妊娠期糖尿病诊断标准变迁及其对临床管理的挑战

妊娠期糖尿病的国际诊断标准不断变更,根据2008年孕妇高血糖与不良结局关系的研究,诸多国际学术和科研管理机构包括世界卫生组织以及我国卫生部均更改了标准,但新标准仍然存在争议。该文介绍了标准发展变更情况,讨论了我国临床管理对新标准提出的挑战和对策。     

妊娠期糖尿病新旧两种诊断标准对妊娠结局的影响

目的:探讨妊娠期糖尿病(GDM)两种诊断标准对妊娠结局的影响。方法:回顾分析2011年9~11月及2012年9~11月在济南市妇幼保健院分娩的878例和1080例孕妇的临床资料,两时段分别采用GDM旧诊断标准和新诊断标准。采用旧标准诊断的54例GDM孕妇作为旧标准GDM组,其余824例为旧标准正常组;采用新标准诊断的GDM孕妇168例为新标准GDM组,其余912例为新标准正常组。GDM组孕妇给予个体化营养管理,正常组孕妇纳入常规产前保健管理。比较两组GDM患者的母婴结局。结果:新标准组和旧标准组的GDM发生率分别为15.56%和6.15%,差异显著(P0.005)。旧标准GDM孕妇的体重指数(BMI)高于新标准GDM组(P0.05);而剖宫产、早产、产后出血、羊水过多、巨大儿及妊娠期高血压疾病发生率无显著差异(P0.05)。旧标准正常组的妊娠期高血压疾病发生率显著高于新标准正常组(P0.005);而剖宫产、早产、产后出血、羊水过多及巨大儿发生率无显著差异(P0.05)。结论:新诊断标准可检出更多存在血糖问题的孕妇,合理管理GDM患者可能有助于降低妊娠期高血压疾病的发生率。     

糖化血红蛋白在妊娠合并糖尿病诊治中的应用价值

糖尿病(diabetes mellitus,DM)是以高血糖为特点的一组代谢紊乱综合征.妊娠期糖尿病(gestational diabetes mellitus,GDM)自20世纪50年代开始被人们关注,并认为与孕妇及胎儿的不良结局有关[1],1979年世界卫生组织(World Health Organization,WHO)将其归为DM的分类之一.2010年国际糖尿病和妊娠研究组(International Association of Diabetes and Pregnancy Study Groups,IADPSG)依据不同血糖水平与胎儿及新生儿结局的研究结果,推出了GDM的诊断新标准,并将首次产前检查时满足非妊娠期DM诊断标准的血糖异常归为显性DM范畴[2].     

妊娠期糖尿病新诊断标准应用后面临的问题

一、妊娠期糖尿病诊断标准的变更长期以来,妊娠期糖尿病（gestational diabetes mellitus,GDM）的国内、外诊断标准未达成一致。2007年我国制定的妊娠合并糖尿病临床诊断与治疗推荐指南（草案）[1],推荐采用75g口服葡萄糖耐量试验.     

妊娠期糖尿病口服降糖药的应用与评价

高血糖与母儿预后不良相关,因此对妊娠期糖尿病患者进行合理的血糖干预十分必要.近年来,多个国际指南推荐孕期可应用口服降糖药治疗妊娠期糖尿病,国内外专家学者也就此问题进行了研究和探讨,发现妊娠期糖尿病患者应用口服降糖药可有效控制高血糖,改善妊娠结局,但远期安全性仍待进一步研究.     

重视妊娠期糖尿病国际新标准的临床应用

长期以来,妊娠期糖尿病诊断标准存在争议,近年来,国际妊娠合并糖尿病研究组织基于全球多中心的观察性研究,妊娠期高血糖与围产结局研究结果制定的妊娠期糖尿病诊断标准如下:75 g口服葡萄糖耐量试验空腹、服糖后1 h和2 h血糖分别为5.1 mmol/L,10.0 mmol/L和8.5 mmol/L,任何一项血糖达到或超过上述...     

妊娠期高血糖胰岛素应用的种类、特点和技巧

妊娠期高血糖包括妊娠期糖尿病、妊娠期显性糖尿病及孕前糖尿病.妊娠期高血糖患病率高,且与不良妊娠结局明确相关.迄今为止,我国尚未批准任何口服降糖药物用于妊娠期高血糖的治疗,胰岛素是妊娠期间控制血糖的首选.随着胰岛素类似物应用,妊娠期可选用的胰岛素越来越多.本文将对妊娠期间高血糖的特点、胰岛素应用种类及特点和应用技巧进行概...     

妊娠期糖尿病与妊娠期高血压疾病相关性的研究进展

妊娠期糖尿病与妊娠期高血压疾病是妊娠期特有且常见的疾病,对母婴都能产生不良影响。研究表明,妊娠期糖尿病患者并发妊娠期高血压疾病的危险性明显升高,这可能与胰岛素抵抗、高血糖、肥胖等因素密切相关。及早进行妊娠期糖尿病、妊娠期糖耐量异常的诊断,严密监测妊娠期血糖、血压,控制饮食,适量运动,可降低妊娠期糖尿病患者妊娠期高血压疾病的发生率。     

妊娠期甲状腺功能保护

甲状腺疾病可以导致母儿不良妊娠结局,由于妊娠期甲状腺功能发生特异性变化,用非妊娠妇女的诊断标准评估妊娠期甲状腺功能可导致妊娠期甲状腺功能减退症漏诊、甲状腺功能亢进症误诊和药物治疗剂量不足。只有正确诊断妊娠期甲状腺疾病,合理保护妊娠期甲状腺功能,才能避免不良妊娠结局的发生和减少对新生儿远期生存质量的影响,对实现我国优生优育的国策具有非常重要的意义。     

妊娠期糖尿病不同诊断标准适宜性的比较

目的 比较妊娠期糖尿病(GDM)不同诊断标准的适宜性.方法 通过对北京大学第一医院产科2005年1月至2009年12月期间分娩的、孕周≥28周且接受规范的GDM筛查和诊断的非孕前糖尿病产妇14 593例的病历资料进行回顾性分析,比较按照美国国家糖尿病数据组(NDDG)和国际糖尿病与妊娠研究组(IADPSG)诊断标准计算的妊娠期高血糖的发生率及对妊娠结局的影响;并比较对妊娠期高血糖进行管理后不良妊娠结局的改善情况,以同期妊娠分娩的12 403例糖代谢正常孕妇为对照.结果 (1)妊娠期高血糖的发生率:分别按照NDDG、IADPSG标准,需要干预的妊娠期高血糖的发生率分别为8.9%(1293/14 593)和14.7%(2138/14 593),两种标准诊断的需要干预的妊娠期高血糖发生率比较,差异有统计学意义(P＜0.05).(2)妊娠并发症发生情况:不同标准诊断的妊娠期高血糖均将增加巨大儿、大于胎龄儿(LGA)、剖宫产、早产、新生儿低血糖等不良结局的发生率.NDDG、IADPSG标准诊断的妊娠期高血糖和糖代谢正常孕妇巨大儿的发生率分别为8.4%(108/1293)、11.3%(241/2138)和6.7%(835/12 403);LGA的发生率分别为9.7%(125/1293)、11.7%(250/2138)和5.5%(687/12 403);剖宫产率分别为59.0%(763/1293)、60.4%(1291/2138)和51.6%(6397/12 403);早产率分别为11.4%(147/1293)、9.5%(203/2138)和6.3%(777/12 403);新生儿低血糖发生率分别为2.6%(33/1293)、2.2%(46/2138)和0.7%(89/12 403).(3)血糖控制方法:按NDDG标准诊断的妊娠期高血糖孕妇中71.3%(922/1293)可以通过单纯饮食控制达到血糖控制满意.结论 与NDDG标准比较,IADPSG标准诊断的妊娠期高血糖发生率将明显增加,如果未进行管理其围产期并发症也明显增加;提示在我国采用IADPSG标准更适宜.

Abstract：

Objective To investigate the relationship between gestational hyperglycemia and adverse pregnancy outcomes and find out the optimum diagnostic criteria of gestational diabetes mellitus in China. Methods A retrospective population-based study of 14 593 pregnant women, who delivered between Jan. 2005 and Dec. 2009 and accepted the gestational diabetes mellitus ( GDM ) screening and diagnosis was performed. The prevalence of gestational hyperglycemia according to different criteria was calculated, and the incidence of adverse pregnant outcomes relation to gestational hyperglycemia according to different criteria was analyzed. Results ( 1 ) According to National Diabetes Data Group (NDDG) criteria and International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria, the prevalence of gestational hyperglycemia that intervention required was 8.9% (1293/14 593 ) and 14.7% (2138/14 593 )respectively; the prevalence of gestational hyperglycemia differed significantly between NDDG and IADPSG criteria ( P ＜ 0. 05 ). ( 2 ) The prevalence of macrosomia, large for gestational ages ( LGA), cesarean section,preterm birth and neonatal hypoglycemia etc would increase in gestational glucose metabolic disorders according to any criteria. The prevalence of the complications in gestational hyperglycemia according to NDDG criteria, IADPSG criteria and the patients with normal glucose metabolism is as follows, macrosomia:8.4% ( 108/1293), 11.3% (241/2138) and 6. 7% ( 835/12 403 ); LGA: 9. 7% ( 125/1293 ), 11.7% (250/2138) and 5.5% (687/12 403); cesarean section: 59. 0% (763/1293), 60. 4% ( 1291/2138 ) and 51.6%(6397/12403); preterm birth: 11.4% (147/1293), 9.5% (203/2138) and 6.3% (777/12 403); neonatal hypoglycemia: 2. 6% ( 33/1293 ), 2. 2% (46/2138) and 0. 7% ( 89/12 403 ). ( 3 )About 71.3% (922/1293) of the gestational hyperglycemia according to NDDG criteria could be well control only by diet control. Conclusion The prevalence of perinatal complications would increase in gestational hyperglycemia that achieved IADPSG criteria without intervention, so IADPSG criteria is reasonable in China.     

The after breakfast 50-g, 1-hour glucose challenge test in urban Mexican pregnant women: its sensitivity and specificity evaluated by three diagnostic criteria for gestational diabetes mellitus

BACKGROUND: To study the sensitivity and specificity of the 50-g, 1-hour gestational glucose challenge test performed 1 to 2 hours after a non-standardized home breakfast in urban Mexican women by using three different gestational diabetes mellitus diagnostic criteria. METHODS: Four hundred and forty-five consecutive women of 24-28 weeks gestation were studied. The glucose challenge test was performed in the fed state and a week later a fasting 100-g, 3-hours oral glucose tolerance test was carried out in all of them. Duplicate serum glucose concentrations were determined by a glucose-oxidase method. Sensitivity and specificity were calculated using three different diagnostic criteria for gestational diabetes mellitus. RESULTS: The glucose challenge test performed as indicated, with a cutoff of 7.8 mmol/L, had 88-89% sensitivity and 85-87% specificity when using as diagnostic criteria those proposed by the National Diabetes Data Group and by Carpenter & Coustan; by using Sacks et al. criteria, the values were 82% and 88%, respectively. Considering only pregnant women > or = 25 years of age, the sensitivity increased to 92% with the National Diabetes Data Group criteria. Pregnant women < 25 years of age had significantly lower blood glucose values than those with age > or = 25 years during the glucose tolerance test. CONCLUSIONS: For the general group the sensitivity of the glucose challenge test performed 1 to 2 hours after breakfast was similar, based on the National Diabetes Data Group and the Carpenter & Coustan's diagnostic criteria for gestational diabetes mellitus. However, when pregnant women > or = 25 years of age were considered, the use of the former criteria yielded a slightly better sensitivity.     

IADPSG诊断标准用于北京市妊娠期糖尿病诊断的探讨

目的探讨国际妊娠期糖尿病专家组（IADPSG）妊娠期糖尿病（GDM）的诊断标准是否适宜。方法对2667例孕妇进行血糖筛查试验,阳性者进行葡萄糖耐量试验（OGTT）。按照教科书和IADPSG两种诊断标准对孕妇进行诊断并分组,非糖尿病孕妇2325例作为对照组,对各组母儿妊娠结局进行比较。结果血糖筛查试验阳性780例,OGTT试验达到教科书标准和IADPSG标准者分别为270例和276例,检出率分别为10.50%和10.72%（P〉0.05）;两种诊断标准各GDM组间比较,产母子痫前期、羊水过多、低出生体重儿、巨大儿的发生率和剖宫产率差异均无统计学意义（P〉0.05）,而与对照组相比,剖宫产率、巨大儿及低出生体重儿发生率差异存在统计学意义（P〈0.05）,IADPSG组产母子痫前期发生率也显著高于对照组（P〈0.05）。结论用IADPSG标准诊断GDM可使治疗更有针对性,需要进一步的临床研究来证明降低GDM的诊断标准能够带来益处。     

The diagnosis and classification of gestational diabetes mellitus: Is it time to change our tune?

Objective: This study was designed to determine the impact on our population of adopting the Carpenter and Coustan criteria for gestational diabetes mellitus in place of the currently used National Diabetes Data Group criteria, to review the evidence supporting replacement of the National Diabetes Data Group criteria with the Carpenter and Coustan criteria, and to propose analogous diagnostic criteria for diabetes in pregnant and nonpregnant women. Study Design: The National Diabetes Data Group criteria and the proposed Carpenter and Coustan criteria were both used to retrospectively review medical records of patients screened for gestational diabetes mellitus during 1995 and 1996 in the Kaiser Permanente Northwest Division. Computerized search was performed on automated data systems and software was used for statistical analyses. A MEDLINE review of relevant literature was conducted. Results: Of 8857 pregnant women screened for gestational diabetes in 1995 and 1996, 284 (3.21%) met the National Diabetes Data Group criteria, whereas 438 (4.95%) met the Carpenter and Coustan criteria. We estimate that in our population use of the Carpenter and Coustan criteria in 1996 could at best have reduced the prevalence of infants weighing ≥4000 g from 17.1% to 16.9% and the prevalence of infants weighing ≥4500 g from 2.95% to 2.91%. Conclusions: Replacing the National Diabetes Data Group criteria with the Carpenter and Coustan criteria would increase by 54% the number of pregnant women with a diagnosis of gestational diabetes mellitus and would also increase costs, while only minimally affecting prevalence of infant macrosomia. The medical literature does not provide compelling evidence for adopting the Carpenter and Coustan criteria. Standardization of both measurement of venous plasma glucose level and diagnostic criteria for gestational diabetes mellitus is an important goal. Parallel criteria for diagnosis and classification of diabetes mellitus in pregnant and nonpregnant women should be developed. (Am J Obstet Gynecol 1999;180:1560-71.)     

妊娠期糖尿病诊断标准的探讨

目的　探讨妊娠期糖尿病 ( GDM)的诊断标准。　方法　对 1 578例孕妇进行血糖筛查试验 ,阳性者进行葡萄糖耐量试验 ( OGTT)。按照世界卫生组织 ( WHO)、美国糖尿病资料组 ( NDDG)和国内 (董志光等 )三种诊断标准对孕妇进行诊断并分组 ,随机选择糖筛查试验阴性孕妇 1 0 0例作为对照组 ,对四组母儿妊娠结局进行比较。　结果　血糖筛查试验阳性 2 76例 ,OGTT试验达到 WHO、NDDG、国内标准者分别为 3 3、60、68例 ,检出率分别为 2 .1 % ( 3 3 / 1 578) ,3 .8% ( 60 / 1 578) ,和 4 .3 %( 68/ 1 578)。各 GDM组间比较 ,产母重度妊高征、羊水过多、羊水过少、巨大儿的发生率和剖宫产率均无显著性差异 ( P>0 .0 5) ,而与对照组相比 ,存在显著性差异 ( P<0 .0 5)。　结论　及时诊断并积极处理 GDM对获得良好的妊娠结局是极为必要的。 WHO标准过于严格 ;NDDG标准可以应用 ,但有漏诊的可能 ,国内标准有待大样本证实。     

Recurrence of Gestational Diabetes

Summary: We conducted a retrospective review of 540 women with gestational diabetes managed by our Service between 1990 and 1996. The aim was to determine the recurrence rate of gestational diabetes and the factors associated with recurrence. Of 117 women who had a subsequent pregnancy, 82 (70%) had a recurrence of gestational diabetes according to criteria where the fasting glucose value ≥ 5.5 and/or 1 hour ≥10.0 and/or 2-hour ≥8.0 mmol/L after a 75 g oral glucose load. The recurrence rate was 62.4% (58), using the criteria of the Australian Diabetes in Pregnancy Society (ADIPS). Older age in both the index and subsequent pregnancy and insulin requirement during the index pregnancy were the strongest predictors for recurrence of gestational diabetes. Non-English speaking country of birth, higher diagnostic glucose tolerance test (GTT) levels, greater prepregnancy BMI and weight gain between pregnancies were also associated with recurrence.     

Are the new IADPSG criteria for gestational diabetes useful in a country with a very high prevalence?

The International Association of Diabetes and Pregnancy Study Groups released new recommendations on screening methods and diagnostic criteria for gestational diabetes. The main objectives of the present study were to analyze characteristics of mothers who underwent the new screening test, and to assess the prevalence of gestational diabetes and related pregnancy complications such as the 5-minute Apgar score <7, in a urban maternity clinic in Djibouti. The effect of treating gestational diabetes was also evaluated. Totally, 231 mothers underwent the new screening test, and 106 were diagnosed as having gestational diabetes (45.9%). Mothers with gestational diabetes had an excess risk of low Apgar scores, even after adjustment for socio-economic and medical covariates, with an odds ratio of 6.34 (1.77–22.66), p value <0.005. Only 46.2% of mothers with gestational diabetes followed the recommendations regarding treatment. Among these patients, 18.6% of infants from untreated mothers had a 5-minute Apgar score <7, compared to 3.9% infants from treated mothers (p value?=?0.017). After adjustment, untreated mothers still had a high excess risk of low Apgar scores, although non-significant, with an odds ratio of 4.67 (0.78–27.87), p value?=?0.09. In conclusion, gestational diabetes is highly prevalent in Djibouti and is related to low Apgar scores.     

Screening for gestational diabetes in Sicily.

OBJECTIVE: To establish the prevalence of gestational diabetes in a universally screened population living in Messina, Sicily, as the first step in evaluating the cost: benefit ratio of screening for carbohydrate intolerance in pregnancy. STUDY DESIGN: Between October 1989 and March 1995, 1,000 pregnant women underwent screening for gestational diabetes with a 50-g, one-hour glucose challenge test. All the risk factors were registered. RESULTS: Two hundred sixty subjects had a value of > or = 135 mg/dL and underwent a full three-hour oral glucose tolerance test. Of them, 46 (4.6%) met the Carpenter-Coustan diagnostic criteria for gestational diabetes. CONCLUSION: The apparent incidence of gestational diabetes (1.2%) prior to screening was only 25% of the incidence determined with the protocol of universal screening (4.6%). If we assume that timely diagnosis and treatment of gestational diabetes provides an important opportunity to improve obstetric outcome and reduce perinatal morbidity, and since women with gestational diabetes are at increased risk of developing diabetes later, the knowledge that the true prevalence is almost four times that previously reported is a determinant of a future evaluation of the cost:benefit ratio of screening universally for gestational diabetes.     

Gestational diabetes mellitus increased the risk of adverse neonatal outcomes: A prospective cohort study in Northwest Ethiopia

BackgroundGestational diabetes mellitus is a rising global public health problem that can have short- and long-term sequelae for both mother and offspring. However, there are limited evidences on the effect of gestational diabetes mellitus on adverse neonatal outcomes using the updated international diagnostic criteria on adverse effects on neonatal outcomes. Therefore, this study was aimed to examine the effects of gestational diabetes mellitus on the risk of adverse neonatal outcomes in Ethiopia.MethodsA prospective cohort study was conducted among pregnant women recruited from antenatal clinics and followed through pregnancy to delivery. Gestational diabetes mellitus was diagnosed using a two-hour 75g oral glucose tolerance test strategy with recent criteria. Multivariable log-binomial model was used to identify the effects of gestational diabetes mellitus on the risk of adverse neonatal outcomes which includes macrosomia, low birth weight, large for gestational age, small for gestational age, preterm birth, low Apgar score at the first minute, low Apgar score at fifth minute, and composite adverse neonatal outcome.ResultsAmong pregnant women (n=1027) included in the follow up data on neonatal outcomes were available for 684 (118 newborns of mothers with gestational diabetes mellitus and 566 newborns of women without gestational diabetes mellitus). There was a statistical baseline difference between the two groups by maternal age, dietary diversity status, level of physical activity, and antenatal depression. The incidence of composite adverse neonatal outcome was significantly higher (P<0.001) among newborns from mothers with gestational diabetes mellitus (51.7%) than among newborns from mothers without gestational diabetes mellitus (25.8%). Significantly higher risk of developing adverse neonatal outcomes among newborns from gestational diabetes mellitus mothers was observed for composite adverse neonatal outcome (Adjust Relative Risk (ARR)=1.72; 95% CI: 1.35, 2.19), macrosomia (ARR= 3.81; 95% CI: 1.95, 7.45), large for gestational age (ARR= 2.38; 95% CI: 1.41, 4.03), preterm birth (ARR= 2.03; 95% CI: 1.17, 3.53), low Apgar score at the first minute (ARR= 1.71; 95% CI: 1.02, 2.86), and fifth minute (ARR= 2.14; 95% CI: 1.05, 4.36). However, no significant differences in the risk of low birth weight and small for gestational age by gestational diabetes mellitus status.ConclusionsGestational diabetes mellitus increases the risk of adverse neonatal outcomes particularly macrosomia, large for gestational age, preterm birth, and poor Apgar score. Hence, the role of preventing gestational diabetes mellitus is quite crucial to improve neonatal outcomes.