Diabetic fetopathy (symptoms, treatment, prevention)

Nowadays, almost every woman who is expecting a child undergoes a series of mandatory medical examinations. One of the most common, affordable and informative diagnostic methods during pregnancy is ultrasound.

In our country, there are three mandatory ultrasound examinations, the so-called screening. Their results traditionally excite expectant mothers, because for long months waiting protocol ultrasound - these are the few reliable data that you can find out about the baby.

Which normal sizes baby's head in the womb If she's big on an ultrasound, what does that say? And what does the lag of this indicator in size mean? Let's try to figure it out in this article.

3D echography

At first it seems that such an indicator is as individual as, for example, the height and weight of an adult. But in fact, the embryo develops according to very strict canons. The dimensions of all parts of the fetal body are extremely important, and are regulated in medical reference books not only by months and weeks, but even by days of gestation!

Lagging behind or ahead of development can mean the most various pathologies mother and fetus. This applies even to individual organs, such as the kidneys. But still, the parameters of the head of a child in the womb are of interest to doctors in the first place.

In the ultrasound protocol, the dimensions of the embryo are indicated at the very beginning. This emphasizes the importance of brain development, when even a small “error” can turn into the most serious deviations from the norm.

What parameters of the fetal head are evaluated on ultrasound

When the expectant mother sees the protocol ultrasound, she, as a rule, cannot understand what certain abbreviations mean. Here are the abbreviations doctors use:

OG - head circumference;
BDP / BRGP - biparietal, i.e., the distance from temple to temple;
LZR - fronto-occipital (distance from the forehead to the back of the head).

Normal values are estimated according to the tables. For each of them on a certain period pregnancy there are some fluctuations, which are expressed in percentiles. Most often, the doctor focuses on average(50), but also take into account general development fetus, proportionality of body parts.

The growth of the baby's head in the womb occurs unevenly during pregnancy. The highest growth rate can be observed in the second trimester.

Figure 2. Weekly Size Chart

mean values are presented

Norm or pathology

It should immediately be noted that the fetus in the womb always grows spasmodically. And if a deviation of any size from the tabular norm is detected once on ultrasound, it’s definitely too early to sound the alarm! If the difference with the indicators in the table is small (1-2 weeks), then they can talk about:

individual characteristics of the child, hereditary differences;
spasmodic development (ultrasound control is required after 2-4 weeks);
wrong calculation.

It should be noted that in the early stages of pregnancy, changes in the size and shape of the fetal head will certainly alert the specialist. But if the embryo develops normally, then in the second half of pregnancy, deviations are usually regarded as a feature.

With a single registration of some anomalies, the patient may be referred for additional studies. These include Doppler ultrasound, CTG, laboratory tests, less often invasive diagnostics of developmental anomalies in early pregnancy (amnio- and chordocentesis, chorion biopsy, etc.). Additionally, a control ultrasound examination of the fetus is usually prescribed after 2-4 weeks.

What does a big head say on ultrasound

The most common condition in which it has a larger diameter in the womb than necessary is hydrocephalus. And if earlier this diagnosis threatened the life of the mother and fetus, today such a condition timely diagnosis treatable. In the first few days after childbirth, a puncture and removal of pathological fluid from the child's cranium is performed, which gives a quick effect.

Other reasons why the fetal bone grows faster than usual are neoplasms of the brain. These include tumors, cysts. As a rule, such pathological formations are well visualized on ultrasound, and changes in the size of the fetal head will only indirectly indicate pathology.

Figure 3. Hydrocephalus

dilated ventricles

If the head is undersized

Another sign that expectant mothers often worry about is the small head of the fetus. It is worth worrying only if the backlog is significant and has been recorded repeatedly.

In addition, the overall formation of the child and the proportionality of all parts of his body are evaluated. Diagnosis intrauterine delay development” can be established only after an assessment of all factors by the attending obstetrician-gynecologist.

Medical tactics

Notwithstanding the foregoing, the council (doctor of ultrasound and laboratory diagnostics) can make a diagnosis in the womb. But as a rule, treatment is carried out after childbirth. Therefore, the size and other characteristics of the fetal head do not affect the course of pregnancy.

The doctor may suggest changing the tactics of delivery if the anatomical dimensions of the patient's pelvis do not correspond to the head of the fetus. It can be either an episiotomy or planned operation caesarean section.

Other deviations in the parameters of the child's skull

Among other issues that arise after screening, it is not uncommon to find a double contour of the fetal head on sonography. Although there is no such diagnosis in official medicine, many patients look at the “photo” of the ultrasound of the child and notice the unusual contour of the fruiting head and body.

In fact, this may be the result of serious developmental anomalies (especially in early pregnancy). But the so-called artifacts in the ultrasound image also look. The double contour of the child's head indicates swelling of his subcutaneous fatty tissue.

Video 1. Fetal brain

Preeclampsia of pregnancy - the most common cause not only in a woman, but also in her unborn child. This condition can be caused by Rh conflict between mother and fetus, diabetes or dropsy. But if the ultrasound doctor is not alarmed by such a picture, one should not look for a pathology. In the event that there is suspicion ultrasound diagnostics the patient is referred for further investigations. It is necessary to check the presence of antibodies, blood glucose levels and a number of other indicators.

As a general rule, the double contour of a baby's head on its own is rarely the first sign of problems. If a woman has preeclampsia, she will be more likely to be disturbed by an increase blood pressure, swelling of the legs and the whole body, protein will be found in the urine. When diabetes there will be dizziness, fainting, tremor, in the blood elevated level fasting glucose. All these symptoms, as well as any suspicions, should be reported to the observing obstetrician-gynecologist.

Conclusion

Probably, every expectant mother is looking forward to an ultrasound scan in order to “see” and “get to know” her child. Today, medicine allows you to thoroughly study the state of all organs and systems of the fetus long before its birth. It helps doctors choose the right tactics management of pregnancy and childbirth.

But unfortunately such progress has also back side. A huge number of mothers-to-be are in suspense because of the alleged diagnoses of their children.

It is worth remembering that one ultrasound examination rarely serves as the basis for making a final diagnosis of the mother and child. Only complex diagnostics and a balanced approach of competent specialists give a good result.

Video 2. Dropsy on ultrasound

Unfortunately, no one is immune from numerous troubles both before the actual pregnancy and during it, because for the entire period of gestation, the baby is extremely vulnerable and completely dependent not only on the mother, but also on the external environment. Therefore, it is extremely important to protect yourself as much as possible from all possible harmful conditions that can cause dire consequences.

This is especially true for those whose body is already working with some kind of malfunction.

Women with diabetes who want to have a baby should remember the huge responsibility that falls on their shoulders, as an uncompensated disease causes various complications. One of which is fetal fetopathy.

Diabetic fetopathy (DF) is a special disease of the fetus that develops against the background of diabetes mellitus or in a pregnant woman when the glucose level is kept above normal levels.

It is characterized by a functional change in the state of the fetus with impaired functioning of the kidneys, pancreas, micro- and macrovascular systems of the child.

If there is a history of phytopathy of the fetus, then this is one of the grounds for operative delivery.

The favorable course of pregnancy in a woman with diabetes depends on numerous factors, especially on the type of disease, the degree of its compensation and the existing complications (preeclampsia, polyhydramnios, etc.), medications taken in the treatment of the disease, pregnancy management tactics developed jointly with the attending doctor.

The favorable course of pregnancy directly depends on the degree of diabetes compensation!

If the level of glycemia throughout pregnancy has always been kept within the target values, then you can not be afraid of any harmful consequences (subject to all the recommendations of the attending physicians).

If the disease is not compensated, it affects the development of the fetus and the period of actual gestation, which, as a rule, is always less than normal, because doctors have to urgently intervene in the process in order to save the life of both the mother and her child in cases where it is necessary.

For such a state, a change in the ultrastructure is typical placental barrier, When negative impact undergo compensatory-adaptive reactions of the placenta. It cannot function properly and provide the fetus with everything necessary. There is a kind of violation of contact with the blood of the mother. Doctors can make a diagnosis of capillary hyperplasia.

As a result, the weight of the fetus may change (large, but poorly developed), intrauterine diseases or any anomalies develop.

Signs, symptoms

macrosomia ( large fruit weighing more than 4 kg)
characteristic appearance(disproportionate size, when the volume of the abdomen exceeds the size of the head for more than 2 weeks, short arms and legs, swollen face, broad shoulders, big belly)
frequency of malformations
excessive deposition of subcutaneous fat
swelling of the soft tissues of the fetus
delivery time shortened
high perinatal mortality
intrauterine growth retardation
breathing disorder
reduced activity
cardiomegaly (enlargement of the liver, kidneys and adrenal glands, but they are poorly developed)

Also, the circumference of the baby's head can be significantly less than the circumference of the shoulder girdle. This leads to numerous postpartum injuries, since the baby's head is relatively small and there are no difficulties in withdrawing it, but the exit of the shoulders is very difficult.

Therefore, at first they can free one hand, even to the detriment of the baby (they can severely injure her). They have overdeveloped subcutaneous fat, there may be edema, often there is hypertrichosis.

But the most striking indicator of fetal fetopathy is macrosomia.

Most practitioners tend to believe that main reason the formation of malformations is hypoglycemia and hypoinsulinemia in early pregnancy, additional adverse factors are hypoxia, vascular disorders, lipid metabolism disorders.

Causes

Under the influence of excess glucose in the mother's blood, the baby's pancreas begins to produce an excessive amount of insulin. An excess of glucose that has entered the baby through the mother's blood begins to be intensively consumed, but for full development babies need a certain amount of it. The entire excess is converted into fat, which affects the weight of the fetus.

If you do not normalize glycemia, then this will lead to an increase in excess fatty tissue of the fetus and slow down, aggravate further normal development all internal system organs and tissues of the baby's body.

Diagnostics

The main method for detecting any abnormalities in the fetus, of course, is reflected in the ultrasound examination, when it is possible to visualize part of the process of intrauterine development.

in the first trimester of pregnancy once (at the first appearance in women's consultation obstetrician-gynecologist will definitely send for an ultrasound)
in the II trimester (between 24 and 26 weeks) once. This is done in order to determine whether there are any malformations of the central nervous (18 - 24 weeks), genitourinary and osteoarticular (24 - 28 weeks), cardiovascular systems and digestive organs (26 - 28 weeks).
III trimester is assigned to ultrasound 2, or even three 3 times until the end of delivery. If a woman has, then an ultrasound examination is carried out at 30 - 32 weeks, and after 1 time per week.

What can ultrasound show in an unfavorable course of pregnancy (with embryofetopathy)?

macrosomia
body imbalance
double contour of the fetus due to possible soft tissue swelling or increased subcutaneous fat
double contour of the head (the thickness of the soft tissues of the dark area in the III trimester is increased by more than 3 mm, although normally no more than 2 mm)
in the area of the skull bones and the skin of the fetus, an echo-negative zone was noticed (indicates edema)
polyhydramnios (determined by the difference between the anteroposterior size of the uterine cavity and the average diameter of the fetal abdomen from 20 mm or more)

Studies of the biophysical state of the fetus

It is necessary in order to identify violations in the morphofunctional development of the brain, which is the most severe manifestation of embryopathy. To check this, doctors record for at least 1.5 hours motor activity fetus, respiratory movements and heart rate.

If there is a fetopathy, then restful sleep the baby is short-term, most of the time he remains active. A short nap lasts no more than 50 minutes. During this time, prolonged and frequent decelerations of the heart rate (decrease in heart rate, slow heart rate) are noticeable.

Doppler

Look at the following metrics:

myocardial fiber contraction rate
determine the time of expulsion of the left ventricle of the heart
measure cardiac output (left ventricle)
determine the index of blood flow resistance in the umbilical artery and the systolic-diastolic ratio of blood flow in the artery

Dopplerometry is performed at 30 weeks and allows you to assess the state of the central nervous system(CNS). In fact, this is also an ultrasound examination, but, let's say, narrowly focused.

Cardiotocography with evaluation of functional tests (CTG)

During this procedure, the heart rate is assessed at rest, in motion, during uterine contraction and in the presence of environment. Doctors will conduct tests, during which they will take several samples.

Assessment of biochemical markers of the fetoplacental system

It is necessary to determine whether there are signs of feto-placental insufficiency (FPI). Determined by blood and urine tests. Diagnostic biochemical parameters these are: placental lactogen, progesterone, oxytocin, α-fetoprotein (AFP). By the concentration of AFP, the severity of diabetic fetopathy is judged (in this disease, the amount of this protein exceeds the norm in the third trimester of pregnancy).

Therefore, it is recommended to determine the hormonal profile of a pregnant woman every 2 weeks during the II and III trimesters.

Treatment

During pregnancy

Throughout the entire period, a pregnant woman also maintains blood pressure. If necessary, additional insulin therapy is prescribed. For prevention, sugar is examined daily every 3-4 hours. The level of glycemia is corrected with either inulin or glucose (for prevention purposes).

Be sure to take additional vitamins, follow a balanced diet, the total calorie content of which is from 2800 to 3200 kcal, and also take into account other recommendations of the attending physicians. Dietary intake is reduced fatty foods, and before the immediate birth, the diet of a pregnant woman should be enriched with easily digestible carbohydrates.

During childbirth

Initially, on the basis of ultrasound, it is necessary to determine the optimal term for childbirth. In an uncomplicated pregnancy, the most favorable time 37 weeks is considered. At possible threats life and health of both the mother and the child, termination of pregnancy is prescribed before 36 weeks. More early dates can be appointed in case of a clear threat to the life of the mother, as a rule, it is not necessary to talk about saving the child.

This is possible if severe preeclampsia progresses in a pregnant woman, there are angiopathy, polyhydramnios, kidney failure, fetal hypoxia progresses or are noticed serious violations fetal life, consistently high hyperglycemia, and so on.

Be sure to monitor glycemia during childbirth. If the blood sugar level is too low, then it will be much more difficult for a woman to give birth due to a lack of energy (it takes a large number of glucose). During childbirth or after them, she may lose consciousness, fall into a hypoglycemic coma.

Also, the birth itself should not be delayed. If they last more than 8 - 10 hours, then doctors resort to the help of a caesarean section, after which they prescribe antibiotic treatment. With prolonged childbirth, a soda solution is administered to prevent the development of ketoacidosis in a pregnant woman.

If before childbirth a woman has toxicosis, then soda enemas are prescribed, oxygen inhalations are carried out.

If a woman has symptoms of hypoglycemia, then it is necessary to stop them with fast carbohydrates: it is suggested to drink sweet water in the proportion of sugar and water, 1 tablespoon per 0.1 liter, if the condition does not improve, then a 5% glucose solution is injected intravenously in a volume of 500 ml (put a dropper). For convulsions, hydrocortisone is administered in a volume of 100 to 200 mg, as well as adrenaline (0.1%), not more than 1 ml.

To speed up metabolic processes use vitamin solutions (vitamins A, C, P, E, B 12, rutin, nicotinic acid and others).

After childbirth

To prevent the development of hypoglycemia and subsequent complications 30 minutes after birth, a 5% glucose solution is administered to the baby. Every two hours it is necessary mother's milk.

It's pretty frequent occurrence in newly born children, since glucose from the mother’s blood no longer enters their blood and only mother’s milk, saturated nutrients, can buy given state.

After cutting the umbilical cord, the pancreas continues to produce insulin, and as such, energy is no longer supplied to the body. To replenish the balance, frequent feeding is necessary.

After giving birth to a child with signs of diabetic fetopathy, doctors carefully monitor his condition, in particular - breathing. In his absence, seek help. artificial ventilation lungs. In order for the lungs to expand and begin to fulfill their functions, the baby can be injected with a special substance - a surfactant, which helps the child take the first breath. At normal course pregnancy and development in children without signs of fetopathy, a sufficient amount of surfactant is produced and they immediately begin to breathe well.

If neurological disorders are noted, then magnesium-calcium solutions will help correct the situation. In case of a liver disorder, when the child's skin and the whites of the eyes have an icteric hue, sessions of strictly dosed ultraviolet irradiation are prescribed.

As for the mother herself, the level of insulin administered to her after childbirth is always reduced by 2-3 times to prevent hypoglycemia, since the concentration of glucose in the blood drops sharply. In the early days, simple insulin can be used, but after 2 to 4 days after the birth of the baby, its level, as a rule, rises sharply. Therefore, at this time it is necessary to carefully monitor glycemia and switch to a more intensive course of insulin therapy.

After 7-10 days (by the time of discharge), normoglycemia is restored to those values that corresponded to the woman before pregnancy.

Possible Complications

neonatal diabetes mellitus (newborn diabetes)

As a rule, diabetic fetopathy can quickly develop into.

neonatal hypoxia

Develops due to lack of oxygen.

hypoglycemia
hypocalcemia

Maximum low level calcium in the blood born baby observed on the 2nd - 3rd day, the calcium concentration decreases to 1.74 mmol / l and less. This condition manifests itself in the hyperexcitability of the child, twitching of the arms, legs, and a piercing cry. There is tachycardia and tonic convulsions.

hypomagnesemia

If in the blood test the concentration of magnesium is below 0.62 mmol / l. The symptomatic picture is similar to the behavioral state of the baby with hypocalcemia. For confirmation similar states also carry out.

perinatal asphyxia

It is characteristic of premature babies with phytopathy.

respiratory distress syndrome (RDS)

It is also called hyaline membrane disease. Develops when premature birth, with a delay in the maturation of the surfactant system of the lungs. It is caused by a deficiency of the surfactant substance, which progresses against the background of hyperinsulinemia, which suppresses the action of cortisol.

transient tachypnea

Otherwise, wet lung syndrome, which is similar to RDS. Its manifestations usually disappear 72 hours after birth. The respiratory rate increases, but the concentration of oxygen in the blood decreases.

As soon as the baby is born, some amount of fluid remains in his lungs, which is quickly absorbed and enters the bloodstream. If this process is slowed down, then this condition develops, which is stopped by the supply of oxygen. It is more common in children born by caesarean section.

cardiomyopathy

Leads to congestive heart failure due to an increase in excess fat deposits, glycogen in the myocardium. This negatively affects cardiac activity.

hyperbilirubinemia

Jaundice, which manifests itself after 2 - 3 days after birth.

polycythemia

A characteristic condition in which the number of red blood cells increases, but the mechanisms of its origin have not yet been studied.

thrombosis of the veins of the kidneys (embolism)

If the viscosity of the blood increases, then this complication may develop. It occurs relatively rarely in a small number of children whose mothers had diabetes before conception. Manifests itself with edema, tumors abdominal cavity which can be detected by ultrasound.

Necessary tests that are taken from the baby after birth

the level of glycemia is determined

It is monitored immediately after birth, and then a blood sample is taken for glucose after 1, 4, 8, 12, 20, 24 hours. Repeat the analysis on the day of discharge.

blood for calcium and magnesium

Blood serum is determined 6, 24 and 48 hours after delivery.

blood biochemistry

The concentration of protein and its fractions, urea, the level of potassium, sodium, cholesterol, if necessary, are also determined: alkaline phosphatase, ACT, ALT, and so on.

Determine hematocrit

On the first and third days of a baby's life.

electrocardiography

It is carried out with suspicion of possible malformations of the heart.

Prevention

It is easy to guess that all preventive actions come down to ensuring that before conception (ideally 4-6 months) a woman achieves stable compensation for the disease and maintains normoglycemia throughout pregnancy.

In addition, it is necessary to closely and daily monitor blood sugar levels to prevent manifestations of hyper- or hypoglycemia. Strictly observe the dosage of insulin adapted to a specific diet.

In addition, it is important to undergo ultrasound in a timely manner to prevent the progression of diabetic fetopathy, to follow all the recommendations of an obstetrician-gynecologist.

Favorable delivery and development of the baby depends primarily on the mother, who must always monitor diabetes mellitus and timely prevent hyperglycemic conditions characteristic of diabetics.

During ultrasound diagnosis of pregnancy, the doctor receives a lot of information about the condition of the fetus, and some terms can be very scary. future mother. Among such frightening information is the double contour of the head and torso of the fetus. What can be associated with such changes during an ultrasound examination and are they dangerous?

Double head contour, what does it mean?

In general, a double contour on ultrasound means the appearance of edema of the subcutaneous fatty tissue of the child. The skin forms one contour, and the subcutaneous tissue the second. The pronounced accumulation of fluid is the reason for the increased echogenicity of these tissues and the characteristic picture on ultrasound.

Fetal edema always indicates that the baby is suffering, the water-salt balance is disturbed. With a dead baby during a frozen pregnancy, everything is clear (there is an accumulation of fluid in the tissues because normal metabolism does not occur, this is called fetal maceration). At birth, in a dead macerated baby, the skin simply lags behind the tissues, easily tears and flakes off. And due to what can a double contour of an embryo or fetus appear if it is alive?

Consultations of related specialists and laboratory research
- At a period of 15-20 weeks determine the level of AFP in serum
- Cardiotocography (CTG)
  since 28 weeks CTG, at late gestosis regularly every 1-2 weeks
  from 38 weeks daily CTG
- Amniocentesis to determine the maturity of the lungs (if necessary)
- Periodically determine the level of hemoglobin
- In the III trimester of pregnancy, ophthalmoscopy is repeated to resolve the issue of the possibility of physiological management of childbirth.

In the presence of risk factors for the development of diabetes, the result of a blood test for sugar in the first trimester of pregnancy is evaluated, taking into account the mechanism of the physiological course of pregnancy, in which fasting glucose tends to decrease in early pregnancy (the fetus takes glucose).

Consequently, in the morning, on an empty stomach, a pregnant woman is characterized by hypoglycemia (the mother did not eat anything, the fetus continues to take glucose).

If we see fasting glucose of 6.1 mmol / l in a pregnant woman, which is the normal limit for a non-pregnant woman, then in a pregnant woman this can be considered a pathology. This means that the fetus has already taken glucose from her and continues to take it, but she still has 6.1 mmol / l and this, of course, is not normal. Such a pregnant woman needs an oral glucose tolerance test with 50 g of glucose.

In the presence of risk factors for the development of diabetes, the test is carried out at the first visit to the doctor, and then repeated at 24-28 weeks.
If the plasma glucose level is below 7.8 mmol / l, examination and treatment are not required.
At a glucose level of 7.8 to 10.6 mmol / l, a three-hour test with 100 g of glucose is indicated.
When the plasma glucose level is above 10.6 mmol/l, a preliminary diagnosis of gestational diabetes is established.
If there are risk factors for gestational diabetes and negative result test at a gestational age of less than 30 weeks, it is repeated every 4 weeks.

In addition to a blood test, a urine test is performed to diagnose diabetes. in the urine healthy person glucose is absent, and glucosuria appears only when the blood glucose level exceeds 8.8-9.9 mmol / l. However, during pregnancy, glucosuria (without diabetes mellitus) may occur as a result of changes in the filtration function of the kidneys. Therefore, only glucosuria, which occurs quite often during pregnancy, in this case does not have a great diagnostic value. In addition to glucose in the urine, acetone can be determined, which is indirect sign decompensation of diabetes mellitus. A parallel increase in the number ketone bodies in the blood will confirm the diagnosis of diabetes mellitus.

Patients with diagnosed gestational diabetes mellitus are given diet therapy for 2 weeks, followed by determination of the level of glucose in the blood on an empty stomach and three times with an interval of 1 hour after a meal. In the case of the norm, glucose control continues to be determined every 2 weeks. If the norm of one of the indicators is exceeded, insulin therapy is started. Availability gestational diabetes does not require any special measures for delivery.

After the baby is born, the mother does not need insulin, but glycemia should be monitored until discharge and a full glucose tolerance test should be performed within 6 weeks.

Patients with test results typical of diabetes mellitus are transferred to the supervision of an endocrinologist. Patients with normal glucose tolerance should be informed of the importance of maintaining ideal body weight through diet and physical activity. In any subsequent pregnancy, they should immediately be registered and given oral glucose tolerance test. If the result is within the normal range, then the test will need to be repeated at the 28th week of pregnancy.