ADA妊娠糖尿病的管理:糖尿病的医疗护理标准(2022年).pdf
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1、15. Management of Diabetes inPregnancy:Standards of MedicalCare in Diabetes2022Diabetes Care 2022;45(Suppl. 1):S232S243 | https:/doi.org/10.2337/dc22-S015American Diabetes AssociationProfessional Practice Committee*The American Diabetes Association (ADA) “Standards of Medical Care in Dia-betes” incl
2、udes the ADAs current clinical practice recommendations and isintended to provide the components of diabetes care, general treatment goalsand guidelines, and tools to evaluate quality of care. Members of the ADA Profes-sional Practice Committee, a multidisciplinary expert committee (https:/doi.org/1
3、0.2337/dc22-SPPC), are responsible for updating the Standards of Careannually, or more frequently as warranted. For a detailed description of ADAstandards, statements, and reports, as well as the evidence-grading system forADAs clinical practice recommendations, please refer to the Standards ofCare
4、Introduction (https:/doi.org/10.2337/dc22-SINT). Readers who wish tocomment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.DIABETES IN PREGNANCYThe prevalence of diabetes in pregnancy has been increasing in the U.S. in parallelwith the worldwide epidemic of obesity. N
5、ot only is the prevalence of type 1 diabe-tes and type 2 diabetes increasing in women of reproductive age, but there is alsoa dramatic increase in the reported rates of gestational diabetes mellitus (GDM).Diabetes confers significantly greater maternal and fetal risk largely related to thedegree of
6、hyperglycemia but also related to chronic complications and comorbid-ities of diabetes. In general, specific risks of diabetes in pregnancy include sponta-neous abortion, fetal anomalies, preeclampsia, fetal demise, macrosomia, neonatalhypoglycemia, hyperbilirubinemia, and neonatal respiratory distr
7、ess syndrome,among others. In addition, diabetes in pregnancy may increase the risk of obesity,hypertension, and type 2 diabetes in offspring later in life (1,2).PRECONCEPTION COUNSELINGRecommendations15.1Starting at puberty and continuing in all women with diabetes andreproductive potential, precon
8、ception counseling should be incorpo-rated into routine diabetes care. A15.2Family planning should be discussed, and effective contraception (withconsideration of long-acting, reversible contraception) should be pre-scribed and used until a womans treatment regimen and A1C are opti-mized for pregnan
9、cy. A15.3Preconception counseling should address the importance of achievingglucose levels as close to normal as is safely possible, ideally A1C 6.5%*A complete list of members of the AmericanDiabetes Association Professional Practice Com-mittee can be found at https:/doi.org/10.2337/dc22-SPPC.Sugge
10、sted citation: American Diabetes Asso-ciation Professional Practice Committee. 15.Management of diabetes in pregnancy: Stan-dardsofMedicalCareinDiabetes2022.Diabetes Care 2022;45(Suppl. 1):S232S243 2021 by the American Diabetes Association.Readers may use this article as long as thework is properly
11、cited, the use is educationaland not for profit, and the work is not altered.Moreinformationisavailableathttps:/diabetesjournals.org/journals/pages/license.15. MANAGEMENT OF DIABETES IN PREGNANCYS232Diabetes Care Volume 45, January 2022Downloaded from http:/diabetesjournals.org/care/article-pdf/45/S
12、upplement_1/S232/636911/dc22s015.pdf by guest on 10 July 2022(48 mmol/mol), to reduce therisk of congenital anomalies,preeclampsia, macrosomia, pre-term birth, and other complica-tions. AAll women of childbearing age with dia-betes should be informed about theimportance of achieving and maintaininga
13、s near euglycemia as safely possibleprior to conception and throughout preg-nancy. Observational studies show anincreased risk of diabetic embryopathy,especiallyanencephaly,microcephaly,congenital heart disease, renal anomalies,and caudal regression, directly propor-tional to elevations in A1C durin
14、g the first10 weeks of pregnancy (3). Althoughobservational studies are confounded bythe association between elevated peri-conceptional A1C and other poor self-care behavior, the quantity and consis-tency of data are convincing and supportthe recommendation to optimize glyce-mia prior to conception,
15、 given thatorganogenesis occurs primarily at 58weeks of gestation, with an A1C 6.5%(48 mmol/mol) being associated with thelowest risk of congenital anomalies, pre-eclampsia, and preterm birth (37). Asystematic review and meta-analysis ofobservational studies of preconceptioncare for women with preex
16、isting diabetesdemonstrated lower A1C and reducedrisk of birth defects, preterm delivery,perinatal mortality, small-for-gestational-age births, and neonatal intensive careunit admission (8).There are opportunities to educateall women and adolescents of reproduc-tive age with diabetes about the risks
17、 ofunplannedpregnanciesandaboutimproved maternal and fetal outcomeswith pregnancy planning (9). Effectivepreconception counseling could avertsubstantial health and associated costburdens in offspring (10). Family plan-ning should be discussed, including thebenefits of long-acting, reversible con-tra
18、ception, and effective contraceptionshould be prescribed and used until awomanispreparedandreadytobecome pregnant (1115).To minimize the occurrence of compli-cations, beginning at the onset of pubertyor at diagnosis, all girls and women withdiabetes of childbearing potential shouldreceive education
19、about 1) the risks ofmalformations associated with unplannedpregnancies and even mild hyperglycemiaand 2) the use of effective contraceptionat all times when preventing a pregnancy.Preconception counseling using develop-mentally appropriate educational toolsenables adolescent girls to make well-info
20、rmed decisions (9). Preconceptioncounseling resources tailored for adoles-cents are available at no cost through theAmericanDiabetesAssociation(ADA)(16).Preconception CareRecommendations15.4Women with preexisting dia-beteswhoareplanningapregnancy should ideally bemanaged beginning in precon-ception
21、in a multidisciplinaryclinic including an endocrino-logist, maternal-fetal medicinespecialist, registered dietitiannutritionist, and diabetes careand education specialist, whenavailable. B15.5In addition to focused atten-tion on achieving glycemic tar-gets A, standard preconceptioncare should be aug
22、mented withextra focus on nutrition, diabeteseducation, and screening for dia-betes comorbidities and compli-cations. E15.6Women with preexisting type1 or type 2 diabetes who areplanning pregnancy or whohave become pregnant shouldbe counseled on the risk ofdevelopment and/or progres-sion of diabetic
23、 retinopathy.Dilated eye examinations shouldoccur ideally before pregnancyor in the first trimester, andthen patients should be moni-tored every trimester and for 1year postpartum as indicatedby the degree of retinopathyand as recommended by theeye care provider. BThe importance of preconception car
24、efor all women is highlighted by the Amer-ican College of Obstetricians and Gyne-cologists(ACOG)CommitteeOpinion762, “Prepregnancy Counseling” (17). Akey point is the need to incorporate aquestion about a womans plans forpregnancy into routine primary and gyne-cologic care. The preconception care of
25、women with diabetes should include thestandard screenings and care recom-mended for all women planning preg-nancy(17).Prescriptionofprenatalvitamins (with at least 400 mg of folicacid and 150 mg of potassium iodide18) is recommended prior to concep-tion. Review and counseling on the useof nicotine p
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