2022年中国妊娠期高血糖诊治指南与美国糖尿病学会妊娠合并糖尿病诊治指南比较

doi:10.12280/gjfckx.20220262

摘要/Abstract

摘要：

在全球范围内，妊娠合并糖尿病/妊娠期高血糖的发病率不断攀升，不仅增加围生期母儿不良结局的风险，而且增加母体和子代远期患代谢性疾病的风险。对妊娠合并糖尿病的诊治目前各国仍存在诸多争议。2022年我国中华医学会（Chinese Medical Association，CMA）、2021年美国糖尿病学会（American Diabetes Association，ADA）分别发布了最新指南，目的在于为妊娠合并糖尿病的诊断和治疗提供最新建议，现就两份指南在疾病分类、诊断、孕前咨询及孕前保健、生活方式和行为管理、妊娠期降糖药物治疗、血糖的监测、母儿并发症、产后管理与产后随访、产科管理这9个方面进行对比解读，探寻两份指南间异同的可能原因，为临床医生的实践提供参考。

关键词: 糖尿病，妊娠, 指南, 产前保健, 诊断, 治疗, 随访研究

Abstract:

The prevalence of gestational hyperglycemia/diabetes in pregnancy (DIP) or gestational diabetes mellitus (GDM) has been increasing in the world. It is not only associated with perinatal adverse events for mother and fetus, but also increases the risk of metabolic diseases in mother and offspring in the long term. However, there are still controversies about the diagnosis and treatment of DIP. Chinese Medical Association (CMA) in 2022 and American Diabetes Association (ADA) in 2021 had issued and updated their guidelines of DIP in order to provide the latest suggestion for the management of DIP. Two guidelines have been comparated in the nine aspects，such as disease classification, diagnosis, preconception counseling and care, lifestyle and behavior management, hypoglycemic drug therapy during pregnancy, glucose monitoring, maternal and child complications, postpartum care and follow-up, obstetric management. The possible causes of similarities and differences between the two guidelines were explored for providing a reference for clinicians′ practice.

Key words: Diabetes, gestational, Guidebooks, Prenatal Care, Diagnosis, Therapy, Follow-up studies

黄俊巧, 李映桃, 刘梦玥, 吴伟珍. 2022年中国妊娠期高血糖诊治指南与美国糖尿病学会妊娠合并糖尿病诊治指南比较[J]. 国际妇产科学杂志, 2022, 49(6): 691-698.

HUANG Jun-qiao, LI Ying-tao, LIU Meng-yue, WU Wei-zhen. Guide Interpretation/Contrast the Guideline of Gestational Hyperglycemia from CMA and the Guideline of Gestational Diabetes Mellitus from ADA in 2022[J]. Journal of International Obstetrics and Gynecology, 2022, 49(6): 691-698.

图/表 3

参考文献 32

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	ADA指南	CMA指南
高危人群	包括所有肥胖或超重的女性[即体质量指数（body mass index，BMI）>25 kg/m²或亚裔美国人>23 kg/m²]并且具有以下一种或多种危险因素:①一级亲属罹患糖尿病；②高危种族或民族，例如非裔美国人、拉丁裔美国人、美洲原住民、亚裔美国人及太平洋岛民；③心血管病史；④高血压[血压≥140/90 mmHg（1 mmHg=0.133 kPa）]或正在治疗的高血压；⑤高密度脂蛋白<0.90 mmol/L（35 mg/dL），三酰甘油>2.82 mmol/L（250 mg/dL）；⑥患有多囊卵巢综合征；⑦缺乏体能运动；⑧与胰岛素抵抗相关的其他因素，如重度肥胖、黑棘皮症等；⑨HbA1c≥5.7%，IFG或IGT；⑩有巨大儿分娩史（新生儿出生体质量≥4 000 g）和GDM史	肥胖（尤其是重度肥胖）、一级亲属患有T2DM、冠心病史、慢性高血压、高密度脂蛋白<1 mmol/L和（或）三酰甘油>2.8 mmol/L、GDM史或巨大儿分娩史、多囊卵巢综合征史、妊娠早期空腹尿糖反复阳性、年龄>45岁
筛查和诊断的时机	高危人群:妊娠15周前，诊断标准同非妊娠期，筛查并诊断PGDM，筛查GDM高危人群普通人群:妊娠24~28周，筛查并诊断GDM	高危人群:首次产检时（妊娠早期），诊断标准同非妊娠期，筛查并诊断PGDM以及糖尿病前期普通人群:妊娠24~28周，筛查并诊断GDM或PGDM。若首次产前检查在妊娠28周以后，建议行OGTT检查；若具有GDM高危因素，但首次OGTT检查结果正常者，必要时可在妊娠晚期重复OGTT检查
妊娠期PGDM诊断标准	同妊娠前	同妊娠前。但取消了OGTT 2 h血糖≥11.1 mmol/L（妊娠24~28周及以后）诊断PGDM的标准
妊娠期糖尿病前期的诊断	无明确的诊断标准，建议筛查早期糖代谢异常的预警范围为:FPG 6.1~6.9 mmol/L（110~125 mg/dL）或HbA1c 5.9%~6.4%	若妊娠早期首次产检筛查FPG 5.6~6.9 mmol/L可诊断为妊娠合并IFG FPG在5.1~5.6 mmol/L范围内，不作为GDM的诊断依据，建议在妊娠24~28周直接行OGTT检查，也可以复查FPG，FPG≥5.1 mmol/L可诊断为GDM；FPG<5.1 mmol/L则行75 g OGTT检查并诊断
GDM诊断策略	一步法和两步法均可	一步法

	ADA指南	CMA指南
高危人群	包括所有肥胖或超重的女性[即体质量指数（body mass index，BMI）>25 kg/m²或亚裔美国人>23 kg/m²]并且具有以下一种或多种危险因素:①一级亲属罹患糖尿病；②高危种族或民族，例如非裔美国人、拉丁裔美国人、美洲原住民、亚裔美国人及太平洋岛民；③心血管病史；④高血压[血压≥140/90 mmHg（1 mmHg=0.133 kPa）]或正在治疗的高血压；⑤高密度脂蛋白<0.90 mmol/L（35 mg/dL），三酰甘油>2.82 mmol/L（250 mg/dL）；⑥患有多囊卵巢综合征；⑦缺乏体能运动；⑧与胰岛素抵抗相关的其他因素，如重度肥胖、黑棘皮症等；⑨HbA1c≥5.7%，IFG或IGT；⑩有巨大儿分娩史（新生儿出生体质量≥4 000 g）和GDM史	肥胖（尤其是重度肥胖）、一级亲属患有T2DM、冠心病史、慢性高血压、高密度脂蛋白<1 mmol/L和（或）三酰甘油>2.8 mmol/L、GDM史或巨大儿分娩史、多囊卵巢综合征史、妊娠早期空腹尿糖反复阳性、年龄>45岁
筛查和诊断的时机	高危人群:妊娠15周前，诊断标准同非妊娠期，筛查并诊断PGDM，筛查GDM高危人群普通人群:妊娠24~28周，筛查并诊断GDM	高危人群:首次产检时（妊娠早期），诊断标准同非妊娠期，筛查并诊断PGDM以及糖尿病前期普通人群:妊娠24~28周，筛查并诊断GDM或PGDM。若首次产前检查在妊娠28周以后，建议行OGTT检查；若具有GDM高危因素，但首次OGTT检查结果正常者，必要时可在妊娠晚期重复OGTT检查
妊娠期PGDM诊断标准	同妊娠前	同妊娠前。但取消了OGTT 2 h血糖≥11.1 mmol/L（妊娠24~28周及以后）诊断PGDM的标准
妊娠期糖尿病前期的诊断	无明确的诊断标准，建议筛查早期糖代谢异常的预警范围为:FPG 6.1~6.9 mmol/L（110~125 mg/dL）或HbA1c 5.9%~6.4%	若妊娠早期首次产检筛查FPG 5.6~6.9 mmol/L可诊断为妊娠合并IFG FPG在5.1~5.6 mmol/L范围内，不作为GDM的诊断依据，建议在妊娠24~28周直接行OGTT检查，也可以复查FPG，FPG≥5.1 mmol/L可诊断为GDM；FPG<5.1 mmol/L则行75 g OGTT检查并诊断
GDM诊断策略	一步法和两步法均可	一步法

指标	PGDM			GDM
指标	备孕	妊娠期	产后	妊娠期	产后
FPG（mmol/L）	3.9~6.1	3.9~5.3^a <5.3^c	3.9~7.0	<5.3	3.9~7.0
餐后1 h血糖（mmol/L）	-	6.1~7.8^a <7.8^c	-	<7.8	-
餐后2 h血糖（mmol/L）	-	5.6~6.7^a <6.7^c	-	<6.7	-
HbA1c	6.0%~6.5%	<6.0%，必要可放宽至<7.0%	-	<6.0%，必要可放宽至<7.0%	-

指标	PGDM			GDM
指标	备孕	妊娠期	产后	妊娠期	产后
FPG（mmol/L）	3.9~6.1	3.9~5.3^a <5.3^c	3.9~7.0	<5.3	3.9~7.0
餐后1 h血糖（mmol/L）	-	6.1~7.8^a <7.8^c	-	<7.8	-
餐后2 h血糖（mmol/L）	-	5.6~6.7^a <6.7^c	-	<6.7	-
HbA1c	6.0%~6.5%	<6.0%，必要可放宽至<7.0%	-	<6.0%，必要可放宽至<7.0%	-

项目	ADA指南	CMA指南
血糖监测方法	自我监测空腹和餐后血糖，部分PGDM妇女或血糖控制不良妇女需加测餐前血糖*
血糖监测频率	未详细提及，但强调应避免出现妊娠期低血糖（≤3.9 mmol/L）	①A1型GDM至少每周监测1 d空腹和三餐后血糖；②A2型GDM至少每2~3 d监测三餐前后血糖；③睡前胰岛素应用初期、夜间低血糖发作、增加睡前胰岛素剂量但FPG仍控制不佳的情况下加测夜间血糖，避免夜间血糖<3.3 mmol/L
妊娠期HbA1c的监测频率	比妊娠前更频繁地监测HbA1c水平，如每个月监测1次	①用于GDM妇女的首次评估；②A2型GDM孕妇每2~3个月监测1次；③PGDM孕妇分别在妊娠早、中、晚期至少监测1次