Diabetes mellitus in pregnant women: recommendations and diary

Pregnancy is a very exciting time for women. The upcoming changes in lifestyle, childbirth, and the health of the baby are also worrying. During this period, such an unexpected and formidable diagnosis as diabetes mellitus causes panic and many questions. Where did he come from? What to do? Is this for life? Will diabetes be passed on to the child?

Don't panic! Once you understand everything, it will become clear that pregnancy diabetes is not a death sentence, but a lifestyle change during pregnancy.

Analysis and research for diabetes in pregnant women

All pregnant women must have their venous blood plasma glucose tested on an empty stomach , in a laboratory setting - against the background of a normal diet and physical activity - when first contacting an antenatal clinic or perinatal center, no later than 24 weeks of pregnancy.

If the results of the study correspond to normal indicators during pregnancy, then an oral glucose tolerance test - OGTT ("stress test" with 75 g of glucose) is mandatory at 24-28 weeks of pregnancy in order to actively identify possible disorders of carbohydrate metabolism.

OGTT with 75 g of glucose is a safe and the only diagnostic test for detecting disorders of carbohydrate metabolism during pregnancy.

Rules for conducting OGTT

• OGTT is performed against the background of a normal diet (at least 150 g of carbohydrates per day) and physical activity for at least 3 days preceding the study;
• The test is carried out in the morning on an empty stomach after an 8-14 hour overnight fast;
• The last meal must contain at least 30-50 g of carbohydrates;
• Drinking plain water is not prohibited;
• The patient must sit during the test;
• Medicines that affect blood glucose levels (multivitamins and iron supplements containing carbohydrates, glucocorticoids, β-blockers), if possible, should be taken after the end of the test;
• Determination of venous plasma glucose is performed only in the laboratory using biochemical analyzers or glucose analyzers. The use of portable self-monitoring devices (glucometers) for testing is prohibited.

Stages of performing OGTT

After taking the first sample of venous blood plasma on an empty stomach, the patient drinks a glucose solution within 5 minutes, consisting of 75 g of dry glucose dissolved in 250-300 ml of drinking still water, or 82.5 mg of glucose monohydrate. The start of taking the glucose solution is considered the start of the test.

The following blood samples to determine venous plasma glucose levels are taken 1 and 2 hours after the glucose load.

Venous plasma glucose standards for pregnant women:

• Fasting <5.1 mmol/l;
• 1 hour after glucose load <10.0 mmol/l;
• 2 hours after glucose load <8.5 mmol/l.

The diagnosis of gestational diabetes mellitus is established when glycemia is detected higher than or equal to the above indicators. To establish a diagnosis, it is enough to obtain an abnormal result at one of three points.

After a diagnosis of gestational diabetes mellitus is made, all women need constant monitoring by an obstetrician-gynecologist, a therapist, together with an endocrinologist.

Management of pregnancy with diagnosed gestational diabetes mellitus:

In women with gestational diabetes mellitus, taking into account the characteristics of the pathological condition, nutrition should be adjusted .

Diet for diabetes in pregnant women

Easily digestible carbohydrates are completely excluded from the diet (they are quickly absorbed from the intestines and increase blood glucose levels within 10-30 minutes after consumption):

• Sugar, fructose, jam, honey, caramel, candies, chocolate;
• Fruit juices (including juices provided in the antenatal clinic);
• Lemonades;
• Ice cream, pastries, cakes, condensed milk;
• Bakery products made from high-grade flour;
• Butter pastries (buns, buns, pies).

Foods with a high glycemic index are completely excluded from the diet .

The glycemic index (GI) is a measure of the effect of food on blood sugar levels. Each food is given a score from 0 to 100 depending on how quickly it raises your blood glucose levels. Glucose has a GI of 100, meaning it enters the bloodstream immediately, which is the benchmark against which other foods are compared.

Another indicator that helps predict how high your blood sugar level will rise after a meal and how long it will stay at this level is the glycemic load (GL) . Calculated using the formula:

GL = [GI (%) x amount of carbohydrates per serving (g)] / 100

Glycemic load shows that eating foods with a low glycemic index but high amounts of carbohydrates will not be effective in maintaining normal post-meal blood sugar.

For example, let’s compare the glycemic load of different foods:

Watermelon:

GI – 75, carbohydrates – 6.8 g per 100 g of product, GL = (75x6.8) / 100 = 6.6 g.

Donuts:

GI – 76, carbohydrates – 38.8 g per 100 g of product, GL = (76x38.8) / 100 = 29.5 g

Crumbled buckwheat:

GI – 50, carbohydrates – 30.6 g per 100 g of product, GL = (50x30.6) / 100 = 15.3 g.

Pearl barley:

GI – 22, carbohydrates – 23 g per 100 product, GL = (22X23) / 100 = 5.1 g.

Obviously, the glycemic load of foods increases as the amount of carbohydrates consumed and the glycemic index increase. Accordingly, it is possible to control the glycemic load by consuming low-GI foods in small portions several times a day.

Glycemic load scale:

During one meal

• Low up to 10 g;
• Average from 11 to 19 g;
• High – more than 20.

During the day

• Low up to 80 g;
• Average from 100 to 120 g;
• High – more than 120.

It is necessary to give preference to foods with a medium and low glycemic load, consuming food in small portions, several times a day, excluding the intake of easily digestible carbohydrates.

It is necessary to exclude foods that have a high GI:

• Sweet fruits and berries: grapes, bananas, persimmons, figs, cherries, melon, dates;
• Vegetables: Potatoes, parsnips, pumpkin, boiled beets, boiled carrots, canned sweet corn and peas;
• Porridges – millet, wheat grits, semolina, millet, polished varieties of rice, as well as all instant porridges;
• Homemade noodles, rice noodles;
• Milk;
• Varieties of white or black bread made from premium quality flour.

Also, you should not eat foods containing large amounts of hidden fat, so as not to gain unnecessary weight:

• Meat delicacies;
• Sausages;
• Sausages;
• Sausages;
• Carbonates;
• Ham;
• Salo;
• Buzhenina;
• Offal.

Preference is given to products with medium and low GI:

• Vegetables: Any cabbage (cabbage, broccoli, cauliflower, Brussels sprouts, collards, kohlrabi), salads, greens (onion, dill, parsley, cilantro, sorrel, mint, basil, asparagus, spinach, wild garlic, tarragon), eggplant, zucchini, pepper , radish, radishes, cucumbers, tomatoes, asparagus, onions, garlic, squash, turnips, paprika, capsicums, raw carrots;
• Legumes: peas, beans, lentils, beans;
• Mushrooms;
• Fruits: Grapefruit, lemon, lime, kiwi, orange, apples, pears, tangerine;
• Berries: chokeberry, lingonberry, blueberry, blueberry, blackberry, feijoa, currant, wild strawberry, strawberry, raspberry, gooseberry, cranberry, cherry;
• Fermented milk products - kefir, fermented baked milk, yogurt, ayran, tan (no more than 1 glass at a time), yogurt, cottage cheese, cheese;
• Meat, chicken, fish. When cooking, remove visible fat and render as much of it as possible. The best culinary processing of foods is boiling, steaming, baking, open fire.

How to reduce the glycemic index and glycemic load:

• Combine starchy foods with a medium GI with vegetables that have a low GI;
• Pasta made from durum wheat flour without vegetables is worse than the same pasta with vegetables;
• Do not cook durum wheat pasta until it becomes sticky;
• Eat whole grain porridge (preference is given to: pearl barley, buckwheat, oatmeal, wheat, spelt, bulgur) and wholemeal bread with bran;
• It is better to simply brew porridge (buckwheat, rolled oats) with boiling water and keep it warm for several hours. Then starch under the influence of water and high temperature will not transform into a state that is easily and quickly absorbed by the body;
• The more a product is crushed, the higher its glycemic index. There is nothing not to puree;
• Eat whole fruits (unlike juices, they contain fiber, which reduces GI);
• Give preference to raw vegetables. Vegetables that are subject to heat treatment should not be boiled. Fiber is not destroyed during this treatment;
• Try, whenever possible, to consume vegetables and fruits with the skin, which consists of whole fiber;
• Combine protein foods with vegetables, eat starches at the same time as proteins;
• Dress salads with a small amount of olive oil (1 tablespoon) with lemon juice;
• Fat also lowers the glycemic index;
• If you really want something sweet, eat it along with proteins and foods rich in fiber and fat;
• Products containing carbohydrates with a high amount of dietary fiber should make up no more than 45% of the daily calorie intake, they should be evenly distributed throughout the day (3 main meals and 2-3 snacks) with a minimum carbohydrate content for breakfast, because. the counter-insular effect of increased levels of maternal hormones and the feto-placental complex in the morning increases tissue insulin resistance;
• Breakfast should be “protein” (cottage cheese, egg, meat, fish, chicken with vegetables). This allows you to improve blood sugar levels in the first half of the day after breakfast, before and after lunch.

Food and lowering sugar during pregnancy

Regular physical activity is important in the treatment of gestational diabetes:

Physical activity lowers blood sugar levels and helps you avoid gaining excess weight.

Recommended physical activity: brisk walking or Nordic walking 10-15 minutes after main meals to improve blood sugar control after meals, and 30 minutes before bed, which will help normalize fasting blood glucose levels.

Pregnant women with gestational diabetes mellitus should conduct regular self-monitoring - measuring glycemia using self-monitoring devices (glucometer) - on an empty stomach and 1 hour after each main meal, sometimes before meals and 2 hours after meals.

Self-control targets:

• Fasting <5.1 mmol/l;
• 1 hour after eating <7.0 mmol/l;
• Before meals <5.8 mmol/l;
• 2 hours after eating <6.7 mmol/l.

Pregnant women regularly need to monitor ketone bodies in the urine to identify insufficient carbohydrate intake from food, since the “rapid fasting” mechanism with a predominance of fat breakdown can immediately start. Measurements are taken in the morning urine sample. If ketone bodies appear in the urine (the test strip has changed color), then you need to additionally eat 12-15 g of carbohydrates (a glass of kefir, an unsweetened cracker, an apple) before going to bed to shorten the long period of fasting at night.

Keeping a personal self-control diary, where you must enter:

• glycemic measurement indicators;
• dietary habits (number of foods eaten) at each meal;
• physical activity;
• the level of ketones (acetone) in the morning urine (using urine test strips for ketones);
• weight (weekly);
• blood pressure values;
• fetal movements.

If, against the background of diet therapy and regular physical activity, it is not possible to achieve target blood glucose values ​​within 1-2 weeks, then the pregnant woman is prescribed insulin therapy (tablet glucose-lowering drugs are contraindicated during pregnancy!).

Prescribing insulin for gestational diabetes mellitus is possible even against the background of normal indicators of self-control of glycemia, but according to ultrasound of the fetus, signs of diabetic fetopathy are revealed (the size of the fetus is ahead of the gestational age, the abdominal circumference exceeds the head circumference, there is swelling of the soft tissues of the fetus, polyhydramnios, changes in the placenta) .

For therapy, insulin preparations that have passed all stages of clinical trials and are approved for use during pregnancy are used. Insulin does not penetrate the placenta and has no effect on the fetus, but excess glucose in the mother’s blood immediately goes to the fetus and contributes to the development of those pathological conditions mentioned above.

Accustomment to insulin does not develop; insulin is discontinued after childbirth.

Measures to stabilize indicators

If a pregnant woman is diagnosed with impaired glucose tolerance, the doctor must explain in detail what to do to eliminate this problem. First of all, correction of eating behavior is necessary. Organization of proper nutrition:

• eliminate from the diet foods rich in fast carbohydrates (confectionery, baked goods, sweet drinks, chocolate, some types of fruit);
• replace 50% of animal fats with vegetable oils;
• give preference to foods rich in fiber (vegetables, legumes and grains);
• increase the amount of protein foods in the diet (dietary poultry, seafood, fish);
• limit salt consumption of table (iodized) salt;
• control the GI (glycemic index) and energy value of each dish.

Products with low GI (not higher than 40 units) are allowed. The daily caloric intake should not exceed the norm of 40 kcal per 1 kg of a woman’s weight. It is also important to follow a drinking regime (at least 1.5-2 liters of water daily), and a food intake regime (5-6 times a day at intervals of 3-3.5 hours), and avoid dishes prepared by the culinary method of frying. A strict diet is the main method of stabilizing glucose levels.

Antihyperglycemic drugs should not be used during pregnancy due to their teratogenic effects. To a healthy diet, you need to add daily physical exercise (preferably in the fresh air). The intensity of physical activity should not exceed the body's capabilities. When planning sports activities, it would be advisable to consult with your doctor.

Insulin preparations approved for use during pregnancy

Rules for storing insulin and administering injections

• Sealed vials and cartridges with insulin should be stored in the refrigerator at a temperature of +4–8°C; opened ones can be kept at room temperature no higher than +25°C for one month;
• Before using a new bottle, you must check the expiration date information;
• You cannot use an insulin syringe pen if its body has cracks, the cartridge is not tightly screwed to the piston, or the pen body is wet from leaking insulin;
• The needle should be changed after each injection, as crystallization of insulin and “clogging” of the needle may occur, which will lead to inaccurate administration of the drug dose;
• Before the injection, it is necessary to “reset” 1 unit of insulin;
• If the insulin does not "reset", it may be low or the plunger is not touching the rubber cap inside the cartridge;
• Optimal absorption of insulin is ensured when it is administered into the subcutaneous fatty tissue. To do this, use two fingers – the thumb and index – to form a skin fold;
• For best absorption of the drug, it is recommended to hold the fold;
• Continue to press the plunger of the syringe pen for 10–15 seconds after the end of the injection so that all the required amount of insulin has time to flow out of the needle;
• If you practice good personal hygiene and use disposable needles for hypodermic insulin injections, there is no need to wipe your skin with alcohol before injection. Alcohol causes the destruction of insulin and has a tanning or irritating effect on the skin.

Hypoglycemia is a condition characterized by low blood sugar levels. Hypoglycemia is considered to be blood sugar below 3.9 mmol/l during pregnancy only during insulin therapy. It is very rare in gestational diabetes mellitus.

Causes of hypoglycemia in gestational diabetes mellitus:

• Too much insulin was administered;
• Lack of carbohydrates in the diet;
• Skipping meals;
• Too intense physical activity.

Signs of hypoglycemia:

• Headache, dizziness;
• Hunger;
• Visual impairment;
• Restlessness, feeling of anxiety;
• Frequent heartbeat;
• Sweating;
• Shiver;
• Deterioration of mood;
• Poor sleep;
• Confusion.

What others might notice if you experience hypoglycemia:

• Pallor;
• Drowsiness;
• Speech disorders;
• Anxiety, aggressiveness, inappropriate behavior;
• Impaired concentration.

Algorithm of action for signs of hypoglycemia

• Stop any physical activity;
• Determine your sugar level - is it really low?
• Immediately eat or drink something containing quickly digestible carbohydrates: 100 ml of juice, or 4 pieces of sugar (can be dissolved in water;
• After this, you need to eat or drink something containing slowly digestible carbohydrates in quantity (a glass of kefir,
• piece of bread, apple).

The most reliable method of preventing hypoglycemia is regular self-monitoring of glycemia.

Signs

Pregnant women often attribute symptoms of high glucose to a change in the general condition of the body. At a routine appointment with a doctor managing a pregnancy, expectant mothers rarely complain about the manifestation of primary signs of hyperglycemia. A high glucose level is detected only during routine screening.

If your blood sugar has increased, the following symptoms should attract your attention:

• Polydipsia (permanent thirst). The desire to drink water arises regardless of the consumption of salty foods. Increased amounts of glucose in the blood require additional fluid, and the body tries to prevent dehydration (dehydration).
• Pollakiuria (frequent urination). It occurs, firstly, due to impaired absorption of free fluid by the kidneys, characteristic of hyperglycemia. Secondly, because of the growing baby (the enlarged uterus puts pressure on the bladder). Thirdly, due to the constant replenishment of water supplies (quenching thirst).
• Polyphagia (increased appetite) or anorexia (lack of appetite). Impaired insulin perception negatively affects the functioning of the hypothalamus, an area of ​​the brain that regulates homeostasis and hunger. Eating behavior is out of control.
• Chronic fatigue syndrome (CFS). Fatigue and weakness are caused by a lack of energy and tissue nutrition, since the delivery of glucose is stopped (or the cells refuse to absorb it).

External signs of high glucose levels: loss of elasticity and dryness of the skin, slow skin regeneration after damage, swelling, brittle hair and nails, telangiectasia (spider veins on the legs). If sugar increases by 2 or more mmol/l, manifestations of hyperhidrosis (increased sweating), cephalgic syndrome (headache), and increased heart rate (tachycardia) are possible.

Important! You should tell your doctor about all your sensations. A seemingly insignificant change in condition may be a sign of hyperglycemia.

Gestational diabetes mellitus in pregnant women

Prenatal monitoring program for pregnant women with gestational diabetes mellitus by an endocrinologist:

• Monitoring a pregnant woman’s nutrition using a self-control diary;
• Assessment of glycemic self-control indicators: Target fasting glycemic level <5.1 mmol/l, before meals <5.8 mmol/l, 1 hour after meals <7.0 mmol/l, 2 hours after meals <6.7 mmol /l;
• Self-monitoring of ketonuria daily in the morning urine;
• Control of physical activity;
• From the 32nd week of pregnancy, ultrasound of the fetus (fetal growth dynamics, size and estimated weight in percentiles) every 2 weeks;
• CTG weekly;
• Consultation with an endocrinologist every 7-14 days;
• If necessary, consultation and supervision of related specialists.

Childbirth with gestational diabetes mellitus

Childbirth according to obstetric indications in a general maternity hospital during a full-term pregnancy.

The type of delivery will depend on the period at which labor begins, the expected weight of the fetus, and the state of health of the pregnant woman and the fetus.

The timing and method of delivery are determined by an obstetrician-gynecologist, based primarily on the well-being of the mother and fetus before birth, as well as the opinions of specialists (endocrinologist, ophthalmologist, therapist and others).

Until delivery, the usual glucose-lowering therapy is maintained.

• Insulin is discontinued;
• In the perinatal period, avoid infusions of solutions containing glucose and lactate;
• Target glycemic level 4.0 – 6.1 mmol/l;
• Glycemic control in a newborn: immediately after birth in umbilical cord blood, whole capillary blood, after 2, 24, 72 hours in whole capillary blood.

In pregnant women with gestational diabetes mellitus, after delivery and expulsion of the placenta, hormones return to normal levels, and, consequently, cell sensitivity to insulin is restored, which leads to normalization of carbohydrate metabolism. However, women with gestational diabetes remain at high risk of developing diabetes in the future.

Therefore, all women with gestational diabetes mellitus undergo an oral glucose tolerance test 4-8 weeks after birth (“load test” with 75 g of glucose - a study of venous plasma glycemia on an empty stomach and 2 hours after exercise), in order to reclassify the condition and actively identify disorders on the part of carbohydrate metabolism.

• If fasting venous plasma glycemia is detected ≥5.6 mmol/l, or 2 hours after exercise ≥7.8 mmol/l, consult an endocrinologist at the place of residence;
• If fasting venous plasma glycemia <5.6 mmol/l, and 2 hours after exercise <7.8 mmol/l, study fasting venous plasma glycemia every 3 years;
• All women who have had gestational diabetes mellitus are recommended to change their lifestyle (diet and physical activity) in order to maintain normal body weight and plan subsequent pregnancies.

The main causes of increased blood glucose

To answer why the concentration of glucose in the blood of pregnant women increases, you need to understand what is happening in the female body. During gestation (pregnancy), the endogenous steroid and progestogenic sex hormone progesterone reaches high concentrations. Its main function is to maintain pregnancy and ensure the successful development of the fetus. Active production of progesterone partially or completely blocks insulin production.

In the second half of the perinatal period, the synthesis of placental hormones increases. The provisional (temporary) organ begins to perform its endocrine function. Hormonal imbalance has a negative impact on metabolic processes, in particular carbohydrate metabolism. Pregnant women have an increased need for glucose, since two organisms need to be provided with energy and nutrition (one of which requires permanent sugar replenishment, since it is in a state of growth).

The expectant mother begins to eat more foods containing simple carbohydrates (confectionery, chocolate, etc.). With such a glucose attack, the pancreas tries to compensate for the situation by increasing the production of insulin. Considering that in the 2-3 trimester, a woman’s physical activity decreases, cells and tissues lose sensitivity to the hormone, and the pancreas wears out greatly.

Insulin resistance occurs (insulin synthesis is maintained, but the ability to realize it is lost). As a result, glucose accumulates in the blood, sugar levels rise, and body tissues are left without the necessary nutrition. Both mother and child are “starving.” Additional causes of unstable glycemia (blood sugar) during gestation may include the following:

• chronic pathologies of the pancreas and hepatobiliary system (usually diagnosed before pregnancy);
• unstable functioning of the renal apparatus;
• a woman’s genetic predisposition to diabetes mellitus (hereditary predisposition);
• distress (constant stay in a state of neuropsychological discomfort);
• high BMI (body mass index), indicating obesity.

Clinical manifestations of hyperglycemia are moderate, therefore, women are not inclined to pay due attention to them

Breastfeeding for diabetes

Gestational diabetes is not an obstacle to breastfeeding. Breastfeeding is an indispensable way to achieve normal body weight and prevent the development of diabetes in the future for women who have had gestational diabetes. The longer breastfeeding continues, the lower the risk of developing diabetes.

Children born to mothers with gestational diabetes mellitus during pregnancy should be observed by appropriate specialists (endocrinologist, therapist, nutritionist, if necessary) to prevent the development of obesity and/or carbohydrate metabolism disorders (impaired glucose tolerance).

Given the high risk of developing gestational diabetes in the future, mandatory planning for subsequent pregnancies is necessary.

Why is sugar dangerous during pregnancy?

First of all, excess glucose can lead to fetal pathology. These babies are born very large. In addition, they are at risk of developing neurological diseases, jaundice, respiratory problems, and mental retardation.

But the most serious consequence of high sugar is miscarriage. Medical statistics indicate the risk of losing a child in most cases precisely with high sugar levels. With excess glucose, blood vessels are primarily affected. They do not supply blood and nutrients to the placenta in the required volume, which leads to its “drying out,” which is the cause of premature birth.

Moreover, a pregnant woman suffers:

• swelling;
• overweight;
• high blood pressure;
• deterioration of vision, which increases the risk of retinal detachment;
• the occurrence of inflammatory processes in the genitourinary system due to increased proliferation of bacteria in a sweet environment;
• in 60% of cases, the expectant mother develops excess amniotic fluid.

It is very important to periodically visit a doctor who monitors the progress of pregnancy in a particular woman. She should undergo all research procedures and adhere to the gynecologist’s recommendations.