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。     

Diabetes complicating pregnancy

Despite the well-documented relationship between morbidity in pregnancy and pregestational maternal diabetes, the corrected perinatal outcome is, in most series, equal to or better than that of the general reference obstetric population. No single aspect or element of contemporary management is responsible for this improvement; rather, a combination of interventions seems responsible. Targeting delivery early in term, improved compliance, better glycemic control during pregnancy, improved control at conception, improved neonatal care, family planning, and early screening for fetal abnormalities all likely contribute to improved outcome. The currently observed rates of perinatal mortality suggest that an irreducible minimum mortality rate may be reached; however, large disparities in access to care and treatment continue to result in a wide range in rates of morbidity and mortality, a fact that pertains to outcomes in general as well as to pregnancies complicated by diabetes. The identification of women with lesser degrees of hyperglycemia as diabetic by lowering the thresholds for glucose tolerance test abnormality suggests an importance of the diagnosis that is not supported by evidence of either related morbidity or therapeutic benefit. The extrapolation of risk to women with lesser degrees of hyperglycemia seems to have little basis, and the management of women with mild glucose intolerance as if they had overt diabetes is unwarranted. The excess of resources dedicated to the identification and monitoring of an increasing number of women with mild abnormalities of glucose metabolism should prompt a reevaluation of these practices. Perinatal benefits of this expenditure are difficult to document or nonexistent, and there is a predictable increase in iatrogenic morbidities associated with the diagnosis. The exception in the most recent recommendations is the addition of a random glucose measure to screen for the rare women with overt undiagnosed diabetes who presents for prenatal care, because these women are at increased risk of morbidities related to diabetes. A curious statement was made in the summary and recommendations of the fourth International Congress on Gestational Diabetes: "There remains a compelling need to develop diagnostic criteria for GDM [gestational diabetes mellitus] that are based on the specific relationships between hyperglycemia and risk of adverse outcome." If these relationships are undefined, what is the import of the diagnosis? At the author's center, application of the new diagnostic thresholds for the diagnosis of gestational diabetes mellitus has increased the incidence to over 6%. Without a clear expectation of benefit, this increase represents an unsupportable investment of resources. What are the prospects for improving understanding of the relationships between glucose intolerance and pregnancy risks? The direction of new guidelines and recommendations seems to be moving away from resolution of the relationships. The new criteria result in the diagnosis of gestational diabetes in an increasing number of women who were previously normal. It is easier to differentiate women at an extreme of hyperglycemia from normal. Investigations will be even less able to identify attributable effects of glucose intolerance in pregnancy with the inclusion of women with lesser degrees of hyperglycemia. As evidenced in O'Sullivan's original series, women with fasting hyperglycemia in pregnancy are still presumed to be at increased risk of fetal death. This risk factor remains important in clinical management if insulin treatment, fetal surveillance, and early term delivery can reduce the risk of fetal loss. At the author's center, the relationships among outpatient measures of fasting glycemia, glucose tolerance testing results, and perinatal outcomes are evaluated. Preliminary results suggest that fasting glycemia measured at the time of a 50-g glucose tolerance test is significantly correlated with and as sensitive and predictive of morbidity as the glucose tolerance test diagnosis of gestational diabetes. If these results are confirmed, it will be difficult to rationalize continued glucose tolerance testing.     

Gestational diabetes: aetiology and management

It is well known that raised glucose levels in women with established diabetes increase both morbidity and mortality among their offspring due mainly to an increased incidence of congenital abnormalities and excessive fetal growth in the third trimester. Whether milder elevations of maternal glucose are clinically relevant in pregnancy has been controversial. However, emerging evidence points to a linear increase in fetal risk as maternal glucose concentrations rise. Much of this morbidity can be prevented with aggressive treatment of hyperglycaemia, often with insulin. Furthermore, transient glucose intolerance in pregnancy has major implications for the women affected, since it confers a risk of type 2 diabetes in later life which exceeds 50%. It is therefore now established that gestational diabetes mellitus is of considerable clinical relevance. Obstetric units should establish clear policies to ensure that those at risk are reliably identified, appropriately treated during pregnancy and then equipped to make the necessary lifestyle changes to try and prevent them developing diabetes in later life.     

Type 2 diabetes in pregnancy: exposing deceptive appearances.

Now that we have been forewarned of the growing pandemic of type 2 diabetes and obesity in pregnancy, we need to become forearmed. Over the past few decades there has been no significant improvement in perinatal outcome complicated by diabetes mellitus (type 1 and type 2). The recognition of modifiable risk factors such as maternal glycemic control using self-monitoring blood glucose in combination with pharmacological therapy (intensified therapy) and weight gain in pregnancy should enhance pregnancy outcome. The overemphasis and concentration on the non-modifiable risk factors in pregnancy is a futile pursuit that may generate lively discussion but paucity of results. The focus needs to be in education for the care provider, i.e., enhanced recognition of this growing entity and a heightened awareness of the need for pre-pregnancy counseling about preconception glycemic control. Another center of attention should be the dissemination of information to patients of the impending maternal and fetal risks of type 2 diabetes in pregnancy. This care would include antenatal care for surveillance of maternal diabetes complications as well as careful obstetric surveillance to improve maternal and fetal outcomes.     

Type 2 diabetes in pregnancy: Exposing deceptive appearances

Now that we have been forewarned of the growing pandemic of type 2 diabetes and obesity in pregnancy, we need to become forearmed. Over the past few decades there has been no significant improvement in perinatal outcome complicated by diabetes mellitus (type 1 and type 2). The recognition of modifiable risk factors such as maternal glycemic control using self-monitoring blood glucose in combination with pharmacological therapy (intensified therapy) and weight gain in pregnancy should enhance pregnancy outcome. The overemphasis and concentration on the non-modifiable risk factors in pregnancy is a futile pursuit that may generate lively discussion but paucity of results. The focus needs to be in education for the care provider, i.e., enhanced recognition of this growing entity and a heightened awareness of the need for pre-pregnancy counseling about preconception glycemic control. Another center of attention should be the dissemination of information to patients of the impending maternal and fetal risks of type 2 diabetes in pregnancy. This care would include antenatal care for surveillance of maternal diabetes complications as well as careful obstetric surveillance to improve maternal and fetal outcomes.     

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。     

The challenges of diagnosis and treatment of malaria in pregnancy in low resource settings

Malarial infestation in pregnancy is a major public health concern in endemic countries and ranks high amongst the commonest complications of pregnancy, especially in large areas of Africa and Asia. It is an important preventable cause of significant maternal morbidity and mortality with associated fetal as well as perinatal wastage. The burden of malaria is greatest in sub-Saharan Africa where it contributes directly or indirectly to maternal and perinatal morbidity and mortality. The need for prompt and accurate diagnosis as well as prevention and treatment of malaria during pregnancy cannot, therefore, be overemphasized. This commentary focuses on the challenges of diagnosis and treatment of malaria in pregnancy.     

Diabetes mellitus in pregnancy in an African population.

OBJECTIVES: To compare the pregnancy outcome among diabetic and non-diabetic Nigerian women. METHODS: A retrospective case record review of 200 pregnant diabetic patients and control was carried out over a 10-year period (1990-1999) at the Maternity unit of the University of Nigeria Teaching Hospital Enugu, Nigeria. RESULTS: The prevalence of diabetes mellitus among pregnant mothers was 1.7%. Pre-gestational diabetes mellitus accounted for 39% of cases while gestational diabetes was responsible for 61% of them. Late antenatal booking and poor control of diabetes mellitus were common features, while maternal and fetal morbidity was high. Hypertension, vulvovaginitis, premature labor, polyhydramnios and ketoacidosis were significantly higher among diabetic mothers than controls. The perinatal mortality was also higher among diabetics than controls (12.5% vs. 3.5%) with stillbirth being the major contributor. Patients with gestational diabetes were at increased risk of fetal macrosomia than controls (28.7% vs. 5.5%). The overall cesarean section rate was high (36%) among diabetics with previous cesarean section and cephalopelvic disproportion being the commonest indications. CONCLUSIONS: Health education and provision of modern affordable methods of management of diagnosed cases such as uristix and hemastix will improve maternal and fetal outcome in pregnant diabetics in Africa.     

格列苯脲治疗妊娠期糖尿病

妊娠期糖尿病(GDM)是妊娠期最常见的合并症之一,妊娠期血糖的稳定情况可影响妊娠结局.目前国内临床上对于GDM的治疗,除饮食控制、运动锻炼控制外,主要依靠注射胰岛素,较少应用口服降糖药.目前一些动物试验和临床试验的研究表明,格列苯脲作为一种常用的口服降糖药,在GDM的治疗中未发现致畸作用,其在国外GDM的临床治疗中应用日益增加.通过文献复习,评论格列苯脲在GDM治疗中的应用.     

Review: Placental transport and metabolism of energy substrates in maternal obesity and diabetes

Maternal obesity is growing in prevalence and is associated with increased morbidity and mortality for both mother and child. Women who are obese during pregnancy have a greater risk of metabolic complications such as gestational diabetes mellitus (GDM) as well as type 2 diabetes after pregnancy. Children of obese and/or GDM mothers have an increased susceptibility to congenital abnormalities and a range of cardio-metabolic disorders. The placenta is at the interface of the maternal and fetal environments and, its function per se, plays a major role in dictating the impact of maternal health on fetal development. Here, we review the literature on how placental function is affected in pregnancies complicated by obesity, and pre-gestational and gestational diabetes. The focus is on the availability of three key substrates in these conditions: glucose, lipids, and amino acids, and their impact on placental metabolic activity. Maternal obesity and diabetes are not always associated with fetal compromise and the adaptation of the placenta may partially determine the outcome. Understanding the differences in metabolic adaptation may open avenues for therapeutic development.     

Course of pregnancy and delivery in patients with pregestational diabetes mellitus

INTRODUCTION: Pregnancy in a woman with pregestational diabetes mellitus (PGDM) is associated with increased risk of complications in both the mother and the fetus. A close surveillance is strongly recommended in these pregnancies. OBJECTIVES: The aim of the study was to assess perinatal outcome in pregnancies complicated by PGDM. Study design: The study covered 127 pregnancies with PGDM. Apart from perinatal outcome the patient's age, past obstetric history, the duration of perinatal diabetic care and the course of pregnancy were taken into consideration. Diabetes mellitus was classified according to White. RESULTS: 37.8% of patients were diagnosed PGDM B class, 38.6%--C class, 15.7%--D class, 1.6%--F class and 6.3%--RF class. Less than half of women (45.5%) remained under medical care since the first trimester. The arterial hypertension was the most common complication of pregnancy and occurred in over 18% of studied pregnancies. The incidence of preterm delivery was 41.7%. Cesarean section was performed in 55.9% of patients. 16.6% of the neonates had a birth weight below 2500 g. 4 neonates were stillborn (2.4%) and the next 3 ones (2.4%) died within the first month following the delivery. Congenital heart defects were found in 8.7% of offsprings. CONCLUSIONS: Despite the progress in perinatal care pregestational diabetes mellitus is still associated with increased risk of maternal and fetal mortality and morbidity.     

Hypertension in pregnancy

Hypertensive disorders of pregnancy remain a common complication of pregnancy and a major cause of maternal and perinatal morbidity and mortality worldwide. Hypertensive disorders range from mild gestational hypertension to early onset pre-eclampsia which remains a leading cause of maternal death worldwide. Although there have been major advances in understanding the pathophysiology of the disease in recent years, interventions to screen for and prevent hypertensive disorders of pregnancy have had disappointing results. Due to their unpredictable nature and potential poor outcomes, patients with hypertensive disorders of pregnancy warrant cautious care including consultant obstetric, neonatal and anaesthetic involvement to optimise both maternal and fetal outcomes.     

Determination of reference ranges and effect of maternal and fetal factors on insulin and C-peptide level in umbilical cord blood

OBJECTIVE: The risks of pregnancy caused by maternal diabetes are well known. Patients with unrecognized gestational diabetes mellitus (GDM) represent a special problem. The aim of our study was to find out, whether the determination of insulin and C-peptide in cord blood serum offers a valuable tool for retrospective analysis. MATERIAL AND METHODS: In 600 paired serum samples from maternal venous blood and neonatal cord blood insulin and C-peptide were determined radioimmunologically. A reference group consisting of 338 mothers and their newborns was established by exclusion of all patients with known pregnancy complications. RESULTS: Positive correlations could be identified between fetal insulin and fetal C-peptide, as well as correlations of these parameters with birth weight and body length, with maternal values of insulin, C-peptide, body-mass index, weight, and weight gain during pregnancy respectively. Increased levels of cord serum insulin were found in complicated pregnancies as well as in patients with previous pregnancy losses, preterm deliveries or stillbirths. CONCLUSIONS: Cord serum insulin and C-peptide were found to be useful parameters for immediate postnatal identification of impaired glucose tolerance during the course of pregnancy.     

Management of diabetes mellitus in pregnancy

During the past decade, our major objective in the management of pregnancies complicated by diabetes mellitus has become normalization of maternal and, therefore, fetal glucose levels. For most women with insulin-dependent diabetes, this goal may be achieved through the use of multiple insulin injections combined with an appropriate dietary intake. The results of such therapy can now be accurately assessed by means of home glucose monitoring. Patients with gestational diabetes can be properly treated only if they are first identified. Therefore, all pregnant women should be tested for this disorder because screening based on past obstetric history or clinical criteria alone may miss up to 50% of patients with gestational diabetes. Between 1980 and 1984, the perinatal mortality rate reported in the American literature for more than 800 insulin-dependent patients was 21 per 1000, with more than 50% of these deaths resulting from major malformations. Such data emphasize the need to achieve maternal euglycemia before conception, as poor maternal control has been associated with teratogenesis. Prepregnancy assessment should also include a thorough evaluation of maternal vasculopathy.     

Intrapartum application of the continuous glucose monitoring system in pregnancies complicated with diabetes: A review and feasibility study

Intrapartum maternal normoglycemia seems to play an important role in the prevention of adverse perinatal, maternal and neonatal outcomes. Several glucose monitoring protocols have been developed, aiming to achieve a tight glucose monitoring and control. Depending on the type of diabetes and the optimal or suboptimal glycemic control, the treatment options include fasting status of the parturient, frequent monitoring of capillary blood glucose, intravenous dextrose infusion and subcutaneous or intravenous use of insulin. Continuous glucose monitoring system (CGMS) is a relatively new technology that measures interstitial glucose at very short time intervals over a specific period of time. The resulting profile provides a more comprehensive measure of glycemic excursions than intermittent home blood glucose monitoring. Results of studies applying the CGMS technology in patients with or without diabetes mellitus (DM) have revealed new insights in glucose metabolism. Moreover, CGMS have a potential role in the improvement of glycemic control during pregnancy and labor, which may lead to a decrease in perinatal morbidity and mortality. In conclusion, the use of CGMS, with its important technical advantages compared to the conventional way of monitoring, may lead into a more etiological intrapartum management of both the mother and her fetus/infant in pregnancies complicated with DM.     

Complications and fetal outcome in diabetic pregnancy. Intensified conventional versus insulin pump therapy

From 1978 to 1986 a total of 189 pregnant diabetic women gave birth at our hospital. In this randomized prospective study the influence of maternal diabetes treatment in normoglycemic patients, continuous subcutaneous insulin infusion (n = 48) versus intensified conventional treatment (n = 41), is evaluated. These two groups of patients are further compared to patients (n = 28) who underwent conventional diabetes treatment during pregnancy. It can be shown from our data that the rate of complications such as preeclampsia, intrauterine growth retardation, premature labor and premature delivery can be reduced by intensified conventional and insulin pump treatment as compared to conventionally treated patients with late onset of pregnancy care. As expected, in the groups of CSII and ICT patients no difference in the rate of pregnancy complications nor in fetal outcome could be demonstrated. Among CSII pregnancies 12/48 were complicated, in the ICT population the respective figure was 13/41 (CT: 20/28). The mean gestational age at the time of delivery ranged between 38 and 40 weeks, depending on the severity of maternal diabetes. CT patients were delivered earlier in all White classes. Fetal morbidity was nearly equal in CSII and ICT children, in CT patients it was greatly enhanced. Also the mortality (perinatal and neonatal) was considerably larger in CT patients (6/28), again, in the CSII and ICT population the mortality was nearly identical (2/48 and 3/41). We conclude, from our prospective information, that insulin pump therapy during pregnancy is indicated if intensified conventional treatment does not lead to normoglycemia.(ABSTRACT TRUNCATED AT 250 WORDS)     

Hypertension in pregnancy

Hypertension is a common complication of pregnancy and remains a major cause of maternal and perinatal morbidity and mortality worldwide. Hypertensive disorders range from mild gestational hypertension to severe pre-eclampsia which remains one of the leading causes of maternal death in the UK. Although there have been major advances in understanding the pathophysiology of the disease in recent years, interventions to prevent hypertensive disorders in pregnancy have had disappointing results. Due to their unpredictable nature and potential poor outcomes, patients with hypertensive disorders of pregnancy warrant cautious care with consultant obstetric, neonatal and anaesthetic involvement to optimize both maternal and fetal outcomes.     

Intensive insulin therapy in pregnancy: Strategies for successful implementation in pregestational diabetes mellitus

The role of intensive insulin therapy (IIT) in the reduction of long-term diabetes-related complications is well established. Normal blood glucose level prior to and during pregnancy is critical in reducing both short- and long-term morbidity and mortality in mother and infant. IIT in pregnancy, though occasionally challenging, is necessary to achieve and maintain normal blood glucose level during pregnancy. Current knowledge and recent advances in insulin formulations and delivery systems have improved our ability to achieve glycemic targets in pregnancy while limiting maternal and fetal morbidity. The objective of this review is to discuss contemporary strategies for successful use of IIT in pregnancy.     

Intensive insulin therapy in pregnancy: strategies for successful implementation in pregestational diabetes mellitus.

The role of intensive insulin therapy (IIT) in the reduction of long-term diabetes-related complications is well established. Normal blood glucose level prior to and during pregnancy is critical in reducing both short- and long-term morbidity and mortality in mother and infant. IIT in pregnancy, though occasionally challenging, is necessary to achieve and maintain normal blood glucose level during pregnancy. Current knowledge and recent advances in insulin formulations and delivery systems have improved our ability to achieve glycemic targets in pregnancy while limiting maternal and fetal morbidity. The objective of this review is to discuss contemporary strategies for successful use of IIT in pregnancy.     

Diabetes in pregnancy

Diabetes is probably the most frequent pathological condition that influences the outcome of pregnancy. 0.2–0.3% of women of reproductive age are known to have diabetes prior to conception and a further significant proportion of pregnancies in otherwise normal women may be complicated by gestational diabetes. Diabetic pregnancy is a high risk state for both the woman and fetus. The usual complications of pregnancy such as infection, hydramnios, pre-eclampsia and placental insufficiency may occur more frequently and the diabetic state predisposes additional complications. These include: the development of progression of specific diabetic complications; particularly retinopathy; miscarriage; stillbirth; intrauterine death; congenital malformation and macrosomia in the fetus; increased perinatal mortality rate and neonatal morbidity. Without appropriate care of established diabetes during pregnancy, perinatal mortality may exceed 10% and the rate of major congenital malformations is at least 2–3 times higher than in non-diabetic pregnancies. Increased fetal growth in the last trimester of pregnancy is the main risk in gestational diabetes and early recognition through screening is important. Most of these complications can be reduced to the level of the non-diabetic pregnant population by expert medical care and the achievement of nearly normal glucose levels in the pregnant woman.