Diabetes Mellitus In Pregnancy (Gestational Diabetes)

Pregnancy aggravates the situation of pre-existing type 1 (insulin-dependent) and type 2 (non-insulin-dependent) diabetes, but seems to be a diabetic retinopathy, nephropathy or neuropathy does not become symptomatic.

(Diabetes mellitus (DM).) A pregnancy exacerbated the situation of pre-existing type 1 (insulin-dependent) and type 2 (non-insulin-dependent) diabetes, but seems to be a diabetic retinopathy, nephropathy or neuropathy does not become symptomatic. Similarly, gestational diabetes (diabetes that starts during pregnancy) can develop in obese, hyperinsulinemic, insulin-resistant pregnant or thin pregnant with relative insulin deficiency. Gestational diabetes occurs in at least 5% of all pregnancies, wherein the percentage in specific population groups (z. B. Mexican-Americans inner, American Indians, Asian, Indian women and Polynesian) may be much higher. Women with gestational diabetes are at increased risk for future type 2 diabetes. Diabetes during pregnancy increases fetal and maternal morbidity and mortality. Newborns have a higher risk of respiratory distress, hypoglycemia, hypocalcemia, polycythemia and increased blood viscosity. A poorly controlled, pre-existing or pregnancy-induced diabetes during the period of organogenesis (approximately up to the 10th week of pregnancy) increases the risk of serious congenital malformations and of a spontaneous abortion. Later insufficient Diabetes setting increases during pregnancy, the risk of macrosomia (usually defined by fetal birth weight> 4000 g or> 4500 g), pre-eclampsia, miscarriage and shoulder dystocia. Gestational diabetes can lead to fetal macrosomia however, when the blood glucose is controlled almost normally. Diagnostic oral glucose tolerance test (OGTT) or a single plasma glucose measurement (fasting or random) Most doctors recommend to examine all pregnant women for gestational diabetes (laboratory tests). An OGTT will indeed usually recommended, but the diagnosis can probably by a fasting blood sugar> 126 mg / dL (> 6.9 mmol / l) or a routine determination of blood glucose are placed> 200 mg / dl (> 11 mmol / l) , a two-stage test is recommended for screening. First, a test load of 50 g glucose is orally, and conducted a glucose determination after 1 hour. If the blood sugar level after 1 hour at> 130-140 mg / dl (> 7.2-7.8 mmol / l), a second load test is performed to confirm after 3 hours with 100 g of glucose (see Table: Glucose limits for gestational with a 3-hour oral glucose tolerance test *). Most organizations outside the US recommend a 1-stage 2-hour test. Glucose limits for gestational with a 3-hour oral glucose tolerance test * organization fasting mg / dL (mmol / l) 1 hour mg / dL (mmol / l) for 2 h mg / dL (mmol / L) for 3 h mg / dL (mmol / l) and Carpenter Coustan 95 (5.3) 180 (10) 155 (8.6) 140 (7.8) National diabetes Data Group 105 (5.8) 190 (10.5) 165 (9 , 1), 145 (8) * It is a glucose load of 100 g was used. Treatment Close monitoring Strict control of blood sugar treatment of complications counseling before conception and optimal control of diabetes before, during and after pregnancy minimize the maternal and fetal risk, including the risk of congenital malformations. As malformations can develop before the diagnosis of pregnancy, it is for the women who have diabetes and are planning to become pregnant (or use the no contraceptives) to conduct necessarily a permanent strict control of glucose levels. Risks are minimized by consulting a diabetes team (eg. As doctors, nurses, dietitians, social workers) and a pediatrician Conversely Hendes recognize and treat complications of pregnancy, no matter how inconsequential they seem birth planning and provision of an experienced pediatrician ensuring an available intensive care of the newborn in regional perinatal centers are specialists in diabetology available. During pregnancy, the treatment may be different, but some general treatment guidelines are useful (see table: control of type 1 diabetes mellitus during pregnancy *, control of type 2 diabetes mellitus during pregnancy * and control of gestational diabetes during Pregnancy). Women with type 1 or type 2 diabetes should monitor their blood sugar levels at home. During pregnancy, the normal fasting blood glucose levels are about 76 mg / dl (4.2 mmol / l). Goals of treatment are fasting blood glucose levels in <95 mg / dl (<5.3 mmol / l) 2-hr postprandial values ??at ? 120 mg / dl (? 6.6 mmol / l) No major blood sugar fluctuations Glycosylated Hb (Hb A1c ) - mirror in <8% control of type 1 diabetes mellitus during pregnancy * timeframe measures prior to designing diabetes is set. Lowest risk for HbA1c values ??? 8% at the time of conception. † clarification comprises 24-hour urine collection, a (protein excretion and creatinine clearance) the question of renal complications Ophthalmic Examination for evaluation of retinal complications ECG for evaluation of cardiac complications Prenatal start of provision as soon as the pregnancy is detected. The frequency of inspections depends on the quality of glycemic control. Individual diet after ADA guidelines in coordination with the insulin therapy. 3 meals and 3 snacks / day are recommended emphasizing a consistent schedule. Patients should be instructed to home blood sugar control and practice it. Patients must be made aware of the risk of hypoglycemia at night and during sports activities. Patient and family members should be trained in the use of glucagon. HbA1c levels should be measured in each trimester. The monitoring of the fetus should be up to the birth of 32 weeks (or sooner if indicated) on a weekly basis with: Nonstress test biophysical profile counting the kicks amount and type of insulin should be determined individually. Morning: administration of two thirds of the total dose (60% NPH, 40% Normal); Afternoon: transfer of one-third (50% NPH, 50% Normal). Or women can 2 times / take day NPH insulin and insulin aspart immediately before breakfast, lunch and dinner. ‡ During labor and birth vaginal birth at term is possible if the patient has demonstrated a safe dating and a good BZ setting , An amniocentesis is not performed unless there is an indication of another problem due before or desired by the couple. A caesarean section is obstetric indications or fetal macrosomia (> 4500 g) with an increased risk of shoulder dystocia reserve. The delivery should be done around the 39th week of pregnancy. During childbirth, a constant is most preferred “low-dose” insulin infusion; the SC. Insulin use is discontinued. In the case of induction of labor, the usual afternoon dose of NPH insulin can be given on the previous day. For a continuous and postpartum diabetes monitoring must be ensured. The postpartum Insulin requirements may be reduced by up to 50%. * The guidelines are only a suggestion; significant individual differences require appropriate adjustments. † Depending on laboratory methods normal values ??may be different. ‡ Some hospital programs recommend up to four insulin injections every day. A continuous s.c. Insulin infusion, which is very labor intensive, can sometimes be used in specialized diabetes clinics. ADA = American Diabetes Association; HbA1c = glycosylated hemoglobin; NPH = neutral protamine Hagedorn. Clinical Calculator: Pregnancy progress based Naegele’s rule and ultrasound biometry control of type 2 diabetes mellitus during pregnancy * Timeframe measures prior to designing fever is controlled. Lowest risk at HbA1c ? 8% at the time of conception. † In BMI> 27 kg / m2 recommendation for weight loss. The diet should be low in fat and relatively rich in complex carbohydrates and fiber. Exercise is recommended. Prenatal For obese patients customization diet and calorie intake to gain weight> 9 kg (> 20 lb) prevent; Obese women should not be more than about 7 kg (> 16 lb) increase. Easy walks after dinner are recommended. Patients should be instructed to home blood sugar control and practice it. The 2-hour blood glucose levels after breakfast, if possible monitored weekly at Visits. HbA1c levels should be measured in each trimester. The monitoring of the fetus should be up to the birth of 32 weeks (or sooner if indicated) on a weekly basis with: Nonstress test biophysical profile counting the kicks amount and type of insulin are determined individually. Obese receive regular insulin before each meal. Non-obese patients will receive the morning two-thirds of the total dose (60% NPH, 40% normal), in the afternoon a third (50% NPH, 50% Normal). Or women can take days NPH insulin and insulin aspart immediately before breakfast, lunch and dinner 2 times /. During labor and birth, the handling is similar to Type 1 (see table: control of type 1 diabetes mellitus during pregnancy *). * The guidelines are only a suggestion; significant individual differences require appropriate adjustments. † Depending on laboratory methods normal values ??may be different. BMI = body mass index; HbA1c = glycosylated hemoglobin; NPH = neutral protamine Hagedorn. Clinical Calculator: Body Mass Index (Quetelet’s index) control of gestational diabetes during pregnancy timeframe measures prior to designing patients with gestational diabetes in previous pregnancies should try to reach their normal weight and do a light workout. The diet should be low in fat and relatively rich in complex carbohydrates and fiber. Fasting blood sugar levels and HbA1c levels must be controlled. Prenatal diet and calorie intake are individually designed to gain weight> 9 kg prevent (> 20 lb); Obese women should not be more than about 7 kg (> 16 lb) increase. Light physical exercise after meals is recommended. The monitoring of the fetus should be up to the birth of 32 weeks (or if indicated earlier) on a weekly basis with: Nonstress test biophysical profile counting the kicks Insulin therapy is persistent hyperglycemia (fasting blood glucose level> 95 mg / dl or 2-h -Nüchtern blood glucose> 120 mg / dL) despite a diet trial on ? 2 weeks reserved. Amount and type of insulin are determined individually. Obese patients receive regular insulin before each meal. Non-obese patients will receive the morning two-thirds of the total dose (60% NPH, 40% normal), in the afternoon a third (50% NPH, 50% Normal). Or women can take days NPH insulin and insulin aspart immediately before breakfast, lunch and dinner 2 times /. During labor and birth, when patients have a well-documented date of birth and a well-controlled diabetes, a vaginal birth at term possible An amniocentesis is not absolutely necessary. A caesarean section is obstetric indications or fetal macrosomia (> 4500 g), which increases the risk of shoulder dystocia reserved. The delivery should be done around the 39th week of pregnancy. HbA1c = glycosylated hemoglobin; NPH = neutral protamine Hagedorn. Insulin Insulin has traditionally been the drug of choice, because it can not cross the placenta, and provides a more accurately predictable glycemic control and is used in type 1 and type 2 diabetes and in some women with gestational diabetes. If possible, human insulin is used because it keeps the formation of antibodies very low. Insulin antibodies cross the placenta, but their effect on the fetus is unknown. In some women with long existing type 1 diabetes, hypoglycemia will not trigger the normal responses versus-regulating hormones (catecholamines, glucagon, cortisol and growth hormone); Therefore, an excess of insulin can lead to a hypoglycemic coma without vorwarnende symptoms. All pregnant women with type 1 diabetes should have a glucagon kit and (as well as their family members) are trained in the use of glucagon in the occurrence of threatening hypoglycaemia (indicated in unconsciousness, confusion or blood glucose levels <40 mg / dL [<2, 2 mmol / l]). Tips and risks All pregnant women with type 1 diabetes should have and a glucagon kit (as well as their family members) are trained in the use of glucagon in the occurrence of threatening hypoglycaemia. For control of diabetes in pregnant women oral blood glucose-lowering drugs (eg. As glibornuride) are increasingly being given as their application is very simple (tablets versus injections), the cost is low and is dosed once a day. Some studies have shown that glibornuride is safe in pregnancy, and that allows insulin compared with an equal recruitment of women with gestational diabetes. For women with existing before pregnancy Type 2 diabetes are scant data on oral agents; Insulin is almost always preferred. The use of oral hypoglycemic agents during pregnancy may be continued post-partum lactation, the child should it be monitored closely for signs of hypoglycemia but. (N. D. Talk .: In Germany the gift orally blood pressure-lowering drugs [z. B. glyburide] during pregnancy and lactation is rated restraint.) Dealing with complications Although diabetic retinopathy, nephropathy and mild neuropathy are no contraindications of pregnancy, but they require before and during pregnancy a pre-conception counseling and careful guidance. In one retinopathy, it is necessary that in each trimester an ophthalmological examination takes place. After detecting a proliferative retinopathy at the first examination in pregnancy, is as soon as possible photocoagulation conduct to prevent progressive deterioration. Nephropathy, especially in women with renal transplant, predisposes to pregnancy-induced hypertension. The risk of preterm delivery is higher if kidney function is impaired or the transplant took place only a short time. Finds the birth ? instead of 2 years after transplant, the prognosis is most favorable. At elevated HbA1c levels at the time of conception and during the first 8 SSW congenital malformations larger organs are predetermined. When the value during the first trimester ? 8.5%, the risk of congenital malformations is increased significantly; for clarification of malformations a targeted ultrasound and fetal echocardiography are then performed during the second trimester. If pregnant women are taking with type 2 diabetes during the first trimester oral blood glucose lowering drugs, the risk of fetal congenital malformations is unknown (see Table: Some drugs with adverse effects during pregnancy) .Wehentätigkeit and birth, certain precautions are necessary to ensure the best possible position. The timing of the birth depends on the well-being of the fetus. The pregnant woman is stopped, a day to count the duration of an hour (fetal kick count) and any sudden reduction to report the movements of the fetus immediately to the obstetrician. With prenatal examinations (monitoring of the fetus) is started at 32 weeks; they are made earlier when the pregnant woman has a pronounced hypertension or kidney disease, or when a fetal growth retardation is suspected. An amniocentesis to assess fetal lung maturity is often in women required to: Obstetric complications in previous pregnancies Inadequate prenatal care Unsichem due date Poor blood sugar control Inadequate adherence The type of birth is usually a spontaneous vaginal delivery at term. Risk of stillbirth and dystocia increases in the short term. If the contractions do not start spontaneously around the 39th week of pregnancy, the birth is usually initiate; the birth between the 37th and 39th SSW without amniocentesis can be initiated if the patient compliance insufficient or blood sugar is poorly controlled. Disturbances of labor, a fetopelvines mismatch or the risk of shoulder dystocia can make a caesarean necessary. During labor and birth, the blood sugar levels are best by a continuous "low-dose" - Check the insulin infusion. If an induction of labor is planned that pregnant women eat their normal diet the day before and take their normal dose of insulin. On the morning of induction of labor breakfast and Insulinvorenthalten be. After determination of basal fasting blood glucose value is with the aid of an infusion pump with an i.v. started infusion of 5% dextrose in 0.45% saline solution at a dose of 125 ml / h. The initial rate of insulin infusion based on the capillary glucose levels. The insulin dose is defined as follows: Initial: 0 I.U. at a capillary level <80 mg / dl (<4.4 mmol / L) or 0.5 IU / h at a level of 80-100 mg / dl (4.4 to 5.5 mmol / l) Then: increase in levels above 100 mg / dl for each rise in glucose levels to 40 mg / dl (2.2 mmol / l) to 0.5 IU / h up to 2.5 IU / h at levels> 220 mg / dl (> 12.2 mmol / l). Every hour during labor: Glucose the bed and adjusting the dose, so that the levels between 70 and 120 mg / dl (3.8 to 6.6 mmol / l) are maintained. At significantly elevated glucose levels: possibly additional bolus doses at a vaginal delivery is same treatment except that the insulin dose should be reduced if an intermediary was given insulin during the previous 12 hours. In women with fever, infection or other complications and obese women with type 2 diabetes, the pre-pregnancy daily> 100 IU required insulin needs the insulin dose werden.Post increased partum After the birth, the insulin requirement decreases immediately with the delivery of the placenta, which synthesizes large amounts of insulin-antagonistic hormones during pregnancy. Therefore, women need to gestational diabetes and many women with type 2 diabetes after the birth of insulin. For women with type 1 diabetes, insulin requirements decreased dramatically, but rises to about 72 hours gradually returning to. During the first 6 weeks postpartum, the goal is a strict blood sugar control. The glucose levels are determined before meals and at bedtime. Breastfeeding is not contraindicated, but can result in use of oral hypoglycemic agents to neonatal hypoglycemia. In women who had gestational diabetes, about 6-12 weeks should be post-partum performed an oral 2-hour glucose tolerance test to determine if the diabetes is gone. Summary Diabetes in pregnancy increases the risk of macrosomia, shoulder dystocia, eclampsia, miscarriage and – if a pre-existing diabetes or gestational diabetes during organogenesis is badly adjusted – for severe congenital malformations and spontaneous abortion. All pregnant women should be tested with an oral glucose tolerance test for gestational diabetes. If possible, a diabetes team should be involved; The aim is to keep the fasting blood sugar levels in <95 mg / dl (<5.3 mmol / l) and the postprandial 2-h values ??at ? 120 mg / dl (? 6.6 mmol / l). The prenatal examinations should begin at 32 weeks and be born in the 39th week of pregnancy. The insulin dose is adjusted immediately after delivery of the placenta.

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