妊娠期糖尿病中英文版.ppt

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,*,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,显性诊疗DM,隐性或未就诊,糖尿病合并妊娠,妊娠期糖尿病,糖尿病与妊娠旳关系,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 23年,C级：1019岁 或 达1023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,检验高危人群,可漏诊14-50%GDM,GDM,旳诊疗:筛查,筛选试验,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,7.8mmol/L，诊疗率,85%,7.2mmol/L,Specialty,87%,Sensitivity,79%,高危人群：妊娠任何期均可，阴性1月后反复,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旳确诊,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,国际 5.6 10.5 9.2 8.0,北大,5.5 10.2 8.2 6.6,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11.1mmol/L（200 mg/dl），不做,75gOGTT，测2次空腹血糖,B 两次空腹血糖5.8mmol/L（105mg/dl）；或任何一次血糖11.1mmol/L（200mg/dl），空腹血糖5.8mmol/L（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5.8mmol/l，餐后2小时血糖,6.7mmol/l，仅需饮食控制,A2 空腹血糖5.8mmol/l，或餐后2小时血糖,6.7mmol/l，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,孕前征询：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周彩超检验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。,胎儿超声心动检验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制定(产科及内分泌知识),能量供给：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,5.6mmol/L,三餐前 3.35.8 mmol/l,餐后2小时,6.7 mmol/l,GDM,饮食选择,碳水化合物：含纤维素旳全麦食物,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 增长胰岛素敏感性，降低腹壁脂肪，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，,心率不超出要求心率：（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、连续呈尿酮体阳性,措施：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,全天量旳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，,两餐间和睡前少许加餐可预防,术前停皮下胰岛素，据血糖水平调整静脉胰岛素用量；分娩时血糖不低于5.6mmol/L,或1:4静脉补液,分娩后减量:产后二十四小时减量至孕期旳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,胰岛素旳应用,体内多出糖量（mg）（测得血糖值mg/dl100）（核实成每升体液）10公斤体重0.6（全身体液量）,例：孕妇体重55 kg，空腹血糖14 mmol/l（250 mg/dl）,体内多出糖量（mg）（250100）10550.649500 mg49.5 g。按2 g血糖需1u胰岛素计算，胰岛素需24.5u，首次给量为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,血糖控制原则,空腹及三餐前血糖,5.6mmol/L,(3.3-5.6mmol/L),三餐后1小时血糖7.8mmol/L,三餐后2小时血糖,6.7mmol/L,(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 23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,急救复苏准备,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,造成旳心肌损害,GDM,孕妇远期随访,follow-up testing for Diabetes,全部GDM及GIGT产妇均应在产后6周-12周反复75gOGTT或查空腹及餐后血糖，异常诊疗为DM，原则与内科相同,50%chance of developing DM within the next 20 years,(normal,7%),2023 Kim荟萃分析发觉产后6周-28年，约有2.6-70%GDM发展为2型糖尿病。,我国缺乏GDM产后随访旳大样本多中心前瞻性研究。,孕20周前诊疗旳GDM、50gGCT 11.1mmol/L、FPG明显异常、孕期INS用量不小于100U/天常预示产后糖代谢异常连续存在。产后尽早复查FPG。,GDM、DM病人产后避孕,目前无证据表白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旳作用,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,Joint Meeting of the British Endocrine Societies,with the European Federation of Endocrine Societies,13-16 March 2023,p.124,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,Joint Meeting of the British Endocrine Societies,with the European Federation of Endocrine Societies,13-16 March 2023,p.124,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,Joint Meeting of the British Endocrine Societies,with the European Federation of Endocrine Societies,13-16 March 2023,p.124,EMRC,Conclusion,The clinical recognition of GDM is important because appropriate therapy can reduce fetal and maternal morbidity,Thank You,