The contingent of pregnant women is becoming heavier, it is accompanied by severe chronic pathology: diseases of the eyes, kidneys, cardiovascular diseases, infections, neuropathies, etc. At the same time, perinatal mortality is high, which ranges from 10 to 40%. The incidence of newborn babies whose mothers suffer from diabetes is also increasing. Diabetes mellitus is a disease based on the absolute or relative lack of insulin, causing metabolic disorders and pathological changes in various organs and tissues. All this happens against the background of the existence of the system: the mother, the placenta, is the fetus. Insulin is known to be an anabolic hormone that promotes glucose utilization, glycogen and lipid biosynthesis. With insulin deficiency, hyperglycemia develops – the main diagnostic sign of diabetes. The course of diabetes during pregnancy is undulating, with a tendency to ketoacidosis, hyper and hypoglycemic conditions. In the first half of pregnancy, the course of the disease in most patients remains unchanged. In the second half of pregnancy, due to an increase in the contrainsular activity of the adrenal cortex, pituitary, and placenta, a deterioration in the condition of patients is noted. There is thirst, dry mouth, skin itching in the area of pilaf organs, the level of glycemia and glucosuria increases, the tendency to ketoacidosis increases, which leads to an increase in the need for insulin. Towards the end of pregnancy, the need for insulin is often reduced, due to fetal hyperinsulinism associated with maternal hyperglycemia. Patients with diabetes mellitus during labor can have both hyper- and hypoglycemia. After childbirth, especially after cesarean section, the level of glycemia drops sharply, but then rises, and reaches its original value. What should be the management of pregnancy and childbirth in diabetes? At the first stage, it is necessary to identify an increased risk for developing diabetes:
1. In the case of a disease in the family of relatives of a pregnant woman with diabetes;
2. Childbirth by a large fetus – 4 kg or more. Giant fruit – 5 kg or more;
3. Re-birth of children weighing 4 kg and above;
4. Malformations of the fetus;
6. The manifestation of glucosuria in early pregnancy;
7. Sudden perinatal fetal death;
8. The development of late toxicosis, obesity, frequent severe pustular diseases.
A history of women may have ovarian dysfunction, infertility. By the presence of one or more symptoms, a pregnant woman is classified as a risk group for diabetes mellitus. Diagnosis of diabetes in pregnant women is based on the detection of hyperglycemia and glucosuria. At the same time, three degrees of diabetes severity are distinguished: mild, moderate, severe. In mild diabetes, fasting glucose does not exceed 7.7 mmol / L, and there is no ketosis. Normalization of glycemia is achieved only by diet. With moderate severity of diabetes, the level of glycemia does not exceed 12.2 mmol / l, ketosis is absent or eliminated by following a diet. In severe diabetes, the fasting glycemia level exceeds 12.2 mmol / l, there is a tendency to develop ketosis, often there is angiopathy, arterial hypertension, IHD, trophic ulcers of the lower leg, retinopathy, and diabetic nephrosclerosis. Fortunately, in 50% of pregnant women, diabetes is transient in nature. This form of diabetes is associated with pregnancy and the symptoms of diabetes disappear after childbirth. With repeated pregnancy, the return of the same ketonuria is possible, therefore, with a thorough examination in 50% of pregnant women, ketonuria can be detected. All pregnant women in this group need to determine the blood sugar level on an empty stomach. With an increase in sugar above 6.66 mmol / L, the product of the sample for glucose tolerance is shown. The fasting blood glucose level is determined and after 30, 60, 90, 120, 180 minutes after taking 50 or 100 g of glucose, depending on the weight in 250 ml of water. In parallel, daily urine for sugar content is examined. The glucose norm in an hour after loading is 9.99 mmol / l, in 2 hours – 6.66 mmol / l. blood sugar 2 hours after a load of 8.32 mmol / l at a normal level of fasting sugar and an hour after a load indicates the presence of latent diabetes mellitus. In the diabetic type of curve, fasting sugar levels exceed 7.2 mmol / L, after an hour exceed 11.1 mmol / L, after 2 hours exceed 8.32 mmol / L. the onset of the disease is often accompanied by a clinic – this is furunculosis, pyoderma, itchy skin, dry mouth, increased appetite, along with weight loss, polyuria. Three stages of a diabetes clinic are identified.
The first stage begins at 10 weeks of gestation and lasts three months. It is characterized by impaired glucose tolerance, a change in insulin sensitivity. In this case, it becomes necessary to reduce the dose of insulin by one third.
The second stage develops in 24-28 weeks. There is a decrease in glucose tolerance. This is a precomatous state, or a state of acidosis, and therefore it is necessary to increase the dose of insulin. 3-4 weeks before giving birth, the patient’s condition often improves.
The third stage is associated with childbirth and the postpartum period. During childbirth, there is a risk of metabolic acidosis, which can quickly turn into diabetic. During lactation, the need for glucose is lower than before pregnancy, this is due to the undoubted change in the balance of hormones, which is due to the development of pregnancy. The level of estrogen, progesterone, corticosteroids affects carbohydrate metabolism, and placental lactogen is an insulin antagonist. Pregnant women with diabetes can develop severe complications such as diabetic and hypoglycemic coma. The basis of violations of the functional activity of trophoblast are changes in the placenta, in diabetes mellitus, of a sclerotic nature. These changes of a sclerotic nature are present in the vessels of the uterus, which invariably leads to a violation of the uteroplacental circulation, malnutrition of the fetus with the development of chronic hypoxia.
Dysfunction of the mother-placenta-fetus system during pregnancy complicated by diabetes is often manifested by macrosomia of the fetus, that is, a high fetal mass. In diabetes mellitus, the mother has a fetal excess weight syndrome for a given period. This is noted in every second woman. Moreover, the body weight of the fetus is more than 4 kg in every fourth woman. Hyperglycemia in the mother is accompanied by hyperglycemia in the fetus with the development of hypertrophy of the islets of Langerhans. In 80% of children whose mothers suffer from diabetes mellitus, this condition is called macropolynesia. Insulin has the properties of anabolic hormone, helps to enhance glycogen synthesis, increase the amount of fat, which leads to fetal macrosomia. The body weight of the fetus is also lower than necessary for the existing gestational age. The placenta in relation to the mass of the fetus is large, that is, the placenta is large, and the fetus can be small. With gestosis, placental hypoplasia is almost always observed, combined with diabetic macrosomia and fetal hypotrophy. But there is polyhydramnios, gestosis, iron deficiency anemia and tissue hypoxia of the fetus with sudden fetal death is inevitable, which is typical for diabetes mellitus is a sudden death of the fetus. In macrosomia, the main factors of stillbirth are hypoxia and birth trauma.
Clinical signs and pathogenesis of diabetic ketopathy:
Diabetic ketopathy is a sign in a newborn that reflects the adverse effect of maternal diabetes on the fetus. The bottom line is that there is an increased growth of body weight and some organs of the fetus: liver, heart, spleen. This is combined with the slow development of functional systems. Children look not only obese and pasty, but they have a characteristic cushingoid type and some imbalance in addition, that is, with a long body (56058 cm), the lower limbs appear short, the head, especially its brain part is small, its face is moon-shaped, rounded with full protruding cheeks, making the nose and eyes appear small. The abdomen is large, the skin is a crimson hue, cyanosis of the feet. But the most important thing is not only external changes, but, unfortunately, there are changes on the part of internal organs: an increase in the heart, liver, and at the same time a decrease in the thymus and brain. These children also have reduced motor activity, there are all signs of pregnancy complications: hormonal disorders, impaired lipid and carbohydrate metabolism, impaired function of organs and systems. The frequency of diabetic ketopathy is from 5.7 to 42%. Hypoglycemia, hypercalcemia and hyperbilirubinemia contribute to this. The most common complications are:
1. Spontaneous abortion;
2. Late toxicosis – 30-50%;
3. Polyhydramnios – 30-40%;
4. Pyelonephritis – 16%;
5. Asymptomatic bacteriuria – 10%;
The expressed polyhydramnios does not present difficulties for diagnosis. To do this:
2. Dynamic observation: once a week, the height of the uterine fundus and the size of the abdomen are measured. There will be a mismatch between the height of the standing of the bottom of the uterus and the circumference of the abdomen.
With polyhydramnios, the uterus is tense, parts of the fetus are palpated with difficulty or are not detected at all. Increasing polyhydramnios (2-3-4 liters) leads to cardiovascular failure. A pregnant woman cannot stand up and take a few steps.
Of course, such a situation requires early resolution of the issue of abortion.
Treatment of polyhydramnios:
1. antibiotic therapy: penicillins, cephalosporins, which depends on the flora;
2. In addition, early termination of pregnancy, especially in cases of increased polyhydramnios. An amniotomy should be done very carefully, since due to the rapid redistribution of fluid, there may be premature detachment of the placenta;
3. prevention of ICG
The threat of abortion.
Preservation therapy is not carried out with severe retinopathy, diabetic nephropathy. In this case, pregnancy is contraindicated. If there are no serious complications, then hormonal treatment should be started early. Hormonal treatment includes:
Microfolliculin tablets (0.01 μg) are prescribed 0.5 tablets 2 times a day in combination with an injection of progesterone (1% 1 ml) intramuscularly. This therapy takes 4-5 weeks. Then the dose of estrogen decreases sharply to 1/4 tablet. After 12 weeks of pregnancy, that is, when the formation of the placenta comes to an end, we switch to 17-hydroxyprogesterone until 32-34 weeks of pregnancy. Active vitamin therapy is useful: vitamin E, C, A, D. Well combined drugs are good. To remove the increased excitability of the uterus, tocolytics are used: magnesium sulfate, etc., physiotherapeutic treatment, low-dose prostaglandin inhibitors: acetylsalicylic acid, indomethacin. In small doses, aspirin inhibits the synthesis of thromboxane. Papaverine, antispasmodics, magnesium sulfate are indicated.
Now consider late pregnancy toxicosis as a complication of diabetes. The success of treatment is determined by timely pathogenetic and reasonable treatment. The treatment should be comprehensive, hemodynamics should be improved, microcirculation in vital organs, including uteroplacental circulation, should be restored. The basic principles of treatment:
1. Hospitalization and bed rest.
2. Therapeutic and protective regime. This mode is created using sedatives, antihypertensive drugs, antioxidants, antiplatelet agents.
3. The use of ganglion blockers should be avoided. Along with pipolfen and diphenhydramine, magnesia occupies a central place. We use the sedative, hypotensive effects of magnesium sulfate. In addition, this drug has anticonvulsant, vasodilating, antiplatelet, diuretic effects. Magnesium sulfate is prescribed for diabetes in individual doses. We start with 10 ml of a 25% solution, and not immediately according to Brovkin’s scheme. Gradually, considering tolerance, increase to 20 ml. the drug is combined with dibazole, papaverine, no-spear, phenobarbital. We use albumin, a plasma protein that maintains colloid osmotic pressure. From the second trimester of pregnancy, we dilute in saline or rheopolyglucin solution. We use vitamins B6, C, D, A, E, PP. The use of essentials in ampoules and capsules is effective. The fact is that the essence contains essential phospholipids unsaturated with fatty acids: linoleic, linolenic, oleic acid and vitamins. In addition, we widely use clofibrate, actovegin, chimes. In recent years, calcium antagonists have been used. In the absence of proper treatment for preeclampsia (treatment in a hospital for 1-2-3 weeks), the question is raised about labor excitement.
Preeclampsia begins before the 30th week of pregnancy against the background of generalized vasospasm, diabetic nephropathy, polyhydramnios, impaired uteroplacental circulation. Therapy of gestosis has its own characteristics. Along with diet therapy, insulin therapy, the general principles of the treatment of gestosis are also observed. There should be caution due to the tendency to hypoglycemia when using droperidol. Usually we introduce droperidol with pipolfen. Here, very carefully, as there may be a collapse. In addition, it is better to use diphenhydramine more widely, but in individually selected doses, and of course, antispasmodics. Fasting days are contraindicated. Especially fast days on the background of insulin therapy. Patients with diabetes mellitus are treated both in the conditions of the antenatal clinic and in the hospital. One of the main conditions for managing such pregnant women is compensation for diabetes. Compensating for diabetes mellitus is especially important if the diabetes begins in the early stages of pregnancy. This diabetes compensation is a method for preventing complications. If we cope with diabetes, then there will not be those complications that we have already talked about. Note that insulin therapy is indicated even in the most mild forms of diabetes. Pregnant women at high risk of developing diabetes can be monitored by a female consultation with an endocrinologist and general practitioner in the community. With an increase in diabetes mellitus, the patient must be hospitalized in a specialized institution. In St. Petersburg, this is maternity hospital No. 1 and the Institute of Obstetrics and Gynecology. For the first time, pregnant women with diagnosed diabetes should be sent to the endocrinological department, which was mentioned above. Hospitalization is necessary for an additional examination, determining the dose of insulin, and conducting a course of preventive treatment. After birth, the woman should again be observed by an endocrinologist. The optimal is the follow-up of these pregnant women on the basis of the obstetric department specializing in diabetes. At the first appearance in a antenatal clinic, a pregnant woman should be warned about the complications of pregnancy and the dubious prognosis for the fetus. We must remember the possibility of sudden death of the fetus. It is necessary to offer early termination of pregnancy. In the absence of obstetric complications up to 20 weeks, treatment should be carried out in the endocrinology department. Purpose of hospitalization:
1. A thorough clinical examination, as we agree, “give the go-ahead” for the continuation of pregnancy.
2. Obstetric and diabetic diagnosis.
3. The solution to the issue of maintaining pregnancy.
4. Determination of the optimal dose of insulin.
5. Conducting a course of preventive treatment: oxygen therapy, vitamin therapy, therapy with lipotropic drugs.
All these goals and objectives are set and solved during the first hospitalization.
The second hospitalization is carried out in the second half of pregnancy and is caused by a deterioration in the course of diabetes mellitus or pregnancy complications. The optimal period for a second hospitalization is 30-32 weeks. Late toxicosis increases during this period, placental insufficiency appears, placental hypoplasia is determined by ultrasound, and there is the possibility of diabetic ketopathy. Contraindications to the preservation of pregnancy:
1. The presence of progression of vascular complications.
2. The presence of severe resistant forms of diabetes.
3. The presence of diabetes in both spouses.
4. The combination of diabetes and Rh incompatibility.
5. The combination of diabetes and tuberculosis.
6. A history of stillbirth or children with developmental defects.
Now let’s talk about choosing a term for delivery. With an uncomplicated pregnancy and diabetes, a good condition of the fetus, under the supervision of ultrasound and other methods, of course, timely delivery is optimal, that is, 38-40 weeks. In the case of insufficient compensation for diabetes and complications of pregnancy, a burdened anamnesis, with an increase in fetal hypoxia, one should resort to early excitation, the optimal period of which is 37 weeks. Delivery earlier than 35 weeks is justified only if there is a threat to the mother and fetus and is permissible according to serious indications from the mother. The optimal delivery is delivery through the natural birth canal. It is necessary to prepare the birth canal in advance by creating a hormonal background. With prepared birth canals, labor excitement should begin with amniotomy, since polyhydramnios is often present. In the absence of effective labor, an hour and a half hours after amniotomy, they do not hesitate, but proceed to a drug-induced excitation regimen, that is, an intravenous drip of oxytocin with prostoglandins. The unpreparedness of the birth canal, the absence of the effect of labor stimulation, the appearance of symptoms of increasing hypoxia serve as an indication for abdominal delivery. The complicated course of pregnancy and childbirth, as well as increased vulnerability and large sizes of the fetus require an expansion of indications for cesarean section up to 50%. In addition to the generally accepted, well-known indications for cesarean section, there are additional indications for it:
1. The presence of vascular complications.
2. The labile course of diabetes with a tendency to ketoacidosis.
3. Progressive hypoxia in the absence of conditions for urgent delivery for a period of at least 36 weeks.
4. Pelvic presentation of the fetus.
5. Severe preeclampsia.
6. The presence of a giant fetus.
So, abortion before 36 weeks is indicated only with a clear threat to the mother and fetus. Early delivery is possible by the operational method and conservative. The first conservative method is drug-induced labor with an optimal period of 36-37 weeks. Indications combined:
1. Progressive polyhydramnios
2. Violation of the fetus.
3. Decompensation of diabetes mellitus
4. Repeated hypoglycemia.
Surgical delivery by cesarean section for health reasons:
1. An increase in angioretinopathy
2. The appearance of hemorrhages in the eyeball
3. An increase in the severity of toxicosis
Organization of obstetric care.
Examination of pregnant women should be attended by: therapist, optometrist, nephrologist, dermatologist, dentist, neuropathologist.
The main tasks of the antenatal clinic:
1. All women of childbearing age who have diabetes or are at risk of developing the disease should be taken to the dispensary.
2. Individual solution of pregnancy planning and its conservation after discussion with specialists.
3. The widespread use of contraception in diabetes. Abortion up to 12 weeks has an adverse effect on the course of diabetes and exacerbates its severity. Hormonal methods of contraception are prototype for diabetes. If pregnancy termination fails, a woman should be warned about a genetic predisposition to diabetes.
4. When pregnancy is established, immediately send the pregnant woman to the hospital and repeat hospitalization at 20-24 weeks, then at 32-34 weeks.
5. Outpatient monitoring of a pregnant woman with diabetes is carried out at least 2 times a month by an endocrinologist in the first half of pregnancy and weekly in the second half of pregnancy.
6. It is necessary to strictly take into account the increase in body weight, the dynamics of blood pressure, monitor the height of the uterine fundus, the circumference of the abdomen in connection with the tendency to develop gestosis and polyhydramnios.
7. Given the greater tendency of pregnant women with diabetes to urogenital infections, it is necessary to systematically take vaginal smears, sow the flora separated from the cervix and vagina. In case of complications from the urogenital tract – urgent hospitalization in a hospital.
8. At 14-18 weeks, it is necessary to determine alpha-fetoprotein in the blood.
Medical indications for abortion. Order No. 302.
1. Diabetes in both parents.
2. Diabetes mellitus insulin resistant.
3. Diabetes mellitus with microangiopathy, retinopathy, nephrosclerosis, azotemia.
4. The presence of children with developmental defects in patients with diabetes mellitus.
Hypothyroidism and pregnancy.
Hypothyroidism is a symptom complex that occurs when there is a significant deficiency in the body of a pregnant thyroid hormone. But, fortunately, pregnancy with hypothyroidism is much less common than with diffuse non-toxic goiter. Pregnancy can occur in women with congenital hypothyroidism or acquired as a result of operations on the thyroid gland, that is, with secondary hypothyroidism. During pregnancy, symptoms of hypothyroidism are less pronounced. It depends on the compensatory increase in the thyroid gland in the fetus and the flow of thyroid hormones from the fetus to the mother. The most pronounced form of hypothyroidism is myxedema. The increase in this pathology noted in recent years can be explained by an improvement in diagnosis, an increase in the frequency of autoimmune lesions of the thyroid gland and lymphoid thyroiditis in which thyroid tissue is destroyed by autoantibodies.
Distinguish between primary and secondary hypothyroidism. At primary, the tissue of the gland itself suffers. Secondary hypothyroidism develops as a result of damage to the hypothalamic-pituitary system that regulates the function of the thyroid gland. There are two main pathogenetic forms of hypothyroidism – it is congenital and acquired. Among the acquired forms of primary hypothyroidism, autoimmune hypothyroidism or postoperative hypothyroidism is most often observed. There may be hypothyroidism after treatment with radioactive iodine. There are rare pathogenetic forms of primary hypothyroidism, in particular Hashimoto’s goiter, which is characterized by an enlarged, dense, “rubbery” consistency of the thyroid gland.
A pregnant woman with hypothyroidism is at high risk for maternal mortality. In women suffering from hypothyroidism, a violation of the menstrual cycle, reproductive function, that is, barren marriage, is often observed. But, despite this, nevertheless pregnancy sometimes occurs. Conception is possible in women with a totally strengthened thyroid gland, as well as in patients with congenital hypothyroidism during hormonal therapy in adequate doses. Against the background of hypothyroidism throughout pregnancy, complications are noted, such as the threat of termination of pregnancy, gestosis, iron-deficiency or so-called thyroid-giving anemia, premature birth, stillbirth, deformity of the fetus. The development and health of children whose mothers suffer from hypothyroidism has its own characteristics. Early correction of hormonal disorders with the help of thyroid drugs leads to a favorable outcome. If hypothyroidism is suspected in pregnant women, it is necessary to assess the state of the functional state of the thyroid gland. Thyroid function assessment is based on:
2. Clinical symptom complex
3. Laboratory studies.
Let us consider these points in more detail.
– Anamnesis. There is a hereditary predisposition to thyroid disease. We find out the nature of surgical treatment on the thyroid gland. Every fifth woman has a history of oligo or amenorrhea. Every fourth woman suffers from miscarriage.
– Complaints: weakness, depression, chilliness, memory loss, drowsiness, dry skin, hair loss, persistent constipation.
– Inspection: pale, swollen skin. Slow motion and speech, bradycardia, hoarse voice.
– In the nearest blood test – hypercholesterolemia – 9.36 mmol / l. However, there are also erased forms that are difficult to diagnose. Not all laboratory diagnostic methods may be applicable during pregnancy. Naturally, scanning, the use of radioactive agents is contraindicated. You can determine: the main metabolism associated with iodine proteins. The most reliable is the assessment of the concentration in the serum TSH of the pituitary gland and thyroid hormones: thyroxine and triiodithyronine. Based on these indicators, the volume for replacement therapy is estimated. Based on these same indicators, the effectiveness of drug therapy is evaluated. If thyroid hypofunction is detected from the earliest possible time, hormone therapy should be started immediately in order to fully or insufficiently existing thyroid function. For this, it is recommended: thyroidin alone or in combination with triiodothyronine in individual dosages, depending on the severity of the disease. The dosage of the drug may vary depending on the duration of pregnancy, indicators of thyroid function.