7.1 Detection of diabetic embryopathy: the leading cause of perinatal morbidity and mortality in patients with pregestational DM are fetal congenital malformations with an incidence between 7.5 and 14.9% (7 to 15 times more frequent than in normal pregnancies) . Morphological changes are the most common cardiovascular (transposition of the great arteries, ventricular septal defects and atrial) and neurological (anencephaly, holoprosencephaly and CNS defects closure). (1, 3, 5).The diabetic patient wishes to become pregnant, should receive adequate preconception counseling. Now, the detection of structural abnormalities (hyperglycemia produced by this during the first eight weeks of pregnancy - critical period) includes:
HbA1C measurement of patient 4 - 6 weeks post-conception: levels above 8.5% is associated with a 20-25% chance of developing fetal anomalies versus 2 - 3.5% when the figures are normal HbA1C (3-4). vaginal ultrasound between 8-10 weeks of pregnancy, especially in those patients with abnormal numbers of HbA1C. Some defects are easily diagnosed by this time (anencephaly, holoprosencephaly). maternal serum alpha-fetoprotein screening (MSAFP) at 16 weeks of gestation. Normally this MSAFP is decreased in diabetic patients and often indicate the need for genetic testing by amniocentesis / cordocentesis. tertiary ultrasound between 18-20 weeks of pregnancy to detect fetal abnormalities not visualized on initial echoes. fetal echocardiography between 24 to 28 weeks gestation7.2 Prenatal: top quality, performing them every 15 days until week 24 and then every week, requesting paraclinical the following: (1) Urinalysis and urine culture: UTIs are more common during pregnancy and are the leading cause of decompensation in the diabetic patient. Be requested in the first prenatal visit and then monthly. BUN - creatinine and uric acid: as indicators of renal function minimum, quarterly. Lipid profile: initial at 24 to 26 weeks gestation and at the end of it HbA1C: at 4-6 weeks after conception and then every month to analyze the quality of metabolic control, keeping it below 7.2%. glycemic monitoring and tests of fetal wellbeing (see below) fundoscopy and EKG: in pregestational DM with vascular compromise ultrasound scans: detecting malformations and assess fetal growth7.3 Strict maternal metabolic control: the mainstay of treatment of gestational diabetes: Tight control of blood glucose during pregnancy, and The early detection of risk factors and / or aggravating s metabolic state (1, 19)Metabolic control objectives are:Avoid symptomatic hypoglycemia Keep the following plasma glycemia:Fasting ------> 65 to <105 mg / dl (ideal <95 mg / dl)Preprandial ------> 70 to 100 mg / dl An hour postprandial ------> <140 mg / dl (ideal <130 mg / dl)Two hours postprandial ------> <120 mg / dl negative ketonuria HbA1C and / or fructosamine: normal lowNow, to achieve the goals of metabolic control should formulate a treatment plan that includes diet, exercise, insulin (if needed) and the management of complications. Diet: is the key or mainstay of therapy in women with gestational diabetes. Weight gain is necessary for proper fetal growth and varies between 8 and 12kg, depending on the weight of the patient prior. Remember that the patient must never lose weight during pregnancy, as this leads to fat mobilization, lipolysis and substances that cross the placenta and have pontenciales teratogenic effects (1). The diet should provide an average of 30-35 cal / kg in patients of average weight and 25 cal / kg in obese patients, divided into three meals and three snacks, emphasizing the refreshment of 22:00 to 23:00 hours to avoid maternal hypoglycemia at dawn (glass of milk and cookies) (15,20). Remember that a gram of protein or H of C provide four calories and one gram of fat provides nine calories. It has been found that by limiting the intake of C to H of 35 to 45% of total calories, more suitably controlling postprandial glycemia (9). regulated and proper exercise is beneficial and safe; releases epinephrine, which increases glucose uptake by the cell and increases the sensitivity of the receivers, keeping blood sugar levels stable. They must walk 10 to 20 minutes after each main meal. Insulin: Insulin requirements increase progressively during pregnancy. In the first quarter are frequent severe hypoglycemia and decrease insulin requirements. During the second quarter, a slight increase occurs monthly, on the third quarter nocturnal hypoglycemia may occur and insulin requirements increase by 50 - 100% above the baseline. The oral hypoglycemic agents are contraindicated for pregnant diabetic control, and that cross the placenta and cause fetal hypoglycemia is severe malformations (1, 5).They must take insulin: DM1 and DM2's always to become pregnant Among patients with GDM, the White group A2 modified by Freinkel (fasting glucose between 105 and 129 mg / dl) and group B (fasting glucose> 130 mg / dl), andThose patients with GDM (15-22%), those with a strict regimen of diet and exercise for two weeks, fasting glucose present ≥ 105 mg / dl two hours postprandial blood glucose or ≥ 120 mg / dl on two or more occasions . These patients benefit greatly from insulin, decreasing rates of fetal and neonatal morbidity (macrosomia, birth trauma, etc).The insulin used during pregnancy should be preferably human, which reduces the formation of insulin antibodies, which pass the placenta and contribute to increased fetal insulin and therefore free to fetal macrosomia and neonatal hypoglycemia. It is intended to maintain blood glucose levels below 95, 140 and 120 mg / dl, postprandial one and two hours respectively (3, 9, 13, 23). In 1997, the market appears Lispro insulin, which has the following advantages: a higher absorption rate for 10 should be positioned immediately before meals and less duration of action, which reduces the possibility of postprandial hypoglycemia and the need for between meals; this insulin lispro, may be substituted 1: 1 by regular insulin. In Table 6, (3.24) we can see the action of the various insulins.Preferred schemes of gestational diabetic insulin are: (1, 4)1. According to the glycemic profile before breakfast, start with a small dose of NPH (5-10 each) before breakfast, with a mixture of NPH and regular insulin (15 U of NPH plus 5 or regulate) before breakfast or with a small dose of regular insulin (10 u) before the food causing the postprandial elevation adjusting the dose according to the self-monitoring as follows: posdesayuno If BG is> 140 mg / dl, place or increase crystalline insulin before breakfast. If BG two hours posalmuerzo is> 140 mg / dl, you should increase the NPH before breakfast.