Diabetes gestationnel

The diabetes gestationnel represents any state of Intolérance to the Glucose, whatever its severity, appeared during the Grossesse at a woman without Diabète sweetened known before. The Diabète is defined by a Glycémie venous in jeun higher than 1,26 grams per liter of Sang, twice. But, here, it is a simple intolerance with the glucose which must be dealt with. It is a frequent complication of the diabetes (approximately 5% of the pregnancies), and which exposes to complications maternal and fetal potentially severe. It appears classically between the 24e and the 28e week of Aménorrhée, corresponding to the Sécrétion of the Hormone placental lactogene (HPL) by the Placenta, person in charge of Insulino-resistance in the mother.

Risk factors

  • multiparité : if the basic risk is from 5 to 6% in France, it should be known that the incidence climbs to 19% at the multigestes.
  • maternal Age higher than 35 years, Obesity (IMC > 25kg/m2).
  • Previous family of Diabetes of the type 2
  • During former pregnancies: personal antecedents of diabetes gestationnel, premature birth, fetal death In utero unexplained, of Macrosomia (new born weighing more than 3800 G), of Hydramnios (excessive quantity of Amniotic liquid)
  • During the pregnancy: excessive catch of weight, hydramnios, macrosomia.
  • the women originating in North Africa, Asia or the Antilles, are also with increased risk.

Tracking of the diabetes gestationnel

Two protocols are opposed, without the scientific community still slicing to date (2004):

Test of O' Sullivan

  • It consists in carrying out a glycemia one hour after the ingestion of 50 grams Glucose the patient having to be with jeun
In the event of glycemia lower than 1,3 grams/liter, the test is negative.
  • In the event of glycemia ranging between 1,3 and 2 grams per liter, the test is positive and it is necessary to practice a oral caused Hyperglycémie
  • For a glycemia equal or higher than 2 grams per liter, the diabetes gestationnel is proven.

    Test of WHO

    The test of WHO is of more recent development. It is different from the precedent by the fact that it requires only one stage: catch of 75 grams glucose, then measurement of the venous glycemia at 2 a.m.: the test is positive (and the proven diabetes gestationnel) for a value higher than 1,4 grams/liter, without need for confirmation.

    Diagnosis by Hyperglycemia caused by oral way

    • the second stage of the test consists of a caused Hyperglycémie per bone (HGPO) with 100 grams of glucose, then to measure the glycemia every hour of H0 with H3. The pathological thresholds are of > 0.95 g/l in H0, > 1.8 g/l in H1, > 1.55 with H2, > 1.4 with H3.
    Two measurements of venous glycemia equal or higher than these thresholds sign the diabetes gestationnel
  • a measurement of venous glycemia equal or higher than these thresholds intolerance with glucose signs

    Complications

    A great study (Hyperglycemia and Unfavourable Pregnancy Outcomes) undertaken on 25.000 women rrecrutées in 9 countries, could involve a revision of the definition of the Diabetes gestationnel. Indeed, whereas it was thought that intolerance with glucose made run only little of risks to the child, study HAPO shows that an increase moderate in the maternal glycemia to involve complications foeto-nursery schools little. Thus, a glycemia with jeun located enters to 0,95 and 1 g/L induces already a muliplication by 4 to 6 of the risk of macrosomia, a multiplication by 10 of the risk of hyperinsulinism.

    Fetal complications, obstétricales and néonatales

    • Prematurity

    • fetal Death in-utéro (of cause badly included/understood)
    • Macrosomia, with risk of Dystocie of the shoulders (childbirth by low way where the shoulders of the fetus make obstacle at the end of the childbirth: risk lesions of the Plexus brachial, fracture of the Clavicule, paralysis of the upper limbs, néo-native death by Asphyxie). This risk is of 5% for the women whose glycemia is in the levels low (less than 0,75 g/L) but of 27% when it is higher than 1 g/L (according to study HAPO revealed with the congress of the ADA in June 2007).
    • Hydramnios
    • Maladie of the hyaline membranes (the fetal hyperinsulinism slows down pulmonary maturation and the synthesis of surfactant)
    • hypertrophic Cardiomyopathie concerning the inter-ventricular septum
    • Hypoglycémie néonatale
    • Ictère néonatal
    • Polyglobulie (by chronic hypoxia in utéro)
    • Hypocalcémie
    • It does not have there a risk of Malformation S

    Maternal complications

    • Increased risk of infection, in particular urinary (the hyperglycemia supports the development of the Bactérie S)
    • Increased risk of gravidic arterial Hypertension
    • Hémorragie of the more frequent delivery with lengthened work.

    Late complications

    • For the mother:

    • For the child: increased risk of obesity and diabetes of the type 2.

    Treatment

    In preamble, it must be stressed that the treatment of the TRUE diabetes gestationnel (with the difference in a pregnancy on preexistent diabetes, known or not) was not the proof of an improvement of the perinatal morbi_mortality.

    Objectives

    To avoid above the majority of described complications Ci by a control glycemic rigorous

    To avoid the fatal consequences of the chronic hyperglycemia, and with this intention to ensure a normal and stable glycemia, by a rigorous follow-up and therapeutic adapted. The objectives glycemic are a glycemia with jeun lower than 0.95 g/l, and a glycemia post-prandiale (one hour 1/2 after the end of the meal) lower than 1,20 g/l.

    Average therapeutic

    • dietetic Mode: it is measurement to be undertaken in first, and which is sometimes sufficient when it is well led. It consists of a mode limited to 2000 Calorie S per day divided into 3 meals and 2 collations, with control of sugar slow. One advises a physical exercise moderate and adapted to pregnancy (walk, swimming, soft gymnastics, etc)

    • Insulin treatment in the event of failure of the mode only followed well (by 3 or 4 daily injections)

    Monitoring obstétricale

    The follow-up of the patient and her pregnancy must be rigorous, with monitoring of the glycemias on capillary blood (car-measurement before and after each meal) consigned on a notebook, the proportioning of the HbA1c (glyquée hemoglobin, which testifies to the chronicity of the hyperglycemia - to see Glycation ).
    • Echography both to three weeks
    • Evaluation of the fetal Wellbeing every week
    • Tracking of macrosomia
    • Programming of the childbirth by Release of work (only in the extreme cases).
    • Fund of eye at the beginning of the pregnancy and the 5th month

    A later dépisage of diabetes will have to be proposed (6 to 8 weeks after the childbirth). The Allaitement is advised particularly in this context.

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