Gestational-diabetes-mellitus：妊娠期糖尿病课件

GestationaldiabetesmellitusPiyawadeeWuttikonsammakit,M.D.GestationaldiabetesmellitusPPrevalenceofdiagnoseddiabeteshasincreased:14.5(1991)47.9cases/1000(2003)Increasingprevalenceoftype2diabetesinyoungerpeopleMaternalhyperglycemialeadstofetalhyperinsulinemia,obesity&insulinresistanceinchildhoodGDMPrevalenceofdiagnoseddiabetDefinedascarbohydrateintoleranceofvariableseveritywithonsetorfirstrecognitionduringpregnancySomewomenwithGDMhavepreviouslyunrecognizedovertdiabetesFastinghyperglycemiaearlyinpregnancyalmostinvariablyrepresentsovertdiabetesGDMDefinedascarbohydrateintoleNoconsensusregardingtheoptimalapproachUniversalorselectivescreeningPlasmaglucoseafter50gglucosetest(50gmglucosechallengetest–GCT)isthebesttoidentifywomenatriskforGDMOne-stepapproachortwo-stepapproachScreeningNoconsensusregardingtheoptLowrisk:bloodglucosetestingnotroutinelyrequiredifallthefollowingarepresent:MemberofanethnicgroupwithalowprevalenceofGDMNoknowndiabetesinfirst-degreerelativesAge<25yearsWeightnormalbeforepregnancyWeightnormalatbirthNohistoryofabnormalglucosemetabolismNohistoryofpoorobstetricaloutcomeFifthinternationalworkshop-conferenceongestationaldiabetesLowrisk:bloodglucosetestiAveragerisk:performbloodglucosetestingat24-28weeksusingeither:Two-stepprocedure:50-gGCT,followedbyadiagnostic100-gOGTTOne-stepprocedure:diagnostic100-gOGTTperformedonallsubjectsGDMscreeningAveragerisk:performbloodgHighrisk:Performbloodglucosetestingassoonasfeasible,suingtheproceduresdescribedaboveifoneormoreofthesearepresent:SevereobesityStrongfamilyhistoryoftype2diabetesPrevioushistoryofGDM,impairedglucosemetabolism,orglucosuriaIfGDMisnotdiagnosed,bloodglucosetestingshouldberepeatedat24-28weeksoratanytimetherearesymptomsorsignssuggestiveofhyperglycemiaGDMscreeningHighrisk:PerformbloodglucCriteriaNDDGcriteria

(OGTT)**Carpenter-Coustancriteria(OGTT)**IADPSG

(OGTT)*Fasting10595921hr1901801802hr1651551533hr145140-DiagnosisNationalDiabetesDataGroup.Classificationanddiagnosisofdiabetesmellitusandothercategoriesofglucoseintolerance.Diabetes1979;28:1039-57CarpenterMW,CoustanDR.Criteriaforscreeningtestsforgestationaldiabetes.AmJObstetGynecol1982;144:768-73AmericanDiabetesAssociation.DiagnosisandClassificationofDiabetesMellitus.DiabetesCare2011;34(suppl1):S62-S69CriteriaNDDGcriteriaCarpenteDiagnosisFasting2hourafterloaded75gmglucoseDiabetes>=126mg/dor>=200mg/dlImpairedglucosetolerance(IGT)<126mg/dland>=140and<200mg/dlImpairedfastingglucose(IFG)110-125mg/dland<140WHOcriteriadiagnosisDiagnosisFasting2hourafterlFastingplasmaglucose2hrpostprandialGDMA1<105mg/dland<120mg/dlGDMA2>=105mg/dlor>=120mg/dlGDMFastingplasmaglucose2hrposFetalanomaliesarenotincreasedRiskoffetaldeathisnotapparentforthosewhohavediet-treatedpostprandialhyperglycemiaElevatedfastingglucoselevelshaveincreasedratesofunexplainedstillbirthsduringthelast4-8weeksofgestationIncreasedfrequencyofhypertensionandcesareandeliveryMaternalandfetaleffectsFetalanomaliesarenotincreaACOG2000:birthweightexceeds4500gAnthropometricallydifferentfromotherLGAinfants:excessivefatdepositionontheshouldersandtrunkPredisposestoshoulderdystociaorcesareandeliveryMaternalhyperglycemiapromptsfetalhyperinsulinemiaduringsecondhalfofgestation,whichinturnstimulatesexcessivesomaticgrowthMacrosomiaACOG2000:birthweightexceedMacrosomiaandErb’spalsyMacrosomiaandErb’spalsyNeonatalhyperinsulinemiamayprovokehypoglycemia(<35mg/dl)withinminutesofbirthMaternalobesityisanindependentandmoreimportantriskfactorforlargeinfantsinwomenwithGDMthanisglucoseintoleranceMaternalobesityisanimportantconfoundingfactorinthediagnosisofGDMMacrosomiaNeonatalhyperinsulinemiamayDietExerciseGlucosemonitoringInsulinManagementDietManagementAverageof30kcal/kg/dbasedonprepregnantbodyweightfornonobesewomen30%caloricrestrictionforobesewomenwithBMI>30kg/m2MonitoredwithweeklytestsforketonuriaMaternalketonemialinkedwithimpairpsychomotordevelopmentinoffspringDietAverageof30kcal/kg/dbasedExerciseimprovedcardiorespiratoryfitnessPhysicalactivityreducedriskofGDMResistanceexercisediminishedtheneedforinsulintherapyinoverweightwomenwithGDMExerciseExerciseimprovedcardiorespirGestational-diabetes-mellitus：妊娠期糖尿病课件BodyweightcontrolPrepregnancyBMITotalweightgain(kg)Ratesofweightgain2ndand3rdtrimester(kg/wk)Underweight(<18.5kg/m2)12.5-180.51(0.44-0.58)Normalweight(18.5-24.9kg/m2)11.5-160.42(0.35-0.50)Overweight(25.0-29.9kg/m2)7-11.50.28(0.23-0.33)Obese(>=30.0kg/m2)5-90.22(0.17-0.27)RasmussenKM,YaktineAl.Weightgainduringpregnancy:reexaminingtheguildelines.Washington:CommitteetoReexamineIOMPregnancyWeightGuidelines;InstituteofMedicine;NationalResearchCouncil2009:254BodyweightcontrolPrepregnancAimFastingplasmaglucose<95mg/dl1hrpostprandial<140mg/dl2hrpostprandial<120mg/dlGlucosemonitoringAimGlucosemonitoringDailyselfglucosemonitorVSintermittentfastingglucoseevaluationsemiweekly:fewermacrosomicinfantsandgainlessweightindiet-treatedGDMThewomenwithGDMA2:1hourpostprandialbloodglucosesuperiortopreprandial:fewerneonatalhypoglycemia,lessmacrosomia,fewerCSfordystociaGlucosemonitoringDailyselfglucosemonitorVSACOG2001hasnotrecommendedtheseagentsduringpregnancyHalfofmaternalconcentrationinwomentreatedwithglyburideIncreasingsupportuseofglyburideasanalternativetoinsulininGDMMeta-analysis2008:noincreasedperinatalriskswithglyburidetherapyandrecommendedfurtherrandomizedtrialsOralhypoglycemicagentsACOG2001hasnotrecommendedTheFifthInternationalworkshopconferencerecommendedthatmetformintreatmentforGDMbelimitedtoclinicaltrialswithlong-terminfantfollowupRCT2008:metforminVSinsulin:notassociatedwithincreasedperinatalcomplications,but46%requiredsupplementalinsulinMetforminTheFifthInternationalworkshRapidactingShort(regular)IntermediateLongactingInsulintherapyRapidactingInsulintherapyInsulinactingInsulinactingInitiateinsuliniffastingglucoselevels>105mg/dlTotaldoseof20-30unitsdailyBeforebreakfastiscommonlyusedtoinitiatetherapySplit-doseinsulin(twicedaily):dividedinto2/3intermediate-actingandathirdshort-actinginsulinInsulintherapyInitiateinsuliniffastingglACOG2001hassuggestedthatCSdeliveryshouldbeconsideredinwomenwithasonographicallyEFW>=4500ElectiveinductiontopreventshoulderdystociainwomenwithsonographicallydiagnosedfetalmacrosomiaiscontroversialSonographicsuspicionofmacrosomiawastooinaccuratetorecommendinductionorprimaryCSdeliverywithoutatrialoflaborObstetricalmanagementACOG2001hassuggestedthatCNoconsensusregardingwhetherantepartumfetaltestingisnecessary,andifso,whentobeginsuchtestinginwomenwithoutseverehyperglycemiaThosewomenwhorequireinsulintherapyforfastinghyperglycemia,typicallyundergofetaltestingandaremanagedasiftheyhadovertdiabetesObstetricalmanagementNoconsensusregardingwhetherLaborevaluationElectronicfetalmonitoringDTXq1-2hrInsulinivdripOffinsulinafterdeliveryNewbornevaluation:birthweight,APGARscore,hypoglycemiaIntrapartummanagementLaborevaluationIntrapartummaBloodglucose(mg/dl)Insulindosage(unit/hour)Fluids(125ml/hr)<1000D5(N/2orLRS)100-1401.0D5(N/2orLRS)141-1801.5Normalsaline181-2202.0Normalsaline>2202.5NormalsalineInsulinIVdripAmericanCollegeofObstetriciansandGynecologists.PregestationaldiabetesMellitus.ACOGPracticeBulletin60.Washington,DC;ACOG;2005Bloodglucose(mg/dl)InsulindTimeTestPurposePostdelivery(1-3d)FastingorrandomPGDetectpresistent,overtdiabetesEarlypostpartum(6-12wk)75g2-hOGTTPostpartumclassificationofglucosemetabolism1yrpostpartum75g2-hOGTTAssessglucosemetabolismannuallyFPGAssessglucosemetabolismTri-annually75g2-hOGTTAssessglucosemetabolismPrepregnancy75g2-hOGTTClassifyglucosemetabolismPostpartumevaluation:Fifthinternationalworkshop-conferenceTimeTestPurposePostdelivery(NormalImpairedfastingglucoseorimpairedglucosetoleranceDiabetesmellitusFasting<110mg/dlFasting110-125mg/dlFasting>=126mg/dl2hr<140mg/dl2hr>=140-199mg/dl2hr>=200mg/dlClassificationoftheADA2003NormalImpairedfastingglucose33-37%underwentpostpartumscreeningtestsRecommendationsforpostpartumfollow-uparebasedonthe50%likelihoodofwomenwithGDMdevelopingovertdiabeteswithin20yearsIffastinghyperglycemiadevelopsduringpregnancy,thendiabetesismorelikelytopersistpostpartumInsulintherapyduringpregnancy,andespeciallybefore24weeks,isapowerfulpredictorofpersistentdiabetesPostpartumevaluation33-37%underwentpostpartumscWomenwithHxofGDMarealsoatriskforcardiovascularcomplicationsassociatedwithdyslipidemia,hypertension,abdominalobesity–themetabolicsyndromeRecurrenceofGDMinsubsequentpregnancieswasdocumentedin40%ObesewomenweremorelikelytohaveimpairedglucosetoleranceLifestylebehavioralchanges:weightcontrolandexercisePostpartumevaluationWomenwithHxofGDMarealsoLow-dosehormonalcontraceptivesmaybeusedsafelybywomenwithrecentGDMContraceptionLow-dosehormonalcontraceptivPregestationaldiabetesmellitusPregestationaldiabetesmellitClassAgeofonsetDurationVasculardiaseaseBOver20<10NoneC10-1910-19NoneDBefore10>20BenignretinopathyFAnyAnyNephropathyRAnyAnyProliferativeretinopathyHAnyAnyHeartWhiteclassificationClassAgeofonsetDurationVascuDiagnosisofovertdiabetesduringpregnancyAmericanDiabetesAssociation2011DiagnosisofovertdiabetesduPregestational-orovert-diabeteshasasignificantimpactonpregnancyoutcomeRelatedtodegreeofglycemiccontrol,degreeofunderlyingcardiovascularorrenaldiseasePregestationaldiabetesPregestational-orovert-diabetFactorDiabetic(%)Nondiabetic(%)PvalueGestationalhypertension289<0.001Pretermbirth285<0.001Macrosomia4513<0.001Fetalgrowthrestriction510<0.001Stillbirths1.00.40.06Perinataldeaths1.70.60.004PregnancyoutcomesFactorDiabetic(%)NondiabeticImprovedfetalsurveillance,neonatalintensivecare,andmaternalmetaboliccontrolhavereducedperinatallossesto2-4%Twomajorcausesoffetaldeath:congenitalmalformationsandunexplainedfetaldeathIncidenceofmajormalformationsinwomenwithtype1diabetesisapproximately5%Hyperglycemia-inducedoxidativestressthatinhibitsexpressionofcardiacneuralcrestmigrationFetaleffectsImprovedfetalsurveillance,nAnomalyRatioofincidenceCaudalregression252Situsinversus84Spinabifida,hydrocephaly,orotherCNSdefects2Anencephaly3Cardiacanomalies4Anal/rectalatresia3Renalanomalies5Renalagenesis4Cystickidney4Duplexureter23CongenitalmalformationsininfantsofwomenwithovertdiabetesAnomalyRatioofincidenceCaudCaudalregressionsyndromeCaudalregressionsyndromePregestationalDMEarlyabortionisassociatedwithpoorglycemiccontrol(HbA1c>12%,persistentpreprandial>120mg/dl) Increasedpretermdelivery(bothspontaneous&indicated)MacrosomiaandhydramniosIUGR(advancedvasculardiseaseorcongenitalmalformations)PregestationalDMEarlyabortioStillbirthswithoutidentifiablecausesareaphenomenonrelativelyuniquetopregnanciescomplicatedbyovertdiabetes.Noobviousplacentalinsufficiency,abruption,FGR,oroligohydramniosTypicallylarge-for-gestationalageanddiebeforelabor,usuallyat35weeksorlaterHyperglycemia-mediatedchronicabberationsintransportofoxygenandfetalmetabolitesUnexplainedfetaldemiseStillbirthswithoutidentifiabRespiratorydistresssyndrome:fetallungmaturationwasdelayedindiabeticpregnanciesHypoglycemiaHypocalcemiaHyperbilirubinemiaPolycythemiaHypertrophiccardiomyopathyLong-termcognitivedevelopmentInheritanceofdiabetesNeonatalmortalityandmorbidityRespiratorydistresssyndromeExceptionofdiabeticretinopathy,,thelong-termcourseofdiabetesisnotaffectedbypregnancyMaternaldeathisuncommon,ratesarestillincreasedtenfoldDeathsmostoftenresultfromketoacidosis,hypertension,preeclampsia,pyelonephritis,ischemicheartdiseaseMaternaleffectsExceptionofdiabeticretinopa3stages1.microalbuminuria–30to300mgofalbumin/24h:manifestasearlyas5yearsafteronsetofdiabetes2.overtproteinuria–>300mg/24hr(maydevelophypertension):developafteranother5to10years3.end-stagerenaldisease-risingcreatinine,decreasedGFR:developinnext5to10yearsPGDMclassFsignificantlyincreasedpreeclampsiaandindicatedpretermdeliveryDiabeticnephropathy3stagesDiabeticnephropathyThefirstandmostcommonvisiblelesionsaresmallmicroaneurysmsfollowedbyblothemorrhages,hardexudates–benignornonproliferativeretinopathyAbnormalvesselsonbackgroundeyediseasebecomeoccluded,leadingtoretinalischemiaandinfarctions“cottonwoolexudate”–preproliferativeretinopathyNeovascularization(inresponsetoischemia)onretinalsurfaceandoutintovitreouscavityandhemorrhage–proliferativeretinopathyDiabeticretinopathyThefirstandmostcommonvisiDiabeticretinopathyDiabeticretinopathyTheeffectsofpregnancyonproliferativeretinopathyarecontroversialLaserphotocoagulationandgoodglycemiccontrolduringpregnancyminimizethepotentialfordeleteriouseffectsofpregnancyDiabeticretinopathyTheeffectsofpregnancyonprPeripheralsymmetricalsensorimotordiabeticneuropathyisuncommonDiabeticgastropathy,istroublesomeinpregnancycausesN/V,nutritionalproblems,anddifficultywithglucosecontrolTreatment:metoclopradmideandH2receptorantagonistsDiabeticneuropathyPeripheralsymmetricalsensoriRiskfactorsforpreeclampsiaincludeanyvascularcomplicationsandpreexistingproteinuria,withorwithoutchronichypertensionRiskofpreeclampsia11-12%inClassB,21-22%inclassC,21-23%inclassD,36-54%inclassF-RPreeclampsiaRiskfactorsforpreeclampsiaOnly1%MostseriouscomplicationMaydevelopwithhyperemesisgravidarum,B-mimeticdrugsgivenfortocolysis,infectionandcorticosteroidsFetallossisabout20%Pregnantwomenusuallyhaveketoacidosiswithlowerbloodglucoselevelsthanwhennonpregnant(293mg/dlVS495mg/dl)DiabeticketoacidosisOnly1%DiabeticketoacidosisABG,serumketone,electrolyte,bloodglucoseq1-2hrInsulinIVinfusion:loading0.2-0.4u/kg,maintenance2-10U/hFluids:NSS1Linfirsthour,500-1000ml/hfor2-4h,250ml/huntil80%replacedBegin5%D/NSSwhenglucoseplasmalevelreaches250mg/dlCorrectelectrolyte:K,bicarbonateManagementofketoacidosisduringpregnancyABG,serumketone,electrolyteAlltypesofinfections:candidavulvovaginitis,urinaryinfection,respiratorytractinfection,puerperalpelvicinfection,woundinfectionRenalinfectionwasassociatedwithincreasedpretermdeliveryInfectionAlltypesofinfections:candOptimalpreconceptionalglucosecontrolusinginsulinPreprandial70-100mg/dl,1hrpostprandial<140mg/dl,2hr<120mg/dlHbA1cwithinorneartheupperlimitofnormal(<6%)Mostsignificantriskformalformationwithlevels>10%Periconceptionalfolicacid400ug/dManagement:preconceptionalcareOptimalpreconceptionalglucosOHDarenotrecommendedforovertdiabetesGlycemiccontrolusuallyachievewithmultipledailyinsulininjectionsandadjustmentofdietaryintakeSelf-monitoringofcapillaryglucoselevelsusingaglucometerisrecommendedManagement:insulinOHDarenotrecommendedforovAcaloricintakeof30-35kcal/kg/d(fornormalweightwomen)ThreemealsandthreesnacksdailyUnderweightwomen:40kcal/kg/dForthose>120%aboveidealweight:24kcal/d55%carbohydrate:20%protein:25%fatDiabeticdietAcaloricintakeof30-35kcalAccuratedatingSecondtrimester:targetedsonographic18-20weekstodetectNTDandotheranomaliesThirdtrimester:followgrowth&fetalsurveillanceCaution:detectionoffetalanomaliesinobesewomenismoredifficultAvoidhypoglycemiaandhyperglycemiaIncreasedinsulinrequirementafterapproximately24weeksObstetriccareAccuratedatingObstetriccareIncreaseCSdeliveryrateDeletethedoseoflong-actinginsulingivenonthedayofdeliveryInsulinrequirementstypicallydropmarkedlyafterdeliveryInsulincalibratedpumpismostsatisfactoryItisnotunusualtorequirenoinsulinforthefirst24hoursorsopostpartumandthenfluctuateduringthenextfewdaysObstetriccareIncreaseCSdeliveryrateObsteNosinglecontraceptivemethodappropriateforallwomenwithdiabetesRiskofvasculardiseaseinhormonalcontraceptivesmaybeproblematicIUDincreasedriskofpelvicinfectionElectsterilizationisanoptionContraceptionNosinglecontraceptivemethodThankyouThankyouGestationaldiabetesmellitusPiyawadeeWuttikonsammakit,M.D.GestationaldiabetesmellitusPPrevalenceofdiagnoseddiabeteshasincreased:14.5(1991)47.9cases/1000(2003)Increasingprevalenceoftype2diabetesinyoungerpeopleMaternalhyperglycemialeadstofetalhyperinsulinemia,obesity&insulinresistanceinchildhoodGDMPrevalenceofdiagnoseddiabetDefinedascarbohydrateintoleranceofvariableseveritywithonsetorfirstrecognitionduringpregnancySomewomenwithGDMhavepreviouslyunrecognizedovertdiabetesFastinghyperglycemiaearlyinpregnancyalmostinvariablyrepresentsovertdiabetesGDMDefinedascarbohydrateintoleNoconsensusregardingtheoptimalapproachUniversalorselectivescreeningPlasmaglucoseafter50gglucosetest(50gmglucosechallengetest–GCT)isthebesttoidentifywomenatriskforGDMOne-stepapproachortwo-stepapproachScreeningNoconsensusregardingtheoptLowrisk:bloodglucosetestingnotroutinelyrequiredifallthefollowingarepresent:MemberofanethnicgroupwithalowprevalenceofGDMNoknowndiabetesinfirst-degreerelativesAge<25yearsWeightnormalbeforepregnancyWeightnormalatbirthNohistoryofabnormalglucosemetabolismNohistoryofpoorobstetricaloutcomeFifthinternationalworkshop-conferenceongestationaldiabetesLowrisk:bloodglucosetestiAveragerisk:performbloodglucosetestingat24-28weeksusingeither:Two-stepprocedure:50-gGCT,followedbyadiagnostic100-gOGTTOne-stepprocedure:diagnostic100-gOGTTperformedonallsubjectsGDMscreeningAveragerisk:performbloodgHighrisk:Performbloodglucosetestingassoonasfeasible,suingtheproceduresdescribedaboveifoneormoreofthesearepresent:SevereobesityStrongfamilyhistoryoftype2diabetesPrevioushistoryofGDM,impairedglucosemetabolism,orglucosuriaIfGDMisnotdiagnosed,bloodglucosetestingshouldberepeatedat24-28weeksoratanytimetherearesymptomsorsignssuggestiveofhyperglycemiaGDMscreeningHighrisk:PerformbloodglucCriteriaNDDGcriteria

(OGTT)**Carpenter-Coustancriteria(OGTT)**IADPSG

(OGTT)*Fasting10595921hr1901801802hr1651551533hr145140-DiagnosisNationalDiabetesDataGroup.Classificationanddiagnosisofdiabetesmellitusandothercategoriesofglucoseintolerance.Diabetes1979;28:1039-57CarpenterMW,CoustanDR.Criteriaforscreeningtestsforgestationaldiabetes.AmJObstetGynecol1982;144:768-73AmericanDiabetesAssociation.DiagnosisandClassificationofDiabetesMellitus.DiabetesCare2011;34(suppl1):S62-S69CriteriaNDDGcriteriaCarpenteDiagnosisFasting2hourafterloaded75gmglucoseDiabetes>=126mg/dor>=200mg/dlImpairedglucosetolerance(IGT)<126mg/dland>=140and<200mg/dlImpairedfastingglucose(IFG)110-125mg/dland<140WHOcriteriadiagnosisDiagnosisFasting2hourafterlFastingplasmaglucose2hrpostprandialGDMA1<105mg/dland<120mg/dlGDMA2>=105mg/dlor>=120mg/dlGDMFastingplasmaglucose2hrposFetalanomaliesarenotincreasedRiskoffetaldeathisnotapparentforthosewhohavediet-treatedpostprandialhyperglycemiaElevatedfastingglucoselevelshaveincreasedratesofunexplainedstillbirthsduringthelast4-8weeksofgestationIncreasedfrequencyofhypertensionandcesareandeliveryMaternalandfetaleffectsFetalanomaliesarenotincreaACOG2000:birthweightexceeds4500gAnthropometricallydifferentfromotherLGAinfants:excessivefatdepositionontheshouldersandtrunkPredisposestoshoulderdystociaorcesareandeliveryMaternalhyperglycemiapromptsfetalhyperinsulinemiaduringsecondhalfofgestation,whichinturnstimulatesexcessivesomaticgrowthMacrosomiaACOG2000:birthweightexceedMacrosomiaandErb’spalsyMacrosomiaandErb’spalsyNeonatalhyperinsulinemiamayprovokehypoglycemia(<35mg/dl)withinminutesofbirthMaternalobesityisanindependentandmoreimportantriskfactorforlargeinfantsinwomenwithGDMthanisglucoseintoleranceMaternalobesityisanimportantconfoundingfactorinthediagnosisofGDMMacrosomiaNeonatalhyperinsulinemiamayDietExerciseGlucosemonitoringInsulinManagementDietManagementAverageof30kcal/kg/dbasedonprepregnantbodyweightfornonobesewomen30%caloricrestrictionforobesewomenwithBMI>30kg/m2MonitoredwithweeklytestsforketonuriaMaternalketonemialinkedwithimpairpsychomotordevelopmentinoffspringDietAverageof30kcal/kg/dbasedExerciseimprovedcardiorespiratoryfitnessPhysicalactivityreducedriskofGDMResistanceexercisediminishedtheneedforinsulintherapyinoverweightwomenwithGDMExerciseExerciseimprovedcardiorespirGestational-diabetes-mellitus：妊娠期糖尿病课件BodyweightcontrolPrepregnancyBMITotalweightgain(kg)Ratesofweightgain2ndand3rdtrimester(kg/wk)Underweight(<18.5kg/m2)12.5-180.51(0.44-0.58)Normalweight(18.5-24.9kg/m2)11.5-160.42(0.35-0.50)Overweight(25.0-29.9kg/m2)7-11.50.28(0.23-0.33)Obese(>=30.0kg/m2)5-90.22(0.17-0.27)RasmussenKM,YaktineAl.Weightgainduringpregnancy:reexaminingtheguildelines.Washington:CommitteetoReexamineIOMPregnancyWeightGuidelines;InstituteofMedicine;NationalResearchCouncil2009:254BodyweightcontrolPrepregnancAimFastingplasmaglucose<95mg/dl1hrpostprandial<140mg/dl2hrpostprandial<120mg/dlGlucosemonitoringAimGlucosemonitoringDailyselfglucosemonitorVSintermittentfastingglucoseevaluationsemiweekly:fewermacrosomicinfantsandgainlessweightindiet-treatedGDMThewomenwithGDMA2:1hourpostprandialbloodglucosesuperiortopreprandial:fewerneonatalhypoglycemia,lessmacrosomia,fewerCSfordystociaGlucosemonitoringDailyselfglucosemonitorVSACOG2001hasnotrecommendedtheseagentsduringpregnancyHalfofmaternalconcentrationinwomentreatedwithglyburideIncreasingsupportuseofglyburideasanalternativetoinsulininGDMMeta-analysis2008:noincreasedperinatalriskswithglyburidetherapyandrecommendedfurtherrandomizedtrialsOralhypoglycemicagentsACOG2001hasnotrecommendedTheFifthInternationalworkshopconferencerecommendedthatmetformintreatmentforGDMbelimitedtoclinicaltrialswithlong-terminfantfollowupRCT2008:metforminVSinsulin:notassociatedwithincreasedperinatalcomplications,but46%requiredsupplementalinsulinMetforminTheFifthInternationalworkshRapidactingShort(regular)IntermediateLongactingInsulintherapyRapidactingInsulintherapyInsulinactingInsulinactingInitiateinsuliniffastingglucoselevels>105mg/dlTotaldoseof20-30unitsdailyBeforebreakfastiscommonlyusedtoinitiatetherapySplit-doseinsulin(twicedaily):dividedinto2/3intermediate-actingandathirdshort-actinginsulinInsulintherapyInitiateinsuliniffastingglACOG2001hassuggestedthatCSdeliveryshouldbeconsideredinwomenwithasonographicallyEFW>=4500ElectiveinductiontopreventshoulderdystociainwomenwithsonographicallydiagnosedfetalmacrosomiaiscontroversialSonographicsuspicionofmacrosomiawastooinaccuratetorecommendinductionorprimaryCSdeliverywithoutatrialoflaborObstetricalmanagementACOG2001hassuggestedthatCNoconsensusregardingwhetherantepartumfetaltestingisnecessary,andifso,whentobeginsuchtestinginwomenwithoutseverehyperglycemiaThosewomenwhorequireinsulintherapyforfastinghyperglycemia,typicallyundergofetaltestingandaremanagedasiftheyhadovertdiabetesObstetricalmanagementNoconsensusregardingwhetherLaborevaluationElectronicfetalmonitoringDTXq1-2hrInsulinivdripOffinsulinafterdeliveryNewbornevaluation:birthweight,APGARscore,hypoglycemiaIntrapartummanagementLaborevaluationIntrapartummaBloodglucose(mg/dl)Insulindosage(unit/hour)Fluids(125ml/hr)<1000D5(N/2orLRS)100-1401.0D5(N/2orLRS)141-1801.5Normalsaline181-2202.0Normalsaline>2202.5NormalsalineInsulinIVdripAmericanCollegeofObstetriciansandGynecologists.PregestationaldiabetesMellitus.ACOGPracticeBulletin60.Washington,DC;ACOG;2005Bloodglucose(mg/dl)InsulindTimeTestPurposePostdelivery(1-3d)FastingorrandomPGDetectpresistent,overtdiabetesEarlypostpartum(6-12wk)75g2-hOGTTPostpartumclassificationofglucosemetabolism1yrpostpartum75g2-hOGTTAssessglucosemetabolismannuallyFPGAssessglucosemetabolismTri-annually75g2-hOGTTAssessglucosemetabolismPrepregnancy75g2-hOGTTClassifyglucosemetabolismPostpartumevaluation:Fifthinternationalworkshop-conferenceTimeTestPurposePostdelivery(NormalImpairedfastingglucoseorimpairedglucosetoleranceDiabetesmellitusFasting<110mg/dlFasting110-125mg/dlFasting>=126mg/dl2hr<140mg/dl2hr>=140-199mg/dl2hr>=200mg/dlClassificationoftheADA2003NormalImpairedfastingglucose33-37%underwentpostpartumscreeningtestsRecommendationsforpostpartumfollow-uparebasedon