Geburtsmedizinische Aspekte bei Gestationsdiabetes mellitus – Was ist zu tun?

Der Gestationsdiabetes mellitus (GDM) zählt zu den häufigsten Erkrankungen in der Schwangerschaft und kann, da er symptomlos ist, nur durch eine gezielte Zweistufendiagnostik aus 50-g-Glukose-Screeningtest und, wenn notwendig, 75-g-oralem Glukosetoleranztest (oGTT) erkannt werden. Die Normalisierung der Blutglukose kann bei 80–85 % der Schwangeren durch Ernährungsumstellung und körperliche Bewegung gelingen. Eine bei 15–20 % notwendige Insulintherapie sollte sich immer an der fetalen Biometrie orientieren. Überschreitet der fetale Abdominalumfang (AU) die 75. Perzentile (V. a. Makrosomie) sollten niedrigere, unterschreitet er die 10. Perzentile (V. a. Wachstumsretardierung / IUGR), sollten höhere Blutglukoseziele angestrebt werden. Orale Antidiabetika sind in Schwangerschaft und Stillzeit kontraindiziert. Die Entscheidung über eine Einleitung und den Entbindungsmodus erfolgt individuell in Abhängigkeit von Insulintherapie und fetalem Wachstum. Insulintherapierte Schwangere müssen in einem Perinatalzentrum entbunden werden. Präventive Maßnahmen wie Aufklärung über Lebensstiländerung und postpartale Kontrollen (oGTT) sowie die Förderung des ausschließlichen Stillens mindestens 4–6 Monate postpartum zielen auf die Vermeidung der Konversion in einen manifesten Typ-2-Diabetes (T2D) bei den Müttern und eine Verminderung des Übergewichtsrisikos der Kinder im späteren Leben ab.

Gestational diabetes mellitus (GDM) is the most common pregnancy-related disease. A two-step screening including a 50 g glucose challenge test followed by a 75 g oral glucose tolerance test (oGTT), if necessary, has to be offered to all pregnant women. In 80–85 % of diabetic pregnancies, a successful therapy due to the change of nutritional habits and exercise is possible. In 15–20 % of pregnant women the hyperglycemia persists. Therefore an additional insulin therapy based on fetal ultrasound parameter should be recommended. If the fetal abdominal circumference (AC) exceeds the threshold for macrosomia (AC > 75^th percentile) lower glycemic targets should be used. Otherwise, in cases of intrauterine growth reduction (IUGR) (AC < 10^th percentile) relaxed glycemic targets can be used. Oral antidiabetic drugs are contraindicated in pregnancy and during breastfeeding. GDM appears to be a high-risk situation in pregnancy and requires individual decisions in induction of labour or mode of delivery, primarily in perinatal care centres. In the postpartum period, the main focus of counselling and treatment should be prevention of GDM progressing into type 2 diabetes. Therefore, women should be advised to undertake an oGTT postpartum and encouraged to breastfeed exclusively for at least 4 to 6 months to improve maternal and child morbidity to prevent non-communicable diseases in later life.

Key words

gestational diabetes - ultrasound - fetal growth - delivery - oral antidiabetic drugs

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