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solid; border-color: #fff;color: #333; background-color: #f1fbff;padding: 10px 5px;"> <a href="http://thedailypurge.net/yishizigekaoshi/baoming/li2412107427.shtml" target="_blank" style="color: rgb(0, 0, 255); text-decoration: underline;"><span style="color: rgb(0, 0, 255);">報名預約>></span></a> </td> <td style="border-style: solid; border-color: #fff;color: #333; background-color: #f1fbff;padding: 10px 5px;"> <a href="http://thedailypurge.net/yishizigekaoshi/kaoshijingyan/ha2412111216.shtml" target="_blank" style="color: rgb(0, 0, 255); text-decoration: underline;"><span style="color: rgb(0, 0, 255);">有問必答>></span></a> </td> <td style="border-style: solid; border-color: #fff;color: #333; background-color: #f1fbff;padding: 10px 5px;"> <a href="http://thedailypurge.net/OtherItem/baomingpingce/index2.shtml" target="_blank" style="color: rgb(0, 0, 255); text-decoration: underline;"><span style="color: rgb(0, 0, 255);">報考測評>></span></a> </td> </tr> </tbody> </table> <p></p> </span> </div>  <div id="wccadwv" class="news_con"> <div id="ofkimkm" class="jxbox clearfix"> <p style="text-indent: 2em; text-align: left;"><span style="text-indent: 32px; background-color: rgb(249, 249, 249);"><a href="http://thedailypurge.net/linchuangzhuliyishi/" target="_blank" title="臨床助理醫(yī)師" class="hotLink" >臨床助理醫(yī)師</a>妊娠合并內、外科疾病：糖尿病對妊娠的影響，</span><span style="text-indent: 32px; background-color: rgb(249, 249, 249);">相信是考生們關注的事情，</span><span style="text-indent: 32px; background-color: rgb(249, 249, 249);">醫(yī)學教育網(wǎng)小編整理了考試重點內容，希望對考生復習有所幫助。</span></p><p><span style="text-indent: 32px; background-color: rgb(249, 249, 249);"></span></p><p style="text-indent: 2em; text-align: left;"><strong>　　第二節(jié)　妊娠期糖尿病</strong></p><p ptag="60" plabel="5" style="text-indent: 2em; text-align: left;">一、類型</p><p ptag="61" plabel="6" style="text-indent: 2em; text-align: left;">（一）糖尿病合并妊娠</p><p ptag="62" plabel="7" style="text-indent: 2em; text-align: left;">在原有糖尿病的基礎上合并妊娠或妊娠前為糖耐量受損，妊娠后發(fā)展為糖尿病。病情較重，多需要胰島素控制病情。</p><p ptag="63" plabel="8" style="text-indent: 2em; text-align: left;">（二）妊娠期糖尿病</p><p ptag="64" plabel="9" style="text-indent: 2em; text-align: left;">妊娠期首次發(fā)現(xiàn)或發(fā)生的糖代謝異常，一般病情較輕。</p><p ptag="65" plabel="10" style="text-indent: 2em; text-align: left;">二、妊娠期糖代謝的特點</p><p ptag="66" plabel="11" style="text-indent: 2em; text-align: left;">（一）胎兒葡萄糖的供應</p><p ptag="67" plabel="12" style="text-indent: 2em; text-align: left;">胎兒通過胎盤從母體獲取葡萄糖是胎兒能量的主要來源。胰島素及胰高血糖素不能通過胎盤，胎兒葡萄糖的利用取決于胎兒自身產(chǎn)生的胰島素水平。</p><p ptag="68" plabel="13" style="text-indent: 2em; text-align: left;">（二）妊娠早中期</p><p ptag="69" plabel="14" style="text-indent: 2em; text-align: left;">孕婦血糖隨妊娠進展而降低，因此孕婦長時間空腹易發(fā)生低血糖及酮癥酸中毒。孕婦空腹血糖約降低10%，原因為：①孕婦除本身需要能量外，尚需供應胎兒生長發(fā)育所需的全部能量；②妊娠期腎血流量及腎小球濾過率均增加，但腎小管對糖的再吸收率不能相應增加，導致部分孕婦尿中葡萄糖排出量增加；③雌激素和孕激素增加母體對葡萄糖的利用。</p><p ptag="70" plabel="15" style="text-indent: 2em; text-align: left;">（三）妊娠中晚期</p><p ptag="71" plabel="16" style="text-indent: 2em; text-align: left;">血糖升高，使原有糖尿病加重或出現(xiàn)妊娠期糖尿病。原因為：①隨孕期發(fā)展，妊娠期體內胎盤生乳素、雌激素等增加，導致周圍組織對胰島素反應的敏感性下降，而抗胰島素作用增多；②妊娠期血容量增加，血液稀釋，造成胰島素相對不足。為了維持正常糖代謝水平，妊娠期胰島素分泌量必須相應增加。對于胰島素分泌受限的孕婦，因不能維持這一生理代償而導致胰島素相對缺乏，血糖升高，使非孕期已有的糖尿病加重或出現(xiàn)妊娠期糖尿病。</p><p ptag="72" plabel="17" style="text-indent: 2em; text-align: left;">三、糖尿病對妊娠的影響</p><p ptag="73" plabel="18" style="text-indent: 2em; text-align: left;">（一）對孕婦的影響</p><p ptag="74" plabel="19" style="text-indent: 2em; text-align: left;">自然流產(chǎn)率增加、妊娠期高血壓疾病的發(fā)病率增加、感染、羊水過多、手術產(chǎn)率增加、易發(fā)生糖尿病酮癥酸中毒。</p><p ptag="75" plabel="20" style="text-indent: 2em; text-align: left;">（二）對胎兒的影響</p><p ptag="76" plabel="21" style="text-indent: 2em; text-align: left;">巨大胎兒發(fā)生率增高、流產(chǎn)和早產(chǎn)、胎兒畸形。</p><p ptag="77" plabel="22" style="text-indent: 2em; text-align: left;">（三）對新生兒的影響</p><p ptag="78" plabel="23" style="text-indent: 2em; text-align: left;">容易發(fā)生胎兒生長受限、新生兒呼吸窘迫綜合征、新生兒低血糖、低血鈣、低血鉀。</p><p ptag="79" plabel="24" style="text-indent: 2em; text-align: left;">【敲黑板】</p><p ptag="80" plabel="25" style="text-indent: 2em; text-align: left;">妊娠期高血壓孕婦的胎兒——“窮人家的孩子早當家”——長得小，但成熟早（34周）。</p><p ptag="81" plabel="26" style="text-indent: 2em; text-align: left;">糖尿病孕婦的胎兒——“富二代”——長得大，但成熟晚（38周）。</p><p ptag="82" plabel="27" style="text-indent: 2em; text-align: left;">四、病史與臨床表現(xiàn)</p><p ptag="83" plabel="28" style="text-indent: 2em; text-align: left;">（一）病史</p><p ptag="84" plabel="29" style="text-indent: 2em; text-align: left;">有糖尿病高危因素（糖尿病家族史、年齡＞30歲、超重或肥胖、巨大兒分娩史、孕婦本人為低出生體重兒、無原因反復流產(chǎn)、死胎、死產(chǎn)、足月新生兒呼吸窘迫綜合征分娩史、胎兒畸形史、多囊卵巢綜合征等）。</p><p ptag="85" plabel="30" style="text-indent: 2em; text-align: left;">（二）臨床表現(xiàn)</p><p ptag="86" plabel="31" style="text-indent: 2em; text-align: left;">“四多”癥狀，包括多飲、多食、多尿、體重增加（孕婦體重＞90kg）。此外，合并以下情況者應警惕合并糖尿病的可能，包括外陰陰道假絲酵母菌病反復發(fā)作、本次妊娠并發(fā)羊水過多或巨大胎兒。</p><p ptag="87" plabel="32" style="text-indent: 2em; text-align: left;">五、診斷</p><p ptag="88" plabel="33" style="text-indent: 2em; text-align: left;">（一）糖尿病合并妊娠的診斷</p><p ptag="89" plabel="34" style="text-indent: 2em; text-align: left;">1.孕前已確診的糖尿病患者。</p><p ptag="90" plabel="35" style="text-indent: 2em; text-align: left;">2.妊娠前未進行過血糖檢查，但有糖尿病高危因素（肥胖、一級親屬患2型糖尿病、有GDM史或大于胎齡兒分娩史、患多囊卵巢綜合征及妊娠早期空腹尿糖反復陽性），當出現(xiàn)下列情況中任何一項，應診斷為糖尿病合并妊娠：①空腹血糖≥7.0mmol/L（126mg/dl）；②糖化血紅蛋白（GHbA1c）≥6.5%；③隨機血糖≥11.1mmol/L并有糖尿病典型癥狀或高血糖危象癥狀；④如果沒有明確的高血糖癥狀，任意血糖≥11.1mmol/L，次日復測①或②陽性。</p><p ptag="91" plabel="36" style="text-indent: 2em; text-align: left;">3.不建議孕早期常規(guī)葡萄糖耐量試驗（OGTT）檢查。</p><p ptag="92" plabel="37" style="text-indent: 2em; text-align: left;">（二）妊娠期糖尿病（GDM）的診斷</p><p ptag="93" plabel="38" style="text-indent: 2em; text-align: left;">1.妊娠24～28周常規(guī)檢測空腹血糖</p><p ptag="94" plabel="39" style="text-indent: 2em; text-align: left;">空腹血糖≥5.1mmol/L者，可以直接診斷GDM；</p><p ptag="95" plabel="40" style="text-indent: 2em; text-align: left;">空腹血糖4.4～5.1mmol/L者，應盡早行OGTT檢查；</p><p ptag="96" plabel="41" style="text-indent: 2em; text-align: left;">空腹血糖≤4.4mmol/L者，可暫不行OGTT檢查。</p><p ptag="97" plabel="42" style="text-indent: 2em; text-align: left;">2.葡萄糖耐量試驗（OGTT）　診斷GDM標準空腹、服糖后1h、服糖后2h的血糖正常值分別為≤5.1mmol/L、≤10.0mmol/L、≤8.5mmol/L。任何一點血糖值達到或超過上述標準即診斷為GDM。</p><p ptag="98" plabel="43" style="text-indent: 2em; text-align: left;">3.具有GDM高危因素的孕婦，首次OGTT正常者，在妊娠晚期可重復OGTT。</p><p ptag="99" plabel="44" style="text-indent: 2em; text-align: left;">4.妊娠28周后首次孕檢者，建議初診查空腹血糖或75g OGTT。</p><p ptag="100" plabel="45" style="text-indent: 2em; text-align: left;">（三）妊娠合并糖尿病分期</p><p ptag="101" plabel="46" style="text-indent: 2em; text-align: left;">A級：妊娠期診斷的糖尿病。</p><p ptag="102" plabel="47" style="text-indent: 2em; text-align: left;">A1級：經(jīng)控制飲食，空腹血糖＜5.3mmol/L，餐后2小時血糖＜6.7mmol/L。</p><p ptag="103" plabel="48" style="text-indent: 2em; text-align: left;">A2級：經(jīng)控制飲食，空腹血糖≥5.3mmol/L，餐后2小時血糖≥6.7mmol/L。</p><p ptag="104" plabel="49" style="text-indent: 2em; text-align: left;">B級：顯性糖尿病，20歲以后發(fā)病，病程＜10年。</p><p ptag="105" plabel="50" style="text-indent: 2em; text-align: left;">C級：發(fā)病年齡10～19歲，或病程達10～19年。</p><p ptag="106" plabel="51" style="text-indent: 2em; text-align: left;">D級：10歲前發(fā)病，或病程≥20年，或合并單純性視網(wǎng)膜病。</p><p ptag="107" plabel="52" style="text-indent: 2em; text-align: left;">F級：糖尿病性<a href="http://thedailypurge.net/jibing/shenbing/" target="_blank" title="腎病" class="hotLink" >腎病</a>。</p><p ptag="108" plabel="53" style="text-indent: 2em; text-align: left;">R級：眼底有增生性視網(wǎng)膜病變或玻璃體積血。</p><p ptag="109" plabel="54" style="text-indent: 2em; text-align: left;">H級：冠狀動脈粥樣硬化性心臟病。</p><p ptag="110" plabel="55" style="text-indent: 2em; text-align: left;">T級：有腎移植史。</p><p ptag="111" plabel="56" style="text-indent: 2em; text-align: left;">【敲黑板】</p><p ptag="112" plabel="57" style="text-indent: 2em; text-align: left;">先有糖尿病，妊娠后加重——診斷：糖尿病合并妊娠——病情更重；</p><p ptag="113" plabel="58" style="text-indent: 2em; text-align: left;">先有妊娠，后血糖升高——診斷：妊娠期糖尿病——病情較輕。</p><p ptag="114" plabel="59" style="text-indent: 2em; text-align: left;">【經(jīng)典例題1】</p><p ptag="115" plabel="60" style="text-indent: 2em; text-align: left;">女性，38歲。初次妊娠，過度肥胖，24周查空腹血糖：4.5mmol/L，患者需要進行</p><p ptag="116" plabel="61" style="text-indent: 2em; text-align: left;">A.尿糖檢測</p><p ptag="117" plabel="62" style="text-indent: 2em; text-align: left;">B.空腹血糖</p><p ptag="118" plabel="63" style="text-indent: 2em; text-align: left;">C.OGTT</p><p ptag="119" plabel="64" style="text-indent: 2em; text-align: left;">D.尿酮體</p><p ptag="120" plabel="65" style="text-indent: 2em; text-align: left;">E.1個月后可重復進行糖篩查</p><p ptag="121" plabel="66" style="text-indent: 2em; text-align: left;">【參考答案】 1.C</p><p ptag="122" plabel="67" style="text-indent: 2em; text-align: left;">六、處理</p><p ptag="123" plabel="68" style="text-indent: 2em; text-align: left;">（一）糖尿病患者可否妊娠的指標</p><p ptag="124" plabel="69" style="text-indent: 2em; text-align: left;">1.未經(jīng)治療的D、F、R級糖尿病不宜妊娠。</p><p ptag="125" plabel="70" style="text-indent: 2em; text-align: left;">2.器質性病變較輕、血糖控制良好者，在確保受孕前、妊娠期及分娩期血糖在正常范圍內可妊娠。</p><p ptag="126" plabel="71" style="text-indent: 2em; text-align: left;">（二）孕婦血糖監(jiān)控</p><p ptag="127" plabel="72" style="text-indent: 2em; text-align: left;">1.妊娠期血糖控制滿意標準　孕婦無明顯饑餓感；空腹和餐前30分鐘血糖在3.3～5.3mmol/L；餐后2小時以及夜間血糖在4.4～6.7mmol/L。</p><p ptag="128" plabel="73" style="text-indent: 2em; text-align: left;">2.醫(yī)學營養(yǎng)治療（飲食治療）　理想的飲食控制既能提供妊娠期間熱量和營養(yǎng)需要，保證胎兒正常生長發(fā)育，又能避免餐后高血糖或饑餓性酮癥出現(xiàn)。糖尿病孕婦妊娠早期（前3個月）熱量需要同孕前。妊娠中期及晚期每日增加熱量200kcal。</p><p ptag="129" plabel="74" style="text-indent: 2em; text-align: left;">3.藥物治療　飲食控制不能達標的患者首選應用胰島素控制血糖，胰島素是大分子蛋白，不通過胎盤，不會對胎盤造成影響。胰島素的用量（劑量必須個體化）：①妊娠前應用胰島素控制血糖的患者，妊娠早期需要根據(jù)血糖監(jiān)測情況調整胰島素用量；②妊娠中、晚期的胰島素需要量常有不同程度增加，妊娠32～36周達最高峰，妊娠36周后胰島素用量稍下降。</p><p ptag="130" plabel="75" style="text-indent: 2em; text-align: left;">（三）妊娠期糖尿病酮癥酸中毒的處理</p><p ptag="131" plabel="76" style="text-indent: 2em; text-align: left;">一旦尿酮體陽性應急查血糖、電解質、血pH及二氧化碳結合力。補液及小劑量胰島素持續(xù)靜點，胰島素0.1U/（kg·h）加入生理鹽水中靜脈滴注。每1～2小時監(jiān)測血糖1次。血糖≤13.9mmol/L后，將胰島素加入5%葡萄糖氯化鈉注射液中靜脈滴注，酮體轉陰后可改為皮下注射。</p><p ptag="132" plabel="77" style="text-indent: 2em; text-align: left;">（四）終止妊娠</p><p ptag="133" plabel="78" style="text-indent: 2em; text-align: left;">1.分娩時機選擇　①孕期正常、非胰島素治療的GDM孕婦，到預產(chǎn)期立刻終止妊娠；②妊娠前糖尿病及需要胰島素治療的GDM者，在血糖控制良好的情況下，妊娠38～39周終止妊娠；血糖控制不滿意者及時收入院；③有母兒合并癥者，嚴密監(jiān)護下，促胎兒肺成熟后，適時終止妊娠。</p><p ptag="134" plabel="79" style="text-indent: 2em; text-align: left;">2.分娩方式</p><p ptag="135" plabel="80" style="text-indent: 2em; text-align: left;">（1）剖宮產(chǎn)：糖尿病本身不是剖宮產(chǎn)的指征，但有下列情況應行剖宮產(chǎn)：①糖尿病伴微血管病變、巨大胎兒、胎盤功能不良、胎位異常、其他產(chǎn)科指征者應行剖宮產(chǎn)；②妊娠期血糖控制不好，胎兒偏大或者既往有死胎、死產(chǎn)史者，應適當放寬剖宮產(chǎn)手術指征。</p><p ptag="136" plabel="81" style="text-indent: 2em; text-align: left;">（2）陰道分娩：無上述指征者，應陰道試產(chǎn)。</p><p ptag="137" plabel="82" style="text-indent: 2em; text-align: left;">3.分娩過程中、剖宮產(chǎn)術中的胰島素控制</p><p ptag="138" plabel="83" style="text-indent: 2em; text-align: left;">陰道分娩：停止皮下注射胰島素，換為靜脈輸注胰島素生理鹽水，根據(jù)測得的血糖值調整靜脈輸液速度。</p><p ptag="139" plabel="84" style="text-indent: 2em; text-align: left;">剖宮產(chǎn)：①在手術前1日，停用晚餐前胰島素；②手術日當天停止皮下注射胰島素；③早晨監(jiān)測血糖及尿酮體后，根據(jù)其空腹血糖水平改用小劑量胰島素持續(xù)靜脈滴注；④按2～3U/h速度持續(xù)靜脈滴注胰島素葡萄糖液；⑤按3～4g葡萄糖加1U胰島素比例配制胰島素葡萄糖液；⑥每1～2小時測血糖1次；⑦術中血糖控制在6.67～10.0mmol/L；⑧術后每2～4小時測1次血糖，直到飲食恢復。</p><p ptag="140" plabel="85" style="text-indent: 2em; text-align: left;">（五）產(chǎn)后處理</p><p ptag="141" plabel="86" style="text-indent: 2em; text-align: left;">胎盤娩出后，體內抗胰島素物質迅速減少，大部分妊娠期糖尿病患者在分娩后即不再需要胰島素，仍需胰島素治療的患者，其用量應減少至分娩前的1/3～1/2。在產(chǎn)后1～2周胰島素用量逐漸恢復至孕前水平。產(chǎn)后6～12周行OGTT檢查。</p><p ptag="142" plabel="87" style="text-indent: 2em; text-align: left;">（六）新生兒處理</p><p ptag="143" plabel="88" style="text-indent: 2em; text-align: left;">無論出生時狀況如何，均應視為高危新生兒，尤其要給予監(jiān)護，注意保暖和吸氧，重點防止新生兒低血糖，早喂糖水、早開奶。</p><p><span style="text-indent: 32px; background-color: rgb(249, 249, 249);"></span></p><p style="text-indent: 2em; 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