Common Sense of Diagnosis and Treatment of Diabetes in Pregnancy

There are two types of pregnancy-combined diabetes in clinical practice: one is pregnancy based on diabetes before pregnancy, or is diagnosed for the first time in pregnancy, also known as diabetes combined with pregnancy; the other is diabetes with normal glucose metabolism before pregnancy and diabetes that only appears after pregnancy. , The second condition is called gestational diabetes. In recent years, the number of patients suffering from gestational diabetes has increased, and it has shown an increasing trend year by year. More than 90% of pregnant women with gestational diabetes have gestational diabetes, and less than 10% of pre-pregnancy diabetes with pregnancy. Most patients with gestational diabetes mellitus with abnormal glucose metabolism can return to normal postpartum, but the probability of developing type 2 diabetes will increase in the future. Diabetes in pregnancy is a great hazard to pregnant women and fetuses, and attention should be paid. Next, I will give you a detailed introduction to the common sense of diagnosis and treatment of gestational diabetes.

In the early and second trimesters, as the gestational week increases, the fetus’ demand for nutrients will also increase. The fetus obtains energy mainly through the maternal placenta to absorb glucose, which is also the main source of fetal energy. Therefore, as the pregnancy cycle increases, the glucose level in the mother’s own plasma will gradually decrease, and the fasting blood glucose will decrease by about 10%. The specific reasons are as follows: ①The fetal intake of maternal glucose level increases; ②During pregnancy, the glomerular filtration rate and plasma flow are significantly increased, but the renal tubular reabsorption rate of sugar cannot be increased correspondingly, which in turn makes some pregnant women excrete sugar The amount increases; ③The maternal glucose utilization rate increases with the increase of progesterone and estrogen. In the middle and late pregnancy, the antagonistic insulin-like substances in pregnant women increase, so that the sensitivity of pregnant women to insulin decreases with the increase in gestational age. In order to maintain normal glucose metabolism levels, insulin requirements must be increased accordingly. For pregnant women with restricted insulin secretion, this physiological change cannot be compensated during pregnancy and the blood sugar will rise. Therefore, the fasting blood sugar of pregnant women is significantly lower than that of normal people. This is one of the reasons why pregnant women are prone to hypoglycemia and ketoacidosis, and it is also one of the reasons why the original diabetes is aggravated. Therefore, if gestational diabetes is not intervened and treated in time, it will easily lead to abnormal early embryonic development, miscarriage, or excessive amniotic fluid, fetal growth restriction, or giant fetuses, fetal malformations, and fetal distress. After delivery, newborns are prone to hypoglycemia, neonatal respiratory distress syndrome, etc., pregnant women are prone to infections, diabetic ketoacidosis and other symptoms, and pregnant women with gestational diabetes have a high recurrence rate of 33% to 69% when they become pregnant again. Therefore, we need to pay attention to the diagnosis and treatment of gestational diabetes.

Diabetes in pregnancy is often accompanied by many high-risk factors: ①Own obesity (especially severe obesity); ②Having a family history of diabetes, first-degree relatives suffering from type 2 diabetes; ③Having a history of gestational diabetes or a history of childbirth, unknown reasons He had a history of stillbirth, stillbirth, and miscarriage; ④ Suffered from polycystic ovary syndrome; ⑤ Repeated positive fasting urine glucose in early pregnancy; ⑥ Suffered from vulvovaginal candida disease and repeated attacks. The most typical symptoms are three symptoms during pregnancy: polyphagia, polydipsia, and polyuria, or recurrent vaginal infections.

Diagnosis of Diabetes in Pregnancy
The clinical diagnosis of pre-pregnancy diabetes is as follows, and it can be diagnosed if it meets any of the following two items: one is a patient with diabetes who has been clearly diagnosed before pregnancy; the other is a pregnant woman who has not had a blood sugar check before pregnancy, but there are high risk factors for diabetes as mentioned above, and Diabetes due to pregnancy should be diagnosed if any one of the following criteria is met: ①Fasting blood glucose result ≥7.08mmol/L; ②75g oral glucose tolerance test (OGTT) 2 hours blood glucose ≥11.1mmol/L; ③With typical hyperglycemia Symptoms or hyperglycemia crisis, and random blood glucose ≥ 11.1 mmol/L; ④ A1C ≥ 6.5%, but this is not recommended for routine diabetes screening during pregnancy.

Diagnosis of gestational diabetes
All pregnant women who have not yet been diagnosed with pre-pregnancy diabetes or gestational diabetes should undergo 75gOGTT screening at 24 to 29 weeks of gestation and at the first visit after 28 weeks. The diagnostic criteria of OGTT are: fasting blood glucose is less than 5.11mmol/L; 1 hour after taking sugar is less than 10.0mmol/L; 2 hours after taking sugar is less than 8.5mmol/L; any point blood sugar level meets or exceeds the above indicators, you can Diagnosed as gestational diabetes. For pregnant women with high-risk factors for gestational diabetes or areas with insufficient medical resources, it is recommended to check fasting blood glucose at 24 to 28 weeks of pregnancy. When fasting blood glucose is ≥5.1mmol/L, gestational diabetes can be directly diagnosed.

Pregnancy monitoring
1. Pregnant women’s blood glucose monitoring method: self blood glucose monitoring and continuous dynamic blood glucose monitoring. Self-monitoring blood glucose should be monitored 7 times a day, that is, 30 minutes before the three meals, 2 hours after the three meals, and night blood glucose. Continuous dynamic blood glucose monitoring is used for pregnant women whose blood sugar control is not ideal or whose blood sugar is obviously abnormal and require insulin.

2. Blood glucose control goals: ①Glucose control goals for pregnant women with gestational diabetes: pre-meal blood sugar ≤5.3mmol/L, 2-hour postprandial blood glucose ≤6.7mmol/L; under special circumstances, the 1-hour postprandial blood glucose ≤7.8mmol/L can be measured The night blood glucose is not less than 3.3mmol/L, and the glycosylated hemoglobin during pregnancy is less than 5.5%. ②Glucose control goals for pregnant women with diabetes mellitus: control the pre-meal and night blood glucose during pregnancy, that is, fasting blood glucose between 3.3 and 5.6 mmol/L; peak blood glucose after meals between 5.6 and 7.1 mmol/L; glycosylated hemoglobin less than 6.0%.

3. Fetal development monitoring: master the growth and development of the fetus. In the process of pregnancy check, patients with gestational diabetes need to pay close attention to the growth and development of the fetus to ensure the healthy growth of the fetus. Generally judged from the following aspects: ① Detect pregnant women’s weight, blood pressure, uterine fundus height, abdominal circumference, edema, proteinuria, fetal heart, fetal position, and through ultrasound examination of double parietal diameter, abdominal circumference, femur length, etc. These results are recorded in detail in the card data; ②B-ultrasound monitors fetal growth, mainly observing head circumference, abdominal circumference, and femur length, of which the fetal abdominal circumference is the most representative; ③Color Doppler ultrasound is used to check the umbilical artery blood flow, all ultrasound Fetuses whose estimated weight or fetal abdominal circumference measurement is less than 10% of the normal value require umbilical artery Doppler blood flow monitoring to understand the uterine placental perfusion.

Treatment of pregnancy complicated with diabetes during pregnancy
The purpose of medical nutrition therapy is to control the blood sugar of pregnant women with diabetes in the normal range, ensure the reasonable nutritional intake of pregnant women and fetuses, and reduce the occurrence of maternal and child complications. Pregnant women need to pay special attention to diet, standardized nutritious food preparation, completed by professional dietitians. The specific diet plan is as follows.

1. Total energy intake per day. No less than 1500kcal/d in the first trimester and no less than 1800kcal/d in the third trimester. ①Carbohydrates: 50% to 60% of the total energy is appropriate, not less than 150g/d. Measuring the intake of carbohydrates is the key to achieving blood sugar control standards. Try to avoid eating refined sugars such as sucrose. ②Protein: 15%-20% of the total energy is appropriate, which can meet the needs of maternal physiological regulation during pregnancy and fetal growth and development. ③Fat: 25%-30% of the total energy is appropriate. Foods with high saturated fatty acid content should be restricted, such as animal fats, red meat, coconut milk, whole milk products, etc. The intake of saturated fatty acids in diabetic patients should not be More than 7% of total energy intake. ④Dietary fiber: It is a polysaccharide that does not produce energy. It controls the increase in blood sugar after a meal, improves glucose tolerance and reduces blood cholesterol. The recommended daily intake is 25-30g, which is mainly found in fruits such as pectin, kelp, and seaweed. In the alginate, eat more fiber-rich oatmeal, tartary soba and other grains, and eat more fresh vegetables, fruits, lean meat, fish, whole grains, beans, etc., and arrange meals daily, with a small amount Multi-meal, regular and fixed meals are very important for blood sugar control. The energy of food or fruit can be 5% to 10%.

2. Exercise therapy. Proper and regular exercise during pregnancy can effectively reduce gestational diabetes and stabilize the blood sugar level of pregnant women. The role of exercise is to control blood sugar, reduce insulin consumption, and control weight gain. Therefore, patients with gestational diabetes should take at least half an hour of physical exercise every day, and at least 5 days of exercise per week. At the same time, exercise can keep blood sugar levels in a normal range. The exercise suitable for pregnant women is walking, and it is very simple to implement.

3. Insulin therapy during pregnancy. Insulin is the drug of choice for hyperglycemia during pregnancy. For hyperglycemia during pregnancy, if diet control is not up to standard, start insulin as soon as possible. Pregnant women with diabetes are treated with diet for 3 to 5 days. If fasting blood sugar or pre-meal blood sugar ≥5.3mmol/L or 2 hours after meal Blood sugar ≥ 6.7mmol/L, or hunger ketosis after diet adjustment, increased caloric intake and blood sugar exceed the pregnancy standard, insulin should be added in time. Ultra-short-acting insulin has the best hypoglycemic effect, fast onset, and short maintenance time. It is used to control the blood glucose level after a meal. Short-acting insulin has a quick onset and a half-life of 5-6 minutes, so it can be used for rescue treatment. Intermediate-acting insulin has a slow onset of action and a long-term maintenance time. Its blood sugar lowering strength is weaker than that of short-acting insulin. Long-acting insulin is used to control night blood sugar and pre-meal blood sugar. Patients with gestational diabetes should go to a professional endocrinology department for treatment, rational use and adjustment of insulin dosage.

4. The principle of using insulin during childbirth and perioperative period. All subcutaneous insulin injections should be stopped before and after surgery, during labor, and during abnormal postpartum diets, and insulin should be used intravenously; blood pressure and urine ketone levels must be monitored during labor or before surgery.

5. Postpartum treatment. Newborns born to pregnant women with gestational diabetes are prone to hypoglycemia after birth, and close monitoring of blood sugar changes can detect hypoglycemia in time. It is recommended that newborns undergo peripheral blood glucose monitoring within 30 minutes after birth, and feed sugar water and milk in advance. Newborns are treated as high-risk infants, pay attention to keeping warm and inhaling oxygen, and pay close attention to the occurrence of neonatal respiratory distress syndrome. Pregnant women with gestational diabetes and their offspring are high-risk groups of diabetes. It is recommended that all women with gestational diabetes receive follow-up at 6-12 weeks postpartum.