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。     

妊娠合并糖尿病急性并发症的诊断与处理

1酮症酸中毒 1.1概述妊娠合并糖尿病酮症酸中毒(diabetic ketoacidosis,DKA)是一种可危及母亲及胎儿生命的急性综合征.由于孕妇代谢变化特点,在妊娠合并糖尿病孕妇中发病率可达3%～22%.妊娠糖尿病并发酮症的主要原因在于高血糖及胰岛素相对或绝对缺乏,导致体内血糖不能被利用,体内脂解增加,酮体产生增多.而其它诱发因素尚有:①医生及孕妇对糖尿病,尤其是对妊娠期糖尿病(GDM)认识不足.②对妊娠期体内胰岛素的需要量认识不足,未能及时调整用药量.③妊娠期生理性缓冲系统代偿功能下降.④并发妊高征时可诱发DKA.⑤糖尿病孕妇易合并感染,此时对胰岛素的需要量明显增加而未予补足.⑥使用肾上腺皮质激素及β受体兴奋剂.⑦临产后食物摄入不足或手术刺激.这些诱发因素多数由于产科医师在处理中不慎所致,也正是由于这些处理中的不及时或不妥当导致了高达35%的围生儿病死率[1].     

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.     

妊娠合并糖尿病──妊娠合并糖尿病急性并发症的诊断与处理

1　酮症酸中毒1.1　概述　妊娠合并糖尿病酮症酸中毒 (ｄｉａｂｅｔｉｃｋｅｔｏａｃｉ ｄｏｓｉｓ ,ＤＫＡ)是一种可危及母亲及胎儿生命的急性综合征。由于孕妇代谢变化特点 ,在妊娠合并糖尿病孕妇中发病率可达 3%～ 2 2 %。妊娠糖尿病并发酮症的主要原因在于高血糖及胰岛素相对或绝对缺乏 ,导致体内血糖不能被利用 ,体内脂解增加 ,酮体产生增多。而其它诱发因素尚有 :①医生及孕妇对糖尿病 ,尤其是对妊娠期糖尿病 (ＧＤＭ )认识不足。②对妊娠期体内胰岛素的需要量认识不足 ,未能及时调整用药量。③妊娠期生理性缓冲系统代偿功能下降。④…     

餐后血糖与妊娠期糖尿病胎儿发育研究进展

妊娠期糖尿病(GDM)系指妊娠期间首次发生或识别的糖耐量异常.GDM患者高血糖对妊娠妇女、胎儿和新生儿的负性影响将引起严重的母婴并发症.餐后血糖增高是GDM血糖控制差的重要表现,也是GDM代谢紊乱的最早期表现.研究发现控制餐后血糖尤其是餐后1h血糖水平可以有效改善妊娠结局,降低剖宫产率,减少巨大儿、大于胎龄儿及畸形儿的发病率,减少产伤.故GDM患者妊娠期监测餐后1h血糖水平可以用于指导饮食控制和胰岛素治疗剂量的调整.     

中孕早期血清铁蛋白水平对妊娠期糖尿病的预测价值

妊娠期糖尿病(gestational diabetes mellitus,GDM)是指妊娠期间发生或首次发现的糖尿病或糖耐量异常.多数GDM孕妇早期无明显自觉症状,部分GDM孕妇空腹血浆血糖(fasting plasma glucose,FPG)也正常,因此,妊娠期仅依靠FPG检查易导致GDM早期漏诊[1].一项包括9个国家共23 316例孕妇的流行病学调查研究了高血糖和不良妊娠结局(hyperglycemia and adverse pregnancy outcomes,HAPO),结果显示母体高血糖与巨大胎儿、新生儿高血糖、高剖宫产率及血清C肽水平均呈正相关[2].因此,探讨如何早期诊断GDM以减少高血糖对母儿的危害具有非常重要的意义.     

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…     

妊娠期高血糖致子代胰岛素抵抗分子机制的研究进展

流行病学研究已经证实,妊娠合并糖尿病患者的子代从儿童期到成年期各年龄段普遍存在胰岛素抵抗,并且与母亲糖尿病的类型无关[1-11].母亲妊娠期任何程度的血糖水平升高都将对子代产生不良影响[12].动物实验研究结果也表明,宫内高血糖环境的仔鼠成年期存在胰岛素抵抗[13-14].这印证了"成人疾病的胎儿起源"学说,说明妊娠期高血糖对子代糖代谢的影响可能有统一的生物学机制[15].     

妊娠期高血糖的诊断及管理

妊娠期高血糖（HIP）母儿不良结局明显增加,不仅近期并发症增加,远期发展为糖尿病风险也明显增加。妊娠期高血糖包括孕前糖尿病合并妊娠（PGDM）和妊娠期糖尿病（GDM）。我国二孩政策全面放开后,高危人群比例增加,HIP孕妇比例将进一步增加。对于妊娠期高血糖的筛查、诊断、管理策略及母儿的远期随访等问题均应引起关注。     

妊娠期高血糖的诊断及管理

妊娠期高血糖（HIP）母儿不良结局明显增加，不仅近期并发症增加，远期发展为糖尿病风险也明显增加。妊娠期高血糖包括孕前糖尿病合并妊娠（PGDM）和妊娠期糖尿病（GDM）。我国二孩政策全面放开后，高危人群比例增加，HIP孕妇比例将进一步增加。对于妊娠期高血糖的筛查、诊断、管理策略及母儿的远期随访等问题均应引起关注。     

孕期持续性空腹高血糖对妊娠糖尿病预后的意义

目的:研究妊娠期空腹高血糖和餐后高血糖与产后发展为糖尿病(DM)之间的关系。方法:随访98例妊娠糖尿病(GDM)患者至产后8年,比较分析了需胰岛素治疗组、需使用夜间发挥作用的胰岛素组以及不需使用胰岛素组3组产后发展为DM几率的差别。结果:需使用夜间发挥作用的胰岛素GDM患者与不需胰岛素治疗者比较,前者有更大的可能产后发展为DM(RR=6.1,95%CI=2.8~14.2,P<0.01)。仅餐前需使用短效胰岛素的患者,与不需使用胰岛素的患者相比,差异无显著性,产后发展为DM(RR=1.4,95%CI=0.4~3.9,NS)的可能性较小。结论:因使用夜间发挥作用的胰岛素用量可反映空腹血糖的水平,故推论孕期出现持续性空腹高血糖的GDM患者,产后进一步发展为DM的可能性更大。     

Diabète gestationnel, surpoids, obésité

Gestational diabetes mellitus might be either an unknown type 2 diabetes mellitus diagnosed during pregnancy or a glucose tolerance impairment appearing during pregnancy; these two conditions have different prognosis. There is a positive linear correlation between maternal hyperglycemia and perinatal complications. Maternal obesity is an independent risk factor for perinatal complications.     

The safety and efficacy of insulin analogs in pregnancy.

Diabetes during pregnancy is accompanied by increasing needs for maternal insulin and ongoing biological changes that cause maternal insulin requirements to reach higher and lower extremes throughout the day than in non-pregnant patients. As maternal hyperglycemia increases the risk of fetal and maternal morbidity, it is essential for the mother to maintain normoglycemia during pregnancy. With the advent of insulin analogs that feature improved absorption and physiological profiles over human insulin, the achievement of normoglycemia throughout pregnancy has become more attainable. This review provides a discussion of the application of the insulin analogs to diabetes during pregnancy and compares the benefits of rapid-acting insulin analogs with long-acting insulin analogs during pregnancy. This review further proposes a treatment protocol for achieving and maintaining normoglycemia throughout pregnancy.     

Recurrence of gestational diabetes mellitus.

OBJECTIVE: To assess the influence of several maternal and neonatal variables on the recurrence of gestational diabetes mellitus. METHODS: A retrospective review was conducted on 90 of our patients whose index pregnancy was complicated by gestational diabetes mellitus and whose subsequent pregnancy was also managed at our institution. RESULTS: Forty-seven women (52%) had a recurrence of gestational diabetes mellitus in their subsequent pregnancy. These 47 women had an increased body mass index (BMI) (32.8 +/- 8.2 versus 28.9 +/- 7.2 kg/m2; P < .03) and more large for gestational age (LGA) neonates (38 versus 14%; P < .05) and more of them required insulin during their index pregnancy (38 versus 19%; P < .05) than did those who did not have a recurrence of gestational diabetes mellitus. Women who developed a recurrence of gestational diabetes mellitus also had higher fasting (P < .05), 1-hour, 2-hour, and total glucose tolerance test values (P < or = .01) during their index pregnancy. CONCLUSION: Women with a history of gestational diabetes mellitus who have a BMI greater than 35 kg/m2, whose previous newborn was LGA, and who required insulin during their previous pregnancy are at increased risk for recurrence of gestational diabetes mellitus.     

Placental glucose transport in gestational diabetes mellitus

OBJECTIVE: We have previously reported that type 1 diabetes mellitus with hyperglycemia during the first trimester is associated with an up-regulation of placental glucose transport at term. We speculated that glucose concentrations regulate placental glucose transporters only during early pregnancy. To test this hypothesis we studied placental glucose transport in gestational diabetes mellitus, which is associated with hyperglycemia mainly during the second half of pregnancy. STUDY DESIGN: Syncytiotrophoblast microvillous membrane vesicles and basal membrane vesicles were isolated from uneventful pregnancies (control group, n = 32) and pregnancies complicated by gestational diabetes mellitus (n = 18). Glucose uptake and glucose transporter 1 expression were studied by means of radiolabeled tracers and Western blotting, respectively. RESULTS: Gestational diabetes mellitus was not associated with alterations in placental glucose transport. Separate analysis of 6 patients in the gestational diabetes mellitus group with large-for-gestational-age babies did not affect these results. CONCLUSION: These findings are consistent with the hypothesis that the sensitivity of placental glucose transporters to regulation by nutrient availability is limited to early pregnancy.     

Interconception Care for Women With Prior Gestational Diabetes Mellitus

The diagnosis of gestational diabetes mellitus (GDM) signals greater pregnancy risk but also increased lifelong risk of developing diabetes and cardiovascular disease. In women with GDM, insulin resistance exceeds that observed in normal pregnancy and to varying degrees may persist or worsen after birth. Therefore, during postpartum and interconception periods, women with a history of GDM must be monitored for manifestations of increasing insulin resistance, hyperglycemia, dyslipidemia, hypertension, and increased adiposity. Care of women with prior GDM in the postpartum and interconception periods affords clinicians a unique opportunity for targeted screening and health promotion. The objective of this review was to synthesize evidence related to interconception care for women following a pregnancy complicated by GDM and to suggest principles of care: 1) case finding and multiple patient/clinician reminders for women with prior GDM are necessary so that screening occurs in the postpartum through interconception periods; 2) monitoring of metabolic (glucose) and cardiovascular risk (lipids, blood pressure, adiposity) should occur at regular intervals and more often in women with additional risk factors such as insulin use during pregnancy, early diagnosis of GDM, obesity, prediabetes, and dyslipidemia; 3) breastfeeding and use of long‐term contraception should be encouraged; and 4) lifestyle modifications that are effective in preventing and delaying disease should be encouraged.     

Restriction fragment length polymorphisms of the insulin gene hypervariable region in gestational onset diabetes mellitus

Restriction fragment length polymorphisms in the insulin gene hypervariable region are compared among 93 women with gestational onset diabetes mellitus and 146 women with normal glucose tolerance during pregnancy. No significant differences in gene or genotype frequencies were observed in the overall sample (p greater than 0.50). However, an increased frequency of one allele (class 1) was observed among nonoverweight patients with gestational onset diabetes mellitus with elevated fasting plasma glucose levels compared with age-, race-, and parity-matched control subjects (p = 0.061). These data suggest that gestational onset diabetes mellitus is a heterogeneous disorder with respect to both genotypic and phenotypic characteristics, and that restriction fragment length polymorphisms near the insulin gene may serve as a molecular marker for susceptibility to gestational onset diabetes mellitus only in some women.     

Does intensive glycemic control in diabetic pregnancies result in normalization of other metabolic fuels?

Intensive treatment of insulin-dependent diabetes mellitus during pregnancy often normalizes plasma glucose levels. However, it is unclear whether this adversely affects other metabolic fuels that are essential to normal fetal growth and development. Metabolic studies were conducted after the subjects ingested a standardized mixed meal during each trimester in 7 normal and 15 insulin-dependent diabetic pregnant women. The latter were treated with continuous subcutaneous insulin infusion or multiple injections, which were adjusted to achieve strict glucose control throughout pregnancy. Insulin, alanine, branched-chain amino acids, triglycerides, free fatty acids, and ketones were measured every 15 to 30 minutes before a standardized breakfast and for 150 minutes after the breakfast. Patients with insulin-dependent diabetes mellitus were studied while they received their unusual insulin dosages. Fasting glucose levels (87 +/- 7 mg/dl) and glucose levels 150 minutes after the meal (112 +/- 11 mg/dl) were near normal. However, normoglycemia was achieved at the expense of increased plasma insulin levels (area under insulin response curves, p less than 0.01, vs nondiabetic curves). Nevertheless, fasting and post-prandial plasma branched-chain amino acids, alanine, and free fatty acids were similar in both groups. Fasting cholesterol, triglyceride, and ketone levels were also normalized. We conclude that normalization of circulating amino acids and lipids in conjunction with correction of hyperglycemia may contribute to favorable outcomes in infants of intensively treated diabetic mothers.     

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.     

妊娠合并糖尿病酮症酸中毒12例临床分析

目的:探讨妊娠合并糖尿病酮症酸中毒(DKA)的临床特征。方法:回顾性分析本院收治的资料完整的妊娠合并DKA 12例患者的临床特征和母儿结局。结果:本组妊娠合并DKA发病率0.36‰;发生在孕早期1例(8.3%)、孕中期2例(16.7%)、孕晚期9例(75.0%);孕前糖尿病(PGDM)8例(66.7%),妊娠期糖尿病(GDM)4例(33.3%)。12例均为单胎自然妊娠、均未进行孕前咨询及正规产检,有不良孕产史4例,孕前超重4例,既往血糖升高史1例,糖尿病家族史1例。12例均未规范产检且胰岛素用量不足;感染5例(41.7%),重度子痫前期3例(25.0%),地塞米松诱发2例(16.6%),先兆临产应激2例(16.6%),饮食不当1例(8.3%)。实验室检查,p H值7.050~7.319,BE-11.6~-28.8,平均血糖20.91±6.13 mmol/L,平均血酮体3.06±1.44 mmol/L,平均糖化血红蛋白(Hb A1c)为(9.04±2.09)%,10例患者尿糖阳性,12例患者尿酮体均为阳性,且均存在不同程度的电解质紊乱。12例患者均在4~8小时内成功酮体转阴,血糖控制达标。入院前就发生死胎者3例,难免流产1例;入院后仅8例继续妊娠,其中4例因妊娠合并症在DKA纠正后的1~3天终止妊娠,4例妊娠足月分娩,8例新生儿均存活。结论:妊娠合并DKA的发病率随孕周的增加而增加,PGDM比GDM者更易发生;患者存在不同程度的内环境紊乱及胰岛素使用不规范和感染。高危妇女应规范筛查并积极诊治糖尿病,早期识别并规范处置DKA,可获得良好的母儿预后。