Diabetes mellitus is a disease that occurs as a result of a lack of insulin, which can be absolute( if its pancreas is insufficiently produced) and relative( insulin is formed in sufficient quantity, but the patient's tissues do not perceive it at the same time).
- 1 Classification
- 2 Gestational diabetes mellitus in pregnancy - what is it?
- 3 Pathogenesis of diabetes mellitus in pregnant women
- 4 Predisposing factors
- 5 Clinic of diabetes mellitus in pregnancy
- 6 Degrees of diabetes
- 7 Diabetes mellitus during pregnancy
- 8 Contraindications to pregnancy with diabetes
- 9 Treatment
Classification of diabetes
Type 1 diabetes or insulin-dependent( IDDM) is a form of pathology that is characterized byinsulin deficiency resulting from death?- cells, of which the pancreas consists. Occurs in childhood, characterized by absolute insulin deficiency, unstable course, the presence of antibodies to the cells of its own pancreas.
Type 2 diabetes or non-insulin-dependent( NIDDM) is characterized by a relative insufficiency of insulin due to a decrease in the sensitivity of body tissues to it. Occurs over the age of 30, has a slow onset, metabolic changes are not pronounced sharply. With this type of diabetes, the probability of inheritance is quite high( autosomal dominant).
Gestational diabetes mellitus in pregnancy - what is it?
Pregnant women have diabetes as an impaired glucose uptake, which is first diagnosed during pregnancy .
Pathology occurs in about 5% of pregnant women, who tend to have an excess of body weight, relatives with diabetes and a history of obstetric anamnesis( miscarriages, stillbirths, polyhydramnios, etc.).For gestational diabetes is characterized by a relative insulin deficiency. Diseases are detected at a period of about 30 weeks gestation, then it disappears after three postnatal months.
Currently, thanks to insulin therapy, most sick patients have the opportunity to have a baby, but the mortality of a newborn( or fetus) in this mother's pathology is still quite high( about 15%).Rational tactics of conducting such pregnant women allows to reduce the level to 3%, which are caused by incompatible with life vices due to decompensation of the disease at the time of conception and in the first trimester of pregnancy.
A woman who has had gestational diabetes mellitus has a high risk of developing diabetes( often of the second type) during the first 10-15 years after childbirth.
Pathogenesis of diabetes of pregnant women
The pathogenetic mechanism of this form of pathology is similar to that of type 2 diabetes;insulin is produced in sufficient quantity, however the cells of the tissues of the body of a pregnant woman become insensitive to it. The difference lies in the factors that determine the resistance to insulin of tissues. They are peculiar to the pregnant changes in the hormonal background and metabolism.
Alertness for diabetes should occur if:
- 1. There is a genetic predisposition and both parents are ill;
- One of the two identical twins is diabetic;
- Presence in this woman of previously born children with a body weight of more than 4.5 kg;
- If children with organic pathology of the pancreas were born earlier;
- Excess body weight of the pregnant;
- Habitual miscarriage in a woman;
- Polyhydramnios in pregnant women;
- In the presence of glucose in the urine.
Clinic for diabetes mellitus in pregnant
diabetes is obvious, in which there are clinical manifestations, and hidden( in the presence of only impaired glucose tolerance).
The woman has complaints about a feeling of dryness in the mouth, a thirst( due to this, a lot of liquids are being drunk - more than two liters), a large amount of urine. Characteristic decrease in appetite, significant weakness and lethargy, sleep disturbance, weight loss. The patient is worried about persistent and severe itching( especially in the genital area), frequent pustular skin diseases.
In the analysis of urine, sugar can be determined both in a pregnant patient( due to a violation of carbohydrate metabolism) and in healthy( which is due to a change in the function of kidney filtration).For differential diagnosis it is necessary to determine the amount of glucose in the blood on an empty stomach. If the kidneys are working normally, glucose in the urine appears, if its level in the blood begins to exceed 10 mmol / l.
In order to have an idea of the fluctuations in blood glucose levels throughout the day, a glycemic profile is determined( the glucose content is measured every three hours).Normal changes in the range of 5.6- 8.2 mmol / l are considered, in pregnant women it is recommended to adhere to the level of 3.6-7 mmol / l.
Microangiopathies( systemic lesions of small blood vessels), which lead to the development of a violation of the function of the organs: eyes, kidneys, skin, digestive tract and nervous system, are among the clinical manifestations. Especially dangerous is the damage to the eyes, which is called diabetic retinopathy and is manifested by rapid deterioration of vision, hemorrhages in the retina and vitreous humor, and further blindness( noted in up to 90% of diabetic patients).When lesions of kidney vessels occur, sclerosis of glomeruli( glomerulosclerosis), which is manifested by increased arterial pressure, edematous syndrome, the appearance of protein in the urine.
Degrees of diabetes
There are three stages of GDD:
- Easy - fasting blood glucose less than 7.7 mmol / l, comes back to normal when dieting;
- For an average degree, fasting glycemia is less than 12 mmol / l, which is adjusted by insulin therapy in an amount not exceeding 60 units per day;
- A severe degree is one in which the fasting blood glucose level is greater than 12.6 mmol, the need for insulin is more than 60 units / day, the presence of microangiopathies.
Diabetes mellitus during pregnancy
The first trimester is characterized by an improvement in the nature of the course of the disease, a drop in the level of glucose in the blood plasma, even a tendency to hypoglycemic conditions of .During this period, hospitalization for the development of treatment tactics and the solution of the issue of maintaining pregnancy are shown.
In the second trimester, there is an increase in the level of glycemia, which, for its correction, requires higher doses of insulin due to the action of the contrinsular hormones produced by the placenta. Showing hospitalization at week 22 to correct insulin.
For the third trimester, starting at 32 weeks, the typical occurrence of decompensated disease. Showing of hospitalization for the decision of a question on term and a method of a delivery.
The delivery in the case of IDDM is carried out at 37 weeks, or earlier - according to the vital signs of the mother or fetus.
Indications for cesarean delivery are as follows:
- Progression of vascular disorders;
- Unstable course of the disease;
- The appearance of severe form of gestosis;
- Appearance of signs of fetal hypoxia;
- Increasing polyhydramnios;
- Pelvic presentation of the fetus;
- Large mass of fruit.
Contraindications to pregnancy with diabetes
Pregnancy to a woman is contraindicated in the case of the following conditions:
- Diabetic vascular disease;
- A type of diabetes that is resistant to insulin therapy;
- Diabetes in both spouses;
- Combination of diabetes with Rh-incompatibility;
- Combination of diabetes with active tuberculosis;
- Presence in the anamnesis of stillborn children or with malformations.
Complications that may occur in the fetus:
- Macrosomia - enlargement of body parts;
- 50% of newborns are addicted to low blood glucose;
- Development of the syndrome of diabetic fetopathy: general puffiness, immaturity, Cushingoid appearance( face of the moon-shaped, petechiae on the skin, obesity);
- In 15% of cases, the newborn has a low body weight;
- Congenital malformations;
- Respiratory disorders;
- Syndrome of impaired development of the fetus.
Factors that contribute to the occurrence of malformations in the fetus are: insufficient control of the disease before conception, the duration of the disease for more than ten years and the presence of diabetic microangiopathy. Excessive amount of glucose in the blood causes a violation of the formation of organs and tissues of the fetus at the very beginning of pregnancy. The highest risk is the pathology of the neural tube, as well as the heart, digestive tract and genitourinary system. A newborn baby is often required intensive therapy to combat low blood glucose levels, respiratory failure and electrolyte disorders.
Mortality in the perinatal period is: with DM type 1 - 15%, with diabetes 2 types - 25%, with gestational diabetes - 45%.
The goal of therapy for women with diabetes is full compensation of the disease during the planning period and throughout the gestation period.
Criteria for compensation of diabetes:
- Fluctuating of glycemia during the day within 4.3-8.2 mmol / L;
- No episodes of hypoglycemia.
For compensated insulin-dependent diabetes mellitus is characterized by: normal fasting blood glucose, its fluctuation during the day from 4 to 8.2 mmol / L, the absence of glucose in the urine.
The main methods of treatment of diabetes:
- Dietotherapy, which is characterized by a decrease in the diet of a pregnant carbohydrate and fat, an increase in protein content, caloric intake should be at least 2500 kcal. Eating should be done taking into account the action of insulin.
- Insulin therapy. Drugs that reduce sugar in tableted form to pregnant women are contraindicated, since they have a damaging effect on the fetus, passing through the placenta. Therefore, for both types of diabetes use insulin injections, the appointment of which is necessary at a fasting glucose level of more than 5.5 mmol / L and more than 7 after eating, while following a diet. The daily dose of insulin is calculated as follows: 6 units of insulin are injected for every 2.5 mmol / l of glucose in the blood above the physiological norm( 5.5).At the beginning of treatment, three injections per day are optimal: in the morning a mixture of short and long insulin is used, then a simple shake before dinner, and a long shot at night. In pregnant women, only human insulin is used.