妊娠期糖尿病空腹血糖筛查的意义及其对妊娠结局的影响

妊娠期糖尿病(gestational diabetes mellitus,GDM)的发生率逐年上升,不良妊娠结局与血糖水平相关,即使妊娠妇女的血糖水平在正常范围,随着血糖水平的升高,大于胎龄儿、剖宫产率、新生儿低血糖、新生儿高胰岛素血症及生后糖尿病的发生等母儿不良预后的发生率增加,尽早诊断及治疗GDM有助于改善不良妊娠结局。利用空腹血糖(fasting plasma glucose,FPG)筛查GDM越来越受关注。其具有操作简单,价格低廉,可重复率高并且容易被妊娠妇女接受等优点。近年来许多研究证实,妊娠早期FPG与葡萄糖负荷试验(glucose challenge test,GCT)及口服葡萄糖耐量试验(oral glucose tolerance test,OGTT)的血糖水平呈正相关,且显著降低了需要行OGTT检查的人数。故FPG筛查对GDM有较高的价值。     

Gestational diabetes. Is a 50-g screening result > or = 200 mg/dL diagnostic?

OBJECTIVE: To evaluate the diagnosis of gestational diabetes based on a 50-g, one-hour glucose screening test result > or = 200 mg/dL. STUDY DESIGN: Retrospective ascertainment of pregnant women who had a 50-g, one-hour glucose screening test result > or = 200 mg/dL was performed among prenatal care registrants. The diagnosis of gestational diabetes was determined by 100-g, three-hour oral glucose tolerance test (GTT) results and/or repeated fasting serum glucose measures. RESULTS: In 1995, 69 women were referred to the gestational diabetes clinic with a 50-g result > or = 200 mg/dL. Four women could not be classified, two had pregestational glucose intolerance and four charts were unavailable. Of the remaining 59 women, 11 (19%) had normal three-hour GTTs, and 48 (81%) were diagnosed with gestational diabetes (35 [59%], A1; 13 [22%], A2). There was one large-for-gestational-age (LGA) infant born in the nondiabetic group (9%), 13 LGA infants born in the A1 group (37%) and 6 LGA infants born to the A2 diabetics (46%). The relationship between maternal diagnosis and LGA outcome was statistically significant. CONCLUSION: A 50-g screening test result > or = 200 mg/dL is not diagnostic of gestational diabetes. Nearly one of five such women had a normal three-hour oral GTT. Overdiagnosis of gestational diabetes may lead to unnecessary pregnancy surveillance and intervention.     

Abnormal results on a second testing and risk of gestational diabetes in women with normal baseline glucose levels.

OBJECTIVE: To examine the rate of women with normal initial results to glucose tolerance tests who have abnormal results to subsequent testing, and estimate the risk of gestational diabetes mellitus (GDM) in these women. METHODS: Baseline plasma glucose levels were classified as normal if they were less than 120 mg/dL (group 1) or between 120 and 139 mg/dL (group 2) by the 50-g glucose challenge test (GCT); as abnormal if they were found abnormal by the 50-g GCT but normal by the 100-g glucose tolerance test (OGTT) (group 3); and as abnormal if 1 of the four 100-g OGTT values was abnormal (group 4). A second testing session with the 50-g GCT and 100-g OGTT was performed between the 24th and 28th weeks of pregnancy for 900 women at risk whose initial test results were normal. RESULTS: Of the 823 women with normal baseline results who completed the study, 41.4% had abnormal results to the second 50-g GCT, and gestational diabetes mellitus was diagnosed by the 100-g OGTT in 7.0% of these 823 women. Compared with group 1, the women in groups 2, 3, and 4 were at a significantly increased risk of having an abnormal result to the second 50-g GCT. They were also at a significantly increased risk for GDM. The adjusted odds ratios (ORs) were 3.0 for group 2 (95% confidence interval [CI], 1.2-7.2), 4.9 for group 3 (95% CI, 2.2-11.0), and 11.3 for group 4 (95% CI, 3.9-32.6). CONCLUSION: The risk of developing GDM significantly increased with increasing baseline plasma glucose levels by the 50-g GCT.     

The twentieth century: The century of progress and medicine

The standard criteria for the diagnosis of gestational diabetes (GDM) is based on two abnormal values of a 3-h-100-g oral glucose tolerance test (GTT). Although a markedly elevated 1 h–50-g screen value has been suggested to support a diagnosis of GDM, limited data are available to substantiate this empiric observation. Our purpose was to examine the utility of various 50-g screen cutoff values in establishing the diagnosis of gestational diabetes.

We identified 422 gravidas with a positive 50-g screen (≥135 mg/dl) who underwent additional glucose testing. GDM was defined according to the National Diabetes Data Group (NDDG) standards for the 3-h GTT. An analysis employing the criteria of Carpenter and Coustan was performed for comparison. If a patient had an elevated 50-g value and no 3-h GTT was performed, a fasting serum glucose ≥140 mg/dl was considered evidence of gestational diabetes.

One hundred twenty four (29.4%) had GDM as defined by the NDDG criteria; this increased to 161 (38%) when the diagnosis was based on Carpenter and Coustan's criteria. The mean (≥SD) gestational age at screening was 24 ± 7 weeks. As expected, the prevalence of GDM increased in relation to an increasing 50-g value. All subjects with a 50-g screen < 216 mg/dl had evidence of gestational diabetes and required insulin for glycemic control.

Patients with a 50-g screen ≥220 mg/dl do not all require a 3-h GTT. Those with a fasting serum glucose of ≥140 mg/dl may begin diet therapy, glucose monitoring, and insulin as indicated. If the fasting serum glucose is < 140 mg/dl, a 3-h GTT should be performed for confirmation of GDM. This approach will facilitate rapid therapeutic intervention and reduce the cost of care in this subset of patients. Gravidas with a very high 50-g screen are at significant risk of requiring insulin to maintain euglycemia during pregnancy.     

Are patients with positive screening but negative diagnostic test for gestational diabetes under risk for adverse pregnancy outcome?

OBJECTIVE: Our aim was to determine the obstetrics outcomes of patients with positive 1-h glucose challenge test (GCT), but negative diagnostic test for gestational diabetes. METHODS: Pregnancy records of 409 pregnants were reviewed. Patients were screened for gestational diabetes mellitus (GDM) with one-hour 50 g glucose challenge test (GCT) at 24-28 weeks of gestation. Patients with glucose challenge tests values > or = 130 mg/dL were refered for the 3 h, 100-g oral glucose tolerance test (OGTT). Positive GCT but negative for OGTT group (Group A) were compared retrospectively with the group of negative GCT (Group B) for obstetrics outcomes. RESULT: GDM and impared glucose tolerance (IGT) were diagnosed in 33 (7.6%) and 46 (10.5%) patients, respectively. We identified 141 (34.4%) patients with positive GCT but negative for OGTT (Group A) and 189 (46.2%) patients with negative GCT (Group B). Gestational weight gain, polyhydramnios, family history of diabetes mellitus were significantly higher in group A than group B (P < 0.05). Prevalance of preterm labor, hypertension, cesarean delivery, mean birthweight, proportion of babies admitted to neonatal intensive care unit were similar in both groups. CONCLUSION: There are some differences for pregnancy outcomes between pregnants with positive GCT but negative for OGTT and negative GCT. These patients should be followed up carefully during the antepartum and intrapartum period.     

糖化血红蛋白在妊娠期糖尿病诊断中的意义

目的:探讨糖化血红蛋白在妊娠期糖尿病(GDM)诊断中的意义。方法:对正常妊娠组44例、糖耐量异常组26例及糖尿病组28例进行空腹血糖(FPG)、糖化血红蛋白(HbAlc)及口服50g葡萄糖筛查试验(GCT)测定。结果:GDM组FPG、GCT、HbAlc较正常妊娠组均显著增高(P<0.05)。正常妊娠组与糖耐量异常组比较,FPG及GCT无差异(P>0.05)。GDM组FPG、GCT、HbAlc阳性率分别为42.9%、89.3%和92.9%。GDM的并发症随HbAlc的增高而增多。结论:HbAlc在妊娠期糖尿病的筛查诊断及并发症的检测方面有一定的意义。     

A population-based risk factor scoring will decrease unnecessary testing for the diagnosis of gestational diabetes mellitus

BACKGROUND: To determine the effectiveness of a population-based risk factor scoring to decrease unnecessary testing for the diagnosis of gestational diabetes mellitus (GDM). METHODS: We formed a risk factor scoring over five, which questions maternal age, body mass index and first-degree relatives with a diagnosis of diabetes mellitus, a prior macrosomic fetus and adverse outcome during the previous pregnancies. All participants underwent a 50-g glucose challenge test (GCT) followed by a 100-g oral glucose tolerence test (OGTT). We opened the 50-g GCT envelope if the participant had a risk score > or = 1 and opened the 100-g OGTT envelope if the 50-g GCT value was > or = 7.2 mmol/l. After all patients delivered we also built other strategies and tested their detection rates. RESULTS: Fourteen patients (3.3%) were diagnosed as having gestational diabetes mellitus via a 100-g OGTT. None of the patients with a score of zero had gestational diabetes mellitus. Logistic regression analysis revealed that an increase in the score by one caused a three times increase in gestational diabetes mellitus risk (OR = 3, CI = 1.9-5). Compared with the universal screening, our strategy to screen if the risk score was > or = 1, followed by a 50-g GCT with a 7.2-mmol/l cut-off value, decreased the number of women to be screened by 30% and diagnosed all cases with GDM. Screening the patients with a score > or = 2 would have decreased the number of women to be screened by 63%, still diagnosing 85% of cases with GDM. Also, risk factor-based screening strategies cause a 50% and 53% reduction in the number of OGTT applied, respectively. CONCLUSION: A well integrated, population-based scoring will decrease the number of unnecessary testing but still diagnose 85-100% of GDM cases.     

Can adiponectin predict gestational diabetes?

The aim of the present study was to evaluate whether adiponectin is a predictive factor for gestational diabetes mellitus (GDM) and is appropriate as a screening test for GDM. Three-hundred and fifty-nine women with singleton pregnancy and indications for GDM screening according to criteria of the American College of Obstetricians and Gynecologists were enrolled in the study between July 5, 2004 and March 11, 2005. After confirming gestational age (GA) and number of fetuses by ultrasound, all women underwent a 1-h glucose challenge test with 50 g glucose load (50-g GCT) between 21 and 27 weeks of GA. Blood samples for determination of adiponectin levels were also obtained on the same day. Subsequently, between 24 and 28 weeks of GA, the women underwent an oral glucose tolerance test with 100 g glucose load (100-g OGTT). The diagnosis of GDM was established when two or more of the following criteria were fulfilled: (1) fasting glucose >95 mg/dl; (2) 1-h glucose >180 mg/dl; (3) 2-h glucose >155 mg/dl; (4) 3-h glucose >140 mg/dl. Sixty women were diagnosed with GDM, a prevalence of 16.7%. There was no difference in age between the GDM and non-GDM groups. Pre-pregnancy and sampling-day body mass index (BMI), increase in weight and all blood glucose levels were greater in women with GDM than in those without (p < 0.05). Adiponectin concentrations were significantly negatively correlated with GA and plasma glucose levels of the GCT and each OGTT. Using logistic regression analyses, adiponectin, but not age, pre-pregnancy BMI and increase in weight, was demonstrated as an independent predictive factor for GDM. The area under the receiver-operator characteristic curve of adiponectin was significantly lower than that of the GCT [0.63 (95% confidence interval (CI) 0.53-0.67) vs. 0.73 (95% CI 0.71-0.80), p < 0.001]. At a cut-off value of 140 mg/dl of the 50-g GCT, the sensitivity and specificity of the test were 90% and 61%, respectively. The 50-g GCT could identify GDM in 54 (90%) out of 60 women. On the other hand, at an arbitrary cut-off value of 10 microg/ml for adiponectin, sensitivity of 91% and specificity of 31% were achieved. If this cut-off value was used for ruling in or out pregnant women for the GDM screening, 27% of all women could be eliminated from needing to perform an OGTT, with five women (8.3%) misclassified. In conclusion, this study demonstrated that adiponectin was an independent predictor for GDM. As for GDM screening, adiponectin was not as strong a predictor as GCT. However, with advantage of being less cumbersome, adiponectin could be used to rule out pregnant women at low risk of GDM.     

Screening for gestational diabetes at antenatal booking in a Malaysian university hospital: the role of risk factors and threshold value for the 50-g glucose challenge test

BACKGROUND: The best method of screening for gestational diabetes (GDM) remains unsettled. The 50-g glucose challenge test (GCT) is used in a two-stage screening process but its best threshold value can vary according to population. AIMS: To evaluate the role of risk factors in conjunction with GCT and to determine an appropriate threshold for the one-hour venous plasma glucose with the GCT. METHOD: In a prospective study, 1600 women at antenatal booking without a history of diabetes mellitus or GDM filled a form on risk factors before GCT. Women who had GCT >or= 7.2 mmol/L underwent the 75-g oral glucose tolerance test (OGTT). GDM was diagnosed according to WHO (1999) criteria. RESULT: Thirty-five per cent had GCT >or= 7.2 mmol/L, 32.6% underwent OGTT and 34.5% of OGTT confirmed GDM. The GDM rate in our population was at least 11.4%. Examination of the receiver operator characteristic curve suggested that the best threshold value for the GCT in our population was >or= 7.6 mmol/L. Multivariable logistic regression demonstrated that only GCT >or= 7.6 mmol/L was an independent predictor for GDM (adjusted odds ratio 3.7: P < 0.001). After GCT, maternal age and anthropometry, OGTT during the third trimester, family history, obstetric history and glycosuria were not independent predictors of GDM. CONCLUSIONS: Risk factors were not independent predictors of GDM in women with GCT >or= 7.2 mmol/L. GCT threshold value >or= 7.6 mmol is appropriate for the Malaysian population at high risk of GDM.     

Maternal obesity and familial history of diabetes have opposing effects on infant birth weight in women with mild glucose intolerance in pregnancy.

OBJECTIVE: Pregnant women with an abnormal screening glucose challenge test (GCT) but without gestational diabetes mellitus (GDM) on subsequent oral glucose tolerance test (OGTT) are at increased risk of delivering macrosomic and large for gestational age (LGA) neonates. We thus sought to evaluate the maternal constitutional and biochemical factors that determine infant birth weight in this patient population. METHODS: Women with an abnormal GCT were evaluated at the time of their OGTT in late pregnancy. This analysis was restricted to Caucasian women without GDM (N = 86). Maternal demographic and biochemical factors were evaluated in relation to infant birth weight and LGA. RESULTS: After adjustment for length of gestation, birth weight was positively associated with pre-pregnancy body mass index (BMI) (r = 0.31, p = 0.0063) and negatively correlated with maternal serum levels of the insulin-sensitizing protein adiponectin (r = -0.30, p = 0.0084). On multiple linear regression analysis, pre-pregnancy BMI and weight gain in pregnancy were positive independent determinants of infant birth weight, while family history of diabetes emerged as a negative independent correlate. Logistic regression analysis confirmed that pre-pregnancy BMI was a positive predictor of LGA (odds ratio (OR) = 1.25, 95% confidence interval (CI) 1.05-1.49), whereas family history of diabetes was again identified as a negative determinant (OR = 0.10, 95% CI 0.02-0.59). In contrast, neither measures of glycemia nor insulin resistance/sensitivity were independently associated with birth weight or LGA. CONCLUSION: In pregnant women with an abnormal GCT but without GDM, pre-gravid maternal obesity predicts increased infant birth weight, whereas family history of diabetes is independently associated with decreased infant size.     

Fasting capillary glucose as a screening test for gestational diabetes mellitus

Objective  To evaluate fasting capillary glucose as a screening test for gestational diabetes mellitus (GDM) compared with traditional risk factors and repeated random capillary glucose measurements.
Design  Cross-sectional, population-based study.
Setting  Maternal Health Care Clinics in Örebro County, Sweden.
Population  An unselected population of women without diabetes.
Methods  Fasting capillary glucose levels were measured at gestational weeks 28–32. Random capillary glucose levels were measured four to six times during pregnancy. Traditional risk factors for GDM were registered. GDM was diagnosed using a 75-g oral glucose tolerance test.
Main outcome measures  Sensitivity, specificity, likelihood ratios.
Results  In 55 of 3616 women participating in the study, GDM was diagnosed before 34 weeks of gestation. For fasting capillary glucose cutoff values between 4.0 and 5.0 mmol/l, sensitivity was in the range between 87 and 47% and specificity between 51 and 96%. Using a combined screening model of traditional risk factors with fasting capillary glucose at various cutoff values increased the sensitivity only slightly compared with using fasting capillary glucose alone.
Conclusion  In this Swedish, unselected, low-risk population, fasting capillary glucose measurements were found to be an acceptable and useful screening test for GDM.     

早孕期空腹血浆血糖与妊娠期糖代谢异常的相关性

目的 探讨早孕期空腹血浆血糖(fasting plasma glucose,FPG)与妊娠期糖代谢异常的相关性.方法 选取2009年1月1日至2009年5月31日在北京大学第一医院妇产科产前保健及分娩的单胎非孕前糖尿病且早孕期5～13周检测FPG、资料齐全的孕妇656例,对其早孕期FPG孕24周后50 g葡萄糖负荷试验结果(glucose challenge test,GCT)、75 g葡萄糖耐量试验结果(oral glucose tolerance test,OGTT)、妊娠期糖尿病(gestational diabetes mellitus,GDM)和妊娠期糖耐量受损(gestational impaired glucose tolerance,GIGT)发病情况进行受试者工作特性(receiver operating characteristic,ROC)分析.结果 (1)早孕期FPG与孕24周后GCT的ROC分析:最大曲线下面积0.539,95%CI:0.493～0.586,两者无明显相关性(P=0.057).(2)早孕期FPG与孕24周后FPG异常的ROC分析:最大曲线下面积0.796(95%CI:0.672～0.920),如取5.05 mmol/L为界值,敏感性为54.5%,特异性为83.2%,两者存在相关性(r=0.432,P=0.000).(3)早孕期FPG与孕24周后OGTT 1、2、3 h血糖无相关性(r=0.093、0.036和0.107,P=0.122、0.549和0.074),OGTT服糖前与服糖后1、2、3 h血糖分别呈正相关(r=0.493、0.421和0.368,P均=0.000).(4)本研究中共656例早孕期孕妇的FPG值均＜6.1 mmol/L,诊断GDM 22例,GIGT 27例,早孕期FPG对预测最终发生GDM及GIGT无相关性.结论 早孕期FPG不能取代现有的50 g GCT作为孕期糖代谢异常的早期筛查指标,但早孕期FPG的检测是必要的.

Abstract：

Objective To investigate the relationship between early pregnancy fasting plasma glucose (FPG) and gestational glucose metabolism disorders. Methods Six hundred and fifty-six pregnant women who were singleton, non-diabetes before pregnancy and had FPG examined during 5-13 weeks of pregnancy were admitted into this study from January 1, 2009 to May 31, 2009. All these subjects had routine prenatal examination and finally delivered in the Department of Obstetrics of Peking University First Hospital. The FPG, 50 g glucose challenge test (GCT) after 24 weeks of pregnancy, 75 g oral glucose tolerance test (OGTT), gestational diabetes mellitus (GDM),gestational impaired glucose tolerance (GIGT) were analyzed with receiver operating characteristic (ROC) curve. Results (1) Relationship between FPG and GCT were analyzed with ROC curve.The maximum area under curve was 0. 539 (95% CI: 0. 493-0. 586) and there was no correlation between the FPG and GCT results(P=0. 057). (2) Relationship between early pregnancy FPG and abnormal FPG examined after 24 gestational weeks were also analyzed . The maximum area under curve was 0. 796(95% CI: 0. 672-0. 920). If 5. 05 mmol/L was taken as the cutoff value, the sensitivity and specificity was 54. 5% and 83. 2%, respectively. There was significant relationship between the two values (r=0. 432, P=0. 000). (3) There were no relationship between early pregnancy FPG and the blood glucose value of 1, 2 and 3 h in 75 g OGTT (r=0. 093, 0. 036 and 0. 107, P=0.122, 0. 549 and 0. 074 respectively). OGTT 0 h value was positively related to OGTT 1, 2 and3 h glucose level (r=0.493, 0.421 and 0.368, P=0.000, respectively). (4) All early pregnant FPG values in this study were under 6.1 mmol/L. Twenty-two GDM and 27 GIGT patients were diagnosed in this study. Early pregnancy FPG did not relate to the GDM and GIGT diagnosis.Conclusions Early pregnancy FPG could not replace 50 g GCT as an early screening for glucose metabolic abnormality in pregnancy, but FPG during early pregnancy is necessary.     

妊娠期糖尿病孕妇分娩后血糖异常的相关因素分析

目的　探讨妊娠期糖尿病 (GDM)孕妇分娩后 2个月的 75g葡萄糖耐量试验 (OGTT)结果 ,及其与血糖异常的相关因素。方法　对 2 94例GDM孕妇于分娩后 2个月行OGTT ,按世界卫生组织标准进行再分类 ,即 2型糖尿病 (2型DM)、糖耐量低减 (IGT)和血糖正常。并对其相关因素进行分析。结果　 (1) 2 94例孕妇中 160例 (5 4 4% )血糖正常 (血糖正常组 ) ,75例 (2 5 5 % )IGT (IGT组 ) ,5 9例 (2 0 1% ) 2型DM(2型DM组 )。 (2 ) 2型DM组的诊断孕周早于其他两组 (P <0 0 1) ;5 0g葡萄糖负荷试验 (GCT)的血糖、OGTT中的空腹血糖、以及诊断时的糖化血红蛋白 (HbA1c)均明显高于其他两组(P <0 0 1) ;胰岛素治疗的孕周最早 ,胰岛素使用率高于血糖正常组 (P <0 0 5 ) ,胰岛素的剂量也明显大于其他两组 ;分娩后 1周内的空腹和餐后 2h血糖仍明显高于其他两组 (P <0 0 1)。 (3 ) 3组孕妇间体重、年龄、家族史等比较 ,差异无显著性 (P >0 0 5 )。结论　GDM孕妇中约有 1/ 4为IGT ,1/ 5为 2型DM ;后者在孕期表现为发病早 ,空腹血糖高 ,使用胰岛素机会多     

Gestational diabetes mellitus in patients receiving long-term corticosteroid therapy during pregnancy

AIM: Little data exist on the impact of chronic low dose corticosteroid therapy during pregnancy on gestational diabetes mellitus (GDM). METHOD: We compared 25 pregnant women receiving long-term (>4 weeks) corticosteroid for newly diagnosed idiopathic thrombocytopenic purpura (ITP) (study group) and 108 normal pregnant women (control group) in this case-control study. Main outcome measures were 1-h, 50-g and 3-h, 100-g glucose tolerance tests (GTTs). Women in both groups were also screened with 75-g GTT 6 weeks after delivery. RESULTS: The mean duration of corticosteroid therapy was 9.8+/-4.9 (range 6-25) weeks. Compared with controls, study group patients had a greater prevalence of diagnosed GDM (24.0 vs. 2.8%, P=0.01). Of these patients, 83.3% were diagnosed with GDM at 16 weeks gestation. An impaired 75-g GTT was also more frequent in the study group (P=0.01). CONCLUSION: Our findings suggest that long-term corticosteroid therapy may be associated with the development of diabetes in pregnant women and early GTT should be performed in pregnant women on corticosteroid therapy.     

The 50-g glucose challenge test and pregnancy outcome in a multiethnic Asian population at high risk for gestational diabetes

Objective

To evaluate the 50-g glucose challenge test (GCT) on pregnancy outcome in a multiethnic Asian population at high risk for gestational diabetes (GDM).

Methods

GCT was positive if the 1-hour plasma glucose level was ≥ 7.2 mmol/L. GDM was diagnosed by a 75-g glucose tolerance test using WHO (1999) criteria. Of the 1368 women enrolled in the study, 892 were GCT negative, 308 were GCT false-positive, and 168 had GDM. Pregnancy outcomes were extracted from hospital records. Multivariable logistic regression analysis was performed with GCT negative women as the reference group.

Results

GCT false-positive status was associated with preterm birth (adjusted odds ratio [AOR] 2.1; 95% CI, 1.2-3.7) and postpartum hemorrhage (AOR 1.7; 95% CI, 1.0-2.7). GDM was associated with labor induction (AOR 5.0; 95% CI, 3.3-7.5), cesarean delivery (AOR 2.2; 95% CI, 1.6-3.2), postpartum hemorrhage (AOR 2.1; 95% CI, 1.2-3.7), and neonatal macrosomia (AOR 2.5; 95% CI, 1.0-6.0).

Conclusion

GCT false-positive women had an increased likelihood of an adverse pregnancy outcome. The role and threshold of the GCT needs re-evaluation.     

妊娠晚期超声检查异常再次行葡萄糖耐量试验结果分析

目的分析妊娠晚期因超声检查异常行75g葡萄糖耐量试验(OGTT)的结果及影响妊娠期糖尿病(GDM)诊断的因素。方法选择2010年9月至2011年1月间北京大学人民医院产科门诊,妊娠中期常规GDM筛查和诊断试验阴性,晚期因超声提示羊水过多和(或)胎儿大再次行75gOGTT的孕妇116例为研究对象,分为GDM组和非GDM组,对可能影响GDM诊断的因素进行统计学分析。结果诊断GDM19例(16.4%)。单因素分析提示年龄>30岁及常规筛查或诊断试验孕周<24周的孕妇GDM诊断阳性率高于年龄≤30岁和常规筛查或诊断试验孕周≥24周的孕妇(P<0.05)。多因素分析提示相对于年龄≤30岁的孕妇,>30岁的孕妇患GDM的OR>30(P<0.05);相对于超声检查时体质指数(BMI)较孕前增幅<4的孕妇,增幅>6的孕妇患GDM的OR=0.08(P<0.05),但增幅>6的孕妇超声检查孕周晚于增幅<4的孕妇(P<0.01)。结论对于妊娠中期常规筛查或诊断试验阴性的孕妇来说,妊娠晚期超声检查提示羊水过多和(或)胎儿大时,年龄>30岁的孕妇患GDM的可能性增加,超声检查时BMI较孕前增幅>6的孕妇可能性减少,但须考虑孕周的影响。     

A comparison between a 75-g and 100-g oral glucose tolerance test in pregnant women.

OBJECTIVES: To test the validity of a 75-g, 2-h oral glucose tolerance test (OGTT) for diagnosing gestational diabetes mellitus (GDM) using the criteria and reference values suggested by the American Diabetes Association for the 100-g, 3-h OGTT. METHODS: The results of a 75-g, 2-h OGTT were compared with those of a 100-g, 3-h OGTT in 42 pregnant women. The women's mean+/-S.D. age and gestational age were 33.6+/-5.4 years and 28.2+/-4.2 weeks, respectively. Each subject was randomly scheduled within 1 week for both the 75-g and 100-g OGTTs. RESULTS: The mean plasma glucose concentrations at 1, 2, and 3 h during the 100-g OGTT were significantly higher than those during the 75-g OGTT. Using the Carpenter and Coustan criteria, the prevalence of GDM was 21.4% when using the 100-g, 3-h OGTT, whereas it was found to be at only 7.1% when using the 75-g, 2-h OGTT. CONCLUSIONS: Plasma glucose responses during the 75-g OGTT were found to be lower than those during the 100-g OGTT. When using the same diagnostic criteria, the prevalence of GDM was also found lower using the 75-g glucose load. It would therefore not be appropriate to use the 75-g OGTT for diagnosing GDM using the criteria and reference values of the 100-g OGTT. To give a comparable prevalence of GDM, the threshold of abnormal plasma glucose levels of the 75-g OGTT would need to be lower than that of the 100-g OGTT.     

Risk of diabetes mellitus after pregnancy complicated by gestational diabetes mellitus (GDM)

OBJECTIVES: The aim of the study was an assessment of glucose tolerance disorders' (GTD) prevalence after pregnancy complicated by GDM. DESIGN: Retro- and prospective clinical study. MATERIAL AND METHODS: The group of 461 women having GDM in their index pregnancies was invited to postpartum glucose metabolism assessment. Of them 192 subjects responded positively. In 47 of them the postpartum diagnosis of diabetes had already been established. The remaining 145 subjects underwent detailed testing that embraced fasting plasma glucose and whole blood HbA1c level measurement. Oral 75-g glucose tolerance test (OGTT) was also performed. RESULTS: OGTT revealed GTD in 55 subjects. Diabetes was found in 8 cases, impaired glucose tolerance (IGT) and impaired fasting glucose (IFG) in 23 and 24 cases respectively. Postpartum GTD appeared in 63.3% of insulin treated subjects (GDM2) compared with 30.1% of women treated with diet only (GDM1). A group with pathological OGTT had mean HbA1c concentration significantly higher compared to the one with normal test results (6.0+/-1.7% vs. 5.1+/-0.3%; p<0.001), although HbA1c>6.0% was observed only in 23.6% women with GTD. Moreover, in 25% of subject with newly diagnosed diabetes HbA1c level did not exceeded 6.0%. CONCLUSIONS: 1. More than 50% of subjects with GDM developed diabetes or other GTD during the first 6 years postpartum. 2. Risk of postpartum GTD is significantly higher in women treated with insulin during pregnancy. 3. HbA1c measurement is less sensitive than OGTT for detection of GTD after pregnancy complicated by GDM.     

Perinatal outcomes after adopting 1- versus 2-step approach to diagnosing gestational diabetes

Objective: The American College of Obstetricians and Gynecologists (ACOG) and the IADPSG (International Association of Diabetes and Pregnancy Study Groups) proposed distinct approaches to diagnosing gestational diabetes mellitus (GDM). We sought to analyze these paradigms: (1) ACOG 2-step approach where screening is followed by diagnostic testing, (2) IADPSG 1-step diagnostic testing.

Study design: We reviewed data from pregnant women (24–28 wks) screened for GDM over two periods: (1) November 2011–May 2012 (2) November 2012–May 2013. Period 1: 2-step approach (screening 1-h glucose challenge test (GCT) followed by a diagnostic 3-h 100-g glucose tolerance test (GTT) when abnormal (≥140?mg/dl)). Period 2: an abnormal value after a 2-h 75-g GTT result was diagnostic of GDM. We compared the incidence of GDM and perinatal outcomes using either approach.

Results: Out of 471 patients screened by ACOG 2-step approach, 72 (15.3%) had an abnormal 1-h screening and underwent the 3-h diagnostic GTT, and 26 (5.5%) developed GDM. The 1-step approach resulted in 53 (15.96%) with GDM of a total 332 evaluated. There was no statistically significant difference in perinatal outcomes between the two cohorts. Maternal weight at the start and the end of pregnancy was greater for patients diagnosed by the ACOG 2-step approach.

Conclusion: Adopting 1-step approach (ADA) to diagnose GDM resulted in a 3-fold increase in prevalence of GDM with no differences in perinatal outcomes.     

Assessment of glucose tolerance and pregnancy outcome of polycystic ovary patients.

OBJECTIVES: To determine the impact of polycystic ovary syndrome (PCOS) on glucose tolerance during pregnancy and perinatal outcome. METHODS: Pregnancy records of 38 PCOS patients were compared retrospectively with 136 non-PCOS patients randomly. Patients with glucose challenge tests values of >130 mg/dl were referred for the 3-h, 100-g oral glucose tolerance test (OGTT). RESULTS: A family history of diabetes mellitus, pre-pregnancy body mass index (BMI), gestational weight gain was significantly higher in PCOS patients than controls. The prevalence of gestational diabetes mellitus (GDM) was similar in both groups. Impaired glucose tolerance (IGT) was observed in 18.4% of PCOS patients vs. 5.1% of controls. The main predictor of GDM was found pre-pregnancy BMI >25 while main predictor of IGT was found as PCOS. Mean gestational age at delivery, prevalence of preterm labor, modes of delivery, mean birthweight, mean Apgar score at 5 min, proportion of babies admitted to the neonatal intensive care unit (NICU) were similar in both groups. CONCLUSIONS: Higher IGT prevalence in PCOS patients might be related to maternal obesity and excess gestational weight gain and does not affect perinatal outcome.