Diabetes mellitus refers to metabolic abnormalities in the human body associated with a lack of pancreatic function, impaired insulin sensitivity, or the combined effect of these factors. The question of whether diabetes and pregnancy can be combined is discussed by many well-known endocrinologists of the world. Most of them are confident that these two concepts should not be combined, but bans do not solve the issue of bearing a child. The best option recognized the conduct of training of sick girls since adolescence. There are even remote "schools of diabetes."
The disease can occur in women until the moment of conception of the baby, and this type of pathology will be called pregestative. If the "sugar disease" appeared during pregnancy, then such diabetes is gestational (ICD-10 code - O24.4).
The first variant of pathology is less favorable for the matter of the child, since the baby’s body, even from the moment of conception, is exposed to uncontrolled excessive glucose intake. This causes the development of metabolic stress and may provoke congenital abnormalities and deformities.
The second option is more loyal. As a rule, diabetes mellitus during pregnancy occurs in the second half of it, which means that during the period when the organs and systems of the fetus were laid down, there was no negative effect of high sugar levels.
Pregestational form of the disease
According to the classification of Dedov from 2006, pregestational diabetes in pregnant women can exist in the following forms and manifestations.
A mild form of pathology is type 2 diabetes, which is corrected by diet and is not accompanied by vascular disorders.
Medium form - a disease of any type, which requires the use of glucose-lowering drugs, which has no complications or is accompanied by their initial stages:
- retinopathy in the proliferative stage (disturbance of the retina trophism of the visual analyzer);
- nephropathy in the form of microalbuminuria (pathology of the kidney vessels with a small amount of protein in the urine);
- neuropathy (damage to the ganglia and cells).
Severe with frequent sugar drops and ketoacidosis.
Type 1 or 2 disease with severe complications:
- pathology trophic retina;
- violation of the kidney vessels, manifested by renal failure;
- diabetic foot;
- coronary artery sclerosis;
- circulatory disorders of the brain vessels;
- occlusion of the arteries of the legs.
Depending on how the body's compensatory mechanisms cope with the task of reducing the level of sugar in the blood, there are several stages of pregestational diabetes mellitus. For each of them there are their own laboratory indicators listed in the table (in mmol / l).
|Time to determine indicators||Compensation stage||Stage of subcompensation||Decompensation stage|
|Before food enters the body||5,0-5,9||6,0-6,5||6.6 and above|
|A few hours after eating||7,5-7,9||8,0-8,9||9.0 and above|
|In the evening before bedtime||6,0-6,9||7,0-7,5||7.6 and above|
Diabetes mellitus, which arose during the childbearing period, also has a division. Depending on how you manage to keep the quantitative indicators of glucose in the blood within the normal range, there is a disease that is compensated by diet and one that is adjusted by diet therapy and the use of insulin.
According to the level of operation of compensatory mechanisms, there is a stage of compensation and decompensation.
The mechanism of diabetes in pregnant women
"Sweet disease" type 1 develops against the background of destructive changes in pancreatic cells responsible for the synthesis of insulin. This form arises as a result of negative actions of exogenous factors against the background of hereditary predisposition.
Hyperglycemia is the basis of any form of diabetes, including gestational
Type 2 disease, which is accompanied by a violation of the sensitivity of cells and tissues of the body to insulin, develops due to improper diet, sedentary lifestyle. Gestational diabetes of pregnant women in their developmental mechanism is more similar to the second variant of the pathology.
The placenta, which is necessary for the implementation of a permanent relationship between the mother and the child during gestation, produces a significant amount of hormones. The fact that the adrenal glands of women begin to synthesize cortisol in large quantities and the accelerated removal of insulin from the body through the urine (activation of insulinase is triggered) leads to the fact that the cells and tissues of the body become less sensitive to insulin. The required amount of the hormonally active substance of the pancreatic cells cannot be produced, which leads to an increase in the level of glucose in the blood and the development of the gestational form of the disease.
Symptoms of pathology
The clinic of diabetes in a pregnant woman depends on the following factors:
- form of the disease;
- compensation stage;
- how long the failure already exists;
- the development of complications;
- applied therapy in history.
Signs of gestational diabetes are similar to the clinical picture of the pregestational form.
In most cases, the gestational form has no manifestations (latent diabetes) or they are quite scarce. Sometimes symptoms specific to hyperglycemia appear:
- constant thirst;
- increased urine excretion;
- high appetite on the background of sufficient intake of food in the body;
- itchy skin;
- rash of the type of furunculosis.
Pregnancy in diabetes of the pregestational type gives a huge number of complications from the mother and child, and the insulin-dependent form of the disease is accompanied by such conditions many times more often than other forms of the disease. The following pathological effects may develop:
- the need for caesarean section;
- large fruit that does not meet the standards of development;
- weight at the time of birth is more than 4.5-5 kg;
- Erb's palsy - a violation of the innervation of the shoulders;
- the development of preeclampsia of varying severity;
- defects and congenital anomalies in a child;
- preterm delivery;
- fetal distress syndrome;
- fading of pregnancy;
- death of the fetus during intrauterine life or in the first month after birth.
High-risk groups include patients who have diabetes for more than 10-12 years, have perinatal death earlier, as well as those who have one or more serious complications, and patients with urinary tract infection.
Depending on the period during which the development of diabetes occurred and how long the influence on the baby's body of high sugar levels became, there are three main pathologies, the development of which is characteristic of the child.
The development of deformities, congenital malformations and anomalies is typical for babies whose mothers have a pregestational form of diabetes. Manifestations and signs of pathology are practically no different from those that can appear in children from mothers without a "sweet disease":
- absence of one or both kidneys;
- heart valve defects;
- malformations of the spinal cord;
- neural tube defects;
- abnormal arrangement of organs;
- pathology of the nasal septum;
- cleft lip and palate;
- abnormalities from the central nervous system.
The absence of one kidney is a variant of the pathology of the child’s body against the background of pregestational diabetes of the mother
In women suffering from the pregestational form of diabetes, the possibility of spontaneous abortions is several times higher. This is attributed not to genetic abnormalities of the fetus, against which miscarriages occur in healthy mothers, but to insufficiency of the placenta and the development of congenital anomalies of the child, incompatible with life.
This is a pathological condition that is accompanied by an excessive increase in the weight of the child at the time of delivery (above 4.5-5 kg). The development of macrosomia is accompanied by the need for caesarean section due to the high risk of trauma to the child and the birth canal of the mother.
Women who have a diagnosis of diabetes before conceiving a baby should be aware of how important it is to plan a pregnancy in this state and be under the constant supervision of a qualified specialist.
Planning includes an inspection and anamnesis, including the following points:
- the presence of complications of the disease;
- clarifying the form of diabetes;
- self-monitoring data recorded in a personal diary;
- the presence of concomitant diseases;
- family history;
- the presence of hereditary pathologies.
Also conduct the following examinations:
- blood pressure measurement, cardiologist consultation;
- examination by an ophthalmologist, treatment of the initial stages of retinopathy;
- screening for ischemic heart disease (ECG, echoCG);
- blood biochemistry;
- clarification of thyroid hormone indicators;
- assessment of the mental health of the patient.
Blood is a biological fluid used to conduct a number of diagnostic activities on the background of diabetes mellitus.
In addition, it is necessary to abandon bad habits in the event of their presence, careful analysis of those drugs that are taken by a woman to avoid a negative impact on the future baby.
There are conditions that are absolute or relative contraindications for bearing a child. The absolute are:
- severe kidney damage;
- Severe CHD;
- progressive pathology of the visual analyzer.
Diabetes and pregnancy - this combination is undesirable (considered individually) in the following cases:
- women over 40 years old;
- the presence of diabetes in both spouses;
- diabetes mellitus and rhesus sensitization;
- diabetes and active tuberculosis;
- the birth of children with deformities in history against the background of the disease;
- ketoacidosis in the first trimester of pregnancy;
- chronic kidney disease;
- asocial living conditions.
Diagnosis of diabetes in the period of childbearing
Gynecologist-endocrinologist examines the physique of a pregnant woman, measures the abdominal circumference, the height of the uterus, the height and weight of the woman, the size of the pelvis. Estimation of the patient's weight is an important diagnostic indicator. Based on the results, which shows a pregnant woman at the first inspection, make up a schedule of permissible weight gain for months and weeks.
Laboratory diagnosis consists of the following tests:
- general clinical tests (blood, urine, biochemistry);
- level of lipids and cholesterol in the blood;
- clotting indicators;
- urine culture;
- urine according to Zimnitsky, according to Nechiporenko;
- determination of the level of female hormones;
- determination of acetone in urine;
- daily urine for albuminuria.
One of the specific methods, which allows to determine the presence of pathology in pregnant women, is considered an oral test for glucose tolerance. It consists in blood sampling on an empty stomach, drinking concentrated hyperosmolar glucose solution and further blood sampling (after 1, 2 hours). The result shows the sensitivity of the cells and tissues of the body.
The glucose tolerance test is one of the stages of the mandatory examination of a pregnant woman.
Management and treatment of diabetes during pregnancy
A prerequisite is the ability of women to carry out self-control of blood sugar levels, followed by fixing the data in her personal diary. During the period of childbearing, clinical recommendations suggest the need to monitor performance up to 7 times a day. There are also test strips to measure the level of ketone bodies in the urine. This can be done at home.
Correction of the diet and the revision of the personal menu allow you to keep sugar indicators within acceptable limits, to prevent the development of ketoacidosis and excessive weight gain by a woman. Experts recommend limiting the amount of carbohydrates consumed to 35% of the total daily diet. About 25% should be consuming protein foods, the remaining 40% should be unsaturated fats.
Nutrition pregnant is as follows:
- breakfast - 10% of daily calories;
- lunch - up to 30%;
- dinner - up to 30%;
- snacks between main meals - up to 30%.
If we talk about the pregestational form of the disease, then the first half of pregnancy with type 1 and type 2 diabetes is similar in the required amount of insulin, but after the 24th week, the need increases with the insulin-independent form of the disease. In the period of carrying a child, preference is given to Actrapid, Humulin R, Novorapid, Humalog.
Insulin therapy and the ability to correct the diet - the ability to save the baby and mother from serious violations of the organs and body systems
The greatest need for insulin therapy is characteristic for the period from the 24th to the 30th week, after the 35th it is significantly reduced. Some experts talk about the possibility of using a pump system for drug administration. This is effective for those women who have enjoyed pumping before the moment of conception.
Insulin-independent type of diabetes is sensitive enough to exercise. There are cases when adequate activity of the pregnant woman allowed to replace the introduction of insulin. Type 1 disease is not so sensitive to stress, and excessive activity, on the contrary, can cause episodes of hypoglycemia.
The need for hospitalization
In the presence of the pregestational form of diabetes, the pregnant woman is hospitalized to the hospital three times:
- At 8-10 week - to determine the work of compensatory mechanisms, to clarify the presence of complications, to train a woman, to correct the diet and treatment.
- At 18-20 weeks - the definition of pathologies on the part of the baby and the mother, the prevention of complications, the correction of metabolic processes.
- At 35-36 weeks - for delivery or preparation for childbirth.
Term and method of delivery
The most suitable time for the birth of a baby with any form of the disease is 37 weeks. From the 36th week, the following indicators are monitored every day:
- movement of the child;
- listening to the heartbeat;
- blood flow study.
A woman can independently give birth in the case of head presentation of the fetus, with normal pelvic size, if there are no complications of diabetes. Early birth is necessary in the following conditions:
- deterioration of the child's well-being;
- degradation of maternal laboratory parameters;
- development of renal failure;
- sharp decrease in visual acuity.
The 1st type of the disease has practically no contraindications to breastfeeding the baby, if the child himself has no birth injuries or complications. The only undesirable option is the progression of maternal renal failure.
Breastfeeding is the allowed stage of establishing a close relationship between mother and child against the background of a "sweet disease"
Type 2 needs postpartum insulin therapy, since drugs that reduce sugar levels may similarly affect the child's body. After termination of breastfeeding, you need to contact an endocrinologist for a review of the tactics of further treatment.
I have 28 weeks of pregnancy, Protafan and Novorapid pricked. Against the background of pregnancy, Protofan began to give hypoglycemia at night. My doctor transferred me to Levemir. Now grief I do not know. The drug does not give a sharp decrease in sugar. I feel great.
Hello! I have type 1 diabetes. Pregnancy 12 weeks. For a long time they did not want to register, because they needed a certificate that I could carry a child. The morning dawn tormented me, sugar jumped to 9. The doctor explained how to do the morning jokes. Now the condition has improved, put on record.
Got sick with diabetes, got pregnant 4 years after the diagnosis. She carried up to 34 weeks. The level of glucose sharply increased, a caesarean section was done. The girl was weak, breathing badly. She is now 5 years old, no different from her peers.