妊娠期糖尿病 Gestational Diabetes Mellitus重点培训.pptVIP

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 4000 gm Satisfactory fetal wellbeing Cephalic presentation satisfactory progress and descend during the first and second stage absence of Obstetric complications, 产 程 处 理 三程计划：总产程控制在12小时内 一程： 监测血糖及尿酮体,（70-120mg/dl）; 5%葡萄糖加RI(1:3-6)调节,避免高糖; 防止胎儿宫内酸中毒及新生儿低血糖; 加强胎心监护，间断吸氧; 注意活跃期进展 ; 二程：缩短产程，注意胎心变化及肩难产可能, 新生儿复苏抢救准备 三程：注意产后出血，预防感染， RI用量减1/2 GDM的剖宫产指征 糖尿病病程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、50gGCT ≥11.1mmol/L、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, 19th Joint Meeting of the British Endo