Laboratory diagnosis and monitoring of diabetes mellitus.

The American Diabetes Association emphasizes fasting plasma glucose (FPG) levels, rather than the oral glucose tolerance test (OGTT), to diagnose diabetes mellitus. The diagnostic cutoff for FPG is 126 mg/dL (7.0 mmol/L). A 2-hour plasma glucose level of 200 mg/dL (11.1 mmol/L) or more during an OGTT or a random plasma glucose level of 200 mg/dL (11.1 mmol/L) or more also is diagnostic of diabetes. The 100-g, 3-hour OGTT remains the "gold standard" for gestational diabetes mellitus (GDM). Two of 4 samples exceeding cutoffs (fasting, > or = 105 mg/dL [5.8 mmol/L]; 1 hour, > or = 190 mg/dL [10.5 mmol/L]; 2 hours, > or = 165 mg/dL [9.2 mmol/L]; 3 hours, > or = 145 mg/dL [8.0 mmol/L]) indicate GDM. An effective GDM screening test is plasma glucose 1 hour after a 50-g oral glucose load. Tight control, which requires self-monitoring of blood glucose, reduces microvascular complications for patients with type 1 or type 2 diabetes. Patients with well-controlled diabetes have glycohemoglobin concentrations of 7% AIc (0.07 AIc/A) or less. Microalbuminuria indicates early, reversible, diabetic nephropathy. The random urine albumin-creatinine ratio is a convenient effective screening test. Albumin-creatinine ratios in the 0.03 to 0.30 (g/g) range indicate microalbuminuria.     

Comparison of The World Health Organization (WHO) two-step strategy and OGTT for diabetes mellitus screening

The new diagnostic criteria recommended by the American Diabetes Association (ADA) will only detect diabetic patients with fasting hyperglycemia, and leave patients with isolated post-challenge hyperglycemia (IPCH) and imparied glucose tolerance (IGT) unidentified. The WHO recommends that all those with abnormal fasting glucose should undergo the oral glucose tolerance test (OGTT) to exclude the diagnosis of diabetes (two-step strategy). This two-step strategy will leave out subjects with normal fasting glucose (<109 mg/dl). The aim of this study is to compare the WHO two-step strategy and the gold standard OGTT for all subjects. We re-analyzed the results of 907 high-risk patients who have been screened for diabetes mellitus and impaired glucose tolerance. All subjects were screened with an OGTT containing a 75-gram glucose load after fasting for 12 hours. The results were classified into three categories: the ADA criteria, the two-step strategy, and the OGTT. Using the ADA criteria, these 907 subjects can be classified has having normal fasting glucose (fasting plasma glucose - FPG < 109 mg/dl) in 715 subjects (78.9%), abnormal fasting glucose (FPG 110 - 125 mg/dl) in 107 subjects (11.8%), and diabetes mellitus (FPG > 126 mg/dl) in 85 subjects (9.4%). The WHO two-step strategy performed in 107 IFG subjects identified another 30 diabetic patients (FPG < 109 mg/dl and 2 hour post load > 200 mg/dl = IPCH) or 3.3%, and 49 patients with IGT, or 5.4% from all subjects. If the OGTT was performed on the 715 normal fasting glucose, it could identify another 40 diabetic patients or 4.4%, and another 178 IGT patients, or 19.6% of all subjects. This means that without OGTT to all subjects, 40 diabetic patients or 25.8% of all diabetic patients and 178 patients or 78.4% from all IGT subjects would have remained unidentified. From this study we can conclude that applying the WHO two-step strategy in subjects with IFG would fail to detect 25.8% of diabetic patients and 78.4% of IGT subjects. It is recommended that the old strategy of screening--the gold standard OGTT--should be used instead of the two-step strategy, at least in high-risk groups.     

Diagnostic criteria for diabetes mellitus

In the last three years, new diagnostic criteria for diabetes mellitus have been proposed by the American Diabetes Association (ADA, 1997), the World Health Organization (WHO) consultation (1998), and the Japan Diabetes Society (JDS, 1999). The most important change from the previous WHO criteria (1985) to these criteria is a decrease in fasting plasma glucose level (FPG) from 140 mg/dl to 126 mg/dl, which defines diabetes mellitus. These criteria attach more importance to FPG than to plasma glucose levels 2 hours after 75 g glucose load (2 hPG). According to these criteria, for example, in one instance with FPG > or = 126 mg/dl, the diagnosis of diabetes mellitus is warranted, if the postprandial plasma glucose > or = 200 mg/dl or another FPG > or = 126 mg/dl were reconfirmed on a subsequent day. The ADA criteria did not recommend an oral glucose tolerance test (OGTT) for routine clinical use. These criteria has established a new category of impaired fasting glucose (IFG) (> or = 110 mg/dl and 126 < mg/dl), similar to impaired glucose tolerance (IGT) which is recognized by performing OGTT. We have reported from a cohort study that there was only one risk factor for IGF: worsening of metabolic derangement progressing to overt diabetes. With IGT, however, there are two risks: a risk for progression to diabetes, and a risk for development of cardiovascular disease. Therefore it seems that whether or not OGTT should be performed depends on the purpose: simply diagnosing for overt diabetes, or detecting risk factors for cardiovascular disease. The JDS criteria proposed the use of HbA1C as a supporting diagnostic tool, because JDS has achieved a fruitful standardization in Japan to a considerable extent. According to the JDS criteria, a diagnosis of diabetes mellitus can be made by an FPG > or = 126 mg/dl when HbA1C > or = 6.5% is confirmed. It is expected that these new criteria will promote further efforts against the increasing number of patients with diabetes mellitus.     

广东地区12000例妊娠期糖尿病筛查结果

目的探讨广东地区50g葡萄糖负荷试验（GCT）筛查妊娠期糖尿病（GDM）的阈值、孕妇年龄对GDM发生的影响以及广东地区GDM的检出率。方法采用回顾性研究,对本院2005年1月至2007年12月全部孕妇实施50g葡萄糖负荷试验,异常者再行75g口服葡萄糖耐量（OGTT）实验,依据美国糖尿病资料小组（NDDG）的诊断标准诊断妊娠期糖尿病和糖耐量受损（IGT）。结果12000例孕妇GCT1h平均血糖水平为（7.37±1.75）mmol/L;以7.80mmol/L为切点,GCT血糖异常率为35.3%;IGT的检出率为6.9%,GDM的检出率为5.4%。GCT1h血糖≥11.1mmol/L者中,GDM的发生率为74.7%（195/261）,其中36.8%（96/261）根据空腹血糖水平可以作出诊断。24岁以下孕妇GDM的发生率为0.83%,显著低于年龄≥24岁的孕妇,GCT的异常率和IGT及GDM的发生率随年龄的增加呈上升趋势。196例GCT1h血糖〈7.8mmol/L存在高危因素的孕妇复行GCT和OGTT后,诊断为IGT和GDM的患者分别为23、17例,分别占总检出率的2.8%（23/824）和2.6%（17/648）。结论广东地区GCT筛查GDM以7.80mmol/L为切点是合理的,但1次GCT1h血糖正常的高危孕妇,复行GCT及OGTT是有必要的;GCT≥11.1mmol/L,仍有部分孕妇必须通过OGTT才能确诊;孕妇年龄与GDM发生密切相关,应加强高龄孕妇血糖的监测及GDM管理。     

妊娠期糖代谢异常性巨大儿与葡萄糖耐量试验结果相关分析

目的回顾性研究妊娠期糖代谢异常性巨大儿与非巨大儿孕产妇,分析妊娠期糖代谢异常孕妇口服葡萄糖耐量试验的特点,探讨OGTT各时点血糖检测,在预测妊娠期糖代谢异常性巨大儿发生的诊断价值。方法回顾性收集、分析我院2007年1月～2009年4月146例GDM和GIGT孕妇,将其分为巨大儿组和非巨大儿组研究两组OGTT血糖的特点,以及各点血糖在糖代谢异常性巨大儿中的价值。结果巨大儿组与非巨大儿组GCT差异无统计学意义,两组空腹血糖值、OGTT 1h血糖值差异有统计学意义,OGTT 2h、OGTT 3h血糖值差异无统计学意义。根据ADA诊断标准重新分组,发现去除OGTT 3h血糖各组发生巨大儿差异无统计学意义。结论 1.妊娠期糖代谢异常性巨大儿的发生与确诊GDM及GIGT时空腹血糖及OGTT 1h血糖有关。2.根据ADA诊断标准并在进行OGTT时省略3h血糖的检测可行。     

The impaired hyperglycemic peak as an additional indicator of Type 2 diabetes development is misdetected

Because there is not an optimal control for Type 2 diabetes mellitus (DM2), which encompasses about 90% of diagnosed diabetic patients, its prevention is key. Early detection of DM2 development can be made through impaired fasting glucose and/or impaired glucose tolerance diagnosis. However, cases exist when oral glucose tolerance test (OGTT) results show an hyperglycemic peak >or =200 mg/dl as a unique alteration. This alteration is defined as impaired hyperglycemic peak (IHP) and should be considered as an additional early indicator of DM2 development. Because IHP is commonly misdetected by the standard OGTT, it is proposed that this misdetection can be solved using a closer sampled OGTT. The objective of this research was to detect IHP on 225 volunteers using a 10 min sampled OGTT during 2 h. Results show the existence of IHP in 25 cases, making it the most frequent and the less detected OGTT alteration. In eight of these cases, IHP could not have been detected using a standard OGTT, because at 30, 60 and 90 min, plasma glucose concentrations were <200 200 mg/dl, however, at 40, 50, 70, and/or 80 min, IHP exists.     

Clinical screening examination for impaired glucose tolerance: is it possible to diagnose impaired glucose tolerance without a 75g oral glucose tolerance test?

It is well known that diabetes mellitus is one of the most crucial risk factors in the pathogenesis of atherosclerosis, including cardiovascular diseases (CVD). Considerable epidemiological and clinical studies, such as the Funagata study and the Diabetes Epidemiology Collaborative analysis of Diagnostic criteria in Europe (DECODE) study, have established that even a prediabetic state, including impaired glucose tolerance (IGT), is strongly associated with the occurrence of CVD. For the diagnosis of IGT, the 75g oral glucose tolerance test (75g OGTT) is required clinically, but the test takes at least 2 hours, at considerable cost. Therefore, for the prevention of atherosclerosis and subsequent CVD, another methods and/or beneficial parameters are anticipated to diagnose IGT without 75g OGTT. Recent studies have suggested that subjects beyond approximately 100 mg/dl fasting plasma glucose (FPG) might be classified into IGT by using receiver operating characteristic (ROC) analyses, and that the FPG 100 mg/dl is a suitable cut-off level between IGT and normal glucose tolerance (NGT). In contrast, although it is difficult to distinguish IGT from NGT by the HbAlc level alone, the combination of FPG with HbAlc is more beneficial for the diagnosis of IGT.     

186例妊娠糖尿病孕妇葡萄糖筛查及葡萄糖耐量试验结果分析

目的探讨妊娠糖尿病（gestational diabetes mellitus,GDM）孕妇口服50g葡萄糖筛查（GCT）和75g葡萄糖耐量试验（OGIT）的特点,分析血糖水平对GDM的诊断和治疗的价值。方法回顾性分析广东省妇幼保健院2008年186例妊娠期糖尿病患者的临床资料和GCT及OGTT的结果。结果50g GCT以7．8mmol／L为界值,GDM的漏诊率约（7／186）3．76％,GCT平均血糖为（9．66±1．49）mmol／L;75g OGTT平均空腹血糖为（5．01±0．84）mmol／L,1h血糖为（11．15±1．71）mmol／L,2h血糖为（9．79±1．61）mmol／L,3h血糖为（6．93±1．94）mmol／L;其中血糖值2项异常有113例,3项异常有53例,4项异常有20例;OGTT血糖2项异常与3项、4项异常的GCT均有统计学意义;75g OGTT不检测3h血糖,将漏诊46例GDM,约24．7％;需饮食合并胰岛素治疗患者空腹及餐后2h血糖明显高于仅需饮食治疗患者。结论GCT以7．8mmol／L为界值漏诊率不高,应较适合本地区临床使用;GCT血糖值与OGTT异常程度有关;孕妇75g OGTT诊断可考虑降低空腹血糖标准,不宜省略OGTT 3h血糖的检测;对空腹及餐后2h血糖水平较高的GDM患者应注意治疗方案的选择。     

三种妊娠期糖尿病诊断标准及结局的临床评价

目的　对三种妊娠期糖尿病的诊断标准及结局进行比较 ,并予以临床评价。方法　对 2 182例孕妇进行血糖筛查试验 ,阳性者进行葡萄糖耐量试验 (OGTT)。按美国糖尿病资料组 (NDOG)、Cousten和国内董志光等 3种标准对孕妇进行诊断分组 ,随机选择糖筛查试验阴性孕妇 112例作对照组 ,分析 4组母儿妊娠结局。结果　血糖筛查试验阳性 184例 ,OGTT试验达到NDDG、Cousten ,国内标准分别为 3.2 1% (70 / 2 182 )、4 .6 3% (10 1/ 2 182 )、5 .5 4 % (12 1/ 2 182 )。各GDM组间在重度PIH、羊水过多、羊水过少、产后出血、剖宫产率、巨大儿、胎儿宫内发育受限、新生儿窒息、新生儿畸形的发生率方面均无显著性差异 (P >0 .0 5 ) ,而与对照组相比 ,存在显著性差异 (P <0 .0 5 )。结论　GDM的诊断和治疗要及时。 3种诊断标准围产期结局无显著性差异 ;按NDDG标准诊断GDM ,可使部分孕妇避免频繁的血糖检查 ,减轻费用及精神上的负担 ;虽有漏诊可能 ,但可有选择地进行复查。NDDG标准优于Couten标准及国内标准 ,可采用。     

Endocrino-metabolic features in women with polycystic ovary syndrome during pregnancy

To elucidate the mechanism of metabolic adaptation of women with polycystic ovary syndrome (PCOS) during pregnancy, the endocrino- metabolic features of a group of PCOS patients with or without gestational diabetes were studied longitudinally during the three trimesters of gestation. Oral glucose tolerance test (OGTT, 100 g) and hyperinsulinaemic-euglycaemic clamp were performed throughout the study. Plasma concentrations of insulin and glucose were determined by radioimmunoassay and glucose oxidase technique, respectively. Five of 13 PCOS patients developed gestational diabetes (GD) at the third trimester (PCOS-GD), while the other eight patients did not develop any alteration of glucose metabolism (PCOS-nGD). Both fasting glucose and insulin plasma concentrations did not change significantly during pregnancy and no difference was seen between the two groups. On the contrary PCOS-GD group early exhibited higher values of area under the curve (AUC) for glucose and insulin response to OGTT with respect to those found in PCOS-nGD group. This difference was already significant in the first gestational trimester. Moreover insulin sensitivity value (M) was significantly lower in the first trimester of gestation in PCOS- GD as compared with that found in PCOS-nGD group. However, as gestation proceeded, M value decreased in PCOS-nDG group and the difference from PCOS patients developing gestational diabetes was not sustained into the second and third trimesters. Both groups had similar body mass index values and AUC insulin increase from first to third trimester of gestation. It is concluded that early alteration of insulin sensitivity and secretion constitute specific risk factors in PCOS patients for the development of abnormalities of glucose tolerance.      

Prevalence of gestational diabetes mellitus and associated risk factors in Turkish women: the Trabzon GDM Study

Introduction

The aim of this study was to investigate the prevalence of gestational diabetes mellitus (GDM) in Turkish pregnant women in the Trabzon Region and further to identify population-specific risk factors for GDM.

Material and methods

In this prospective cross-sectional survey, universal screening for GDM was performed in 815 pregnant women. Screening was done with a 50-g oral glucose challenge test (GCT) with a 140 mg/dl cut-off point, then a diagnostic 100 g oral glucose tolerance test (OGTT) was performed according to Carpenter and Coustan (CC) criteria.

Results

The GCT was positive in 182 (22.3%) cases. The OGTT was performed on the 182 screen-positive pregnant women. Thirty-five were diagnosed with GDM on the basis of their results for a prevalence of 4.3% (35/815). Of the pregnancies with negative GCT but having high risk factors for GDM (n = 31), 4 were diagnosed with GDM (0.5%). Prevalence of GDM was found to be 4.8% (n = 39) for all pregnant women. Gestational diabetes mellitus was positively associated with advanced maternal age (p < 0.001), prepregnancy body mass index (p < 0.001), cessation of cigarette smoking (p < 0.001), excessive weight gain during pregnancy (p = 0.003), previous history of GDM (p < 0.001), history of selected medical conditions (p = 0.018), family history of diabetes (FHD) (p < 0.001), and existence of at least one high risk factor for GDM (p < 0.001). In multiple logistic regression analysis, independent predictors for GDM were maternal age, cessation of cigarette smoking, increasing prepregnancy body mass index, weight gain of more than 8 kg during pregnancy, GDM history in previous pregnancies and a history of diabetes in first-degree relatives of pregnant women.

Conclusions

The prevalence of GDM in Trabzon province was found as moderate. Commonly recognized risk factors including older age, prepregnancy obesity, FHD and past history of GDM, are valid for our urban Turkish population. Also, excessive weight gain in pregnancy and cigarette cessation were observed to be nontradional risk factors of GDM. It was concluded that all pregnant women should be screened for GDM if prevalence was not low.     

Isolated post-challenge hyperglycemia: concept and clinical significance

The American Diabetes Association has strongly recommended that fasting plasma glucose should be sufficient for establishing diagnosis of diabetes mellitus; while World Health Organization supports to maintain the oral glucose tolerance test. Several epidemiological studies confirmed that postprandial hyperglycemia is a significant predictor for cardiovascular mortality and incidence. Post-challenge hyperglycemia following the oral glucose tolerance test is a condition similar to postprandial hyperglycemia. Isolated post-challenge hyperglycemia is a type of diabetes mellitus with a normal fasting plasma glucose level measured by oral glucose tolerance test. However, the glucose level following 2-hour post-challenge glucose test is >or= 200 mg/dl. Several long-term studies on population have shown that subjects with isolated post-challenge hyperglycemia have higher risk for cardiovascular events and mortality. Moreover, they also have an equal risk as those who have previously had diabetes mellitus. Therefore, it is suggested that for screening of diabetes mellitus, especially in the elderly population, oral glucose tolerance test should be performed in addition to measuring fasting plasma glucose.     

妊娠期糖尿病孕妇产后血糖随访的依从性研究

目的探讨影响妊娠期糖代谢异常孕妇产后血糖的高危因素,以加强糖尿病孕妇产后的教育,提高产后血糖检查的随访率。方法160例产前确诊为GIGT和GDM的孕妇,通过宣教和书面嘱托,于分娩后6～8周回院行糖耐量试验,统计随访率,比较随访组与失访组的年龄、学历、家庭收入、分娩方式等指标,分析产后失访的原因。结果160例中120例进行血糖检查,随访率为75%,失访率为25%。随访组的年龄、学历、家族史、剖宫产率、家庭月收入明显高于失访组。随访组OGTT2h血糖大于11.1mmol/L者、新生儿低血糖发生率明显低于失访组。结论医护人员在规范宣教GDM产后随访过程中,应对年轻的、本科以下学历的、无糖尿病家族史的GIGT和GDM孕妇加强产后糖代谢检查的宣教工作。     

Predicting the Metabolic Condition After Gestational Diabetes Mellitus from Oral Glucose Tolerance Test Curves Shape

The objective of this feasibility study is to predict the metabolic condition in women with a history of gestational diabetes mellitus (GDM) from the shape of oral glucose tolerance test (OGTT) data. The rationale for this approach is that the evolution to a metabolic condition could be traceable in the shape of OGTT curves. 3-h OGTT data of 136 women with follow up, for a total of 401 OGTTs were analyzed. Subjects were classified as having normal (NGT) or non-normal glucose tolerance (NON-NGT), according to the American Diabetes Association criteria. The measured glucose, insulin, C-peptide data and combination of them were used to build up NGT and NON-NGT reference curves. Similarity between reference and individual OGTT-based curves was calculated using the Kullback–Leibler divergence. Our findings suggest that the shape of OGTT curves (1) contains information on the evolution to disease and (2) could be a reliable indicator to predict with high sensitivity (75%) and high specificity (69%) the metabolic condition of women with a history of GDM. In the future, the proposed shape-based prediction could be easily translated to the clinical practice, because it does not require the intervention of an operator specifically trained, thus facilitating its application in a clinical setting and ultimately empowering risk estimation, by improving/complementing the information which is currently adopted for risk stratification after pregnancy with GDM.     

Evaluation of the prevalence of gestational diabetes mellitus in North Indians using the International Association of Diabetes and Pregnancy Study groups (IADPSG) criteria

Objective:

Currently, there is controversy regarding the diagnosis of gestational diabetes mellitus (GDM) as per the newer International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria. We studied the prevalence and associations of GDM in North Indians, diagnosed by the IADPSG criteria.

Patients and Methods:

We conducted a cross-sectional study on 332 pregnant women, predominantly belonging to lower and middle socioeconomic strata. The women were screened for GDM between 24 weeks and 28 weeks of gestation by 75g oral glucose tolerance test (OGTT) and GDM diagnosed by the IADPSG criteria.

Results:

The prevalence of GDM was 41.9% [95% Confidence interval (CI) 36.6-47.2%]. Amongst the women diagnosed to have GDM, 91.4% had abnormal fasting plasma glucose (FPG), while 1-h and 2-h post-glucose (PG) levels were abnormal in 18.7% and 17.3% of women, respectively. No maternal factors were significantly associated with GDM. Birth weight of the neonates was similar in women with GDM as compared to those with normal glucose tolerance. In the entire group, fasting glucose levels were associated with the weight of the patient while 1-h PG levels were associated with weight, height, socioeconomic score, and parity.

Conclusions:

There is a very high prevalence rate of GDM using the IADPSG criteria in North Indian women of low and middle socioeconomic strata. Further studies are needed to assess the utility of applying these criteria in settings with limited resources.KEY WORDS: Gestational diabetes mellitus (GDM), International Association of Diabetes and Pregnancy Study Groups (IADPSG), pregnancy     

妊娠前体质指数和胎次对妊娠糖尿病发病的影响

目的：探讨妊娠前体质指数(body mass index,BMI)、胎次与妊娠糖尿病(gestational diabetes mellitus,GDM)发病的关系,并探讨其对妊娠糖尿病(GDM)发病的影响。方法：本研究选择我院2014年2月至2014年12月接受孕产期检查、临床资料完整的且患有妊娠糖尿病的孕妇262名,对其采取葡萄糖耐量实验(OGTT实验),按照WTO标准,对262例足月妊娠初产妇女在孕24~28周常规进行75 g口服糖耐量试验,并完整记录年龄、孕周、文化程度、妊娠前体质指数及胎次等临床资料。根据妊娠前体质指数(BMI)将孕妇分为BMI分为4组,BMI<18.5 kg/m2者为偏瘦组,BMI 18.5~23.0 kg/m2者为正常体质量组,BMI 23.1~25.0 kg/m2者为超重组,BMI>25.0 kg/m2为肥胖组,采用SPSS l8.0统计软件对资料进行描述性分析、两样本t检验、非条件Logistic回归分析两组孕妇妊娠前体质指数(BMI)、胎次与妊娠糖尿病的关系。结果：4组OGTT结果显示妊娠前超重或肥胖的孕妇发生妊娠糖尿病的风险高于正常和偏瘦体质量组;非条件logistic回归分析结果表明,影响GDM的因素依次为：胎次、体质指数、年龄、文化程度,各影响因素回归系数分别为：2.372、     

妊娠期糖代谢异常患者胰岛素抵抗和胰岛β细胞功能的研究

目的探讨妊娠期糖代谢异常患者的胰岛素抵抗和胰岛β细胞功能的变化,以及对妊娠结局的影响。方法选取在我院就诊的171例孕妇检查资料,按照75g葡萄糖耐量试验（0GTT）结果分为妊娠期糖尿病组（GDM）,妊娠期糖耐量受损组（GIGT）,妊娠期空腹血糖受损组（GIFG）和正常对照组（NGT）。对各组的OGTT、胰岛素释放试验结果进行统计分析,计算出胰岛素抵抗指数（HOMA-IR）,胰岛素分泌指数和胰岛素敏感指数,将结果进行比对分析。并对各组的妊娠结局进行分析。结果胰岛素抵抗指数（HOMA-IR）GDM组〉GIFG组〉GIGT组〉对照组（P〈0.05）。胰岛素分泌指数：GDM组     

妊娠期糖尿病最新诊断标准与妊娠结局

目的分析按照国际糖尿病与妊娠研究组（IADPSG）诊断标准新增加的妊娠期糖尿病（GDM）患者的妊娠结局,探讨IADPSG诊断标准在我国临床应用价值。方法选择2011年1月1日至2011年6月30日于复旦大学附属妇产科医院门诊定期产检、孕24-28w行50g糖筛查试验（GCT）阳性,进一步行75g口服葡萄糖耐量试验（OGTT）,按照美国国家糖尿病数据组（NDDG）诊断标准诊断为非GDM或糖耐量受损（GIGT）的产妇332例的病历资料进行回顾性分析。按是否符合IADPSG诊断标准分为new-GDM组和non-GDM组,比较两组患者的妊娠结局。结果根据IADPSG标准新诊断出的new-GDM患者共44名,其在孕24-28w行糖筛查时的血糖筛查值明显高于non-GDM组孕妇（new-GDM组：9.0±0.9 mmol/L,non-GDM组：8.5±0.6mmol/L,P=0.002）。比较两组孕妇的妊娠结局,妊高症、胎盘早剥、剖宫产率、产后出血、胎儿窘迫、早产、新生儿低血糖的发生率无统计学意义（P〉0.05）。两组的巨大儿发生率（new-GDM组：20.5%[9/44],non-GDM组：8.3%[24/288],P=0.026）和新生儿出生体重（new-GDM组：3555.6±507.8g,non-GDM组：3357.2±461.5g,P=0.009）均显著升高,且有显著统计学差异。结论本研究显示采用IADPSG诊断标准可诊断出更多的GDM患者,这些患者若未进行血糖控制,其围产期并发症,尤其是巨大儿的发生率明显增加,提示IADPSG标准作为我国GDM诊断标准具有一定的临床意义。     

Should we consider performing oral glucose tolerance tests more frequently in postmenopausal women for optimal screening of impaired glucose tolerance?

OBJECTIVE: To investigate an optimal screening protocol for impaired glucose tolerance (IGT) and type II or non-insulin-dependent diabetes mellitus (DM) by using fasting plasma glucose (FPG) and oral glucose tolerance test (OGTT) in postmenopausal women. DESIGN: One hundred consecutive postmenopausal women were screened with FPG determination, and then all underwent an OGTT. Basal serum lipid and insulin levels of these women were also determined. Insulin sensitivity was determined by using the homeostasis model assessment. Receiver operating characteristic analysis was performed to determine the efficacy of these variables in detecting women with IGT and DM, and optimal cutoff values were determined. RESULTS: FPG with a cutoff value of 98 mg/dL had the best combination of sensitivity (71%) and specificity (76%) for the detection of IGT and DM. Combined FPG and body mass index screening (with the optimal cutoff value of 26.5 kg/m2) improved the sensitivity to 96% but decreased the specificity to 47%. This combined screening protocol detected 94% of the women with IGT and all diabetic women. CONCLUSIONS: Given that IGT and DM are common among postmenopausal women and DM can be prevented by nonpharmacologic interventions in women with IGT, OGTT may be used more frequently among these women. Our data indicate that for optimal screening of non-insulin-dependent DM and IGT, OGTT should be considered in postmenopausal women, especially when risk factors in addition to age are present. This model may detect most of the women with IGT and almost all diabetic women.     

Conduite à tenir devant une glycémie « limite supérieure »

Type 2 diabetes is preceded by a long preclinical period with progressively glucose tolerance abnormalities. Beside diabetes defined by a venous fasting glucose superior to 7 mmol/l (1.26 g/l), American Diabetes Association identified two others abnormalities of glucose tolerance: the impaired glucose tolerance (IGT) defined by a two hours glycaemia between 7.8 and 11 mmol/l (1.4 and 1.9 g/l) at the oral glucose tolerance test (OGTT) and the impaired fasting glycaemia (IFG) with a fasting glycaemia between 6.1 and 6.9 mmol/L (1.1 and 1.25 g/l). Prevalence of IGF is between 2 and 10% in non diabetic adult subjects. IFG concerns mainly subjects aged 40–50 years and is 1.5 to 3 fold more frequent in man. Most of the well-known risk factors for developing type 2 such us overweight, abdominal obesity, familial history of diabetes, over –consumption of fat and alcohol are present in subjects having IFG. Hypertension is present in more than 50% of the subjects with IFG. Fifty percents of subjects with IFG are also an impaired glucose tolerance. IFG is associated with a high diabetes risk because 10 to 30% of subjects with IFG will develop type 2 diabetes after five years. Both IFG and IGT are associated with an increase of risk of cardiovascular mortality while the two hours glycaemia of OGTT is more predictive than IFG. Microalbuminuria and carotid intima media-thickness are significantly increased in subjects having both IGT and IFG compared to subjects with only IGT. Subjects with IFG are associated with an increase risk of developing diabetes and cardiovascular disease. IFG requires the realization of an OGTT to search IGT or diabetes.