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Impact of diabetes mellitus compensation on pregnancy outcomes
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DOI: http://dx.doi.org/10.20534/ESR-16-9.10-73-75
Atadjanova Muborak Masharipovna, MD, PhD, researcher at the Thyroidology Department of Republican Specialized Scientific and Practical Medical Center of Endocrinology, Uzbekistan.
E- mail muborak288@yandex.com
Impact of diabetes mellitus compensation on pregnancy outcomes
Abstract: 40 pregnant women with type 1 DM were recruited for the study and divided into two groups by terms of DM compensation. Pregnancy outcomes significantly improved with pregnancy planning and adequate and timely self-control over glycemia, and regular visits to a physician for examination.
Keywords: diabetes mellitus, pregnancy, compensation, complication.
High percent of complications both in pregnancy and delivery taken into account [3, 11], management of pregnant women with diabetes mellitus (DM) ever was and still is a challenging task. Leading experts in the sphere believe that among the most important issues to be determined prior to conception in every patient are the degree of DM compensation, presence and stage of microangiopathies, presence of arterial hypertension, and thyroid pathology as well as changes in lipid metabolism, and presence of anemia [1; 7].
DM compensation prior to conception is the most important issue of all above, since it contributes to reduction in the rate of congenital anomalies, stillbirths, neonatal mortality and premature deliveries. As compared with the patients who get antenatal consultation, incidence of fetal and neonatal mortality and congenital anomalies is four times higher in women who do not get it [2; 3]. Hyperglycemia is a teratogen, and it may result in cardiac defects, anomalies in the central nervous system, such as anencephaly and spina bifida, skeletal and urogenital anomalies [4; 11]. Ideally, any pregnancy should be the planned one. A woman should be capable of self-control, and she should have as few diabetic complications as possible. She should be informed that the risk of diabetic complications increases by duration of the disease. 3-4 months before con-
ception ideal DM compensation should be achieved. Changes in the targets of self-control, more frequent decompensation events due to changes in insulin requirements, and potential obstetric complications taken into account, patients who were trained in the "diabetes school" should be trained repeatedly when getting pregnant.
The work was initiated to compare pregnancy outcomes in patients with compensated and decompensated type 1 diabetes mellitus.
Materials and methods
We recruited 40 pregnant women aged 21 to 28 years with type 1 diabetes mellitus to divide them into two groups by terms of DM compensation. Thus, 20 women referred for medical care after 8 weeks of gestation (late term referral and, consequently, late compensation) were included into the 1st group, 20 women referred before conception or under 8 weeks of gestation (early term and, consequently, early carbohydrate metabolism compensation) comprised the 2nd group. The disease duration was 2-13 and 1-10 years in the 1st and 2nd group, respectively.
The fasting glucose and postprandial 1-hour glucose, urinary glucose, HbA1 c and lipid profiles were measured during the first visit and subsequently once in 1-3 months. All patients were capable of self-control. 17 of 40 patients (42.5%) had glucometers
Sectiom 6. Medical science
to measure the fasting and postprandial glycemia by themselves. According to international recommendations, control over diabetic complications was performed during the first visit and subsequently by trimesters [7]. Concentrations of TTH, free T4, Ab-TPO were measured to assess the thyroid status of patients.
Concentrations of a-fetoprotein and chorionic gonadotropin were measured to control condition of a fetus at early terms; clinical ultrasound, Doppler sonography and cardiotocography were used to assess it at the late terms. Apgar score was used to assess condition of a newborn; glycemia and bilirubinemia were measured. Control over status of obstetrics was performed by specialists from the Tertiary Center of Obstetrics and Gynecology.
Results
The changes in the HbAlc levels in two groups were as follows: mean levels in the beginning of gestation were respectively 9.41±0.4% and 8.38±0.36%; by the end of gestation it was 7.29± ±0.26% (p<0.05) in the 1st group and decreased in the 2nd one to 6.56±0.21% (p<0.05). Changes in lipid profiles of the patients, such as, increase in total cholesterol, triglycerides and LDL, were observed in 6 of 20 patients (30%) of the 1st group during the first visit and at the second trimester, the changes during the first visit were found in 4 of 20 patients (20%) of the 2nd group. All patients received folic acid, iodine preparations and L-thyroxine, if necessary.
As to diabetic complications, non-proliferative, preproliferative and proliferative retinopathies were registered in 10 (50%), 2 (10%) and 2 (10%) patients in the 1st group, respectively. In the 2nd group non-proliferative and preproliferative retinopathy was in 9 patients (45%) and 1 patient (5%), respectively. First examination revealed I degree polyneuropathy in 7 (35%) and 6 (30%) patients in the 1st and 2nd group, respectively; the II degree polyneuropathy was found in 9 (45%) and 5 (25%) patients in the groups, respectively. 5 (25%) patients in the 1st group and 2 (10%) patients in the 2nd one had nephropathy. Diabetic encephalopathy was observed in 13 (65%) and 7 (35%) patients of the 1st and 2nd group, respectively. During gestation in patients with the decompensated diabetes mel-litus urinary tract infections or chronic pyelonephritis exacerbation (n=13, 65%), I degree diffuse goiter (n=10, 50%) and II degree diffuse goiter (n=6, 30%) occurred. In the group of patients with the compensated diabetes mellitus urinary tract infections or chronic pyelonephritis exacerbation were registered in 7 (35%), 8 (40%) and 5 (25%) patients, respectively.
As to outcomes of pregnancies, there were 2 (10%) therapeutic abortions, 4 (20%) spontaneous abortions, and 12 (70%) deliveries, 8 (66.6%) cesarean sections and 6 (33.4%) vaginal births among them in the 1st group. Among complications there were 8 (66.6%) cases of preeclampsia, 3 (15%) premature deliveries and 4 (20%) early amniorrheas; uterine inertia was registered in 3 (15%) women, there were 2 cases (10%) of intrapartum hemorrhage, chronic intrauterine fetal hypotrophy took place in 6 (30%) patients and polyhydramnios in 5 (25%). In this group weight at birth for newborns ranged from 2,880 to 5,000g; there were 6 (30%) newborns with macrosomia, that is, with weight at birth > 4,500g. All babies had a score of 5-7 according to Apgar score. Diabetic fetopathy was found in 2 (16.6%) newborns. On the first day, glycemia was within normal limits in 11 (91.6%); in one (8.3%) newborn it was lower than normal (2.0 mmol/l).
In the 2nd group 12 (60%) women perform deliveries at 36-38 weeks of gestation; there were 8 (40%) cesarean sections, two of them (10%) occurred at 34-36 weeks of gestation due to preeclampsia. Among complications there were 3 (15%) cases of preeclampsia, 2 (10%) premature deliveries, 2 (10%) premature
amniorrheas, 3 (15%) cases of uterine inertia; chronic intrauterine fetal hypotrophy and polyhydramnios could be observed in 2 (10%) and 3 (15%) patients. In this group weight at birth for newborns ranged from 2,650 to 4,350g; 6 (15%) newborns at birth weighted > 4,000g. All babies had 5-8 score according to Apgar score. No signs of diabetic fetopathy were registered in newborns by women with the compensated diabetes mellitus.
Discussion
According to IADPSG recommendations, diabetes should be optimally compensated prior to conception and during pregnancy [7]. But during first trimester prior to appearance of insulin counter-regulatory hormones, nausea and high sensitivity to insulin can increase risk of hypoglycemia. Patients should be informed that their requirement for insulin in the first trimester most likely decrease by 10-20% [2; 6]. It is issue of the night when fasting and continuous glucose utilization by the fetus take place. Women with type 1 diabetes mellitus should snack in the evening and reduce night dose of long-acting insulin before sleep to avoid early morning hypoglycemia [10].
HAPO Study demonstrated that both fasting and postprandial hyperglycemia is risk factors of fetal macrosomia [5]. Strict control of glucose in women with pregestation diabetes (both 1 and 2 type) requires rapid-acting insulin, such as, Lispro insulin prior to meal [12]. Frequent glucose monitoring allows correcting insulin dosage. Keeping blood glucose level normal is a key point in prevention of complications, such as fetal congenital anomalies during the first trimester, macrosomia during the second and third trimesters, as well as neonatal metabolic disorders.
Epidemiological and prospective studies demonstrated that HbA1c levels during 6 months prior to conception and during first trimester correlate with frequency of major fetal anomalies, to name those of nervous system and heart, and with spontaneous abortions [3; 4; 13]. In our study spontaneous miscarriages at early terms of gestation were registered in patients with late compensation of diabetes to be the evidence for inadequate compensation prior to conception and at the beginning of pregnancy.
Pregnant patients with nephropathy are at high risk of complications and rapid progression of kidney disease [9]; that is why these women should know that would better conceive on the early stages of nephropathy with optimal compensation of diabetes mellitus. According to Landon, preeclampsia complicates ~20% of pregnancies in patients with type 1 diabetes mellitus and 95% pregnancies in women with creatinine > 1.5 [8]. Incidence of preeclampsia ranges from 9 to 92%; it is the highest one in patients with severe diabetes course and in those with diabetic nephropathy (proteinuria >300 mg), renal insufficiency or arterial hypertension. Patients with prolonged type 1 diabetes mellitus, nephropathy or hypertension are at significant risk or preeclampsia complicating pregnancy to result in fetal growth retardation, premature delivery and fetal lung immaturity [2]. In our study high percent ofpreeclampsia was observed in both groups of patients (40 and 15%, respectively). In addition, premature deliveries and chronic intrauterine fetal hypotrophy took place in the two groups to be the evidence for unfavorable course of diabetes and progression of renal pathology during pregnancy.
Significance of preparation of diabetic patients to conception should be emphasized. In our study there were 8 patients who got pregnant with their diabetes mellitus compensated with regular control of both fasting and postprandial glycemia, and correction of insulin dosage, if necessary. These pregnancies had favorable course; there were no acute variations in blood glucose, progression
The basics of local clinical manifestations of superficial bladder cancer
of microangiopathies, severe gestoses during second half of pregnancy, threat of miscarriage, signs of intrauterine fetal hypotrophy or macrosomia. Thus, adequate preparation to pregnancy and its favorable course raise the prospect for a diabetic woman to have a full-term pregnancy and deliver a healthy baby. A patient's self-control of carbohydrate metabolism plays a leading role in the process.
Conclusions
1. Pregnancy complications could be observed more frequently in patients with late DM compensation: there were 10% of therapeutic abortions, 20% of spontaneous miscarriages, 40% of pre-
eclampsia; premature delivery took place in 20%, 10% of the patients had intrapartum hemorrhage, chronic intrauterine fetal hypotrophy and macrosomia were found in 30% of cases each.
2. Pregnancy outcomes significantly improved with pregnancy planning, and adequate and timely control over glycemia. Thus, there were no abortions or miscarriages in patients with the factors above taken into account; frequency of preeclampsia (15%), premature delivery (10%), chronic intrauterine fetal hypotrophy (20%) and macrosomia (15%) was lower than in the group of patients with the late DM compensation.
References:
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6. Javanovic L., Knopp R. H., Brown Z., Conley M. R., Park E et al. (2001). Declining insulin requirement in the first trimester of diabetic pregnancy. Diabetes Care; 24 (7): 1130-6.
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8. Landon MB. (2007). Diabetic nephropathy and pregnancy. Clinical Obstet Gynecol; 50: 998-1006.
9. Rossing K., Jacobsen P., Hommel E., Mathiesen E., Svenningsen A., Rossing P., Parving H. H. (2002). Pregnancy and progression of diabetic nephropathy. Diabetologia; 45 (1): 36-41.
10. Sacks D. A., Feig D. S., Amy Liu I-L et al. (2006). Managing type 1 diabetes in prgnancy: how near normal is necessary? J Perinat; 26: 458-62.
11. Temple R. C., Aldridge V. J., Murphy H. R. (2006). Prepregnancy care and pregnancy outcomes in women with type 1 diabetes. Diabetes Care; 29: 1744-49.
12. Ter Braak E. W., Evers I. M., Erkelens D., Visser G. H. (2002). Maternal hypoglycemia during pregnancy in type 1 diabetes: maternal and fetal consequences. Diabetes/Metab Res Rev: 18 (2): 96-105.
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DOI: http://dx.doi.org/10.20534/ESR-16-9.10-75-77
Babakulov Sharaf Hamrakulovich, Navruzov Sarimbek Navruzovich, Babakulova Shahlo Hamidullaevna, National cancer research center of Uzbekistan E-mail: drsharof@mail.ru
The basics of local clinical manifestations of superficial bladder cancer
Abstract: According to a study The stage of the patients in both groups expressed LIR were observed. Mainly observed mild LIR bladder of 63.7% and 66.7% respectively of the studied groups. In contrast, with T1 stage were pronounced bladder LIR, which in the main group amounted to 73.2% in the control — 81,8%. Therefore, reasonable LIR in the main group was 16.1%, in the control of 36.3%. The results indicate the existence of a relationship between LIR and the tumor stage in the bladder. Keywords: bladder cancer, probiotics, transurethral resection, microflora, relapse.
Treatment of patients with bladder cancer is a difficult and not solved problem. Difficulties due to many factors: late detection of the disease, early emerging complications, frequent recurrence of the tumor and high risk of progression. Despite the fact that chemotherapy drugs and means of immunotherapy are widely used to prevent recurrence after TUR in patients with bladder cancer, many aspects recurrent in programme h plus adjuvant therapy continues to be a matter for discussion and at the present time. Unsolved questions remain about the indications and contraindications to this method, regimes and dosages, as well as methods of preventing unwanted side effects and complications [1; 4; 5,].
Objective: to Study the severity of local inflammatory reactions in superficial bladder cancer.
Material and methods: The object of the study were 167 patients with bladder cancer (BC), the subject of the study — bladder cancer at stage Ta and T1N0M0. Of the total number of surveyed 133 (79,6%) patients had stage BC T1N0M0, and 34 (20.4 per cent) — TaN0M0. The ratio of the frequency of occurrence of BC in men and women was almost 3:1. The age of patients ranged from 27 to 83 years, averaging — 56,3+0.4 years.
In the study of the anamnestic data of 167 patients with BC TA-1N0M0 stage, 52,0% — the duration of the disease was
