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the period during which an embryo develops (about 266 days in humans) (同)gestation period
the conception and development of an idea or plan
a polygenic disease characterized by abnormally high glucose levels in the blood; any of several metabolic disorders marked by excessive urination and persistent thirst
of or relating to gestation

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妊娠;妊娠期間 / (計画などの)立案
糖尿病(尿に糖が異常に出る病気)

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出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2012/09/23 06:51:57」(JST)

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Gestational diabetes (or gestational diabetes mellitus, GDM) is a condition in which women without previously diagnosed diabetes exhibit high blood glucose levels during pregnancy (especially during third trimester). There is some question whether the condition is natural during pregnancy. Gestational diabetes is caused when the insulin receptors do not function properly. This is likely due to pregnancy related factors such as the presence of human placental lactogen that interferes with susceptible insulin receptors. This in turn causes inappropriately elevated blood sugar levels.

Gestational diabetes generally has few symptoms and it is most commonly diagnosed by screening during pregnancy. Diagnostic tests detect inappropriately high levels of glucose in blood samples. Gestational diabetes affects 3-10% of pregnancies, depending on the population studied,^[2] so may be a natural phenomenon.

As with diabetes mellitus in pregnancy in general, babies born to mothers with untreated gestational diabetes are typically at increased risk of problems such as being large for gestational age (which may lead to delivery complications), low blood sugar, and jaundice. If untreated, it can also cause seizures or still birth. Gestational diabetes is a treatable condition and women who have adequate control of glucose levels can effectively decrease these risks.

Women with unmanaged gestational diabetes are at increased risk of developing type 2 diabetes mellitus (or, very rarely, latent autoimmune diabetes or Type 1)^{[citation needed]} after pregnancy, as well as having a higher incidence of pre-eclampsia and Caesarean section;^[3] their offspring are prone to developing childhood obesity,^{[citation needed]} with type 2 diabetes later in life.^{[citation needed]} Most patients are able to manage their blood glucose levels with a modified diet and the introduction of moderate exercise, but some require antidiabetic drugs, including insulin.^[3]

Women with gestational diabetes who manage the condition with diet and exercise or with medication generally have smaller birthweight babies, leading to other problems, such as survival rate of premature and early births, particularly male babies.

1 Classification
2 Risk factors
3 Pathophysiology
4 Screening
- 4.1 Pathways
- 4.2 Non-challenge blood glucose tests
- 4.3 Screening glucose challenge test
- 4.4 Oral glucose tolerance test
- 4.5 Urinary glucose testing
5 Management
- 5.1 Lifestyle
- 5.2 Medication
6 Prognosis
- 6.1 Complications
7 Epidemiology
8 References
9 External links

Classification

Gestational diabetes is formally defined as "any degree of glucose intolerance with onset or first recognition during pregnancy".^[4] This definition acknowledges the possibility that patients may have previously undiagnosed diabetes mellitus, or may have developed diabetes coincidentally with pregnancy. Whether symptoms subside after pregnancy is also irrelevant to the diagnosis.^[5]

The White classification, named after Priscilla White,^[6] who pioneered in research on the effect of diabetes types on perinatal outcome, is widely used to assess maternal and fetal risk. It distinguishes between gestational diabetes (type A) and diabetes that existed prior to pregnancy (pregestational diabetes). These two groups are further subdivided according to their associated risks and management.^[7]

The two subtypes of gestational diabetes (diabetes which began during pregnancy) are:

Type A1: abnormal oral glucose tolerance test (OGTT), but normal blood glucose levels during fasting and two hours after meals; diet modification is sufficient to control glucose levels
Type A2: abnormal OGTT compounded by abnormal glucose levels during fasting and/or after meals; additional therapy with insulin or other medications is required

The second group of diabetes which existed prior to pregnancy is also split up into several subtypes.

Type B: onset at age 20 or older or duration of less than 10 years.

Type C: onset at age 10-19 or duration of 10–19 years.

Type D: onset before age 10 or duration greater than 20 years.

Type E: overt diabetes mellitus with calcified pelvic vessels.

Type F: diabetic nephropathy.

Type R: proliferative retinopathy.

Type RF: retinopathy and nephropathy.

Type H: ischemic heart disease.

Type T: prior kidney transplant.

An early age of onset or long-standing disease comes with greater risks, hence the first three subtypes.

Risk factors

Classical risk factors for developing gestational diabetes are:^[8]

Polycystic Ovary Syndrome
A previous diagnosis of gestational diabetes or prediabetes, impaired glucose tolerance, or impaired fasting glycaemia
A family history revealing a first-degree relative with type 2 diabetes
Maternal age - a woman's risk factor increases as she gets older (especially for women over 35 years of age).
Ethnic background (those with higher risk factors include African-Americans, Afro-Caribbeans, Native Americans, Hispanics, Pacific Islanders, and people originating from South Asia)
Being overweight, obese or severely obese increases the risk by a factor 2.1, 3.6 and 8.6, respectively.^[9]
a previous pregnancy which resulted in a child with a macrosomia (high birth weight: >90th centile or >4000 g (8 lbs 12.8 oz))
Previous poor obstetric history

In addition to this, statistics show a double risk of GDM in smokers.^[10] Polycystic ovarian syndrome is also a risk factor,^[8] although relevant evidence remains controversial.^[11] Some studies have looked at more controversial potential risk factors, such as short stature.^[12]

About 40-60% of women with GDM have no demonstrable risk factor; for this reason many advocate to screen all women.^[13] Typically, women with GDM exhibit no symptoms (another reason for universal screening), but some women may demonstrate increased thirst, increased urination, fatigue, nausea and vomiting, bladder infection, yeast infections and blurred vision.

Pathophysiology

Effect of insulin on glucose uptake and metabolism. Insulin binds to its receptor (1) on the cell membrane which in turn starts many protein activation cascades (2). These include: translocation of Glut-4 transporter to the plasma membrane and influx of glucose (3), glycogen synthesis (4), glycolysis (5) and fatty acid synthesis (6).

The precise mechanisms underlying gestational diabetes remain unknown. The hallmark of GDM is increased insulin resistance. Pregnancy hormones and other factors are thought to interfere with the action of insulin as it binds to the insulin receptor. The interference probably occurs at the level of the cell signaling pathway behind the insulin receptor.^[14] Since insulin promotes the entry of glucose into most cells, insulin resistance prevents glucose from entering the cells properly. As a result, glucose remains in the bloodstream, where glucose levels rise. More insulin is needed to overcome this resistance; about 1.5-2.5 times more insulin is produced than in a normal pregnancy.^[14]

Insulin resistance is a normal phenomenon emerging in the second trimester of pregnancy, which progresses thereafter to levels seen in non-pregnant patients with type 2 diabetes. It is thought to secure glucose supply to the growing fetus. Women with GDM have an insulin resistance they cannot compensate with increased production in the β-cells of the pancreas. Placental hormones, and to a lesser extent increased fat deposits during pregnancy, seem to mediate insulin resistance during pregnancy. Cortisol and progesterone are the main culprits, but human placental lactogen, prolactin and estradiol contribute, too.^[14]

It is unclear why some patients are unable to balance insulin needs and develop GDM; however, a number of explanations have been given, similar to those in type 2 diabetes: autoimmunity, single gene mutations, obesity, and other mechanisms.^[15]

Because glucose travels across the placenta (through diffusion facilitated by GLUT3 carriers), in untreated gestational diabetes the fetus is exposed to consistently higher glucose levels. This leads to increased fetal levels of insulin (insulin itself cannot cross the placenta). The growth-stimulating effects of insulin can lead to excessive growth and a large body (macrosomia). After birth, the high glucose environment disappears, leaving these newborns with ongoing high insulin production and susceptibility to low blood glucose levels (hypoglycemia).^[16]

Screening

Diabetes diagnostic criteria^[17]^[18] edit
Condition	2 hour glucose	Fasting glucose	HbA_1c
	mmol/l(mg/dl)	mmol/l(mg/dl)	%
Normal	<7.8 (<140)	<6.1 (<110)	<6.0
Impaired fasting glycaemia	<7.8 (<140)	≥ 6.1(≥110) & <7.0(<126)	6.0–6.4
Impaired glucose tolerance	≥7.8 (≥140)	<7.0 (<126)	6.0–6.4
Diabetes mellitus	≥11.1 (≥200)	≥7.0 (≥126)	≥6.5

A number of screening and diagnostic tests have been used to look for high levels of glucose in plasma or serum in defined circumstances. One method is a stepwise approach where a suspicious result on a screening test is followed by diagnostic test. Alternatively, a more involved diagnostic test can be used directly at the first antenatal visit in high-risk patients (for example in those with polycystic ovarian syndrome or acanthosis nigricans).^[16]

Tests for gestational diabetes
Non-challenge blood glucose test Fasting glucose test 2-hour postprandial (after a meal) glucose test Random glucose test
Screening glucose challenge test
Oral glucose tolerance test (OGTT)

Non-challenge blood glucose tests involve measuring glucose levels in blood samples without challenging the subject with glucose solutions. A blood glucose level is determined when fasting, 2 hours after a meal, or simply at any random time. In contrast, challenge tests involve drinking a glucose solution and measuring glucose concentration thereafter in the blood; in diabetes, they tend to remain high. The glucose solution has a very sweet taste which some women find unpleasant; sometimes, therefore, artificial flavours are added. Some women may experience nausea during the test, and more so with higher glucose levels.^[19]^[20]

Pathways

Opinions differ about optimal screening and diagnostic measures, in part due to differences in population risks, cost-effectiveness considerations, and lack of an evidence base to support large national screening programs.^[21] The most elaborate regimen entails a random blood glucose test during a booking visit, a screening glucose challenge test around 24–28 weeks' gestation, followed by an OGTT if the tests are outside normal limits. If there is a high suspicion, a woman may be tested earlier.^[5]

In the United States, most obstetricians prefer universal screening with a screening glucose challenge test.^[22] In the United Kingdom, obstetric units often rely on risk factors and a random blood glucose test.^[16]^[23] The American Diabetes Association and the Society of Obstetricians and Gynaecologists of Canada recommend routine screening unless the patient is low risk (this means the woman must be younger than 25 years and have a body mass index less than 27, with no personal, ethnic or family risk factors)^[5]^[21] The Canadian Diabetes Association and the American College of Obstetricians and Gynecologists recommend universal screening.^[24]^[25] The U.S. Preventive Services Task Force found there is insufficient evidence to recommend for or against routine screening.^[26]

Some pregnant women and careproviders choose to forgo routine screening due to the absence of risk factors, however this is not advised due to the large proportion of women who develop gestational diabetes despite having no risk factors present and the dangers to the mother and baby if gestational diabetes remains untreated.^[13]

Non-challenge blood glucose tests

When a plasma glucose level is found to be higher than 126 mg/dl (7.0 mmol/l) after fasting, or over 200 mg/dl (11.1 mmol/l) on any occasion, and if this is confirmed on a subsequent day, the diagnosis of GDM is made, and no further testing is required.^[5] These tests are typically performed at the first antenatal visit. They are patient-friendly and inexpensive, but have a lower test performance compared to the other tests, with moderate sensitivity, low specificity and high false positive rates.^[27]^[28]^[29]

Screening glucose challenge test

The screening glucose challenge test (sometimes called the O'Sullivan test) is performed between 24–28 weeks, and can be seen as a simplified version of the oral glucose tolerance test (OGTT). No previous fasting is required for this screening test,^[30] in contrast to the OGTT. The O'Sullivan test involves drinking a solution containing 50 grams of glucose, and measuring blood levels 1 hour later.^[31]

If the cut-off point is set at 140 mg/dl (7.8 mmol/l), 80% of women with GDM will be detected.^[5] If this threshold for further testing is lowered to 130 mg/dl, 90% of GDM cases will be detected, but there will also be more women who will be subjected to a consequent OGTT unnecessarily.

Oral glucose tolerance test

Main article: Oral glucose tolerance test

The OGTT^[32] should be done in the morning after an overnight fast of between 8 and 14 hours. During the three previous days the subject must have an unrestricted diet (containing at least 150 g carbohydrate per day) and unlimited physical activity. The subject should remain seated during the test and should not smoke throughout the test.

The test involves drinking a solution containing a certain amount of glucose, usually 75 g or 100 g, and drawing blood to measure glucose levels at the start and on set time intervals thereafter.

The diagnostic criteria from the National Diabetes Data Group (NDDG) have been used most often, but some centers rely on the Carpenter and Coustan criteria, which set the cutoff for normal at lower values. Compared with the NDDG criteria, the Carpenter and Coustan criteria lead to a diagnosis of gestational diabetes in 54 percent more pregnant women, with an increased cost and no compelling evidence of improved perinatal outcomes.^[33]

The following are the values which the American Diabetes Association considers to be abnormal during the 100 g of glucose OGTT:

Fasting blood glucose level ≥95 mg/dl (5.33 mmol/L)
1 hour blood glucose level ≥180 mg/dl (10 mmol/L)
2 hour blood glucose level ≥155 mg/dl (8.6 mmol/L)
3 hour blood glucose level ≥140 mg/dl (7.8 mmol/L)

An alternative test uses a 75 g glucose load and measures the blood glucose levels before and after 1 and 2 hours, using the same reference values. This test will identify fewer women who are at risk, and there is only a weak concordance (agreement rate) between this test and a 3 hour 100 g test.^[34]

The glucose values used to detect gestational diabetes were first determined by O'Sullivan and Mahan (1964) in a retrospective cohort study (using a 100 grams of glucose OGTT) designed to detect risk of developing type 2 diabetes in the future. The values were set using whole blood and required two values reaching or exceeding the value to be positive.^[35] Subsequent information led to alterations in O'Sullivan's criteria. When methods for blood glucose determination changed from the use of whole blood to venous plasma samples, the criteria for GDM were also changed.

Urinary glucose testing

Women with GDM may have high glucose levels in their urine (glucosuria). Although dipstick testing is widely practiced, it performs poorly, and discontinuing routine dipstick testing has not been shown to cause underdiagnosis where universal screening is performed.^[36] Increased glomerular filtration rates during pregnancy contribute to some 50% of women having glucose in their urine on dipstick tests at some point during their pregnancy. The sensitivity of glucosuria for GDM in the first 2 trimesters is only around 10% and the positive predictive value is around 20%.^[37]^[38]

Management

Main article: Diabetes management

A kit with a glucose meter and diary used by a woman with gestational diabetes.

The goal of treatment is to reduce the risks of GDM for mother and child. Scientific evidence is beginning to show that controlling glucose levels can result in less serious fetal complications (such as macrosomia) and increased maternal quality of life. Unfortunately, treatment of GDM is also accompanied by more infants admitted to neonatal wards and more inductions of labour, with no proven decrease in cesarean section rates or perinatal mortality.^[39]^[40] These findings are still recent and controversial.^[41]

A repeat OGTT should be carried out 6 weeks after delivery, to confirm the diabetes has disappeared. Afterwards, regular screening for type 2 diabetes is advised.^[8]

If a diabetic diet or G.I. Diet, exercise, and oral medication are inadequate to control glucose levels, insulin therapy may become necessary.

The development of macrosomia can be evaluated during pregnancy by using sonography. Women who use insulin, with a history of stillbirth, or with hypertension are managed like women with overt diabetes.^[13]

Lifestyle

Counselling before pregnancy (for example, about preventive folic acid supplements) and multidisciplinary management are important for good pregnancy outcomes.^[42] Most women can manage their GDM with dietary changes and exercise. Self monitoring of blood glucose levels can guide therapy. Some women will need antidiabetic drugs, most commonly insulin therapy.

Any diet needs to provide sufficient calories for pregnancy, typically 2,000 - 2,500 kcal with the exclusion of simple carbohydrates.^[13] The main goal of dietary modifications is to avoid peaks in blood sugar levels. This can be done by spreading carbohydrate intake over meals and snacks throughout the day, and using slow-release carbohydrate sources—known as the G.I. Diet. Since insulin resistance is highest in mornings, breakfast carbohydrates need to be restricted more.^[8] Ingesting more fiber in foods with whole grains, or fruit and vegetables can also reduce the risk of gestational diabetes.^[43]

Regular moderately intense physical exercise is advised, although there is no consensus on the specific structure of exercise programs for GDM.^[8]^[44]

Self monitoring can be accomplished using a handheld capillary glucose dosage system. Compliance with these glucometer systems can be low.^[45] Target ranges advised by the Australasian Diabetes in Pregnancy Society are as follows:^[8]

fasting capillary blood glucose levels <5.5 mmol/L
1 hour postprandial capillary blood glucose levels <8.0 mmol/L
2 hour postprandial blood glucose levels <6.7 mmol/L

Regular blood samples can be used to determine HbA1c levels, which give an idea of glucose control over a longer time period.^[8]

Research suggests a possible benefit of breastfeeding to reduce the risk of diabetes and related risks for both mother and child.^[46]

Medication

If monitoring reveals failing control of glucose levels with these measures, or if there is evidence of complications like excessive fetal growth, treatment with insulin might become necessary. The most common therapeutic regime involves premeal fast-acting insulin to blunt sharp glucose rises after meals.^[8] Care needs to be taken to avoid low blood sugar levels (hypoglycemia) due to excessive insulin injections. Insulin therapy can be normal or very tight; more injections can result in better control but requires more effort, and there is no consensus that it has large benefits.^[16]^[47]^[48]

There is some evidence that certain oral glycemic agents might be safe in pregnancy, or at least, are significantly less dangerous to the developing fetus than poorly controlled diabetes. Glyburide, a second generation sulfonylurea, has been shown to be an effective alternative to insulin therapy.^[49]^[50] In one study, 4% of women needed supplemental insulin to reach blood sugar targets.^[50] Metformin has shown promising results, with its oral format being much more popular than insulin injections.^[3] Treatment of polycystic ovarian syndrome with metformin during pregnancy has been noted to decrease GDM levels.^[51] A recent randomized controlled trial of metformin versus insulin showed that women preferred metformin tablets to insulin injections, and that metformin is safe and equally effective as insulin.^[52] Severe neonatal hypoglycemia was less common in insulin-treated women, but preterm delivery was more common. Almost half of patients did not reach sufficient control with metformin alone and needed supplemental therapy with insulin; compared to those treated with insulin alone, they required less insulin, and they gained less weight.^[52] With no long-term studies into children of women treated with the drug, here remains a possibility of long-term complications from metformin therapy,^[3] although follow-up at the age of 18 months of children born to women with polycystic ovarian syndrome and treated with metformin revealed no developmental abnormalities.^[53]

Prognosis

Gestational diabetes generally resolves once the baby is born. Based on different studies, the chances of developing GDM in a second pregnancy are between 30 and 84%, depending on ethnic background. A second pregnancy within 1 year of the previous pregnancy has a high rate of recurrence.^[54]

Women diagnosed with gestational diabetes have an increased risk of developing diabetes mellitus in the future. The risk is highest in women who needed insulin treatment, had antibodies associated with diabetes (such as antibodies against glutamate decarboxylase, islet cell antibodies and/or insulinoma antigen-2), women with more than two previous pregnancies, and women who were obese (in order of importance).^[55]^[56] Women requiring insulin to manage gestational diabetes have a 50% risk of developing diabetes within the next five years.^[35] Depending on the population studied, the diagnostic criteria and the length of follow-up, the risk can vary enormously.^[57] The risk appears to be highest in the first 5 years, reaching a plateau thereafter.^[57] One of the longest studies followed a group of women from Boston, Massachusetts; half of them developed diabetes after 6 years, and more than 70% had diabetes after 28 years.^[57] In a retrospective study in Navajo women, the risk of diabetes after GDM was estimated to be 50 to 70% after 11 years.^[58] Another study found a risk of diabetes after GDM of more than 25% after 15 years.^[59] In populations with a low risk for type 2 diabetes, in lean subjects and in patients with auto-antibodies, there is a higher rate of women developing type 1 diabetes.^[56]

Children of women with GDM have an increased risk for childhood and adult obesity and an increased risk of glucose intolerance and type 2 diabetes later in life.^[60] This risk relates to increased maternal glucose values.^[61] It is currently unclear how much genetic susceptibility and environmental factors each contribute to this risk, and if treatment of GDM can influence this outcome.^[62]

There are scarce statistical data on the risk of other conditions in women with GDM; in the Jerusalem Perinatal study, 410 out of 37962 patients were reported to have GDM, and there was a tendency towards more breast and pancreatic cancer, but more research is needed to confirm this finding.^[63]^[64]

Complications

GDM poses a risk to mother and child. This risk is largely related to uncontrolled high blood glucose levels and its consequences. The risk increases with higher blood glucose levels.^[65] Treatment resulting in better control of these levels can reduce some of the risks of GDM considerably.^[45]

The two main risks GDM imposes on the baby are growth abnormalities and chemical imbalances after birth, which may require admission to a neonatal intensive care unit. Infants born to mothers with GDM are at risk of being both large for gestational age (macrosomic)^[65] in unmanaged GDM, and small for gestational age and Intrauterine growth retardation^[66] in managed GDM. Macrosomia in turn increases the risk of instrumental deliveries (e.g. forceps, ventouse and caesarean section) or problems during vaginal delivery (such as shoulder dystocia). Macrosomia may affect 12% of normal women compared to 20% of patients with GDM.^[16] However, the evidence for each of these complications is not equally strong; in the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study for example, there was an increased risk for babies to be large but not small for gestational age in women with uncontrolled GDM.^[65] Research into complications for GDM is difficult because of the many confounding factors (such as obesity). Labelling a woman as having GDM may in itself increase the risk of having an unnecessary caesarean section.^[67]^[68]

Neonates born from women with consistently high blood sugar levels are also at an increased risk of low blood glucose (hypoglycemia), jaundice, high red blood cell mass (polycythemia) and low blood calcium (hypocalcemia) and magnesium (hypomagnesemia).^[69] Untreated GDM also interferes with maturation, causing dysmature babies prone to respiratory distress syndrome due to incomplete lung maturation and impaired surfactant synthesis.^[69]

Unlike pre-gestational diabetes, gestational diabetes has not been clearly shown to be an independent risk factor for birth defects. Birth defects usually originate sometime during the first trimester (before the 13th week) of pregnancy, whereas GDM gradually develops and is least pronounced during the first and early second trimester. Studies have shown that the offspring of women with GDM are at a higher risk for congenital malformations.^[70]^[71]^[72] A large case-control study found that gestational diabetes was linked with a limited group of birth defects, and that this association was generally limited to women with a higher body mass index (≥ 25 kg/m²).^[73] It is difficult to make sure that this is not partially due to the inclusion of women with pre-existent type 2 diabetes who were not diagnosed before pregnancy.

Because of conflicting studies, it is unclear at the moment whether women with GDM have a higher risk of preeclampsia.^[74] In the HAPO study, the risk of preeclampsia was between 13% and 37% higher, although not all possible confounding factors were corrected.^[65]

Epidemiology

Gestational diabetes affects 3-10% of pregnancies, depending on the population studied.^[2]

References

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^ Nachum, Z.; Ben-Shlomo, I.; Weiner, E.; Shalev, E. (1999). "Twice daily versus four times daily insulin dose regimens for diabetes in pregnancy: Randomised controlled trial". BMJ (Clinical research ed.) 319 (7219): 1223–1227. PMC 28269. PMID 10550081. //www.ncbi.nlm.nih.gov/pmc/articles/PMC28269/.
^ Walkinshaw, S. A. (2006). Very tight versus tight control for diabetes in pregnancy. In Walkinshaw, Stephen A. "Cochrane Database of Systematic Reviews". Cochrane database of systematic reviews (Online) (2): CD000226. doi:10.1002/14651858.CD000226.pub2. PMID 17636623.
^ Kremer, C. J.; Duff, P. (2004). "Glyburide for the treatment of gestational diabetes". American Journal of Obstetrics and Gynecology 190 (5): 1438–1439. doi:10.1016/j.ajog.2004.02.032. PMID 15167862.
^ ^a ^b Langer, O.; Conway, D. L.; Berkus, M. D.; Xenakis, E. M. -J.; Gonzales, O. (2000). "A Comparison of Glyburide and Insulin in Women with Gestational Diabetes Mellitus". New England Journal of Medicine 343 (16): 1134–1138. doi:10.1056/NEJM200010193431601. PMID 11036118.
^ Simmons, D.; Walters, B. N.; Rowan, J. A.; McIntyre, H. D. (2004). "Metformin therapy and diabetes in pregnancy". The Medical journal of Australia 180 (9): 462–464. PMID 15115425.
^ ^a ^b Rowan, J. A.; Hague, W. M.; Gao, W.; Battin, M. R.; Moore, M. P.; Mig Trial, I. (2008). "Metformin versus Insulin for the Treatment of Gestational Diabetes". New England Journal of Medicine 358 (19): 2003–2015. doi:10.1056/NEJMoa0707193. PMID 18463376.
^ Glueck, C. J.; Goldenberg, N.; Pranikoff, J.; Loftspring, M.; Sieve, L.; Wang, P. (2004). "Height, weight, and motor-social development during the first 18 months of life in 126 infants born to 109 mothers with polycystic ovary syndrome who conceived on and continued metformin through pregnancy". Human Reproduction 19 (6): 1323–1330. doi:10.1093/humrep/deh263. PMID 15117896.
^ Kim, C.; Berger, D. K.; Chamany, S. (2007). "Recurrence of Gestational Diabetes Mellitus: A systematic review". Diabetes Care 30 (5): 1314–1319. doi:10.2337/dc06-2517. PMID 17290037.
^ Löbner, K.; Knopff, A.; Baumgarten, A.; Mollenhauer, U.; Marienfeld, S.; Garrido-Franco, M.; Bonifacio, E.; Ziegler, A. G. (2006). "Predictors of postpartum diabetes in women with gestational diabetes mellitus". Diabetes 55 (3): 792–797. PMID 16505245.
^ ^a ^b Järvelä, I. Y.; Juutinen, J.; Koskela, P.; Hartikainen, A. L.; Kulmala, P.; Knip, M.; Tapanainen, J. S. (2006). "Gestational diabetes identifies women at risk for permanent type 1 and type 2 diabetes in fertile age: Predictive role of autoantibodies". Diabetes care 29 (3): 607–612. PMID 16505514.
^ ^a ^b ^c Kim, C.; Newton, K. M.; Knopp, R. H. (2002). "Gestational diabetes and the incidence of type 2 diabetes: A systematic review". Diabetes care 25 (10): 1862–1868. PMID 12351492.
^ Steinhart, J. R.; Sugarman, J. R.; Connell, F. A. (1997). "Gestational diabetes is a herald of NIDDM in Navajo women. High rate of abnormal glucose tolerance after GDM". Diabetes care 20 (6): 943–947. PMID 9167104.
^ Lee, A. J.; Hiscock, R. J.; Wein, P.; Walker, S. P.; Permezel, M. (2007). "Gestational Diabetes Mellitus: Clinical Predictors and Long-Term Risk of Developing Type 2 Diabetes: A retrospective cohort study using survival analysis". Diabetes Care 30 (4): 878–883. doi:10.2337/dc06-1816. PMID 17392549.
^ Boney, C. M.; Verma, A.; Tucker, R.; Vohr, B. R. (2005). "Metabolic Syndrome in Childhood: Association with Birth Weight, Maternal Obesity, and Gestational Diabetes Mellitus". Pediatrics 115 (3): e290–e296. doi:10.1542/peds.2004-1808. PMID 15741354.
^ Hillier, T. A.; Pedula, K. L.; Schmidt, M. M.; Mullen, J. A.; Charles, M. -A.; Pettitt, D. J. (2007). "Childhood Obesity and Metabolic Imprinting: The ongoing effects of maternal hyperglycemia". Diabetes Care 30 (9): 2287–2292. doi:10.2337/dc06-2361. PMID 17519427.
^ Metzger, B. E. (2007). "Long-term Outcomes in Mothers Diagnosed with Gestational Diabetes Mellitus and Their Offspring". Clinical Obstetrics and Gynecology 50 (4): 972–979. doi:10.1097/GRF.0b013e31815a61d6. PMID 17982340.
^ Perrin, M. C.; Terry, M. B.; Kleinhaus, K.; Deutsch, L.; Yanetz, R.; Tiram, E.; Calderon-Margalit, R.; Friedlander, Y. et al. (2007). "Gestational diabetes and the risk of breast cancer among women in the Jerusalem Perinatal Study". Breast Cancer Research and Treatment 108 (1): 129–135. doi:10.1007/s10549-007-9585-9. PMID 17476589.
^ Perrin, M. C.; Terry, M. B.; Kleinhaus, K.; Deutsch, L.; Yanetz, R.; Tiram, E.; Calderon, R.; Friedlander, Y. et al. (2007). "Gestational diabetes as a risk factor for pancreatic cancer: A prospective cohort study". BMC Medicine 5: 25. doi:10.1186/1741-7015-5-25. PMC 2042496. PMID 17705823. //www.ncbi.nlm.nih.gov/pmc/articles/PMC2042496/.
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^ Setji, T. L.; Brown, A. J.; Feinglos, M. N. (1 January 2005). "Gestational Diabetes Mellitus". Clinical Diabetes 23 (1): 17–24. doi:10.2337/diaclin.23.1.17.
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^ Jovanovic-Peterson, L.; Bevier, W.; Peterson, C. (2008). "The Santa Barbara County Health Care Services Program: Birth Weight Change Concomitant with Screening for and Treatment of Glucose-Intolerance of Pregnancy: A Potential Cost-Effective Intervention?". American Journal of Perinatology 14 (4): 221–228. doi:10.1055/s-2007-994131. PMID 9259932.
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External links

IDF Diabetes Atlas
International Diabetes Federation
National Institute of Child Health and Human Development - Am I at Risk for Gestational Diabetes?
National Institute of Child Health and Human Development - Managing Gestational Diabetes: A Patient's Guide to a Healthy Pregnancy
Gestational Diabetes Resource Guide - American Diabetes Association
World Diabetes Day
Diabetes.co.uk: Gestational Diabetes
More information on gestational diabetes

UpToDate Contents

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1. 妊娠糖尿病：血糖コントロールおよび母体の予後 gestational diabetes mellitus glycemic control and maternal prognosis
2. 妊娠糖尿病：産科的問題とマネージメント gestational diabetes mellitus obstetrical issues and management
3. 妊娠中の糖尿病：スクリーニングおよび診断 diabetes mellitus in pregnancy screening and diagnosis
4. 糖尿病の母親の小児 infant of a diabetic mother
5. 妊娠前糖尿病および妊娠糖尿病：分娩時および分娩後の血糖コントロール pregestational and gestational diabetes intrapartum and postpartum glycemic control

English Journal

Controversies on how diabetes is diagnosed.

Malkani S, Desilva T.SourceaUniversity of Massachusetts Medical School, Worcester, Massachusetts bLouisiana State University School of Medicine, New Orleans, Louisiana, USA.
Current opinion in endocrinology, diabetes, and obesity.Curr Opin Endocrinol Diabetes Obes.2012 Apr;19(2):97-103.
PURPOSE OF REVIEW: To evaluate the controversial aspects of diabetes diagnosis.RECENT FINDINGS: Within the past 2 years, revised guidelines for the diagnosis of diabetes have been issued which endorse the use of the hemoglobin A1C as a diagnostic test, in addition to the previously recommended tests
PMID 22327369

Cytokine profile, metabolic syndrome and cardiovascular disease risk in women with late-onset gestational diabetes mellitus.

López-Tinoco C, Roca M, Fernández-Deudero A, García-Valero A, Bugatto F, Aguilar-Diosdado M, Bartha JL.SourceDepartment of Endocrinology, Hospital Puerta del Mar, Cádiz, Spain.
Cytokine.Cytokine.2012 Apr;58(1):14-9. Epub 2011 Dec 24.
Inflammation is an important component of the metabolic syndrome (MetS) which could be the link between the metabolic and the cardiovascular consequences of this condition. Gestational diabetes mellitus (GDM) has been recognized as a significant risk factor for MetS and an inflammation component has
PMID 22200508

Japanese Journal

妊娠糖尿病の血糖管理法の実際(<特集>妊娠糖尿病)

和栗雅子
日本産科婦人科學會雜誌 65(3), 1140-1146, 2013-03-01
NAID 110009596757

妊娠糖尿病と周産期合併症対策(<特集>妊娠糖尿病)

杉山隆
日本産科婦人科學會雜誌 65(3), 1133-1139, 2013-03-01
NAID 110009596756

妊娠糖尿病の診断と産後のフォローアップ(<特集>妊娠糖尿病)

平松祐司
日本産科婦人科學會雜誌 65(3), 1125-1132, 2013-03-01
NAID 110009596755

Related Pictures

★リンクテーブル★

リンク元	「妊娠糖尿病」
拡張検索	「pregestational diabetes mellitus」
関連記事	「gestation」「diabetes」

「妊娠糖尿病」

Gestational diabetes
	Classification and external resources
	; Universal blue circle symbol for diabetes.
ICD-10	O24
ICD-9	648.8
MedlinePlus	000896
MeSH	D016640

　　[★]

英: gestational diabetes mellitus GDM, gestational diabetes
同: 妊娠性糖尿病
関: 糖尿病、糖代謝異常妊娠

定義

~~妊娠により発生した妊娠中にのみ認められる糖代謝異常合併妊娠で、分娩後に改めて糖負荷試験を行うと、正常化する疾患概念~~
妊娠中にはじめて発見または発症した糖尿病に至っていない糖代謝異常である。あきらかな糖尿病（overt diabetes）は含めない。(参考1)

危険因子

NGY.429

糖尿病の家族歴の有無、巨大児の分娩の有無、先天奇形の分娩歴の有無、原因不明の流産歴・早産歴・死産歴の有無、35歳以上、肥満者、尿糖陽性者

合併症

G10M.164 参考1

母体

流産、早産

胎児

妊娠高血圧症候群、子宮内胎児発育遅延、胎児機能不全、胎児死亡、先天奇形、羊水過多

新生児

呼吸窮迫症候群、多血症、高ビリルビン血症、低カルシウム血症、巨大児、新生児低血圧症

妊婦の妊娠糖尿病のスクリーニング

食後血糖値

正常食(約400-600lcal)摂取後2-4時間の間に静脈血採取。血糖値が100 mg/dl以上であればOGTT 75gを行う。
100 mg/dlであっても、尿糖(+)、肥満、糖尿病の家族歴、あるいは巨大児出産の既往のいずれかがある場合にもOGTT 75gを行う。

診断基準

新診断基準

参考1,2

初診時およびインスリン抵抗性の高まる妊娠中期に随時血糖値検査を行い、100mg/dl以上の陽性者に対してOGTTを施行して診断

<OGTT判定基準>

・空腹時血糖値≧92mg/dl

・１時間値≧180mg/dl

・2時間値≧153mg/dl

の1点以上を満たした場合に妊娠糖尿病と診断する．

※但し，「臨床診断」における糖尿病と診断されるものは除く．

[show details]

治療・管理

管理

合併症の定期的な評価

糖尿病性網膜症
糖尿病性腎症
妊娠初期の胎児奇形

管理目標

空腹時血糖 100mg/dl以下、食後2時間血糖値 120mg/dl以下、1日平均血糖値 100mg/dl以下、HbA_1c 6%以下

食事療法

分食とする
摂取熱量

妊娠前半：標準体重 x 30 + 150 kcal/日
妊娠後半：標準体重 x 30 + 350 kcal/日

インスリン療法

経口血糖降下薬は胎盤通過性があり、胎児の安全性が確認されておらず、また乳汁中にも分泌されるため、妊娠から授乳がおわるまでは禁忌

分娩後の管理

分娩後6-12週に75g OGTTをおこない、糖尿病の評価を行う。

参考

1. クリニカルカンファレンス1 母体合併症 3）糖代謝異常合併妊娠 - 日産婦誌62巻9号

http://www.jsog.or.jp/PDF/62/6209-114.pdf

2.

http://d.hatena.ne.jp/bonbokorin/20100608/p1

「pregestational diabetes mellitus」

　　[★]

同: preGDM
同: preGDM

「gestation」

　　[★]

n.

計画を練ること、立案。妊娠、妊娠期間

関: conceive、gestational age、gestational period、gravid、pregnancy、pregnant

「diabetes」

　　[★]

関: 糖尿病 diabetes mellitus DM

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[17] Vijan, S (March 2010). "Type 2 diabetes". Annals of Internal Medicine 152 (5): ITC31-15. doi:10.1059/0003-4819-152-5-201003020-01003. PMID 20194231.

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Gestational diabetes
Classification and external resources
Universal blue circle symbol for diabetes.^[1]
ICD-10	O24
ICD-9	648.8
MedlinePlus	000896
MeSH	D016640

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案内

gestational diabetes