妊娠期糖尿病中英文版

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,妊娠期糖尿病中英文版,American Diabetes Association: Clinical practice Recommendations, Diabetes Care, 21, 1, S60, 1988,EMRC,GDM,Gestational Diabetes Mellitus,(GDM) is defined as:,Carbohydrate intolerance of varying severity with the first recognition of onset occurring during pregnancy,Epidemiology of glucose intolerance and GDM in women of child bearing age, Diabetes Care, 21, 1998,EMRC,Percent,Prevalence,：,Diabetes affects 2-4% of pregnancies overall in the U.S.,90% of cases are Gestational Diabetes,10% with pre-existing DM (65% type 2),Higher in African-American, Hispanic, Native-,American and Asian women,1-5%,Etiology,During pregnancy, the,placenta,is secreting diabetogenic hormones, which increase insulin production,growth hormone,corticotropin releasing hormone,human placental lactogen,progesterone,妊娠前,妊娠后,糖代谢异常,显性诊断DM,隐性或未就诊,糖尿病合并妊娠,妊娠期糖尿病,糖尿病与妊娠的关系,糖代谢正常临界,发病年龄 病程 其他器官受累,B级：显性糖尿病 20岁 10年,C级： 1019岁 或 达1019年,D级：,30 years old,previous history of large baby,pre-pregnancy weight of 110% of ideal body weight,previous unexplained perinatal loss or malformed child,suspicious Macrosomia polyhydramnios,检查高危人群, 可漏诊14-50%GDM,GDM,的诊断:筛查,筛选实验,Screening Test,50 gram oral glucose load,：,1973年OSullivan Mahan,正常人群妊24-28周口服50克糖，一小时后抽血，血糖,， 诊断率,85%,7.2mmol/L, Specialty,87%,Sensitivity,79%,高危人群：妊娠任何期均可，阴性1月后重复,血浆或血清血糖值较全血值高14%，不推荐使用微量血,糖仪检测,GDM,的确诊,A,75gOGTT,(oral glucose tolerance test),：,禁食812小时，取空腹fasting血，再用300毫升水冲75克糖口服，服糖后1、2、3小时取血,空腹 1小时 2小时 3小时,北大,OGTT两点异常，确诊为GDM；,一点异常诊为妊娠期糖耐量低减(GIGT):,50g糖筛（200 mg/dl），不做,75gOGTT，测2次空腹血糖,B 两次空腹血糖（105mg/dl）；或任何一次血糖（200mg/dl），空腹血糖（105mg/dl）。,根据饮食控制后空腹血糖及餐后2小时血糖分为：,A1 空腹血糖，餐后2小时血糖,，仅需饮食控制,A2 空腹血糖，或餐后2小时血糖,，饮食控制+用胰岛素,GDM,治疗原则,高危管理,饮食管理,运动治疗,药物治疗,分娩处理,新生儿处理,高危孕期管理,孕前咨询： 血压、EKG、肝,肾功能及眼底,不宜妊娠：心肾功能受损；增生性视网膜病变；孕前3-6个月停口服降糖药, 胰岛素控制血糖,糖化血红蛋白示8周左右血糖水平,高危门诊产检： 28周前 2周；28周后 1周 监测血糖、尿,糖及酮体,B ultrasound 20-24周彩超检查除外心脏和神经系统畸形;,28周后每4-6周复查彩超，了解胎儿生长发育及羊水情况。,胎儿超声心动检查除外先心病和肥厚性心肌病,Fetal monitoring,34周 NST,BPS biophysical profile score,fetal pulmonary maturity 适时入院,GDM,:饮食治疗,dietician制订 (产科及内分泌知识),能量供应：33 kcal/kg,碳水化合物45-50；蛋白质20-25；脂肪30,热量分配为：早10，午30，晚30，睡前10,四餐间加餐：5， 10， 5,监测血糖： 空腹,mmol/L,三餐前 5.8 mmol/l,餐后2小时,6.7 mmol/l,GDM,饮食选择,碳水化合物：含纤维素的全麦食物,水果：草莓，菠萝，文旦，猕猴桃,绿叶蔬菜,蛋白质：海洋鱼类，禽蛋，乳类，豆制品,钙：,1200,毫克,/,日,维生素,:,Vit.D;Vit.B,C,;,叶酸,GDM,运动,运动治疗 增加胰岛素敏感性，减少腹壁脂肪，降低,游离脂肪酸水平,坐位：上臂及下肢脚踏运动，3次/周，20分/次；,散步，缓慢游泳，太极拳,原则：不负重、不引起早产， BP140/90mmHg，,心率不超过规定心率：（220年龄）X70%,禁忌: 糖尿病重症 妊高征,GDM,药物治疗,禁用口服降糖药,；,胰岛素治疗：,饮食控制不满意、持续呈尿酮体阳性,方法：三餐前短效胰岛素，睡前中效胰岛素；,或速效加中效胰岛素混合（,1,：,2,），早餐前用,全天量的,2/3,，晚上,1/3,。,短效胰岛素（诺和灵、优必林）,皮下：,30,分作用，,2-4h,高峰，半衰期,4h,静脉：血中半衰期,4-5,分，小剂量滴注,6-8u/h,中效胰岛素 高峰4-8h，皮下,血糖控制正常水平时易发生低血糖反应，,两餐间和睡前少量加餐可预防,术前停皮下胰岛素，据血糖水平调节静脉胰岛素用量；mmol/L,或1:4静脉补液,分娩后减量:产后24小时减量至孕期的1/2, 第二日减至1/3, 后根据血糖水平渐停用胰岛素或恢复孕前用量；产后鼓励母乳喂养、运动,胰岛素的应用,体内多余糖量（mg）（测得血糖值mg/dl100）（核算成每升体液）10公斤体重（全身体液量）,例：孕妇体重55 kg，空腹血糖14 mmol/l（250 mg/dl ）,体内多余糖量（mg）（250100）49500 mg49.5 g。按2 g血糖需1u胰岛素计算，胰岛素需，初次给量为1/21/3,RI开始剂量按体重及孕周计算：,2432周0.8u / kg /d,3236周0.9u / kg /d,3640周1.0u / kg /d,血糖控制标准,空腹及三餐前血糖 (3.3-5.6mmol/L),三餐后1小时血糖,三餐后2小时血糖 (4.4- 6.7mmol/L),HbA1c正常值4-6%，糖尿病患者控制7%。,GDM 分娩,处理,Must weigh maternal and fetal risks , With excellent glycemic control and normal fetal surveillance, can await spontaneous labor,If antepartum testing is non-reassuring and lungs are mature - deliver patient,timing and mode of delivery,labor induction,38 week,or cesarean section，,amniocentesis,fetal pulmonary maturity,Time of Delivery,Controlled DM between 38-40 weeks;,Uncontrolled Diabetes 37 38 weeks;,Poorly uncontrolled DM, severe pre-eclampsia 36 weeks;,Earlier if fetal distress;,Mode of Delivery,Vaginal delivery is expected in the:,average estimated weight of fetus 10年,巨大胎儿,胎盘功能不良,其他产科合并症,CESARIAN SECTION,Macrosomic fetus (risk of shoulder dystocia) 4000 gm,Certain cases of IUGR or fetal distress,Malpresentations,Slow progress and descent during labour,complications such as Hypertension polyhydromnios,other obstetric indications such as placenta praevia,Severe vaginal infections especially with primigravida,Others,: Elderly primigravida, bad obstetric history,GDM,新生儿处理,新生儿医师在场,抢救复苏准备,分娩后两小时查血糖,:,血糖,40,毫克,/,分升,查血常规,如,HCT70%,必要时换血,注意低钙,预防黄疸,注意高胰岛素血症,导致的心肌损害,GDM,孕妇远期随访,follow-up testing for Diabetes,所有GDM及GIGT产妇均应在产后6周-12周重复75gOGTT或查空腹及餐后血糖，异常诊断为DM，标准与内科相同,50% chance of developing DM within the next 20 years,(normal,7%),2002 Kim荟萃分析发现产后6周-28年，约有2.6-70%GDM发展为2型糖尿病。,我国缺少GDM产后随访的大样本多中心前瞻性研究。,孕20周前诊断的GDM、FPG明显异常、孕期INS用量大于100U/天常预示产后糖代谢异常持续存在。产后尽早复查FPG。,GDM、DM病人产后避孕,目前无证据表明DM可损害生育能力,contraceptive choices,：工具、宫内环；,口服避孕药：仅限于无心血管及视网膜病变者，且注意其对抗胰岛素的作用,Multicenter Survey of GDM (1993-1994),2416 pregnant women,Five hospital clinics of TUMS,Universal Screening,Carpenter &,Custan,Criteria,GCT*,130 mg /dl (Positive),*,Glucose Challenge Test,Iranian Journal of Endocrinology and Metabolism, 1999, Vol 1, No 2, 125-133,Journal of Endocrinology, Abstract Supplement, 19,th,EMRC,Multicenter Survey The prevalence of GDM,2416 Cases,GDM : 4.7%,IGT : 7.6 %,It is a moderate prevalence in the world,Iranian Journal of Endocrinology and Metabolism, 1999, Vol 1, No 2, 125-133,Journal of Endocrinology, Abstract Supplement, 19,th,EMRC,86%,of all GDM patients can be diagnosed by,Screening based on historical risk factors,.,Iranian Journal of Endocrinology and Metabolism, 1999, Vol 1, No 2, 125-133,Journal of Endocrinology, Abstract Supplement, 19,th,EMRC,Conclusion,The clinical recognition of GDM is important because appropriate therapy can reduce fetal and maternal morbidity,Thank You,Thank You !,不尽之处，恳请指正！,