孕前糖尿病合并妊娠临床管理新进展

孕前糖尿病合并妊娠母儿不良结局增加。孕前糖尿病孕妇计划妊娠是避免和减少胎儿先天畸形等的重要一步。推荐的糖化血红蛋白控制目标孕前为<6.5%,孕期为<6.0%。糖尿病合并症的筛查及管理至关重要,血压控制目标应更谨慎,尤其是有糖尿病肾脏疾病者。对于1型糖尿病患者,孕期动态血糖监测有助于改善血糖控制水平。胰岛素是孕期糖尿病患者的一线治疗方案。优化血糖控制和药物治疗方案,并密切关注并发症,能够降低孕前糖尿病合并妊娠的母儿不良结局风险,并确保孕前、妊娠期间和产后的糖尿病管理质量。     

妊娠合并糖尿病的治疗(二)

糖尿病是一种比较复杂的代谢障碍性疾病 ,妊娠常使糖尿病病情不稳定 ,对母儿影响严重 ,其影响程度与糖尿病病情程度及妊娠期血糖控制等处理密切相关。治疗之目的在于及时纠正代谢紊乱 ,保证妊娠过程顺利进展 ,及时发现与防治并发症 ,以减少母婴并发症。因此 ,糖尿病患者在决定妊娠前应进行全面体格检查 ,包括血压、心电图、眼底、肾功能等检查。受孕前血糖水平及早孕期血糖与自然流产及胎儿畸形发生密切相关 ,为确保受孕前及早孕期间血糖正常 ,妊娠前应将血糖调整到正常水平。口服降糖药如 D86 0、优降糖、降糖灵等均能通过胎盘 ,导致胎儿…     

进一步提高对妊娠合并糖尿病的研究水平

妊娠合并糖尿病是妊娠期最常见的内科合并症之一,它包括孕前患有糖尿病者妊娠（pre-gestational diabetes mellitus,PGDM,一般称之为糖尿病合并妊娠）和妊娠期糖尿病（gestational diabetes mellitus, GDM）.妊娠合并糖尿病会导致母儿并发症明显增加. 自胰岛素在临床开始应用之后，通过严格控制糖尿病孕妇的血糖，加强孕期监测，妊娠合并糖尿病的母儿预后均有了明显改善，20世纪80年代初国外已经有报道，如果将孕期血糖控制到正常范围，围产儿死亡率就能够降低到同孕龄而糖代谢正常孕妇的水平。     

妊娠合并自身免疫性1型糖尿病对母胎的影响及诊治

妊娠合并自身免疫性1型糖尿病是孕期常见的合并症之一,可导致母儿并发症增加。文章介绍了妊娠合并自身免疫性1型糖尿病的筛查和诊断标准,提出做好充足的孕前准备,加强孕期监护,应用饮食控制以及胰岛素注射使血糖降至理想状态可降低母儿并发症,改善妊娠结局。     

孕前合并糖尿病孕妇的胎儿出生体重与孕期血糖控制的关系

孕前胰岛素依赖型糖尿病妇女妊娠后,实行严密监护的胰岛素治疗方案,使其血糖水平接近正常,虽可明显减少围产儿的发病率和死亡率,但巨大儿的发生率在多数报道中居高不下。为此,研究了113例孕前胰岛素依赖型糖尿病孕妇及其新生儿,目的:了解该型孕妇孕期血糖控制所能达到的程度,及孕期不同时间血糖和糖化血红蛋白(HbAlc)水平与新生儿出生体重间的关系。     

妊娠合并糖尿病对胎儿及新生儿的影响

妊娠合并糖尿病与围产儿预后有密切关系，尽管经孕期血糖控制围产儿死亡明显降低，但胎儿畸形及新生儿合并症仍较高。积极开展糖尿病孕前咨询，血糖控制以维持孕前及早孕期血糖在正常范围可明显减少胎儿畸形发生；新生儿合并症发生主要在于胎儿高胰岛素血症存在，将孕期血糖控制在正常范围可明显减少巨大胎儿及胎儿窘迫等发生。常规的产前监测方法并不能准确反映胎儿宫内酸中毒的情况，故因急性胎儿糖代谢紊乱所致的胎儿酸中毒、胎儿     

妊娠糖尿病患者补镁的意义

分析了８１例妊娠糖尿病患者低镁原因和常见的影响因素，妊娠糖尿病血清镁明显低于正常妊娠组，低镁的程度与病变的类型、孕期、血糖水平及是否合并微血管有关。妊娠胰岛岛素依赖型糖尿病组血清镁明显低于胰岛晨依赖型糖尿病组。孕期越长，血糖水平越高，血清镁水平越低。合并妊高任者血压越高，其血糖水平越高，血清镁水平越低。提出补镁以小剂量、间断、静脉补给为宜。     

妊娠合并糖尿病的处理

妊娠合并糖尿病的处理樊尚荣，杨慧霞（１０００３４北京医科大学第一医院）问：妊娠合并糖尿病处理应注意什么问题？答：妊娠合并糖尿病包括：糖尿病患者妊娠及妊娠期发现或发生的糖尿病．妊娠合并糖尿病对母儿危害较大，尽早诊断及严格控制孕期血糖可明显改善母儿预后，...     

妊娠合并糖代谢异常患者糖化血红蛋白检测的临床意义

妊娠合并糖代谢异常包括孕前糖尿病以及妊娠期糖尿病（gestational diabetes mellitus，GDM）和妊娠期糖耐量低减（gestational impaired glucose tolerance，GIGT），是妊娠期最常见的合并症之一。妊娠合并糖代谢异常患者如不进行有效的血糖管理，其母、儿并发症的发生率较高。近年来，许多研究表明，糖代谢异常对孕妇和围产儿的影响与孕期血糖控制密切相关。糖化血红蛋白（HbA1）c作为监测糖尿病患者平均血糖水平的指标日益受到重视。对此，本研究对妊娠合并糖代谢异常的患者进行了HbA1c水平的监测，以探讨HbA1c用于妊娠合并糖代谢异常患者的诊断价值，现将结果报道如下。     

血糖控制不佳与不良妊娠结局

妊娠期高血糖是最常见的一种妊娠并发症。孕期血糖控制不佳，会增加不良妊娠结局的发生，包括近远期的各种母儿风险。文章拟通过介绍血糖控制不佳与不良妊娠结局的关系，提高医护人员和妊娠合并糖尿病患者对妊娠期高血糖危害的认识。     

Management of Pregnancy Complicated by Diabetes: Experience with 232 Patients in a 4-year Period

Two hundred and thirty two women with diabetes complicating pregnancy were seen at a metropolitan teaching hospital during a 4-year period. Management during pregnancy in insulin dependent diabetics was directed towards strict metabolic control using conventional insulin regimens and diet. A similar programme was followed for women in whom screening revealed glucose intolerance. Control of maternal blood glucose levels, assessment of fetal maturity and modes of delivery were reviewed in an attempt to define factors which could predict optimal neonatal outcome. Patients with insulin dependent diabetes were less likely to have optimal metabolic control both during pregnancy and parturition than patients with gestational diabetes. Women with gestational, but not preexisting diabetes, demonstrated a close correlation between gestational age and parameters of fetal pulmonary maturity. A high rate of intervention to deliver infants in both groups (50%) was noted. These data indicate the need for meticulous care of women with insulin dependent diabetes during pregnancy.     

The usefulness of glycosuria and the influence of maternal blood pressure in screening for gestational diabetes

OBJECTIVE: Although gestational diabetes is among the most common diseases arising during pregnancy, glucose stix is the only screening test to date in Germany. Our goal was to evaluate the sensitivity of the glucose-stix for diabetes screening and the possible influence of other parameters. METHODS: 1001 patients who underwent the 50 g glucose screening test between June 1, 1997 and January 5, 2000 as part of prenatal care were asked to participate. In accordance with the guidelines of the American Diabetes Association, patients with a screening test result >/= 140 mg/dl underwent a oral glucose tolerance test (Carpenter/Coustan criteria). A urine sample was collected prior to the test. The glucose content of the urine was semiquantitatively analyzed using a test strip (Multistix 10 SG Bayer), Munich, Germany). Blood pressure was measured in 349 consecutive cases according to the criteria of the National Institute of Health. RESULTS: The overall frequency of gestational diabetes was 4.1% (37/912). 8.2% of the women presented with glycosuria (82/1001, 36 before screening, 46 based on the pregnancy medical records booklet). 30/82 (37%) of these patients had a pathological screening test (P = 0.029). 7.1% (52/729) of the healthy patients and 10.8% (4/37) of the gestational diabetics had glycosuria at least once. Therefore, the sensitivity of glycosuria is 10.8%, the positive predictive value is 6.6%. The systolic blood pressure was 116+/- 12 mmHg and the diastolic blood pressure 72 +/- 9 mmHg. Three of 349 (0.9%) patients were documented with preexisting hypertension, 14/349 (4.0%) patients with "pregnancy induced hypertension". Patients with glycosuria were both significantly more advanced in gestational age (34.4 +/- 2.8 versus 33.7 +/- 2.9, P = 0.673) and had higher diastolic blood pressure (79 +/- 9 versus 71 +/- 9, P = 0.005). The 50 g glucose screening test results showed only a tendency to differ (131 +/- 23 versus 127 +/- 24, P = 0.073). A multivariate analysis of these factors showed a significant influence of the diastolic blood pressure (P = 0.016) and the 50 g glucose screening test (P = 0.032), whereas the gestational week had no influence (P = 0.673). CONCLUSIONS: Urine glucose dip stick analysis is not useful in the detection of gestational diabetes because of its low sensitivity and negative predictive value. Our study suggests that glycosuria is not only dependent on the blood glucose level, but highly influenced by diastolic blood pressure. The results clearly underscore the need for standardized, routine testing of every pregnant woman.     

A comparison of amniotic fluid fetal pulmonary phospholipids in normal and diabetic pregnancy

OBJECTIVE: Our purpose was to determine whether there are differences in the timing of the appearance of various amniotic fluid fetal pulmonary phospholipids in normal and diabetic pregnancy. STUDY DESIGN: A case-control study of 295 subjects with diabetes and 590 control subjects was performed by use of gestational age-matched amniocentesis specimens analyzed for lecithin/sphingomyelin (L/S) ratio, phosphatidylinositol (PI), and phosphatidylglycerol (PG) composition. Diabetic subjects were stratified according to type of diabetes, degree of blood glucose control, and birth percentile of the neonate. RESULTS: There was no difference in L/S ratios over gestational age by type of diabetes or quality of glycemic control. Women with preexisting diabetes had significantly higher PI levels at 33 to 35 weeks' gestation, which became similar to levels of control subjects after 36 weeks, whereas patients with gestational diabetes mellitus and control subjects had similar PI levels throughout. In diabetic subjects, the onset of production of PG was delayed from 35.9 +/- 1.1 weeks (controls) to 38.7 +/- 0.9 weeks (overt diabetics) and 37.3 +/- 1.0 weeks for gestational diabetes mellitus (P <.001). The delay in PG synthesis was not related to infant sex, level of maternal glucose control, or fetal macrosomia. CONCLUSIONS: Fetal pulmonary maturation, as evidenced by the onset of PG production in the amniotic fluid, is delayed in diabetic pregnancy by 1 to 1.5 weeks. This delay appears to be associated with an early and sustained elevation in amniotic fluid PI levels at 32 to 34 weeks.     

Diabetic ketoacidosis in pregnancy tends to occur at lower blood glucose levels: case-control study and a case report of euglycemic diabetic ketoacidosis in pregnancy.

Background and Objective: The occurrence of diabetic ketoacidosis (DKA) during pregnancy is considered a medical emergency. The aims of the present study were to evaluate the incidence of DKA in pregnant and non-pregnant women with diabetes; to compare the blood glucose levels at the diagnosis of DKA in pregnant and non-pregnant women; and to show a case of euglycemic DKA in pregnancy. Methods: The subjects consisted of 90 cases of DKA in pregnant women with diabetes and 286 cases of non-pregnant female inpatients receiving treatment for diabetes during 2001 to 2005 in our hospital. The incidence of DKA in pregnant and non-pregnant women with diabetes and the blood glucose levels at the diagnosis of DKA in pregnant and non-pregnant women were compared. Results: DKA had a higher incidence in pregnant women with diabetes (8/90, 8.9%) than in non-pregnant women with diabetes (9/286, 3.1%) (P < 0.05). The blood glucose levels (mmol/L) in pregnant women with DKA were significantly lower than those in non-pregnant women with DKA (16.3 +/- 4.6 vs 27.5 +/- 4.8, P < 0.001). A case of euglycemic DKA in pregnancy was described whose serum glucose level was only 6.9 mmol/L. Conclusions: DKA in pregnant women with diabetes may occur more frequently, and at lower blood glucose levels than DKA in non-pregnant women with diabetes.     

妊娠期血糖异常产后母儿随访分析

目的　探讨妊娠期不同程度的血糖异常者产后发生糖尿病 (DM )的高危因素和预防措施 ,以及妊娠期血糖异常对其子女的远期不良影响等。方法　对 1994～ 2 0 0 0年 196例妊娠期血糖异常者进行产后随访 ,其中50 g葡萄糖筛查阳性 (50g阳性 ) 12 3例 ,葡萄糖耐量减低 (IGT) 3 7例 ,妊娠期糖尿病 (GDM ) 3 6例。此 3组人群均进行 75g葡萄糖耐量试验 (OGTT )及血脂检测。对其子女行血糖检测及生长发育水平观察 ,包括测量头围、胸围、身高及体重等。结果　 196例随访者中发生IGT、空腹血糖异常 (IFG)、DM共 2 2例 (占 11 2 2 % ) ,其中 50g阳性、IGT、GDM者其产后平均 3年内血糖异常发生率依次为 2 43 %、2 1 62 %、3 0 56% ,后两者与 50 g阳性相比差异有显著性意义 (P <0 0 1) ,其相关因素与产妇高龄 (40 90 % )、肥胖体型 (2 1 2 7% )、孕期血糖控制不良(45 45% )、产后体重显著增加 (40 91% )有关。 14 5例随访子女中虽血糖检测未见异常 ,但发生肥胖者 16例 (占11 0 3 % ) ,且其母孕期血糖控制不良者 9例 (占 56 2 5% )。结论　GDM及IGT者产后DM发生率高 ,应引起重视。妊娠期及时有效地控制高血糖及产后继续饮食调理与加强运动疗法 ,对维护产后母儿健康有益     

Measuring and managing hyperglycemia in pregnancy: from glycosuria to continuous blood glucose monitoring

The need to accurately detect and monitor hyperglycemia in pregnancy is becoming more apparent as the incidence of pregestational and gestational diabetes is increasing, especially among adolescents. The risk of adverse perinatal outcome is markedly worsened when pregnancy is complicated by elevated blood glucose. The appropriate management of both pregestational and gestational diabetes as it relates to blood glucose targets is clear. In the past 5 years, a number of studies have concluded that tight glycemic control throughout pregnancy significantly reduces both fetal and maternal risk. These studies have proposed blood glucose targets between 70 to 120 mg/dL. They have concluded that blood glucose levels should be the basis of moving rapidly to more effective treatments. The key to this approach is the adoption of blood glucose monitoring as an integral part of the treatment regimen. To assure sufficient data on which clinical decisions are made, the type of device, frequency of monitoring, and interpretation of results need to be carefully considered.     

Haemoglobin A1c levels in normal and diabetic pregnancies

Serial measurements of the HbA1c levels were performed during pregnancy in 4 groups of patients attending Antenatal Clinics: 36 normal pregnancies; 16 pregnancies in established insulin-dependent diabetic patients; 9 patients with gestational diabetes diagnosed during that pregnancy; and 21 patients who had been diagnosed as having gestational diabetes in at least one previous pregnancy. In the normal pregnancy HbA1c levels showed a small but significant increase from the end of the first trimester to delivery despite blood glucose levels remaining constant throughout. In the insulin-dependent and gestational diabetic patients, blood glucose levels remained significantly higher than in the normal throughout pregnancy but only in insulin-dependent diabetic patients and the newly diagnosed untreated gestational diabetic patients were the HbA1c levels significantly higher than in the normal. In those patients who had previous pregnancies complicated by gestational diabetes, blood glucose levels were significantly higher than in the normal but HbA1c levels were not. This dissociation between blood glucose and HbA1c levels in gestational diabetic pregnancies in particular limits the value of HbA1c levels in monitoring antidiabetic treatment in such pregnancies.     

Diabetic ketoacidosis in pregnancy tends to occur at lower blood glucose levels: Case–control study and a case report of euglycemic diabetic ketoacidosis in pregnancy

Background and Objective:  The occurrence of diabetic ketoacidosis (DKA) during pregnancy is considered a medical emergency. The aims of the present study were to evaluate the incidence of DKA in pregnant and non-pregnant women with diabetes; to compare the blood glucose levels at the diagnosis of DKA in pregnant and non-pregnant women; and to show a case of euglycemic DKA in pregnancy.
Methods:  The subjects consisted of 90 cases of DKA in pregnant women with diabetes and 286 cases of non-pregnant female inpatients receiving treatment for diabetes during 2001 to 2005 in our hospital. The incidence of DKA in pregnant and non-pregnant women with diabetes and the blood glucose levels at the diagnosis of DKA in pregnant and non-pregnant women were compared.
Results:  DKA had a higher incidence in pregnant women with diabetes (8/90, 8.9%) than in non-pregnant women with diabetes (9/286, 3.1%) ( P  < 0.05). The blood glucose levels (mmol/L) in pregnant women with DKA were significantly lower than those in non-pregnant women with DKA (16.3 ± 4.6 vs 27.5 ± 4.8, P  < 0.001). A case of euglycemic DKA in pregnancy was described whose serum glucose level was only 6.9 mmol/L.
Conclusions:  DKA in pregnant women with diabetes may occur more frequently, and at lower blood glucose levels than DKA in non-pregnant women with diabetes.     

21年糖尿病合并妊娠88例母儿结局的临床分析

目的：研究糖尿病患者孕期血糖控制对妊娠结局的影响。方法：回顾性分析1981－2001年间88例糖尿病孕妇孕期血糖水平与妊娠结局的关系。88例患者中2例行中期引产，1例行人工流产，将其余85例分为两组：孕期血糖控制满意者42例（A组），血糖控制不满意或未控制者43例（B组）。结果：B组胎死宫内5例，其中3例发生在围产期，A组无一例发生胎死宫内（P值为0．069）。B组妊高征及早产发生率分别为44．2％和30．2％，显著高于A组的21．4％和9．2％（P值分别为0．026和0．017）；B组新生儿窒息发生率为24．4％，显著高于A组的4．8％（P值为0．011）；新生儿畸形9例（10．2％）。结论：加强糖尿病患者孕前及孕期血糖控制和监测，可明显地减少孕产妇合并症、围产儿病率及死亡率，改善母儿结局。