reading report. translated at 2006.6
2004年中國衛生部疾病控制司中華醫學會糖尿病學分會發布的《中國糖尿病防治指南》中並沒有對GDM做專門介紹。
美國婦產科學會（ACOG） 2001年的GDM臨牀指南[Gestational diabetes. American College of Obstetricians and Gynecologists (ACOG); 2001 Sep. 14 p. ] 建議如下：
1. 以下建議基於有限的或結論不一致的科學證據(Level B： Recommendations are based on limited or inconsistent scientific evidence.)：
• The laboratory screening test should consist of a 50-g, 1-hour oral glucose challenge at 24–28 weeks of gestation, which may be administered without regard to the time of the last meal.
• 妊娠24－28周進行50g口服糖耐量試驗測一小時後血糖（與末餐時間無關）
• A screening test threshold of 140 mg/dL has 10% less sensitivity than a threshold of 130 mg/dL but fewer false-positive results; either threshold is acceptable.
• 糖篩的診斷分割點設爲140 mg/dL比130 mg/dL靈敏性降低10％，但假陽性較少。這兩個診斷分割點都是可以接受的。
• The screening test generally should be performed on venous plasma or serum samples using well-calibrated and well-maintained laboratory instruments.
• Available evidence does not support a recommendation for or against moderate caloric restriction in obese women with gestational diabetes mellitus (GDM). However, if caloric restriction is used, the diet should be restricted by no more than 33% of calories.
• 尚沒有足夠證據支持對患有GDM的肥胖孕婦進行適當的熱量攝入限制。但是如果採用熱量限制，則減少的熱量攝入不應大於33％。
• For women with GDM and an estimated fetal weight of 4,500 g or more, cesarean delivery may be considered because it may reduce the likelihood of permanent brachial plexus injury in the infant.
• GDM孕婦和估計胎兒體重R4500g的應考慮剖宮產，如此可以減少新生兒永久性臂從損傷的發生率。
• When medical nutrition therapy has not resulted in fasting glucose levels less than 95 mg/dL or 1-hour postprandial values less than 130-140 mg/dL or 2-hour postprandial values less than 120 mg/dL, insulin should be considered.
• 如果正確的飲食控制無法使空腹血糖低於95mg/dL或餐後一小時血糖低於130－140 mg/dL，或餐後兩小時血糖低於120mg/dL，則需要考慮使用胰島素。
2. 以下建議主要基於共識和專家意見(Level C： Recommendations are based primarily on consensus and expert opinion.)：
• Although universal glucose challenge screening for GDM is the most sensitive approach, there may be pregnant women at low risk who are less likely to benefit from testing. Such low-risk women should have all of the following characteristics:
1. Age younger than 25 years
2. Not a member of a racial or ethnic group with high prevalence of diabetes (e.g., Hispanic, African, Native American, South or East Asian, or Pacific Islands ancestry)
3. Body mass index of 25 or less
4. No history of abnormal glucose tolerance
5. No previous history of adverse pregnancy outcomes usually associated with GDM
6. No known diabetes in first degree relative
• 儘管通用的糖篩試驗對於發現GDM是最敏感的方法，但有一部分低風險的孕婦並不從中獲益，這一部分低危婦女有以下特點：(1)年齡< 25 歲。(2) 屬於GDM發病率低的種族。(高危種族e.g., Hispanic, African, Native American, South or East Asian, or Pacific Islands ancestry) (3) 體重指數Q25。 (4) 沒有糖耐量異常史。 (5) 以往無與GDM相關的難產史。(6) 一級親屬沒有糖尿病患者。
• There is insufficient evidence to determine the optimal antepartum testing regimen for women with GDM with relatively normal glucose levels on diet therapy and no other risk factors
• 對於通過飲食控制血糖水平相對正常且沒有其他危險因素的GDM孕婦，尚沒有足夠的證據來判定何爲最佳的產前（終止妊娠）檢測方案。
• Either the plasma or serum glucose level established by Carpenter and Coustan or the plasma level designated by the National Diabetes Data Group conversions are appropriate to use in the diagnosis of GDM. Carpenter/Coustan血漿或血清葡萄糖水平標準或者美國糖尿病資料小組提供的血漿葡萄糖水平標準，用於診斷GDM都是適合的。
美國糖尿病協會（ADA）2006年糖尿病診療標準中對妊娠糖尿病的鑑別與診斷建議如下：推薦：1.使用危險評估和口服糖耐量試驗篩查GDM。2.對於妊娠糖尿病婦女應該在產後6～12 周篩查糖尿病,同時應隨訪其糖尿病或糖尿病前期的發展。
• 應該在懷孕後第一次檢查時進行GDM危險評估。具有GDM高危臨牀表現(如顯著肥胖,有GDM病史、尿糖或糖尿病家族史) 者應儘可能早的檢測血糖水平。如果空腹血糖(FPG) ≥7 mmol/ L 或任意血糖≥11. 1 mmol/ L 且有明確的高血糖症狀,即滿足糖尿病的診斷標準,否則需要再測一次血糖以確診。對於初次篩查時未診爲GDM的高危婦女及中等危險的婦女應在妊娠24～28 周時進行以下推薦檢查之一。
• 一步檢查:行100 g 口服葡萄糖耐量試驗(OGTT) 。
• 二步檢查:口服50 g 葡萄糖(葡萄糖耐量試驗,GCT)後1 h 進行初次篩查,測血漿或血清葡萄糖水平,對於GCT中血糖超過閾值的婦女進行再診斷性的100 g OGTT。如果GCT中把葡萄糖閾值定爲≥7. 77 mmol/ L ,則可確診近80 %的GDM婦女,而將切點定爲≥7. 22 mmol/ L 時,則可確診者增加到90 %。100 g OGTT診斷標準:空腹≥5. 27 mmol/ L ,1 h 血糖≥10mmol/ L ,2 h 血糖≥8. 60 mmol/ L ,3 h 血糖≥7. 77 mmol/ L。以上不同時點血漿葡萄糖水平有兩項或多項滿足標準即可診斷GDM。另外,應該在清晨隔夜空腹8～14 h 時進行檢測。也可做75 g 糖負荷試驗,但其在鑑別高危嬰兒及母親的有效性方面不如100 g OGTT。
• 對於滿足以下所有條件的低危婦女無需檢測血糖: 共6項，同ACOG指南，不再贅述。
Screen for diabetes in pregnancy using risk factor analysis and, if appropriate, use of an oral glucose tolerance test (OGTT). (C)
Women with GDM should be screened for diabetes 6 to 12 weeks postpartum and should be followed up with subsequent screening for the development of diabetes or pre-diabetes. (E)
Risk assessment for GDM should be undertaken at the first prenatal visit. Women with clinical characteristics consistent with a high risk for GDM (those with marked obesity, personal history of GDM, glycosuria, or a strong family history of diabetes) should undergo glucose testing as soon as possible. A fasting plasma glucose (FPG) >126 mg/dL or a casual plasma glucose >200 mg/dL meets the threshold for the diagnosis of diabetes and needs to be confirmed on a subsequent day unless unequivocal symptoms of hyperglycemia are present. High-risk women not found to have GDM at the initial screening and average-risk women should be tested between 24 and 28 weeks of gestation. Testing should follow one of two approaches:
One-step approach: perform a diagnostic 100-g OGTT
Two-step approach: perform an initial screening by measuring the plasma or serum glucose concentration 1 hour after a 50-g oral glucose load (glucose challenge test) and perform a diagnostic 100-g OGTT on that subset of women exceeding the glucose threshold value on the glucose challenge test. When the two-step approach is used, a glucose threshold value >140 mg/dL identifies approximately 80% of women with GDM, and the yield is further increased to 90% by using a cutoff of >130 mg/dL.
Diagnostic criteria for the 100-g OGTT are as follows: >95 mg/dL fasting, >180 mg/dL at 1 hour, >155 mg/dL at 2 hours, and >140 mg/dL at 3 hours. Two or more of the plasma glucose values must be met or exceeded for a positive diagnosis. The test should be done in the morning after an overnight fast of 8 to 14 hours. The diagnosis can be made using a 75-g glucose load, but that test is not as well validated for detection of at-risk infants or mothers as the 100-g OGTT.
Low-risk status requires no glucose testing, but this category is limited to those women meeting all of the following characteristics:Age <25 years ,Weight normal before pregnancy ,Member of an ethnic group with a low prevalence of GDM, No known diabetes in first-degree relative, No history of abnormal glucose tolerance ,No history of poor obstetric outcome.