The contingent of pregnant women is becoming increasingly difficult, it is accompanied by severe chronic pathology: diseases of the eyes, kidneys, cardiovascular diseases, infections, neuropathy, etc. At the same time, perinatal mortality is high, which ranges from 10 to 40%. The incidence of newborn babies whose mothers have diabetes is also on the rise. Diabetes mellitus is a disease based on an absolute or relative lack of insulin, which causes metabolic disorders and pathological changes in various organs and tissues. All this takes place against the background of the existence of the system: mother-placenta-fetus. It is known that insulin is an anabolic hormone that promotes glucose utilization, glycogen and lipid biosynthesis. With insulin deficiency, hyperglycemia develops – the main diagnostic sign of diabetes mellitus. The course of diabetes mellitus during pregnancy is undulating, with a tendency to ketoacidosis, hyper and hypoglycemic states. In the first half of pregnancy, the course of the disease in most patients remains unchanged. In the second half of pregnancy, due to an increase in the contrainsular activity of the adrenal cortex, pituitary gland, placenta, the patient’s condition worsens. Thirst appears, dry mouth, skin itching in the area of ​​pilaf organs, increases the level of glycemia and glucosuria, increases the tendency to ketoacidosis, which leads to an increase in insulin requirements. By the end of pregnancy, the need for insulin often decreases, which is explained by fetal hyperinsulinism associated with maternal hyperglycemia. Patients with diabetes mellitus during childbirth may have both hyper- and hypoglycemia. After childbirth, especially after a cesarean section, the level of glycemia drops sharply, but then rises, and reaches its original value. What should be the management of pregnancy and childbirth in diabetes mellitus? At the first stage, it is necessary to identify an increased risk of developing diabetes mellitus:
1. In case of illness in a family of relatives of a pregnant woman with diabetes mellitus;
2. Childbirth with a large fetus – 4 kg or more. Giant fruit – 5 kg or more;
3. Rebirth of children weighing 4 kg and above;
4. Deformities of the fetus;
5. Polyhydramnios;
6. Manifestation of glucosuria in early pregnancy;
7. Sudden perinatal fetal death;
8. Development of late toxicosis, obesity, frequent severe pustular diseases.
A history of women may have ovarian dysfunction, infertility. According to the presence of one or more symptoms, a pregnant woman is referred to a risk group for diabetes mellitus. Diagnosis of diabetes in pregnant women is based on the detection of hyperglycemia and glucosuria. At the same time, there are three degrees of severity of diabetes: mild, moderate, severe. With mild diabetes, the fasting glucose level does not exceed 7.7 mmol / L, the absence of ketosis. Normalization of glycemic levels is achieved only by diet. With a dibet of moderate severity, the level of glycemia does not exceed 12.2 mmol / l, ketosis is absent or eliminated by following a diet. In severe diabetes, the level of fasting glycemia exceeds 12.2 mmol / L, there is a tendency to the development of ketosis, often angiopathy, arterial hypertension, coronary artery disease, trophic ulcers of the leg, retinopathy, diabetic nephrosclerosis. Fortunately, 50% of pregnant women have transient diabetes. This form of diabetes is associated with pregnancy and the signs of diabetes disappear after childbirth. With repeated pregnancy, the same ketonuria may return, therefore, with a thorough examination, ketonuria can be detected in 50% of pregnant women. All pregnant women of this group need to determine the content of fasting sugar in the blood. With an increase in sugar above 6.66 mmol / l, the product of the test for glucose tolerance is shown. Determined the level of glucose in the blood on an empty stomach and after 30, 60, 90, 120, 180 minutes after taking 50 or 100 g of glucose, depending on the weight in 250 ml of water. In parallel, daily urine is examined for sugar content. The glucose rate one hour after exercise is 9.99 mmol / l, after 2 hours – 6.66 mmol / l. The blood sugar content 2 hours after exercise 8.32 mmol / L at normal fasting sugar levels and 1 hour after exercise indicates the presence of latent diabetes mellitus. With a diabetic type of curve, the fasting sugar level exceeds 7.2 mmol / l, after an hour it exceeds 11.1 mmol / l, after 2 hours it exceeds 8.32 mmol / l. the onset of the disease is often accompanied by the clinic – this is furunculosis, pyoderma, pruritus, dry mouth, increased appetite along with loss of body weight, polyuria. There are three stages of diabetes clinic.
The first stage begins at 10 weeks of gestation and lasts three months. It is characterized by impaired glucose tolerance, changes in insulin sensitivity. In this case, it becomes necessary to reduce the dose of insulin by one third.
The second stage develops at 24-28 weeks. There is a decrease in glucose tolerance. This is a precomatose state, or a state of acidosis, in connection with which it is necessary to increase the dose of insulin. 3-4 weeks before delivery, the patient’s condition often improves.
The third stage is associated with childbirth and the postpartum period. During childbirth, there is a risk of metabolic acidosis, which can quickly turn into diabetic. During lactation, the need for glucose is lower than before pregnancy, this is affected by an undoubted change in the balance of hormones, which is due to the development of pregnancy. Carbohydrate metabolism is affected by the level of estrogen, progesterone, corticosteroids, and the placental lactogen is an insulin antagonist. Pregnant women with diabetes can develop severe complications such as diabetic and hypoglycemic coma. At the heart of violations of the functional activity of the trophoblast are changes in the placenta, with diabetes mellitus, of a sclerotic nature. These changes of a sclerotic nature are present in the vessels of the uterus, which invariably leads to a violation of the uteroplacental circulation, a malnutrition of the fetus with the development of chronic hypoxia in it.
Dysfunction of the mother-placenta-fetus system during pregnancy complicated by diabetes is often manifested by fetal macrosomia, that is, high fetal weight. With diabetes mellitus, the mother has a syndrome of excess fetal weight for a given period. This is noted in every second woman. Moreover, the fetal body weight is more than 4 kg in every fourth woman. Hyperglycemia in the mother is accompanied by hyperglycemia in the fetus with the development of hypertrophy of the islets of Langerhans. In 80% of children whose mothers suffer from diabetes mellitus, this condition is called macropolinesia. Insulin has the properties of an anabolic hormone, enhances glycogen synthesis, increases the amount of fat, which leads to fetal macrosomia. The body weight of the fetus is also lower than the required one for the current gestational age. The placenta is large in relation to the weight of the fetus, that is, the placenta is large, and the fetus can be small. With gestosis, hypoplasia of the placenta is almost always noted, combined with diabetic macrosomia and fetal hypotrophy. But at the same time there is polyhydramnios, gestosis, iron deficiency anemia, and at the same time tissue hypoxia of the fetus with sudden fetal death is inevitable, what is characteristic of diabetes mellitus is the sudden death of the fetus. In macrosomia, hypoxia and birth trauma are the main factors for stillbirth.
Clinical features and pathogenesis of diabetic ketopathy:
Diabetic ketopathy is a sign in the newborn, reflecting the adverse effects of maternal diabetes on the fetus. The bottom line is that there is an increased increase in body weight and some organs of the fetus: liver, heart, spleen. This is combined with the retarded development of functional systems. Children look not only obese and pasty, but they have a characteristic cushingoid type and some imbalance in constitution, that is, with a long body (56058 cm), the lower limbs seem to be short, the head, especially its brain part is small, the face is moon-shaped, rounded with full protruding cheeks making the nose and eyes appear small. The abdomen is large, the skin is crimson, cyanosis of the feet. But most importantly, these are not only external changes, but, unfortunately, there are changes on the part of internal organs: an increase in the heart, liver and at the same time a decrease in the thymus and brain. These children also have reduced physical activity, there are all signs of complications of pregnancy: hormonal disorders, disorders of lipid, carbohydrate metabolism, dysfunction of organs and systems. The incidence of diabetic ketopathy is 5.7 to 42%. This is facilitated by hypoglycemia, hypercalcemia and hyperbilirubinemia. The most common complications are:
1. Spontaneous abortion;
2. Late toxicosis – 30-50%;
3. Polyhydramnios – 30-40%;
4. Pyelonephritis – 16%;
5. Asymptomatic bacteriuria – 10%;
6. Colpitis.
Expressed polyhydramnios is not difficult to diagnose. To do this, you need:
1. Ultrasound
2. Dynamic observation: once a week, the height of the uterine fundus and the size of the abdominal circumference are measured. There will be a discrepancy between the height of the fundus and the circumference of the abdomen.
With polyhydramnios, the uterus is tense, parts of the fetus are palpated with difficulty or not at all. The increasing polyhydramnios (2-3-4 liters) leads to cardiovascular failure. A pregnant woman cannot get up and take a few steps.
Of course, such a situation obliges to resolve the issue of termination of pregnancy ahead of schedule.
Treatment of polyhydramnios:
1. antibacterial therapy: penicillins, cephalosporins, depending on the flora;
2. in addition, early termination of pregnancy, especially in cases of increased polyhydramnios. Amniotomy must be done very carefully, as due to the rapid redistribution of fluid, there may be premature placental abruption;
3.Prevention of GSI

The threat of termination of pregnancy.
Conservation therapy is not carried out for severe retinopathy, diabetic nephropathy. In this case, pregnancy is contraindicated. If there are no serious complications, then hormonal treatment should be started early. Hormonal treatment includes:
– estrogens
– progesterone
Microfolliculin tablets (0.01 μg) are prescribed 0.5 tablets 2 times a day in combination with an intramuscular injection of progesterone (1% 1 ml). This therapy takes 4-5 weeks. Then the dose of estrogen is reduced sharply to 1/4 of the tablet. After 12 weeks of pregnancy, that is, when the formation of the placenta comes to an end, we switch to 17-hydroxyprogesterone until 32-34 weeks of pregnancy. Active vitamin therapy is useful: vitamin E, C, A, D. Combined preparations are good. To relieve increased excitability of the uterus, tocolytics are used: magnesium sulfate, etc., physiotherapy, prostaglandin inhibitors in small doses: acetylsalicylic acid, indomethacin. In small doses, aspirin inhibits thromboxane synthesis. Shown are papaverine, antispasmodics, magnesium sulfate.
Now let’s consider late pregnancy toxicosis as a complication of diabetes mellitus. The success of treatment is determined by timely pathogenetic and reasonable treatment. Treatment should be comprehensive, it is necessary to improve hemodynamics, restore microcirculation in vital organs, including uteroplacental circulation. Basic principles of treatment:
1. Hospitalization and bed rest.
2. Medical and protective regime. This mode is created with the help of sedatives, antihypertensive drugs, antioxidants, antiplatelet agents.
3. The use of ganglion blockers should be avoided. Magnesia, along with pipolfen and diphenhydramine, is central. We use the sedative, hypotensive effects of magnesium sulfate. In addition, this drug has anticonvulsant, vasodilator, antiplatelet, diuretic effects. Prescribe magnesium sulfate in diabetes mellitus in individual doses. We start with 10 ml of a 25% solution, and not immediately according to Brovkin’s scheme. Gradually, taking into account the portability, we increase it to 20 ml. the drug is combined with dibazol, papaverine, no-spa, phenobarbital. It is advisable to use albumin – a plasma protein that maintains colloidal osmotic pressure. From the second trimester of pregnancy, we dilute in saline or rheopolyglucin solution. We use vitamins B6, C, D, A, E, PP. The use of Essentiale in ampoules and capsules is effective. The fact is that the Essentiale contains essential phospholipids unsaturated with fatty acids: linoleic, linolenic, oleic acids and vitamins. In addition, we widely use clofibrate, actovegin, courantil. In recent years, calcium antagonists have been used. In the absence of proper treatment for gestosis (treatment in a hospital for 1-2-3 weeks), the question of labor induction is raised.

Gestosis begins before the 30th week of pregnancy against the background of generalized vasospasm, diabetic nephropathy, polyhydramnios, disorders of the uteroplacental circulation. Therapy of gestosis has its own characteristics. Along with diet therapy, insulin therapy, the general principles of treatment of gestosis are also observed. Caution should be exercised because of the tendency to hypoglycemia when using droperidol. Usually droperidol is administered with pipolfen. Be very careful here, as there may be a collapse. In addition, it is better to use diphenhydramine more widely, but in individually selected doses, and of course, antispasmodics. Fasting days are contraindicated. Especially fasting days against the background of insulin therapy. Patients with diabetes mellitus are led both in the antenatal clinic and in the hospital. One of the main conditions for the management of such pregnant women is diabetes compensation. Compensating for diabetes is especially important if diabetes begins early in pregnancy. This diabetes compensation is a method of preventing complications. If we cope with diabetes, then there will be no complications that we have already discussed. Note that insulin therapy is indicated even for the mildest forms of diabetes mellitus. Pregnant women at high risk of developing diabetes mellitus can be monitored by an antenatal clinic with an endocrinologist and a therapist at their place of residence. With an increase in diabetes mellitus, the patient must be hospitalized in a specialized institution. In St. Petersburg, these are maternity hospital No. 1 and the Institute of Obstetrics and Gynecology. Pregnant women with diagnosed diabetes mellitus for the first time should be immediately sent to the endocrine department, which was mentioned above. Hospitalization is necessary for additional examination, determining the dose of insulin, and conducting a course of preventive treatment. After giving birth, the woman should again be observed by an endocrinologist. The optimal is the dispensary observation of these pregnant women on the basis of the obstetric department specializing in diabetes mellitus. At the first visit to the antenatal clinic, a pregnant woman should be warned about complications of the course of pregnancy and a dubious prognosis for the fetus. We must remember about the possibility of sudden fetal death. An early termination of pregnancy should be offered. In the absence of obstetric complications for up to 20 weeks, treatment should be carried out in the endocrinology department. Purposes of hospitalization:
1. Thorough clinical examination, as we agree, “give the go-ahead” to continue the pregnancy.
2. Formulation of obstetric and diabetic diagnosis.
3. Solution of the question of maintaining pregnancy.
4. Determination of the optimal dose of insulin.
5. Carrying out a course of preventive treatment: oxygen therapy, vitamin therapy, therapy with lipotropic drugs.
All these goals and objectives are set and solved during the first hospitalization.
The second hospitalization is carried out in the second half of pregnancy and is due to a worsening of the course of diabetes mellitus or complications of pregnancy. The optimal time for a second hospitalization is 30-32 weeks. During this period, late toxicosis increases, placental insufficiency appears, ultrasound detects placental hypoplasia, there is a possibility of diabetic ketopathy. Contraindications to preservation of pregnancy:
1. Presence of progression of vascular complications.
2. The presence of severe resistant forms of diabetes mellitus.
3. The presence of diabetes in both spouses.
4. The combination of diabetes mellitus and Rh incompatibility.
5. The combination of diabetes and tuberculosis.
6. A history of stillbirth or children with developmental defects.
Now let’s talk about choosing the term of delivery. With an uncomplicated course of pregnancy and diabetes, good fetal condition, under the control of ultrasound and other methods, of course, timely delivery is optimal, that is, 38-40 weeks. In case of insufficient compensation of diabetes and complications of pregnancy, aggravated anamnesis, with an increase in fetal hypoxia, one should resort to early labor induction, the optimal duration of which is 37 weeks. Delivery earlier than 35 weeks is justified only if there is a threat to the mother and fetus and is permissible for serious indications from the mother. The optimal delivery is vaginal delivery. It is necessary to prepare the birth canal in advance by creating hormonal levels. With a prepared birth canal, labor should be started with an amniotomy, since polyhydramnios often occurs. In the absence of effective labor in an hour, an hour and a half after the amniotomy, they do not hesitate, but proceed to the medication scheme of excitation, that is, intravenous drip of oxytocin with prostaglandins. Lack of preparation of the birth canal, lack of effect from labor excitation, the appearance of symptoms of increasing hypoxia serve as an indication for abdominal delivery. Complicated pregnancy and childbirth, as well as increased vulnerability and large size of the fetus require the expansion of indications for caesarean section up to 50%. In addition to the generally accepted, known indications for caesarean section, there are additional indications for it:
1. The presence of vascular complications.
2. A labile course of diabetes mellitus with a tendency to ketoacidosis.
3. Progressive hypoxia in the absence of conditions for urgent delivery at a period of at least 36 weeks.
4. Breech presentation of the fetus.
5. Severe preeclampsia.
6. The presence of a giant fruit.
So, termination of pregnancy before 36 weeks is indicated only with a clear threat to the mother and fetus. Premature delivery is possible with the operative method and conservative. The first conservative method is drug induction with an optimal period of 36-37 weeks. Combined indications:
1. Progressive polyvodia
2. Fetal disorders.
3. Decompensation of diabetes mellitus
4. Repeated hypoglycemia.
Surgical delivery by cesarean section according to vital indications:
1. Increase in angioretinopathy
2. The appearance of hemorrhages in the eyeball
3. Increase in the severity of toxicosis

Organization of obstetric care.
Examination of pregnant women should be involved: therapist, ophthalmologist, nephrologist, dermatologist, dentist, neuropathologist.
The main tasks of the antenatal clinic:
1. All women of childbearing age, patients with diabetes mellitus or at risk of developing the disease should be registered with a dispensary.
2. Individual solution of the issues of planning pregnancy and its preservation after discussion with specialists.
3. Widespread use of contraception in diabetes mellitus. Abortion before 12 weeks has an adverse effect on the course of diabetes mellitus and aggravates its severity. Hormonal methods of contraception are counterproductive in diabetes mellitus. If the termination of pregnancy is refused, the woman should be warned about the genetic predisposition to diabetes mellitus.
4. When pregnancy is established, urgently send the pregnant woman to a hospital and repeat the hospitalization at 20-24 weeks, then at 32-34 weeks.
5. Outpatient monitoring of a pregnant woman with diabetes mellitus is carried out at least 2 times a month by an endocrinologist in the first half of pregnancy and weekly in the second half of pregnancy.
6. It is necessary to strictly take into account the increase in body weight, the dynamics of blood pressure, monitor the height of the uterine fundus, abdominal circumference due to the tendency to develop preeclampsia and polyhydramnios.
7. Given the great tendency of pregnant women with diabetes mellitus to urogenital infections, it is necessary to systematically take vaginal swabs, make crops for the flora, separated from the cervix and vagina. In the event of complications from the urogenital tract, urgent hospitalization.
8. At 14-18 weeks, it is necessary to determine the alpha-fetoprotein in the blood.

Medical indications for termination of pregnancy. Order No. 302.
1. Diabetes mellitus in both parents.
2. Insulin-resistant diabetes mellitus.
3. Diabetes mellitus with microangiopathy, retinopathy, nephrosclerosis, azotemia.
4. The presence of children with developmental defects in patients with diabetes mellitus.

Hypothyroidism and pregnancy.
Hypothyroidism is a symptom complex that occurs when there is a significant deficiency of thyroid hormones in a pregnant woman’s body. But, fortunately, pregnancy with hypothyroidism is observed much less often than with diffuse non-toxic goiter. Pregnancy can occur in women with congenital hypothyroidism or acquired as a result of operations on the thyroid gland, that is, with secondary hypothyroidism. During pregnancy, the symptoms of hypothyroidism are less severe. It depends on the compensatory enlargement of the thyroid gland in the fetus and the supply of thyroid hormones from the fetus to the mother. The most pronounced form of hypothyroidism is myxedema. The increase in this pathology noted in recent years can be explained by improved diagnostics, an increase in the frequency of autoimmune lesions of the thyroid gland and lymphoid thyroiditis, in which the destruction of the thyroid tissue by autoantibodies occurs.
Distinguish between primary and secondary hypothyroidism. With the primary, the tissue of the gland itself suffers. Secondary hypothyroidism develops as a result of damage to the hypothalamic-pituitary system, which regulates the function of the thyroid gland. There are two main pathogenetic forms of hypothyroidism – congenital and acquired. Among the acquired forms of primary hypothyroidism, autoimmune hypothyroidism or postoperative hypothyroidism is most often observed. There may be hypothyroidism after treatment with radioactive iodine. There are also rare pathogenetic forms of primary hypothyroidism, in particular Hashimoto’s goiter, which is characterized by an enlarged, dense, “rubbery” thyroid gland.