Bevier W C, Fischer R, Jovanovic L
Sansum Medical Research Institute, Santa Barbara, California 93105, USA.
Am J Perinatol. 1999;16(6):269-75. doi: 10.1055/s-2007-993871.
Infant macrosomia is a serious medical concern. Pregnant women who do not meet the specific diagnosis for gestational diabetes may still have glucose-mediated macrosomia. In Santa Barbara County all pregnant women are screened for gestational diabetes at 24-28 weeks with a 50-g, 1-hr glucose challenge test (GCT). All patients who fail this test are placed on a standard euglycemic diet (40% carbohydrate, 20% protein, 40% fat) and perform home glucose monitoring of fasting and postprandial glucose levels. The objective of this study was to examine the effectiveness of this treatment program in decreasing infant macrosomia, maternal and infant morbidity, maternal complications, and operative delivery. We studied 103 women who had a positive GCT, but a negative 100-g, 3-hr oral glucose tolerance test (OGTT). The women were randomly assigned to either experimental or control groups with experimental women receiving dietary counseling and home glucose monitoring instruction (HBGM). HBGM diaries were reviewed weekly by clinic nurses. All women had hemoglobin A1c (HbA1c) tests at 28 and 32 weeks. Maternal and fetal charts were reviewed to determine delivery type and complications, indications for cesarean section (C-section), and infant gestational age, gender, Apgar scores, birth weight, morbidities, and congenital anomalies. Of the 103 women, 5 women required insulin treatment, 1 woman had an abortion, and 14 women were indeterminate regarding compliance or were control women who received diet counseling and HBGM. The results are based on 83 women--48 control and 35 experimental. There were no significant differences between the groups for age, parity, or weight at 28-30 weeks or 37 weeks to delivery, or HbA1c at 28 weeks. HbA1c was significantly higher in control women at 32 weeks. Birth weight expressed in grams or as a percentile specific for gender, ethnicity, and gestational age was significantly higher in control infants. Birth weight was significantly correlated with maternal intake weight, weight at 28-30 weeks, and weight at delivery and with HbA1c at 32 weeks' gestation. There were no significant differences between groups for maternal complications. Groups were significantly different for mode of delivery with experimental women having more induced vaginal deliveries but fewer repeat C-sections than control women. Groups were not different for primary C-sections. Women who fail the GCT, but not the OGTT and thus do not receive the diagnosis of GDM are still at risk for delivering a macrosomic infant and operative delivery. Our program of treatment for all women who fail the GCT improves outcome by reducing infant birth weight and the number of cesarean sections.
巨大儿是一个严重的医学问题。未达到妊娠期糖尿病特定诊断标准的孕妇仍可能出现血糖介导的巨大儿情况。在圣巴巴拉县，所有孕妇在孕24 - 28周时都要接受50克1小时葡萄糖耐量试验（GCT）以筛查妊娠期糖尿病。所有该项检查不合格的患者都采用标准的血糖正常饮食（碳水化合物40%、蛋白质20%、脂肪40%），并进行空腹和餐后血糖水平的家庭血糖监测。本研究的目的是检验该治疗方案在降低巨大儿、母婴发病率、母体并发症及手术分娩方面的有效性。我们研究了103名GCT结果为阳性但100克3小时口服葡萄糖耐量试验（OGTT）结果为阴性的女性。这些女性被随机分为实验组和对照组，实验组女性接受饮食咨询和家庭血糖监测指导（HBGM）。诊所护士每周会查看HBGM日记。所有女性在孕28周和32周时都进行了糖化血红蛋白（HbA1c）检测。查阅母体和胎儿病历以确定分娩方式和并发症、剖宫产（C-section）指征以及婴儿的胎龄、性别、阿氏评分、出生体重、发病率和先天性异常情况。在这103名女性中，5名女性需要胰岛素治疗，1名女性流产，14名女性在依从性方面情况不明或为接受饮食咨询和HBGM的对照组女性。研究结果基于83名女性——48名对照组和35名实验组。两组在年龄、产次、孕28 - 30周或孕37周分娩时的体重或孕28周时的HbA1c方面无显著差异。对照组女性在孕32周时的HbA1c显著更高。以克为单位或根据性别、种族和胎龄的百分位数表示的出生体重，对照组婴儿显著更高。出生体重与母体摄入体重、孕28 - 30周时的体重、分娩时的体重以及孕32周时的HbA1c显著相关。两组在母体并发症方面无显著差异。两组在分娩方式上有显著差异，实验组女性诱导阴道分娩更多，但重复剖宫产比对照组女性少。两组在初次剖宫产方面无差异。GCT不合格但OGTT合格因而未被诊断为妊娠期糖尿病的女性，仍有分娩巨大儿和进行手术分娩的风险。我们针对所有GCT不合格女性的治疗方案通过降低婴儿出生体重和剖宫产数量改善了结局。
