主页 > 医学前沿 >
【科普】美国糖尿病协会（ADA）就糖尿病妇女妊
"The intent is to help clinicians deal with the broad spectrum of problems that arise in management of diabetes before and during pregnancy, and to prepare diabetic women for treatment that may reduce complications in the years after pregnancy," write Jennifer M. Block, BS, RN, CDE, from the Santa Clara Valley Medical Center, San Jose, California, and colleagues. "The recommendations are diagnostic and therapeutic actions that are known or believed to favorably affect maternal and perinatal outcomes in pregnancies complicated by diabetes."
The evidence supporting these recommendations is reviewed in the book, Management of Preexisting Diabetes and Pregnancy, authored by the consensus panel and published in 2008 by the ADA. Because few randomized controlled trials (RCTs) have studied the management of diabetes and pregnancy, these recommendations are often based on RCTs in nonpregnant diabetic women or nondiabetic pregnant women as well as on peer-reviewed experience before and during pregnancy in women with preexisting diabetes.
The guidelines authors used the grading system adapted by the ADA to rate the underlying evidence, and they also reviewed and adapted existing diabetes and pregnancy guidelines and guidelines on diabetes complications and comorbidities.
Recommendations regarding management of preexisting diabetes for pregnancy address organization of preconception and pregnancy care, specifically initial evaluation and review of patient history and physical examination.
Other aspects of management of preexisting diabetes addressed in these guidelines include glycemic control in perinatal outcome and glycemic goals as well as evaluation of metabolic control, medical nutrition therapy, insulin therapy, use of oral antihyperglycemic agents for type 2 diabetes, physical activity and exercise, and behavioral therapy.
The second half of these guidelines focuses on managing complications of diabetes. Metabolic disturbances include diabetic ketoacidosis (DKA), maternal hypoglycemia, and thyroid disorders. Management of cardiovascular (CV) risk factors includes screening for cardiovascular disease (CVD), management of hypertension, and treatment of dyslipidemia.
Other complications of diabetes addressed in these guidelines include management of diabetic nephropathy, diabetic retinopathy, and diabetic neuropathies.
Highlights of some of the specific clinical recommendations include the following:
Before pregnancy, women with diabetes and childbearing potential should be educated about the need for good glycemic control and should participate in effective family planning.
Multidisciplinary, patient-centered team care, with regular follow-up visits, is helpful whenever feasible: before, during, and after pregnancy.
Women with preexisting diabetes contemplating pregnancy should be evaluated and treated for diabetic nephropathy, neuropathy, retinopathy, CVD, hypertension, dyslipidemia, depression, and thyroid disease.
Before conception, medication use should be evaluated because drugs often used to treat diabetes and its complications may be contraindicated or problematic in pregnancy. These include statins, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), and most noninsulin therapies.
As soon as possible before conception, or early in pregnancy, complete medical evaluation should detect diabetic, CV, thyroid, or obstetric complications; review history of eating patterns, physical activity or exercise, and psychosocial problems; counsel the patient on prognosis and set goals for patient participation; formulate a management plan with team care members; and plan for continuing care and laboratory testing.
Effective contraception is recommended until stable, acceptable glycemia is achieved (E).
To prevent excess spontaneous abortions and major congenital malformations, target hemoglobin A1c before pregnancy should be as close to normoglycemia as possible without significant hypoglycemia. The same goal is recommended throughout pregnancy to minimize maternal, fetal, and neonatal complications.
Optimal glycemic goals throughout pregnancy are premeal, bedtime, and overnight blood glucose 60 to 99 mg/dL, peak postprandial blood glucose of 100 to 129 mg/dL, mean daily blood glucose level of less than 110 mg/dL, and hemoglobin A1clevels of less than 6.0%.
Provision of basal and prandial insulin needs with intensified insulin regimens (multiple dose regimens of subcutaneous long-acting and short-acting insulins or continuous subcutaneous insulin infusion [CSII]) usually achieves the best results.
Women taking the insulins detemir or glargine should be transitioned to NPH insulin 2 or 3 times daily, preferably before pregnancy.
阅读本文的人还阅读：
作者:admin@医学,生命科学 2010-12-01 17:11
医学,生命科学网