Gestationsdiabetes – noch immer ein nicht zu unterschätzender Risikofaktor

Zusammenfassung:

Ziel: Review der Literatur zu Schwangeren mit Gestationsdiabetes, die ein erhöhtes peripartales Risiko aufweisen, welches im Rahmen des geburtshilflichen Managements Beachtung finden sollte.

Methodik: Systematische Literaturrecherche.

Ergebnisse: Als Gestationsdiabetes wird ein erstmals in der Schwangerschaft auftretender bzw. diagnostizierter Diabetes bezeichnet. Die Pathophysiologie und das Risikoprofil entsprechen dem des Diabetes mellitus Typ 2. Eine entscheidende Rolle spielen dabei, neben einer genetischen Disposition, der mütterliche Body-Mass-Index, der Lebensstil sowie frühere Schwangerschaften mit Gestationsdiabetes. Die Diagnosestellung erfolgt durch einen 75 g oralen Glukosetoleranztest, meist bei 24–28 Schwangerschaftswochen. Die Folgen für die Mutter sind vor allem die schwangerschaftsinduzierte Hypertonie und Präeklampsie sowie im Verlauf die erhöhte Inzidenz für kardiovaskuläre Ereignisse. Intrapartal zeigen sich zudem eine erhöhte Sectio-Rate bei fetalem Large for gestational age und ein erhöhtes Risiko für höhergradige Geburtsverletzungen und atone Nachblutungen. Die Therapie schließt sowohl die Lifestyle-Modifikation als auch die medikamentöse Therapie mit Insulin ein.

Schlussfolgerungen: Durch die frühzeitige Diagnosestellung durch adäquate Testverfahren und konsequent eingeleitete Therapien kann das peripartale maternale und fetale Risiko reduziert werden.

Abstract

Purpose: Pregnant women with gestational diabetes mellitus have an increased peripartal risk. The aim of this article is to summarize the current state of the art for both the diagnosis and management in pregnancy and childbirth.

Methods: Systematic literature review.

Results: Gestational diabetes is defined as diabetes, which is diagnosed for the first time in pregnancy. The pathophysiology and risk profile are similar to diabetes mellitus type 2. A Genetic disposition, the maternal body-mass-index and lifestyle, as well as gestational diabetes in previous pregnancies, are risk factors. The diagnosis is made by a 75g oral glucose tolerance test, usually at 24 to 28 weeks of gestation. Maternal risks include pregnancy-induced hypertension, preeclampsia and an increased incidence for cardiovascular disease. The rate of cesarean section in the case of fetal macrosomia (large for gestational age) and of postpartum hemorrhage is increased. The therapy includes lifestyle modifications and a drug therapy with insulin.

Conclusion: An early diagnosis with adequate test methods and a consequent therapy can reduce the peripartum maternal and fetal risks.

Schlüsselwörter

Gestationsdiabetes - Diabetes mellitus - Large for gestational age - Schwangerschaft - Blutzucker

Key Words

Gestational diabetes - diabetes mellitus - large for gestational age - pregnancy - blood glucose

Publication History

Article published online:
29 June 2021

• Literatur

• 1 Kautzky-Willer A, Prager R, Waldhausl W. et al. Pronounced insulin resistance and inadequate beta-cell secretion characterize lean gestational diabetes during and after pregnancy. Diabetes Care. 1997: 1717-23. DOI: 10.2337/diacare.20.11.1717
• 2 Bouthoorn SH, Silva LM, Murray SE. et al. Low-educated women have an increased risk of gestational diabetes mellitus: The Generation R Study. Acta Diabetol. 2015 DOI: 10.1007/s00592-014-0668-x
• 3 Kun A, Tornczky J, Tabk AG. The prevalence and predictors of gestational diabetes mellitus in Hungary. Horm Metab Res. 2011 DOI: 10.1055/s-0031-1287795
• 4 Teede HJ, Harrison CL, Teh WT. et al. Gestational diabetes: Development of an early risk prediction tool to facilitate opportunities for prevention. Aust New Zeal J Obstet Gynaecol. 2011 DOI: 10.1111/j.1479-828X.2011.01356.x.
• 5 Torloni MR, Betrán AP, Horta BL. et al. Prepregnancy BMI and the risk of gestational diabetes: A systematic review of the literature with meta-analysis: Diagnostic in Obesity and Complications. Obes Rev 2009 DOI: 10.1111/j.1467-789X.2008.00541.x.
• 6 Guariguata L, Linnenkamp U, Beagley J. et al. Global estimates of the prevalence of hyperglycaemia in pregnancy. Diabetes Res Clin Pract 2014 DOI: 10.1016/j.diabres.2013.11.003.
• 7 Pu J, Zhao B, Wang EJ. et al. Racial/Ethnic Differences in Gestational Diabetes Prevalence and Contribution of Common Risk Factors. Paediatr Perinat Epidemiol 2015 DOI: 10.1111/ppe.12209.
• 8 Schwartz N, Nachum Z, Green MS. The prevalence of gestational diabetes mellitus recurrence - Effect of ethnicity and parity: A metaanalysis. Am J Obstet Gynecol 2015 DOI: 10.1016/j.ajog.2015.03.011
• 9 Mohan MA, Chandrakumar A. Evaluation of prevalence and risk factors of gestational diabetes in a tertiary care hospital in Kerala. Diabetes Metab Syndr Clin Res Rev 2016 DOI: 10.1016/j.dsx.2015.09.002
• 10 Abouzeid M, Versace VL, Janus ED. et al. A population-based observational study of diabetes during pregnancy in Victoria, Australia, 1999-2008. BMJ Open 2014 DOI: 10.1136/bmjopen-2014-005394.
• 11 Huy C, Loerbroks A, Hornemann A. et al. Prevalence, trend and determining factors of gestational diabetes in Germany. Geburtshilfe Frauenheilkd 2012 DOI: 10.1055/s-0031-1298390.
• 12 Lacaria E, Lencioni C, Russo L. et al. Selective screening for GDM in Italy: Application and effectiveness of National Guidelines. J Matern Neonatal Med 2015 DOI: 10.3109/14767058.2014.969701.
• 13 Ignell C, Claesson R, Anderberg E. et al. Trends in the prevalence of gestational diabetes mellitus in southern Sweden, 2003-2012. Acta Obstet Gynecol Scand 2014 DOI: 10.1111/aogs.12340
• 14 Leng J, Shao P, Zhang C. et al. Prevalence of gestational diabetes mellitus and its risk factors in Chinese pregnant women: A prospective population-based study in Tianjin, China. PLoS One 2015 DOI: 10.1371/journal.pone.0121029.
• 15 Zhang F, Dong L, Zhang CP. et al. Increasing prevalence of gestational diabetes mellitus in Chinese women from 1999 to 2008. Diabet Med 2011 DOI: 10.1111/j.1464-5491.2010.03205.x.
• 16 Sermer M, Naylor CD, Farine D. et al. The toronto tri-hospital gestational diabetes project: A preliminary review. Diabetes Care 1998
• 17 Çetin M, Çetin A. Time-dependent gestational diabetes screening values. Int J Gynecol Obstet 1997 DOI: 10.1016/S0020-7292(96)02831-7
• 18 Kirkpatrick C, Schwers J, Désir D. Prenatal screening for gestational diabetes throughout office hours. Eur J Obstet Gynecol Reprod Biol 1988 DOI: 10.1016/0028-2243(88)90042-1
• 19 Goldberg RJ, Ye C, Sermer M. et al. Circadian variation in the response to the glucose challenge test in pregnancy: Implications for screening for gestational diabetes mellitus. Diabetes Care 2012 DOI: 10.2337/dc11-2217.
• 20 Jovanovic L. Role of diet and insulin treatment of diabetes in pregnancy. Clin Obstet Gynecol 2000 DOI: 10.1097/00003081-200003000-00005
• 21 Major CA, Henry MJ, De Veciana M. et al. The effects of carbohydrate restriction in patients with diet- controlled gestational diabetes. Obstet Gynecol 1998 DOI: 10.1016/S0029-7844(98)00003-9
• 22 Moses RG, Barker M, Winter M. et al. Can a low-glycemic index diet reduce the need for insulin in gestational diabetes mellitus? A randomized trial. Diabetes Care 2009 DOI: 10.2337/dc09-0007.
• 23 Hu ZG, Tan RS, Jin D. et al. A low glycemic index staple diet reduces postprandial glucose values in Asian women with gestational diabetes mellitus. J Investig Med 2014 DOI: 10.1097/JIM.0000000000000108.
• 24 Retnakaran R, Qi Y, Sermer M. et al. Pre-gravid physical activity and reduced risk of glucose intolerance in pregnancy: The role of insulin sensitivity. Clin Endocrinol (Oxf) 2009 DOI: 10.1111/j.1365-2265.2008.03393.x.
• 25 Owe KM, Nystad W, Bø K. Association between regular exercise and excessive newborn birth weight. Obstet Gynecol 2009 DOI: 10.1097/AOG.0b013e3181b6c105
• 26 Jovanovic L, Ilic S, Pettitt DJ. et al. Metabolic and immunologic effects of insulin lispro in gestational diabetes. Diabetes Care 1999 DOI: 10.2337/diacare.22.9.1422.
• 27 Pettitt DJ, Ospina P, Howard C. et al. Efficacy, safety and lack of immunogenicity of insulin aspart compared with regular human insulin for women with gestational diabetes mellitus. Diabet Med 2007 DOI: 10.1111/j.1464-5491.2007.02247.x.
• 28 Bhat M, Ramesha KN, Sarma SP. et al. Determinants of gestational diabetes mellitus: A case control study in a district tertiary care hospital in south India. Int J Diabetes Dev Ctries 2010 DOI: 10.4103/0973-3930.62599.
• 29 Fadl HE, Östlund IKM, Magnuson AFK. et al. Maternal and neonatal outcomes and time trends of gestational diabetes mellitus in Sweden from 1991 to 2003. Diabet Med 2010 DOI: 10.1111/j.1464-5491.2010.02978.x
• 30 Waters TP, Dyer AR, Scholtens DM. et al. Maternal and neonatal morbidity for women who would be added to the diagnosis of GDM using IADPSG criteria: A secondary analysis of the hyperglycemia and adverse pregnancy outcome study. Diabetes Care 2016 DOI: 10.2337/dc16-1194.
• 31 Shand AW, Bell JC, McElduff A. et al. Outcomes of pregnancies in women with pre-gestational diabetes mellitus and gestational diabetes mellitus; a population-based study in New South Wales, Australia, 1998-2002. Diabet Med 2008 DOI: 10.1111/j.1464-5491.2008.02431.x.
• 32 Shah BR, Retnakaran R, Booth GL. Increased risk of cardiovascular disease in young women following gestational diabetes mellitus. Diabetes Care 2008 DOI: 10.2337/dc08-0706
• 33 Retnakaran R, Shah BR. Mild glucose intolerance in pregnancy and risk of cardiovascular disease: A population-based cohort study. CMAJ 2009 DOI: 10.1503/cmaj.090569
• 34 Carr DB, Utzschneider KM, Hull RL. et al. Gestational diabetes mellitus increases the risk of cardiovascular disease in women with a family history of type 2 diabetes. Diabetes Care 2006 DOI: 10.2337/dc05-2482.
• 35 Kessous R, Shoham-Vardi I, Pariente G. et al. An association between gestational diabetes mellitus and long-term maternal cardiovascular morbidity. Heart 2013 DOI: 10.1136/heartjnl-2013-303945.
• 36 Major CA, DeVeciana M, Weeks J. et al. Recurrence of gestational diabetes: Who is at risk?. Am J Obstet Gynecol 1998 DOI: 10.1016/S0002-9378(98)70211-X
• 37 MacNeill S, Dodds L, Hamilton DC. et al. Rates and risk factors for recurrence of gestational diabetes. Diabetes Care 2001 DOI: 10.2337/diacare.24.4.659.
• 38 Getahun D, Fassett MJ, Jacobsen SJ. Gestational diabetes: Risk of recurrence in subsequent pregnancies. Am J Obstet Gynecol 2010 DOI: 10.1016/j.ajog.2010.05.032
• 39 Lapolla A, Dalfrà MG, Bonomo M. et al. Gestational diabetes mellitus in Italy: A multicenter study. Eur J Obstet Gynecol Reprod Biol 2009 DOI: 10.1016/j.ejogrb.2009.04.023.