妊娠期糖尿病课件篇.ppt

* * * * * * 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 M