现代妇产科学课件：Gestational Diabetes Mellitus

GestationalDiabetesMellitus12ZimmetPetal.DiabetMed.2003;20:693-702.25.039.759%10.419.788%38.244.216%1.11.759%13.626.998%

81.8156.191%18.2

35.997%2003年有1.89亿患者2025年预计患者人数将达3.24亿增长72%单位：百万我国目前有4000万糖尿病患者2015年患病率超过10%，患者数超过1亿目前每天新增病例3000人GDM，definedasglucoseintolerancewithonsetorfirstrecognitionduringpregnancy,isacommonpregnancycomplicationthataffect1-14%ofallpregnanciesandisagrowinghealthconcern.DefinitionGlucosemetabolismchangesduringpregnancyFastingblood-glucose空腹血糖：lowerthan10%whennotpregnancyEstrogenincreasesinsulinsecretionwithbetacellproliferation.Thelackofactivityoffetalliverenzymesystem,theenergyrequiredfrommaternalglucose.Kidneyfiltrationrateareincreasedduringpregnancy.Insulinactionincreaseinfastingsituationwhenthepregnancy。Factorsofinsulinantagonism抵抗剂

duringpregnancyAlotofhormonessecretedbytheplacentahasinsulinantagonism.Accordingtotheeffectintheorder：Adrenocorticalhormone＞HPL＞Progesterone＞Estrogen.Thisantagonismeffectcanbewithdrawwithafewhoursorafewdaysafterbirth.

HPLFatmetabolismLipodieresis

脂肪分解Ketoplasia酮体生成ResultinKetoacidosis酮症酸中毒PhysiologicalcharacteristicsofthepregnancyPhysiologicalcharacteristicsLowerfastingglucoseGlycosuria糖尿aftermealInsulinresistentketonepositivePregnancypromotingtheroleofdiabetesEasytoinducehungerketoacidosis酮症酸中毒complicationssuchashypoglycemiacoma低血糖昏迷.Withtheincreaseofgestationalage,insulinantagonismincreased

PregnancyDiabetes?TheEffectsofdiabetesonpregnancy

Preeclampsia子痫前期ThreetimeshigherPolyhydramnios羊水过多10％～30％，Tentimesmorethannon-diabeticwomen.Fetalmalformationtypeinvolveseachviscera内脏Pretermashighas10%~30％Macrosomia巨大儿incidenceof25～40％PostpartumhemorrhageUterinesmoothmusclecellexcessiveextend,notrecoverintime.Puerperalinfection产褥感染

whitebloodcellshaveavarietyoffunctionaldefects,phagocytosis吞噬作用andbactericidalfunctionaldeficiency,lowerimmunefunctionThecommonsitesofinfection

Vulva外阴vaginacandida假丝酵母菌infectionandurinarytractinfectionGestationaldiabeteswithrichvaginaglycogenenvironmentforcandidayeast酵母growthandadhesion.Theincidenceofpyelonephritis肾盂肾炎fivetimeshigherthanwithoutGDM.

Fetaldistressandtheperinataldeath

突然死亡

mortalityratebetween0~4%bloodglucosefluctuationsketoacidosisSeriouselectrolytedisorder

FetaldistressandevendeathEffectsofGDMonnewbornErythrocytosis

红细胞增多

Hyperinsulinemia高胰岛素血症

Hyperbilirubinemia高胆红素血症

Hypocalcemia低钙血症

Neonatal

respiratory

distress

syndrome

妊娠期高血糖对胎儿及新生儿的影响Macrosomia巨大儿adiposity肥胖substrate底物erythropoietin促红细胞生成素polycythemia红细胞增多TheeffectsofdiabetesonoffspringinfutureOffspringaremorelikelytoshowthelanguagedevelopmentaldisorders,eyemovementcoordinationandsocialinterpersonalskill

willbepoorIn2009Canada,followed-upfor18monthsto84monthsrespectivelybetweendiabeticoffspringandnormalcontrolgroup,theresultsDiabeticoffspringlanguagescoreislowof0.27~0.41thanthecontrolgroupMother'sculturaldegreehadcertaininfluenceonchildren'slanguagedevelopmentEffectsofgestationalhyperglycemiaoncarbohydratemetabolism

ofGDMoffspringGestationalhyperglycemiaincreaseoffspringmetabolicabnormalitiesLindaetalcompareincidenceofGDMbetweendiabeticoffspringandno-diabeticoffspring:IncidenceofGDMis7timesthanthatofnormalchildren'sIncidenceoftype2diabetespostpartumAnalyzed28centresbetween1965-2001,atotalof65222cases,follow-uptothelongest28years.Thecumulativeincidenceoftype2diabetes6weeks2.6%28years70%5yearssignificantlyhigherlevels10yearspostpartumasteadylevelDiabetesCare2002;25:1862HighriskfactorofGDMOvertheageof30DiabetesfamilyhistoryHistoryofunexplainedabnormallabor;Suchasmiscarriagestillbirthprematurestillbirthteras畸胎andhistoryofmacrosomiaHistoryofgestationaldiabetesPolyhydramnios羊水过多

RecurrentepisodesofvaginalcandidainfectionObesity（BMI>25KG/M2）2timesormorepositiveglycosuriaoffasting

Weightgainduringpregnancytoomuch.PCosObesityinpregnancyObesityChildhoodObesityAdolescence

GDMmacrosomiaIR增加ClinicalObstetricsandGynecology,2007,50:972~979DMGDMLGA大于胎龄儿7岁39岁4Diagnoses

Mainlybasedonglucosetolerancetest※Medicalhistoryandclinicalfinding.※AccessoryexamineIADPSG.

Diagnosisofovert显性diabetesduringpregnancyFastingplasmaglucose≥7.0mmol/LRandomplasmaglucose≥11.1mmol/LHbA1C≥6.5%RecommandationofIADPSGAntenatalexaminationofpregnantwomenforthefirsttime：FPG、HbA1CandrandomplasmaglucosewerebeexaminedIfFPG≧7.0mmol/L，HbAlc≧6.5%，orRPG≧11.1mmol/Landsymptomswithdiabetes，itwillbediagnoseaspregnancywithdiabetes.IfFPG≧5.1mmol/L,<7.0mmol/L,diagnosesdasGDM;IfFPG<5.1mmol/L,OGTTwillbedonebetween24~28gestationalweeksRecommandationofIADPSG

75gOGTTissuitableforAllpregnantwomenduringgestation（0、1h、2h）IFFPG≧7.0mmol/L，Pregnancywithdiabetes.ThediagnosisofGDMismadewhenanyofthefollowingplasmaglucosevaluesareexceeded:•Fasting92mg/dl(5.1mmol/l)•1h180mg/dl(10.0mmol/l)•2h153mg/dl(8.5mmol/l).DiagnosticcriteriaofInternationalAssociationofDiabeticPregnancyStudyGroupManagementofGDMPlasmaglucosemonitorPropagndaandenduationDietary/PhysicalactivityDrugPGMonitorofGDMduringpregnancyPlasmaglucose：Self-monitoringissuperiortoahospitalcheckingregularly.Ketonuria：Helpdeterminetheproprietyofcarbohydrates.Urinesugar：nosignificance.Fetal：Ultrasoundassessmentfetalabnormalities.WhenFBG＞5.8mmol/Litshouldpayattentiontotheoccurrenceoffetalintrauterinedeath.PrincipleofNutrition

Nottoloseweightduringpregnancy;Donotadvocatelowquantityofcalorie(notlessthan1800kcal/day).Manymealsbutlittlefoodateach,ithadbetterthreemeals,threedesserts.Fruitisbestbetweenmeals,thenumberoffruitperdaylessthan250grams

.Vegetablesnotlessthan500gramsaday,greenvegetablesarenolessthan50%.Totalcaloric

calculationAtthefirsthalfofpregnancy(DBW)×30～35kcal/kg/d+150kcalInthesecondhalfofpregnancy(DBW)×30～35kcal/kg/d+350kcalLactationperiod泌乳期(DBW)×30～35kcal/kg/d+600kcalHeight≤165cmDBW=height(cm)－105cmHeight>165cmDBW=height(cm)－100cm

DietComposition

Carbohydrate50～60%oftotalCHO(g)=CHO(kcal)÷4Protein(Pro),15～20%oftotalPro(g)=Pro(kcal)÷4Fat,20～30%oftotalFat(g)=Fat(kcal)÷9OutlineoffoodexchangeportionFoodinaccordancewiththesource,naturewillbedividedintoseveralcategories,Similarfoodcontainedincertainweightwithintheprotein,fat,carbohydratesandcaloriessimilar，Thecaloriesofdifferenttypesarethesame,witheach90kcalstandard.

DistributionofmealsBreakfast10~15%dessert5~10%(9-10am)Lunch30%dessert5~10%(2-3pm)Supper30%dessert5~10%(30’-1hbeforesleep)Glycemicindexoffood(GI）

GlucoseofdifferentGI

高GI食物低GI的食物时间血糖血糖时间高GI食物葡萄糖吸收快，RAG，Glu释放入血快低GI食物葡萄糖缓慢吸收，SAG，Glu释放峰值低Whybloodglucosevaluesaredifferentaftermeal?

GlycemicindexofcommonfoodGIofthebeanproductsGIoffruitHowtocontrolplasmaglucosewithGI

Coarsecereals杂粮mixedwithriceorwheat.Simpleness.Eattingmuchmoredietaryfiber.Eattingmoreproteinsindinner

DefinitionofGlycemicLoad(GL)血糖负荷Consideringtheglycemicindex(GI)offoodaswellasthecarbohydratecontentprovidedGIxgCHO/100=GlycemicLoad

HigherGlycemicLoadiseasytoincreasebloodglucose.HighGlycemicLoad(GL)ofthedietforalongtime

mayincreasetheriskoftype2diabetesandcardiovasculardiseaseratesFoster-PowellKetal:AJCN2000;76:5-56GlycemicLoad–ExamplesofcalculationSteamedbread(GL)=

73(GI)x44.2g(CHO)/100=32Halfofcupofrawcarrots:GL=

92(GI)x6g(CHO)/100=5GL值的范围低GL(Low)

10中GL(Medium)=11~19高GL(High)20Foster-PowellKetal.AJCN2002;76:5-56TheidealgoalofPGlevelmg/dl(mmol/L)FPG60-95(3.3-5.3)PPG1.5-2h100-120(5.5-6.7)2:00-6:0060-120(3.3-6.7RecommendationofweightgainduringpregnancyBMIweightgain(kg)weightgain(kg/w)<19.812.5~180.519.8~2611.5~160.426~297~11.50.3>29<7ExerciseIncreaseglucoseutilization,controlplasmaglucose;Improvethestateofinsulinresistance,increaseinsulinsensitivityToreduceweightDrugtreatment

Therearestill20%ofthepatientsneedinsulintherapy.Ingeneral,5.3mmol/LforFPG,ormorethan6.7mmol/L2hoursaftermealwassuggestedasindicatorsforinsulintreatment.Indicationsofinsulintherapy

Type1diabetespatientsFPGmorethan5.3mmol/Land/orPPGmorethan6.7mmol/Lfor3timesaweek.Gestationalagesmalldiagnosedandhighfastingglucose.GlucoseInsulinMotherFetusPlacentaFetalHyperglycemiaFetalHyperinsulinemiaStimulatesfetalpancreasType Onsettime Peaktime duration

shorttime（诺和灵R） 30’ 1~3h 8hIntermediate（诺和灵N）1.5h4~12h 24h

Premix（诺和灵30R） 30’2~8h 24hPremix（诺和灵50R） 30’2~8h24h

InsulinPreparations

SimulatethenormalinsulinsecretionmodeBreakfastLunchDinner8:0012:0016:0020:00PremixedinsulindosesThetotaldose0.2-0.7U/kg/d（basedongestationalage）.Accountsfortwo-thirdsoftotalbeforebreakfast,one-thirdoftotalbeforedinner.AdjustinsulindosebeforebreakfastordinneraccordingtoplasmaglucosemonitoringAttentionsforinsulinadjustmentSmalldoseschange,itisadvisabletoadjustto1to2u,veryfewof4u.Closemonitoringofplasmaglucose:themostidealformonitoringseventimes/day.InsulintherapyforpostpartumGDMisnolongerneededinsulintherapy,mostpatientsneedtimelyreductionorwithdrawal,preventhypoglycemiaDiabeteswithpregnancy,needtoreducedosetoqua