The problem of pregnancy and diabetes must be considered in two ways. The first aspect of the problem is the identification of pregnant women with secretive diabetes mellitus, as well as impaired glucose tolerance that disappears after childbirth (pregnant diabetes, or “gestational diabetes”). Even with such transient insolvency of pancreatic beta cells, the risk of perinatal mortality and various pathologies in childbirth increases significantly.
Therefore, the glucose tolerance test in pregnant women with various risk factors (family history of diabetes, obesity, birth of children weighing more than 4.5 kg, burdened obstetric history) is of paramount importance. Repeated detection of glycosuria in such women is a direct indication for GTT. It should be borne in mind that in almost a third of women who have been diagnosed with “pregnancy diabetes,” in the coming years it will transform into permanent diabetes.
In almost a third of women who have been diagnosed with “pregnancy diabetes,” in the coming years it will transform into permanent diabetes.
The second aspect of the problem is pregnancy with concurrent diabetes. Pregnancy significantly complicates the course of diabetes and its manifestations. In pregnant women with diabetes, the birth of large babies is noted, various diseases during pregnancy and mortality of fetuses and newborns are more frequent. The causes of mortality are intrauterine fetal death, respiratory failure syndrome and congenital malformations, resulting from hyperinsulinemia, placental changes in the type of diabetic capillaropathy. Pregnancy and childbirth can contribute to the progression of diabetic angiopathies – especially retino-and nephro, often they provoke their manifestation.
Clinical monitoring of women of childbearing age with diabetes should be carried out with particular care and, in addition to general tasks, include the following:
- Before pregnancy, identify women who, for diabetes or diabetic angiopathy, are contraindicated in the birth of children;
- It is necessary to explain to them the great risk of pregnancy and childbirth, and also recommend (together with the gynecologist) to carefully protect themselves from pregnancy. Direct contraindications to the preservation of pregnancy with diabetes are
- insulin-resistant and labile diabetes with a tendency to ketosis;
- progressive forms of diabetic retinopathy and nephropathy with symptoms of renal failure and arterial hypertension;
- a combination of diabetes mellitus and active pulmonary tuberculosis or other serious concomitant diseases in which pregnancy often leads to a severe exacerbation of the process;
- the presence of diabetes in both spouses, especially with burdened heredity;
- a combination of diabetes mellitus and Rh sensitization of the mother, which significantly worsens the prognosis for the fetus;
- history of repeated cases of fetal death or the birth of children with developmental defects in patients with diabetes mellitus compensated during pregnancy.
An endocrinologist, together with an obstetrician-gynecologist and specialists of other profiles (optometrist, neuropathologist, cardiologist, etc.), must conduct early rehabilitation and compensate for diabetes in women seeking motherhood. At the first visit to the antenatal clinic and the establishment of the gestational age, it is necessary, together with the gynecologist, to warn the patient about all its possible negative consequences for diabetes, about the dubious prognosis for the fetus and suggest aborting. It should be noted that among some patients there is a false idea about the beneficial effects of pregnancy on the course of diabetes. Perhaps it is based on the fact that in some women after childbirth there is a clear, short-term remission of diabetes, due to hormonal changes with the suppression of the counterinsular effect of somatotropic hormone. After 1-1.5 months, these phenomena disappear and diabetes returns to its original state, often during this period diabetic angiopathies manifest or worsen.
An idea about the beneficial effects of pregnancy on the course of diabetes is false.
While maintaining pregnancy, the tactics of doctors should be as follows. An endocrinologist and a gynecologist should examine the patient, determine blood sugar and urine in the first half of pregnancy 2 times a month, in the second half – weekly. In case of any deterioration, accompanied by decompensation of diabetes, hospitalization in an endocrinological hospital is necessary to adjust the dose of insulin. Moreover, the first half of pregnancy is usually characterized by a decrease in insulin requirements, often due to anorexia and dyspeptic symptoms due to toxicosis of the first half of pregnancy. During this period, hypoglycemic conditions are frequent, which are dangerous to the fetus. Long-term hypoglycemia with loss of consciousness in the first half of pregnancy is a direct indication for its termination due to the severe consequences for the baby: The second half of pregnancy is more often characterized by an increase in the need for insulin, often ketoacidosis. During these periods, most often there is a need for hospitalization. Typically, up to 20 weeks of pregnancy in the absence of obstetric complications, diabetes mellitus is advisable to compensate for in the endocrinology department. In the second half of pregnancy, due to the great risk of miscarriage, treatment is recommended in specialized obstetric wards. Monitoring for pregnant women with diabetes should be carried out by an endocrinologist and gynecologist throughout the pregnancy.
Monitoring for pregnant women with diabetes should be carried out by an endocrinologist and gynecologist throughout the pregnancy.
If the diet does not allow full compensation for diabetes, all pregnant women, regardless of the severity of diabetes, should be switched to insulin. Pregnant patients often have to be transferred to fractional administration of insulin 3-4 times a day. Drug therapy should be reduced to critically needed symptomatic agents. Patients with diabetes need more frequent monitoring of blood pressure, dynamics of body weight, albuminuria due to their tendency to develop late pregnancy toxicosis.
Prenatal hospitalization in endocrinology (with subsequent transfer to the obstetric department for delivery) or specialized obstetric department should be carried out no later than 32 weeks of pregnancy. The question of the term of labor is decided depending on the condition of the mother and the fetus (degree of maturity, danger of developing respiratory failure syndrome).
In the presence of aggravating factors (poorly controlled diabetes, progression of pregnancy complications or diabetic angiopathies, the threat of fetal hypoxia, etc.) they resort to early delivery at 36-37 weeks. Earlier dates are possible only for health reasons for the mother. Delivery should be carried out through the natural birth canal, if there is no obstetric indication for cesarean section. However, even in the absence of the latter, the condition of the mother and fetus sometimes necessitates surgical delivery.