Diabetes mellitus in pregnancy

Diabetes mellitus during pregnancy is a group of metabolic diseases characterized by hyperglycemia, which is the result of defects in insulin secretion, insulin action, or both. Chronic hyperglycemia in diabetes leads to the defeat and development of insufficiency of various organs, especially the eyes, kidneys, nervous and cardiovascular systems.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10]

Epidemiology

According to different data, from 1 to 14% of all pregnancies (depending on the population studied and the diagnostic methods used) are complicated by gestational diabetes.

The prevalence of type 1 and 2 diabetes among women of reproductive age is 2%, in 1% of all pregnancies the woman initially has diabetes, 4.5% of cases develop gestational diabetes, including 5% of cases under the guise of gestational diabetes, a manifestation of sugar diabetes.

The causes of increased morbidity of the fruit are macrosomia, hypoglycemia, congenital malformations, respiratory failure syndrome, hyperbilirubinemia, hypocalcemia, polycythemia, hypomagnesemia. Below is the classification of P. White, which characterizes the numerical (p,%) probability of a viable child in relation to the duration and complication of diabetes maternal.

• Class A. Violation of glucose tolerance and absence of complications - p = 100;
• Class B. The duration of diabetes is less than 10 years, occurred at the age of over 20 years, there are no vascular complications - p = 67;
• Class C. Duration from 10 to Shlet, has arisen in 10-19 years, there are no vascular complications - р = 48;
• Class D. Duration more than 20 years, arose up to 10 years; retinopathy or calcification of the vessels of the legs - p = 32;
• Class E. Calcification of the pelvic vessels - p = 13;
• Class F. Nephropathy - p = 3.

[11], [12], [13], [14], [15], [16]

Causes of the diabetes mellitus during pregnancy

Diabetes of pregnant women, or gestagenic diabetes, is a violation of glucose tolerance (NTG) that occurs during pregnancy and disappears after childbirth. The diagnostic criterion for such a diabetes is the excess of any two glycemic parameters in capillary blood from the three values given below, mmol / l: fasting - 4.8, after 1 hour - 9.6 and after 2 hours - 8 after oral loading 75 g glucose.

The violation of glucose tolerance during pregnancy reflects the physiological effect of contrinsular placental hormones, as well as insulin resistance, and develops in about 2% of pregnant women. Early detection of a violation of glucose tolerance is important for two reasons: first, 40% of women with diabetes of pregnant women have a history of clinical diabetes for 6-8 years, and therefore they need regular follow-up; Secondly, against the background of a violation of glucose tolerance, the risk of perinatal mortality and fetopathy increases, as well as in patients with previously established diabetes mellitus.

[17], [18], [19], [20], [21], [22]

Risk factors

At the first visit of a pregnant woman to a doctor, it is necessary to assess the risk of developing her gestational diabetes, as further diagnostic tactics depend on this. Low risk women with gestational diabetes include women younger than 25 years of age, normal body weight before pregnancy, who have no previous history of diabetes mellitus in relatives of the first degree of kinship, who have never had a carbohydrate metabolism disorder (including glucosuria) uncomplicated obstetrical anamnesis. To assign a woman to a group with a low risk of developing gestational diabetes, all these signs are necessary. In this group of women testing with stress tests is not carried out and limited to routine monitoring of fasting glycemia.

According to the unanimous opinion of domestic and foreign experts, women with significant obesity (BMI ≥30 kg / m ² ), diabetes mellitus at relatives of the first degree of kinship, indications of gestational diabetes in the anamnesis or any violations of carbohydrate metabolism belong to the group of high risk of gestational diabetes development beyond pregnancy. To assign a woman to a high-risk group, one of the following characteristics is sufficient. These women are tested at the first visit to the doctor (fasting blood glucose is recommended and a test with 100 g of glucose is recommended, see the procedure below).

In a group with an average risk of developing gestational diabetes, women who do not belong to the group of low and high risks fall: for example, with a slight excess of body weight before pregnancy, with a burdened obstetric anamnesis (large fetus, polyhydramnios, spontaneous abortions, gestosis, fetal malformations, stillbirths ), etc. In this group, testing is carried out at a critical time for the development of gestational diabetes - 24-28 weeks of pregnancy (the examination begins with a screening test).

[23], [24]

Symptoms of the diabetes mellitus during pregnancy

Preventive diabetes

Symptoms in pregnant women with type 1 and type 2 diabetes depend on the degree of compensation and duration of the disease and is mainly determined by the presence and stage of chronic vascular complications of diabetes (arterial hypertension, diabetic retinopathy, diabetic nephropathy, diabetic polyneuropathy, etc.).

[25], [26], [27], [28]

Gestational diabetes

Symptoms of gestational diabetes depend on the degree of hyperglycemia. It can be manifested by a slight hyperglycemia on an empty stomach, postprandial hyperglycemia, or a classical clinical picture of diabetes with high glycemic indexes develops. In most cases, clinical manifestations are absent or nonspecific. As a rule, there is obesity of various degrees, often - rapid weight gain during pregnancy. With high numbers of glycemia, there are complaints of polyuria, thirst, increased appetite, etc. The greatest difficulties for diagnosis are cases of gestational diabetes with moderate hyperglycemia, when glucosuria and fasting hyperglycemia are often not detected.

In our country, there are no unified approaches to the diagnosis of gestational diabetes. According to modern recommendations, the diagnosis of gestational diabetes should be based on the identification of risk factors for its development and the use of tests with glucose load in groups of medium and high risks.

Forms

Among the violations of carbohydrate metabolism in pregnant women it is necessary to distinguish:

1. Diabetes, which existed in a woman before pregnancy (pregast diabetes) - type 1 diabetes, type 2 diabetes, other types of diabetes mellitus.
2. Gestational diabetes or diabetes of pregnant women - any degree of violation of carbohydrate metabolism (from isolated fasting hyperglycemia to clinically apparent diabetes) with the onset and first detection during pregnancy.

[29], [30], [31], [32]

Classification of pregast diabetes

By the degree of compensation of the disease:

• compensation;
• decompensation.

[33], [34], [35], [36], [37], [38], [39]

Classification of gestational diabetes

Distinguish between gestational diabetes depending on the treatment method used:

• compensated by diet therapy;
• compensated with insulin therapy.

By the degree of compensation of the disease:

• compensation;
• decompensation.

• E10 Insulin-dependent diabetes mellitus (in modern classification - type 1 diabetes mellitus)
• E11 Non-insulin-dependent diabetes mellitus (in modern classification - type 2 diabetes)
  • E10 (E11) .0 - with a coma
  • E10 (E11) .1 - with ketoacidosis
  • E10 (E11) .2 - with renal involvement
  • E10 (E11) .3 - with eye damage
  • E10 (E11) .4 - with neurological complications
  • E10 (E11) .5 - with peripheral circulation disorders
  • E10 (E11) .6 - with other specified complications
  • E10 (E11) .7 - with multiple complications
  • E10 (E11) .8 - with unspecified complications
  • E10 (E11) .9 - without complications
• 024.4 Diabetes of pregnant women.

[40], [41], [42], [43], [44], [45], [46]

Complications and consequences

In addition to diabetes, pregnant women are given a pregnancy against diabetes mellitus type I or II. To reduce the complications that develop in the mother and fetus, this category of patients from the early stages of pregnancy need the maximum compensation of diabetes. To this end, patients with diabetes mellitus should be hospitalized in order to detect pregnancy, to stabilize diabetes, to examine and eliminate associated infectious diseases. During the first and repeated hospitalizations, it is necessary to examine the organs of urination for timely detection and treatment in the presence of concomitant pyelonephritis, as well as assess the kidney function for the detection of diabetic nephropathy, paying special attention to monitoring glomerular filtration, daily proteinuria, and serum creatinine. Pregnant women should be examined by an oculist to assess the condition of the fundus and identify retinopathy. The presence of arterial hypertension, especially the increase in diastolic pressure by more than 90 mm Hg. Is an indication for antihypertensive therapy. The use of diuretics in pregnant women with arterial hypertension is not shown. After the survey, the question of the possibility of maintaining a pregnancy is solved. Indications for its interruption in diabetes mellitus, which occurred before the onset of pregnancy, are due to a high mortality rate and fetopathy in the fetuses, which correlates with the duration and complications of diabetes mellitus. The increased mortality of fetuses in women with diabetes is caused by both stillbirth and neonatal mortality as a result of the presence of respiratory insufficiency syndrome and congenital malformations.

[47], [48], [49], [50], [51], [52], [53]

Diagnostics of the diabetes mellitus during pregnancy

Domestic and foreign experts offer the following approaches for the diagnosis of gestational diabetes. One-step approach is most economically justified in women with a high risk of developing gestational diabetes. It consists in conducting a diagnostic test with 100 g of glucose. A two-step approach is recommended for a group of medium risk. With this method, a screening test with 50 g glucose is first performed, and in case of its violation, a 100-gram test is performed.

The procedure for conducting the screening test is as follows: a woman drinks 50 g of glucose dissolved in a glass of water (at any time, not on an empty stomach), and after an hour, glucose in the venous plasma is determined. If an hour later, plasma glucose is less than 7.2 mmol / l, the test is considered negative and the test is discontinued. (In some guidelines, a glycemia level of 7.8 mmol / L is suggested as a criterion for a positive screening test, but it is indicated that a glycemia level of 7.2 mmol / L is a more sensitive marker of an increased risk of gestational diabetes.) If plasma glucose is equal to or more than 7,2 mmol / l, the test is shown with 100 g of glucose.

The method of carrying out the test with 100 g of glucose provides for a more stringent protocol. The test is performed in the morning on an empty stomach, after an overnight fasting for 8-14 hours, against a background of usual nutrition (not less than 150 grams of carbohydrates per day) and unlimited physical activity, at least 3 days prior to the study. During the test, you should sit, smoking is prohibited. During the test, fasting blood plasma glycemia is determined, after 1 hour, 2 hours and 3 hours after the load. The diagnosis of gestational diabetes is established if two or more glycemia values equal or exceed the following figures: fasting at 5.3 mmol / L, after 1 hour - 10 mmol / L, after 2 hours - 8.6 mmol / L, after 3 hours - 7.8 mmol / l. An alternative approach can be the use of a two-hour test with 75 g of glucose (the protocol of carrying out is similar). To establish the diagnosis of gestational diabetes in this case, it is necessary that the plasma levels of plasma in two or more determinations should equal or exceed the following values: fasting at 5.3 mmol / L, after 1 h-10 mmol / L, after 2 hours - 8.6 mmol / l. However, according to experts of the American Diabetes Association, this approach does not have the validity of a 100-gram sample. Use in the analysis of the fourth (three-hour) definition of glycemia when performing a sample with 100 g of glucose makes it possible to more reliably test the state of carbohydrate metabolism in a pregnant woman. It should be noted that routine monitoring of fasting glycemia in women at risk of gestational diabetes in a number of cases can not completely exclude gestational diabetes, as the normal level of fasting glycemia in pregnant women is slightly lower than in non-pregnant women. Thus, fasting normoglycemia does not exclude the presence of postprandial glycemia, which is a manifestation of gestational diabetes and can be detected only as a result of exercise tests. When a pregnant woman in a venous plasma is diagnosed with high glycemia: fasting is more than 7 mmol / L and in a random blood sample is more than 11.1 and confirmation of these values on the next day of the diagnostic tests is not required and the diagnosis of gestational diabetes is established.

[54], [55], [56], [57], [58], [59], [60]

Treatment of the diabetes mellitus during pregnancy

Pregnant women with diabetes are at risk for developing the following obstetric and perinatal complications: spontaneous abortion, gestosis, polyhydramnios, premature birth, hypoxia and fetal death, macrosomia of the fetus, intrauterine growth retardation and fetal development anomalies, birth trauma of the mother and fetus , high intra- and postnatal mortality. That is why the management of pregnant women with diabetes mellitus both at the outpatient and in the inpatient stage should be organized in terms of rational prevention and monitoring of the above complications. The main principles of rational management of pregnant women with diabetes mellitus and gestational diabetes include:

Strict glycemic control and maintenance of a stable compensation of carbohydrate metabolism

Management of diabetes during pregnancy is both in the regular evaluation of diabetes compensation by the endocrinologist (keeping a diary, determining glycated hemoglobin, correcting diet and insulin therapy), and in self-monitoring of blood glucose levels by the most pregnant woman. Self-control of glycemia is carried out on an empty stomach, before, 1 and 2 hours after the main meals, at bedtime. If hyperglycaemia is detected after eating, it is immediately corrected by shortening the short-acting insulin. At present, self-monitoring for urine glucose is not recommended because of its low information content. The woman also performs self-monitoring of ketonuria (in the morning portion of urine, as well as with glycemia more than 11-12 mmol / L), maintains a diabetes diary, which records glycemia, insulin doses, the number of bread units, episodes of hypoglycemia, acetonuria, body weight, blood pressure and etc.

Monitoring of diabetic complications

At least once in a trimester, an ophthalmologist is consulted to resolve the issue of the need for laser photocoagulation of the retina. Particular attention is paid to the dynamic observation of the kidneys. The multiplicity of laboratory tests is determined individually. As an example, you can suggest the following scheme: daily proteinuria - 1 time per trimester, creatinine of the blood - at least 1 time per month, Reberg's test - at least once in a trimester, a general urine test - once every 2 weeks. Blood pressure is monitored, antihypertensive therapy is prescribed (or corrected) if necessary.

• Prophylaxis and treatment of obstetric complications (fetoplacental insufficiency, miscarriage, gestosis, etc.) are included in the use of progesterone preparations, disaggregants or anticoagulants, membrane stabilizers, antioxidants according to conventional schemes in obstetrics.
• Monitoring the fetus

It is carried out with the purpose of timely diagnosis and treatment of such complications as developmental anomalies, hypoxia, macrosomia, intrauterine retardation of fetal development. At the 7th-10th week - perform ultrasound of the fetus (to determine the viability, calculation of the coccyx-parietal size, clarifying the gestation period). At the 16-18th week, serum alpha-fetoprotein (diagnosis of neural tube developmental defects), β-CG, and estriol are analyzed. At the 16-20th week - repeated ultrasound of the fetus (diagnosis of large malformations of the fetus). At the 22nd-24th week - echocardiogram of the fetus in order to diagnose the malformations of the cardiovascular system of the fetus. From the 28th week - every 2 weeks - the ultrasound-biometry of the fetus (to assess the growth of the fetus and the correspondence of its size to the gestation period), dopplerometry, assessment of the fetoplacental complex. From the 32nd week - weekly cardiotocography (according to the indications more often, depending on the obstetric situation). In the late stages of pregnancy, the daily registration of the fetal motor activity of the pregnant woman is necessary with the entry of data into the diabetes diary.

The goals of diabetes during pregnancy

1. Strong compensation of carbohydrate metabolism throughout pregnancy.
2. Prevention of the development and treatment of existing diabetic and obstetrical complications.

Preventive diabetes

• Target values of glycemia (capillary blood): fasting - 4.0-5.5 mmol / l, 2 hours after meals <6.7 mmol / l.
• Target values of HbA1c (at least 1 time per trimester) are within the reference values for non-pregnant or below.
• Ketonuria is absent.

Gestational diabetes

• Target values of glycemia (capillary blood): fasting - <5.0 mmol / l, 2 hours after meals <6.7 mmol / l.
• Target values of HbA1c (at least 1 time per trimester) are within the reference values for non-pregnant or below.
• Ketonuria is absent.

Indications for hospitalization

Preventive diabetes

Usually, 3 planned hospitalizations are recommended for pregnant women with type 1 and type 2 diabetes. The first - early in gestation - for a comprehensive clinical and laboratory examination, the decision on the prolongation of pregnancy, the passage of the diabetes school (for women with diabetes mellitus who are unprepared for pregnancy), clarifying the gestational age, and compensating for diabetes mellitus. The second - in the 21-24th weeks of pregnancy - in a critical period for decompensation of diabetes, to compensate for carbohydrate metabolism and prevent the progression of diabetic and obstetrical complications. The third is at the 32nd week of pregnancy for further monitoring and treatment of obstetric and diabetic complications, careful monitoring of the fetus, determining the timing and method of delivery.

Gestational diabetes

Hospitalization is indicated at the first detection of gestational diabetes for examination and selection of therapy, then - in case of worsening of the course of diabetes and obstetric indications.

Methods of treatment of diabetes mellitus in pregnancy

Preventive diabetes

The most important step in the onset of pregnancy in women with diabetes is the modification of hypoglycemic therapy. The "gold standard" of hypoglycemic therapy during gestation is intensified therapy with human genetically engineered insulin. If a woman's pregnancy was planned, then by the time of pregnancy, she should already be on this kind of insulin therapy. If pregnancy was not planned and occurs in a woman with type 2 diabetes taking oral hypoglycemic drugs (drugs sulfonylurea, acarbose, metformin, glitazones, clay), they should be canceled and insulin therapy should be prescribed. In women with type 2 diabetes mellitus who are on diet, when pregnancy occurs, as a rule, there is also a need for insulin therapy. If a woman was on traditional insulin therapy (for type 1 and type 2 diabetes), she should be transferred to intensified insulin therapy in the regime of fivefold injections (short-acting insulin 3 times a day before basic meals and insulin of average duration in the morning before breakfast and before bedtime ). Data on the use of human insulin analogues in pregnancy are currently limited (insulin lyspro, insulin aspart, insulin glargine, etc.).

In the face of the ever-changing need for insulin during pregnancy, timely consultation with insulin doses requires consultation of the endocrinologist with an analysis of the diabetes diary every 2 weeks at an early date and weekly from the 28th week of pregnancy. In this case, it is necessary to take into account the patterns of changes in insulin sensitivity and the features of insulin therapy at different stages of pregnancy and the postpartum period.

In the first trimester of pregnancy, the sensitivity of tissues to insulin rises, which leads to a decrease in the body's need for an insulin. The risk of hypoglycemia increases significantly, so the dose of insulin needs to be reduced in a timely manner. However, hyperglycemia should not be tolerated, because during this period the fetus does not have its own insulin synthesis, and the mother's glucose easily penetrates the placenta into its organs and tissues. Excessive reduction in the dose of insulin quickly leads to the development of ketoacidosis, which is especially dangerous, since ketone bodies easily overcome the placental barrier and have a powerful teratogenic effect. Thus, maintenance of normoglycemia and prevention of ketoacidosis in early pregnancy are a prerequisite for the prevention of fetal development abnormalities.

From the 13th week of pregnancy, under the influence of placenta hormones, which have a counterinsular effect, the need for insulin increases, so the insulin dose necessary to achieve normoglycemia is gradually increased. During this period, the fetus already synthesizes its own insulin. With inadequate compensation for diabetes, hyperglycemia in the mother leads to hyperglycemia and hyperinsulinemia in the fetal blood flow. Hyperinsulinemia of the fetus causes such complications as macrosomia (diabetic fetopathy), impaired fetal lung maturation, neonatal respiratory distress syndrome, neonatal hypoglycemia.

Starting from the 32nd week of pregnancy and until the birth, the risk of hypoglycemia increases again. During this period, the dose of insulin can be reduced by 20-30%. Improvement of the course of diabetes during this period of pregnancy is associated with increased consumption of glucose by the growing fetus and the "aging" of the placenta.

During childbirth, there may be significant fluctuations in blood glucose levels. Perhaps the development of both hyperglycemia and ketoacidosis (against the background of the release of counterinsulant hormones under the influence of pain, fear) and severe hypoglycemia associated with high physical stress during childbirth.

Immediately after delivery, the need for insulin decreases sharply, reaching in some women 0-5 ED per day. The lowest level of glycemia occurs on the 1-3 days after delivery, during this period the dose of insulin should be minimal. By the 7th-10th day of the postpartum period, the need for insulin is gradually restored to the level that existed in a woman before pregnancy.

Gestational diabetes

The first stage of treatment of gestational diabetes is diet therapy in combination with dosed physical exertion. The main principles of dietotherapy are the exclusion of easily digestible carbohydrates (sugar, honey, jam, sweets, fruit juices, etc.), as well as the fractional uniform intake of complex carbohydrates during the day (3 basic and 3 intermediate meals), which allows you to monitor postprandial glycemia and prevent hungry ketosis. The main sources of carbohydrates are cereals, pasta, biscuits, corn, beans, potatoes, etc. The diet should be rich in proteins (1.5 g / kg body weight), fiber, vitamins and minerals. Moderately restrict fat (to prevent excessive weight gain). Sharp restriction of caloric intake and complete starvation during pregnancy is contraindicated!

If against the background of the diet for 1-2 weeks the target values of glycemia are not attained, insulin therapy is prescribed. Often, the normalization of carbohydrate metabolism is sufficient to introduce small doses of short-acting insulin before basic meals. However, as pregnancy progresses, the need for insulin can change. It should be especially noted that if diet is ineffective, prescribing oral hypoglycemic drugs to pregnant women is absolutely unacceptable! Symptoms of macrosomia in ultrasound biometry of the fetus may serve as an indication for prescribing insulin therapy for a pregnant woman with gestational diabetes. Pregnant women with gestational diabetes who are on insulin therapy need to maintain a diary where they register: self-monitoring of blood glucose level (6-8 times a day), carbohydrate intake for food counted according to the system of bread units (XE), insulin doses, weight body (weekly), notes (episodes of hypoglycemia, acetonuria, blood pressure, etc.). To assess the effectiveness of any type of treatment for gestational diabetes (diet therapy, insulin therapy) at least once in a trimester, the level of glycated hemoglobin is examined.

Complications and side effects of treatment

In pregnant women with diabetes mellitus and gestational diabetes, who are on insulin therapy and well compensated, there is inevitability of the appearance of mild hypoglycemia, which are harmless for the mother and fetus. Women should be able to independently manage mild forms of hypoglycemia to prevent the development of severe (with a violation of consciousness) hypoglycemic reactions.

[61], [62], [63], [64], [65], [66], [67]

Terms and methods of delivery

Preventive diabetes

The term and method of delivery are determined individually. The optimal term is 37-38 weeks, the preferred method is programmed delivery through natural birth canals. The course of labor in women with diabetes can be complicated due to the presence in most cases of fetoplacental insufficiency, gestosis, often - fetal macrosomia, polyhydramnios. Caesarean section should be aimed only at obstetric indications, however, in practice, the frequency of operative delivery by caesarean section in women with diabetes often reaches 50% or more. Additional indications for cesarean section in diabetes mellitus may be the progression of chronic and development of acute diabetic complications. Early delivery is undertaken with a sharp deterioration of the fetus, progression of gestosis, retinopathy (the appearance of multiple fresh hemorrhages on the fundus), nephropathy (development of signs of kidney failure). The night before the operation of a cesarean section of a pregnant woman with diabetes mellitus, the usual dose of insulin of average duration of action is administered. On the day of surgery, subcutaneous insulin injections are canceled, and intravenous infusion of the glucose-potassium mixture with insulin under glycemic control begins every 1-2 hours by the express method. The target level of glycemia during labor or cesarean section (in capillary blood) is 4-7 mmol / l. To reduce the risk of infectious complications in the postpartum period, antibiotic therapy is used.

Gestational diabetes

Gestational diabetes alone is not an indication for caesarean section or for early delivery until the completion of a full 38 weeks of gestation. The optimal period for delivery is during the 38th week of gestation (if the obstetric situation does not dictate another). Prolongation of pregnancy more than 38 weeks is not indicated, since it increases the risk of macrosomia. The method of delivery is determined by obstetric indications.

Further management

Preventive diabetes

With type 2 diabetes mellitus during breastfeeding it is recommended to continue insulin therapy, since the use of oral hypoglycemic drugs during lactation can cause hypoglycemia in the child. After cessation of lactation, women with type 1 and type 2 diabetes need the endocrinologist's advice for modifying the hypoglycemic and symptomatic therapy [the appointment of modern human insulin analogues, oral hypoglycemic drugs (for type 2 diabetes), statins, etc.], and for continuation of monitoring and treatment of diabetic complications. Before discharge from the hospital (after childbirth) it is advisable to discuss possible methods of contraception.

Gestational diabetes

After delivery, 98% of women who underwent gestational diabetes, carbohydrate metabolism is normalized. If this does not happen, think about the first type 1 diabetes mellitus (if insulin is needed) or type 2 diabetes mellitus (if insulin therapy is not needed). All women who underwent gestational diabetes are at increased risk for developing type 2 diabetes, therefore, after 1.5-3 months after delivery, they need an endocrinologist's consultation for an accurate assessment of the state of carbohydrate metabolism (an oral glucose tolerance test with 75 g glucose) and determining the multiplicity of dynamic observation.

Prevention

Prevention of pregast diabetes depends on its pathogenetic form (type 1 diabetes mellitus, type 2 diabetes, other types of diabetes mellitus) and is one of the most urgent and still completely unsolved problems of modern medicine.

Prevention of complications of pregast diabetes (for the mother and fetus) is based on extensive advocacy of pre-gravity training in women with diabetes mellitus. It has now been proven that pregnancy planning is the most promising direction in improving the prognosis of pregnancy in women with type 1 and type 2 diabetes. The basic principles of pre-gravity training include:

• informing a woman about the risks associated with an unplanned pregnancy against a background of poor metabolic control (high risk of malformations and fetal loss, complicated course of pregnancy, progression of chronic vascular complications of diabetes until loss of vision and the emergence of the need for hemodialysis);
• achievement of strict compensation for diabetes mellitus (reaching glycoglymoglobin less than 7% without increasing the frequency of hypoglycemia) for at least 2-3 months before pregnancy and throughout pregnancy;
• screening and treatment of chronic diabetic complications prior to pregnancy;
• identification and treatment of concomitant gynecological and extragenital diseases before pregnancy.

The implementation of the basic principles of pre-gravity training is carried out by the following methods:

• lifestyle modification: healthy eating, smoking cessation, folic acid supplementation (4-5 mg / day), use of iodized salt is recommended;
• complex examination and treatment of an experienced multidisciplinary team of specialists (endocrinologist, obstetrician-gynecologist, therapist, ophthalmologist, neurologist, geneticist and others);
• the integration of women into diabetes care (schooling in diabetes);
• contraception for the entire period of achievement of diabetes compensation and treatment of concomitant pathology;
• modification of hypoglycemic and other drug therapy: in type 2 diabetes it is necessary to cancel oral hypoglycemic drugs and prescribe insulin therapy; abolish ACE inhibitors, statins, etc.

The most important points in the survey of specialists of different profiles are the following. When examining the cardiovascular system, it is necessary to clarify the presence and severity of arterial hypertension, ischemic heart disease, diabetic macroangiopathy, and other cardiac and vascular diseases. A detailed examination of the kidneys should answer the question of the presence and stage of diabetic nephropathy, asymptomatic bacteriuria, chronic pyelonephritis, etc. Consultation of a neurologist is necessary for the diagnosis of sensorimotor neuropathy, various forms of autonomic diabetic neuropathy (cardiovascular, gastrointestinal, urogenital), diabetic foot syndrome. It is also necessary to evaluate the state of other organs of the endocrine system: first of all, the thyroid gland. Mandatory examination of the fundus with dilated pupil in an experienced ophthalmologist to determine the stage of diabetic retinopathy and indications for laser photocoagulation of the retina. When detecting such indications, laser photocoagulation of the retina should be performed before pregnancy. A comprehensive examination of the obstetrician-gynecologist is needed to assess the condition of the reproductive function, the presence of specific and nonspecific genital infections. When identifying foci of infection (urogenital, odontogenic, ENT), it is necessary to sanitize them before the onset of pregnancy, since the presence of a chronic inflammatory process in the body makes it difficult to compensate for diabetes.

After receiving the results of the survey, consultative determine the relative and absolute contraindications to gestation.

Absolute contraindications to pregnancy in diabetes mellitus are:

• severe diabetic nephropathy with proteinuria and signs of beginning chronic renal failure;
• Progressive, non-treatable proliferative retinopathy;
• severe ischemic heart disease;
• severe autonomic neuropathy (orthostatic hypotension, gastroparesis, enteropathy, loss of ability to recognize hypoglycemia).

Relative contraindications to pregnancy in diabetes should be considered:

• Decompensation of the disease in the early period of pregnancy (the development of diabetic ketoacidosis during these periods increases the risk of fetal development abnormalities);
• combination of diabetes mellitus with severe concomitant diseases (for example, with chronic continuously-relapsing pyelonephritis, with active tuberculosis, diseases of the blood, heart, etc.).

Prophylaxis of gestational diabetes is to correct the removable risk factors for its development (especially obesity). Preventing complications of gestational diabetes (for the mother and fetus) is the early detection and active treatment (expansion of indications for insulin therapy) of this disease.

[68], [69], [70], [71], [72], [73], [74], [75]

Forecast

Despite the fact that pregnancy in women with diabetes is accompanied by a high risk of obstetric and perinatal complications, pregnancy planning and its rational management contribute to a significant reduction in adverse pregnancy outcomes for a mother with diabetes and her offspring.

[76], [77], [78], [79], [80], [81], [82], [83]