very good, but only if you are not in a state of semi-starvation. Starvation often produces ketone bodies, and if there is long-term starvation and long-term presence of ketone bodies, it is harmful to the fetus and the pregnant woman. That’s why we monitor blood glucose along with urine routine in order to find out if the diet is reasonable. This is the purpose of the blood glucose profile for hospital admission.
If the diet is well controlled, urinary ketone bodies (-) and blood glucose is in the normal range, then it is good to be discharged and continue to control the diet + exercise outside the hospital.
If after diet control, blood glucose is within normal range, ketone bodies (+), increase diet, ketone bodies (-), blood glucose is elevated, then you need to increase insulin to adjust blood glucose.