推进循证依据在妊娠期糖尿病诊治实践中的应用

随着健康与疾病的发育起源(Development of Health and Disease,DOHaD)学说研究的不断深入,孕期高血糖对胎儿近远期的影响越来越受到关注.尽管我国对妊娠期糖尿病(gestational diabetes mellitus,GDM)的研究仅有20余年历史,但该领域的相关研究已经取得一定进展,并受到国际同行的关注.     

妊娠期糖尿病医学营养治疗

妊娠期糖尿病进行医学营养治疗能够减少孕期并发症发生,改善妊娠结局。文章从营养治疗的目标及原则、与运动和胰岛素治疗的关系以及产后营养治疗的方向等方面分别进行阐述,并以举例的方式阐述妊娠期糖尿病膳食的制定方法及注意事项。     

妊娠期糖尿病的医学营养治疗

妊娠期糖尿病(Gestationaldiabetesmellitus,GDM)系指在妊娠期发生或首次发现的不同程度的糖代谢异常,近年来其发病率逐年升高。GDM会导致母、儿并发症的增加,如妊娠期高血压、先兆子痫、早产、羊水过多等。胎儿处于高血糖及高胰岛素状态时,其巨大儿、肩难产、新生儿产伤及低血糖等并发症也将增加。一系列关于GDM产后追访研究表明,GDM者产后2型糖尿病风险明显增加;其子代易发生胰岛素抵抗、糖耐量异常及成年2型糖尿病,同时,心血管疾病和肥胖的风险也增加。国外2005年一项前瞻性、随机对照研究表明,妊娠期的血糖控制可以明显降低GDM者…     

妊娠期糖尿病的治疗依据和实际方法

妊娠期糖尿病是妊娠中期以后出现对胰岛素抵抗性增大,母体胰腺不相适应而出现糖耐量异常。其诊断标准见表1,至少要有2项达到方可诊断。     

妊娠期糖尿病的医学营养治疗疗效评价

目的:探讨医学营养治疗对妊娠期糖尿病(GDM)孕妇妊娠结局的影响.方法:将我院门诊产前检查确诊为GDM,并完成随访的孕妇分为医学营养治疗(MNT)组61例与非干预组60例.同时选择同期在我院分娩的正常孕妇作为正常对照组60例.比较3组的母儿并发症的发生率.结果:MNT组巨大儿、新生儿低血糖、新生儿住院、羊水过多发生率均低于非干预组,差异有统计学意义(P＜0.05);两组妊娠期高血压疾病、胎膜早破、早产、胎儿窘迫、剖宫产、足月低体重儿(小于胎龄儿)、新生儿呼吸窘迫综合征(NRDS)发生率比较,差异无统计学意义(P＞0.05).非干预组巨大儿、新生儿低血糖、新生儿住院发生率均明显高于正常对照组(P＜0.05),两组羊水过多、妊娠期高血压疾病、胎膜早破、早产、胎儿窘迫、剖宫产、足月低体重儿(小于胎龄儿)、NRDS发生率比较,差异无统计学意义(P＞0.05).MNT组与正常对照组比较,羊水过多、妊娠期高血压疾病、胎膜早破、早产、胎儿窘迫、剖宫产、巨大儿、足月低体重儿(小于胎龄儿)、新生儿低血糖、新生儿住院、NRDS发生率差异均无统计学意义(P＞0.05).结论:医学营养治疗可有效减少GDM围生期母儿并发症,有利于获得良好的母儿结局.     

妊娠期营养干预循证医学评价方法

妊娠期营养缺乏或过剩均可导致后代的不良结局。妊娠期营养缺乏近期可导致出生低体重儿、早产、出生先天畸形、围生期死亡。尽管人类流行病学研究的证据还不确定，但动物实验研究表明，必需脂肪酸的缺乏可导致胎儿发育迟缓及视觉功能障碍。妊娠期营养缺乏者的后代患2型糖尿病、心血管疾病、中心性肥胖和脂代谢异常的危险性明显增高。某些微量元素的缺乏也可能会导致智力发育异常。也有学者提出免疫系统疾病也可能与宫内营养缺乏有关。妊娠期膳食营养素摄入不足，亦可引起孕妇营养性贫血、骨软化症、营养性水肿等。     

个体化饮食控制对妊娠期糖尿病患者治疗结局的影响

目的:探讨个体化饮食控制对妊娠期糖尿病(GDM)治疗结局的影响,并确定GDM患者合适血糖水平.方法:从2009年1月至2012年1月间在本院实施常规产前检查、住院分娩的妊娠妇女中筛选75例GDM患者(其中GDM 50例,妊娠期糖耐量异常25例),实施个体化饮食控制治疗(研究组).比较控制治疗前后血糖水平,并和同期正常妊娠孕妇(对照组)的妊娠结局进行对照.结果:随访所有孕妇的妊娠结局,研究组和对照组比较,妊娠期高血压疾病、羊水过多、胎膜早破、巨大儿及尿路感染的发生率差异无统计学意义(P＞0.05).个体化饮食控制治疗前后最高餐后血糖及空腹血糖比较差异有统计学意义.血糖分层水平妊娠并发症发生率比较显示,血糖相关的指标越高,其发生妊娠并发症的机会越高;空腹血糖和餐后最高血糖控制在4.0 ～4.8 mmol/L和4.8～7.0 mmoL/L时妊娠并发症发生率最低.结论:个体化饮食控制可明显改善GDM的治疗结局,并提出空腹血糖和最高血糖控制在4.0～4.8 mmol/L和4.8 ～7.0mmol/L为合适水平.     

探讨个体化营养管理与集体宣教讲课对妊娠期糖尿病患者的管理作用#br#

目的探讨个体化营养管理与集体宣教讲课两种方式对妊娠期糖尿病(GDM)患者的管理作用。方法选取首都医科大学附属北京地坛医院2017年7月至2019年10月收治的GDM患者108例,根据随机数字表法分为对照组(54例,集体宣教讲课)和研究组(54例,个体化营养管理)。对比两组患者治疗后体质量指数(BMI)、体重增长、糖化血红蛋白(HbA1c)、新生体重有无区别,对比两组治疗后的营养状况[血清白蛋白(Alb)、血清前白蛋白(PA)、血红蛋白(HBG)],对比两组母体及围产儿的妊娠结局情况。结果两组治疗后BMI、体重增长、新生儿体重差异均无统计学意义(P>0.05),两组治疗后糖化血红蛋白差异有统计学意义(P<0.05),且研究组糖化血红蛋白低于对照组;治疗后两组血清Alb、PA、HBG无明显区别(P>0.05);研究组母体及围产儿妊娠不良结局的发生率与对照组相比差异均无统计学意义(P>0.05)。结论相比单纯集体宣教讲课,个体化饮食指导及管理可显著增加患者的依从性,更好地控制GDM血糖水平。     

妊娠期脂代谢异常及其营养治疗

妊娠期妇女的全身各系统会产生一系列变化以适应妊娠过程中自身和胎儿的需要，其中，脂代谢也会发生一些相应的生理改变。脂类是脂肪和类脂及其许多衍生物的总称，脂蛋白复合体是脂类在血液中的运输形式，按照脂蛋白在不同密度的介质中的沉降特性，将血浆脂蛋白分为4类：乳糜微粒（CM），极低密度脂蛋白（VLDL），低密度脂蛋白（LDL），高密度脂蛋白（HDL）。     

绝经激素治疗循证临床实践指南的系统评价

目的:系统评价绝经激素治疗(MHT)循证临床实践指南。方法:计算机检索Pub Med、Web of Science、美国国家指南库(national guideline clearinghouse,NGC)、国际指南网(guideline international network,GIN)及新西兰指南组(New Zealand Guidelines Group,NZGG)、中国期刊全文数据库和万方数据库,纳入MHT循证临床实践指南,检索时限为2005~2015年,采用指南研究与评价工具Ⅱ(Appraisal of Guidelines for Research and EvaluationⅡ,AGREEⅡ)评价指南方法学质量。提取指南中MHT的主要药物雌激素(E)、孕激素(P)、E+P、替代药物替伯龙(Tibolone)和雷洛昔芬(Rolaxifene)对适用人群可能带来的利益、风险和使用方法,并通过核对数据后制成清单。结果:纳入的6篇指南整体质量较好,其中5个指南的总体得分≥60%,仅北美绝经学会指南评分为58%。在范围和目的、参与人员、严谨性、清晰性、应用性、编辑独立性各领域的平均得分依次为81%、74%、67%、74%、53%、65%,应用性领域平均得分最低(53%)。所有指南均强调MHT实践应注意个体化,应充分考虑不同个体的生理情况,评估MHT利益和风险,同时需征求患者意愿。评估的内容包括对患者年龄、绝经类型及年限、绝经症状程度及MHT效用、MHT后心血管疾病及肿瘤风险、家族史等。5个指南推荐使用雌激素最低有效剂量缓解绝经期症状。结论:纳入研究的6个MHT循证临床实践指南整体质量较好,在MHT指南更新或制定新指南时应加强应用性领域的考虑。在MHT的临床实践中应体现个体化原则,做好风险和利益评估工作。激素使用的剂量方面提倡个体化使用雌激素最低有效剂量缓解绝经期症状。     

妊娠期糖代谢异常的医学营养治疗

妊娠期糖代谢异常(gestational impaired glucose tolerance,GIGT)是指妊娠期发生或首次发现的不同程度的糖代谢异常,包括妊娠期糖尿病(gestational diabetes mellitus,GDM)和妊娠期糖耐量减低(impaired glucose tolerance,IGT).有糖尿病家族史、孕妇体重＞90kg、分娩巨大儿或畸形儿史、高龄、反复自然流产等为GIGT的高危因素.随着人们生活水平的提高、部分人群饮食结构的不合理以及妊娠期糖筛查试验的普及等,GIGT的临床发病率呈上升趋势.     

妊娠糖尿病胰岛素治疗与围生儿预后

目的 探讨在妊娠糖尿病（GDM）治疗中胰岛素、饮食以及开始治疗时间早晚对围生儿预后的影响。方法 选择诊断为妊娠糖尿病者109例，其中采用饮食加胰岛素治疗22例，单纯饮食控制组低于应用胰岛素组，差异显著（P＜0.05）。围生儿结局显示：巨大儿发生率、红细胞增多症发生率三组为34周后饮食控制组＞34周前饮食控制组＞胰岛素治疗组。结论 GDM要早诊断、早治疗，尤其是应用胰岛素正规治疗对降低围生儿病率、巨大发生率以及控制孕妇血糖水平有重要意义。     

饮食控制对妊娠糖尿病的治疗作用

目的 研究饮食控制对妊娠糖尿病（ＧＤＭ）的治疗作用。方法 分析１７８例妊娠合并糖尿病患者病例,收集经营养门诊及病房会诊指导后的ＧＤＭ患者的血糖值（包括空腹血糖和早餐后２小时血糖）和未经营养指导ＧＤＭ患者的血糖值。结果 营养指导后的ＧＤＭ患者的血糖水平明显低于非指导组,且营养指导后血糖水平低于指导前。结论 饮食控制对妊娠糖尿病具有治疗作用。     

Birth weight and its relation with medical nutrition therapy in gestational diabetes

Purpose

The cornerstone in treatment of gestational diabetes mellitus (GDM) is medical nutrition therapy (MNT), but the effect on birth weight is disputed. The birth weight was evaluated with respect to length of MNT and adherence to diet.

Methods

We performed a cohort study on 436 women with GDM and 254 non-diabetic women. Women with a normal oral glucose tolerance test were included as controls as they had similar background predisposition as the women with GDM. The GDM women were subdivided according to MNT and the nutritional status was further stratified according to adherence to the current dietary guidelines.

Results

Birth weight above 4 kg was more prevalent in the non-diabetic women compared to the diet-treated GDM women (27 vs. 18%, p = 0.012) but similar to the GDM women who had no MNT (24%). Lower birth weight was associated with longer duration of MNT (r = ?0.13, p = 0.021). The birth weight was 1.2 g lower per day of treatment.

Conclusions

Medical nutrition therapy was associated with reduction of the fetal weight in women with GDM and the weight decreases with length of treatment. Birth weight above 4 kg was as prominent in the non-diabetic women as in the women with GDM without MNT.

     

Incidence of gestational hypertension in gestational diabetes mellitus

The purpose of this study has been to establish the incidence of gestational hypertension (GH) in women with gestational diabetes mellitus (GDM) and to examine the frequency of complications in women with co-existent GDM and GH. Furthermore, we wished to evaluate the significance of urine albumin excretion determined by the urine albumin creatinine ratio (ACR). A total of 215 successive pregnancies with risk factors for gestational diabetes, as defined by the Danish National Board of Health screened for gestational diabetes by the WHO criteria, were reviewed. Women who had a normal OGTT during the screening served as controls. Gestational hypertension was defined as a mean arterial pressure (MAP) >105 mmHg (systolic BP ≥140 mmHg and/or diastolic BP ≥90 mmHg). The two groups were comparable with regard to initial body mass index (BMI) and MAP. GH appeared with a higher frequency in women with GDM (28%) than in women with normal OGTT (10%) P=0.003 χ² test. Serious complications (perinatal mortality, malformations, acute caesarean section) also appeared with a higher frequency in women with GH and GDM (10%) than in women with GH but with normal OGTT (2%) P=0.0083 χ² test. We observed a significant increase in ACR in the group with complications (GDM and GH) during gestation regardless of intensive antihypertensive treatment. We also observed that ACR was significantly higher in women with GDM and GH when compared to women with GDM and a normal blood pressure. The BMI was consistently higher in women with GH, regardless of whether they had GDM or not as compared to the normotensive group. GH appears with a higher frequency in women with GDM and the co-existence seems correlated with a higher frequency of complications. The correlation between urine albumin excretion and complications might suggest that regulating GH should strive to normalise ACR in women with GDM. Received: 25 October 2001 / Accepted: 8 December 2001 Correspondence to J. Kvetny     

Inflammatory mediators in gestational diabetes mellitus

The connection between inflammation and insulin resistance has garnered much interest in the past decade. Epidemiologic as well as experimental data have supported the association. The purpose of this article is to review the current evidence linking inflammatory mediators and gestational diabetes mellitus.     

Placental vanadium in gestational diabetes mellitus

Although many studies in animal models and in cell cultures have shown that vanadate has insulin-like effects, it has not been studied in human diabetes mellitus. In this study the levels of vanadium in human placentae from 23 pregnancies complicated by gestational diabetes mellitus were compared with 18 uncomplicated non-diabetic pregnancies closely matched for maternal age, gravidity, and gestational age. Using the unpaired Student's t-test, the mid-disc placental levels in gestational diabetes (7.62 +/- 1.29 micrograms/g dry weight) were significantly lower (p less than 0.05) than controls (8.73 +/- 1.85 micrograms/g dry weight). These findings appear to be independent of placental size and birthweight. When these data were analyzed according to treatment, the vanadium levels in insulin-treated cases (8.07 +/- 1.32 micrograms/g dry weight) were not significantly different from the matched controls (8.84 +/- 1.69 micrograms/dry weight); the levels in noninsulin treated cases (7.08 +/- 1.25 micrograms/g dry weight), however, were significantly (p less than 0.005) lower than controls (8.99 +/- 1.96 micrograms/g dry weight). It is interesting to speculate that there may be increased binding of vanadium to maternal tissues in human diabetes mellitus when insulin is deficient.     

肥胖与妊娠期糖尿病

妊娠期糖尿病(gestational diabetes mellitus,GDM)是妊娠期间首次发生或发现的糖代谢异常,是在妊娠期发展的一种对碳水化合物不耐受的状态。近年来肥胖及GDM的发病率逐年增高,成为必须重视的问题。肥胖是GDM发病的独立危险因素,可导致不良妊娠结局。本文从妊娠期肥胖的评价指标及妊娠期肥胖的管理等角度,阐述肥胖与GDM的关系。     

二甲双胍在妊娠期糖尿病药物治疗中的应用

妊娠期糖尿病(gestational diabetes mellitus,GDM)是孕期常见的并发症,可增加母婴并发症的发生,并可能导致母亲及其子代2型糖尿病和代谢综合征的发生风险增加.通常情况下通过饮食控制和运动治疗,可以将75%～80%GDM孕妇的血糖控制理想,对于血糖控制不理想者,目前胰岛素是首选药物,但胰岛素治疗也存在一些缺点,如需皮下注射、花费高、可能发生低血糖和体重增加过度等问题.