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糖尿病肾病合并妊娠

Authors
E Albert Reece, MD, PhD, MBA
Carol J Homko, RN, PhD, CDE
Matthew R Weir, MD
Section Editors
David M Nathan, MD
Michael F Greene, MD
Gary C Curhan, MD, ScD
Deputy Editor
Vanessa A Barss, MD, FACOG
Translators
周莉, 副主任医师

引言

1型和2型糖尿病女性患者在育龄期间均可发生肾病[1]。这种情况通常是由典型的糖尿病肾病引起的，主要临床表现为白蛋白尿和进展性慢性肾脏病(chronic kidney disease, CKD)。CKD是指存在蛋白尿、血尿或肾小球滤过率(glomerular filtration rate, GFR)降低，持续至少3个月(表 1)，无论病因是什么[2]。然而，糖尿病患者的白蛋白尿有时是由肾小球疾病而非糖尿病肾病引起的。糖尿病肾病女性若发生妊娠，那么肾病的存在即会引发一些非常重要的问题，包括肾病对妊娠结局的影响，以及妊娠对进展性肾功能障碍风险的影响。

本专题将总结糖尿病肾病合并妊娠的处理和结局。与非妊娠患者糖尿病肾病的发病机制和治疗相关的一般问题将单独讨论。 (参见“糖尿病肾病概述”和“1型糖尿病的血糖控制和血管并发症”和“糖尿病肾病的治疗”)

现有资料的局限性

目前关于糖尿病肾病合并妊娠的资料有限，人们在展示和解读这些资料时面临许多挑战，包括：

●随着时间的推移，人们已对高血压、白蛋白尿和CKD的定义/标准进行了修订，但许多关于糖尿病肾病合并妊娠的现有数据都是在这些修订之前获得的。

●如果进入妊娠阶段的糖尿病肾病患者存在高血压和“显著”蛋白尿，那么很难做出子痫前期的诊断。在晚期妊娠阶段，上述女性几乎都会出现高血压加重和尿蛋白含量增加的现象，因而在某些甚至很多情况下，这难免会使诊断子痫前期显得有些武断。

          

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Literature review current through: 2017-06 . | This topic last updated: 2017-01-12.
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References
Top
  1. Damm JA, Asbjörnsdóttir B, Callesen NF, et al. Diabetic nephropathy and microalbuminuria in pregnant women with type 1 and type 2 diabetes: prevalence, antihypertensive strategy, and pregnancy outcome. Diabetes Care 2013; 36:3489.
  2. http://kdigo.org/home/guidelines/ (Accessed on March 27, 2014).
  3. Biesenbach G, Zazgornik J, Stöger H, et al. Abnormal increases in urinary albumin excretion during pregnancy in IDDM women with pre-existing microalbuminuria. Diabetologia 1994; 37:905.
  4. Reece EA, Leguizamon G, Homko C. Pregnancy performance and outcomes associated with diabetic nephropathy. Am J Perinatol 1998; 15:413.
  5. Kitzmiller JL, Brown ER, Phillippe M, et al. Diabetic nephropathy and perinatal outcome. Am J Obstet Gynecol 1981; 141:741.
  6. Irfan S, Arain TM, Shaukat A, Shahid A. Effect of pregnancy on diabetic nephropathy and retinopathy. J Coll Physicians Surg Pak 2004; 14:75.
  7. Biesenbach G, Grafinger P, Stöger H, Zazgornik J. How pregnancy influences renal function in nephropathic type 1 diabetic women depends on their pre-conceptional creatinine clearance. J Nephrol 1999; 12:41.
  8. Biesenbach G, Stöger H, Zazgornik J. Influence of pregnancy on progression of diabetic nephropathy and subsequent requirement of renal replacement therapy in female type I diabetic patients with impaired renal function. Nephrol Dial Transplant 1992; 7:105.
  9. Kimmerle R, Zass RP, Cupisti S, et al. Pregnancies in women with diabetic nephropathy: long-term outcome for mother and child. Diabetologia 1995; 38:227.
  10. Miodovnik M, Rosenn BM, Khoury JC, et al. Does pregnancy increase the risk for development and progression of diabetic nephropathy? Am J Obstet Gynecol 1996; 174:1180.
  11. Reece EA, Leguizamon G, Homko C. Stringent controls in diabetic nephropathy associated with optimization of pregnancy outcomes. J Matern Fetal Med 1998; 7:213.
  12. Brenner BM, Cooper ME, de Zeeuw D, et al. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med 2001; 345:861.
  13. Lewis EJ, Hunsicker LG, Clarke WR, et al. Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. N Engl J Med 2001; 345:851.
  14. Diabetes Control and Complications Trial Research Group. Effect of pregnancy on microvascular complications in the diabetes control and complications trial. The Diabetes Control and Complications Trial Research Group. Diabetes Care 2000; 23:1084.
  15. Vérier-Mine O, Chaturvedi N, Webb D, Fuller JH. Is pregnancy a risk factor for microvascular complications? The EURODIAB Prospective Complications Study. Diabet Med 2005; 22:1503.
  16. Purdy LP, Hantsch CE, Molitch ME, et al. Effect of pregnancy on renal function in patients with moderate-to-severe diabetic renal insufficiency. Diabetes Care 1996; 19:1067.
  17. Jones DC, Hayslett JP. Outcome of pregnancy in women with moderate or severe renal insufficiency. N Engl J Med 1996; 335:226.
  18. Nielsen LR, Müller C, Damm P, Mathiesen ER. Reduced prevalence of early preterm delivery in women with Type 1 diabetes and microalbuminuria--possible effect of early antihypertensive treatment during pregnancy. Diabet Med 2006; 23:426.
  19. Carr DB, Koontz GL, Gardella C, et al. Diabetic nephropathy in pregnancy: suboptimal hypertensive control associated with preterm delivery. Am J Hypertens 2006; 19:513.
  20. Young EC, Pires ML, Marques LP, et al. Effects of pregnancy on the onset and progression of diabetic nephropathy and of diabetic nephropathy on pregnancy outcomes. Diabetes Metab Syndr 2011; 5:137.
  21. Yogev Y, Chen R, Ben-Haroush A, et al. Maternal overweight and pregnancy outcome in women with Type-1 diabetes mellitus and different degrees of nephropathy. J Matern Fetal Neonatal Med 2010; 23:999.
  22. Dunne FP, Chowdhury TA, Hartland A, et al. Pregnancy outcome in women with insulin-dependent diabetes mellitus complicated by nephropathy. QJM 1999; 92:451.
  23. Reece EA, Homko CJ. Why do diabetic women deliver malformed infants? Clin Obstet Gynecol 2000; 43:32.
  24. Harris MI, Flegal KM, Cowie CC, et al. Prevalence of diabetes, impaired fasting glucose, and impaired glucose tolerance in U.S. adults. The Third National Health and Nutrition Examination Survey, 1988-1994. Diabetes Care 1998; 21:518.
  25. Feig DS, Palda VA. Type 2 diabetes in pregnancy: a growing concern. Lancet 2002; 359:1690.
  26. Osterman MJK, Martin JA, Menacker F. Expanded Health Data from the New Birth Certificate, 2006. In: National Vital Statistics Reports, National Center for Health Statistics, Hyattsville, MD 2009. Vol 58, p.24.
  27. Mackie AD, Doddridge MC, Gamsu HR, et al. Outcome of pregnancy in patients with insulin-dependent diabetes mellitus and nephropathy with moderate renal impairment. Diabet Med 1996; 13:90.
  28. Gordon M, Landon MB, Samuels P, et al. Perinatal outcome and long-term follow-up associated with modern management of diabetic nephropathy. Obstet Gynecol 1996; 87:401.
  29. Khoury JC, Miodovnik M, LeMasters G, Sibai B. Pregnancy outcome and progression of diabetic nephropathy. What's next? J Matern Fetal Neonatal Med 2002; 11:238.
  30. Howarth C, Gazis A, James D. Associations of Type 1 diabetes mellitus, maternal vascular disease and complications of pregnancy. Diabet Med 2007; 24:1229.
  31. Ekbom P, Damm P, Feldt-Rasmussen B, et al. Pregnancy outcome in type 1 diabetic women with microalbuminuria. Diabetes Care 2001; 24:1739.
  32. Sibai BM. Risk factors, pregnancy complications, and prevention of hypertensive disorders in women with pregravid diabetes mellitus. J Matern Fetal Med 2000; 9:62.
  33. Combs CA, Rosenn B, Kitzmiller JL, et al. Early-pregnancy proteinuria in diabetes related to preeclampsia. Obstet Gynecol 1993; 82:802.
  34. How HY, Sibai B, Lindheimer M, et al. Is early-pregnancy proteinuria associated with an increased rate of preeclampsia in women with pregestational diabetes mellitus? Am J Obstet Gynecol 2004; 190:775.
  35. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. UK Prospective Diabetes Study Group. BMJ 1998; 317:703.
  36. Balsells M, García-Patterson A, Gich I, Corcoy R. Maternal and fetal outcome in women with type 2 versus type 1 diabetes mellitus: a systematic review and metaanalysis. J Clin Endocrinol Metab 2009; 94:4284.
  37. Sattar N, Greer IA. Pregnancy complications and maternal cardiovascular risk: opportunities for intervention and screening? BMJ 2002; 325:157.
  38. Cundy T, Slee F, Gamble G, Neale L. Hypertensive disorders of pregnancy in women with Type 1 and Type 2 diabetes. Diabet Med 2002; 19:482.
  39. Nathan DM. Long-term complications of diabetes mellitus. N Engl J Med 1993; 328:1676.
  40. Gonzalez-Gonzalez NL, Ramirez O, Mozas J, et al. Factors influencing pregnancy outcome in women with type 2 versus type 1 diabetes mellitus. Acta Obstet Gynecol Scand 2008; 87:43.
  41. Hladunewich M, Hercz AE, Keunen J, et al. Pregnancy in end stage renal disease. Semin Dial 2011; 24:634.
  42. Guglielmi KE. Women and ESRD: modalities, survival, unique considerations. Adv Chronic Kidney Dis 2013; 20:411.
  43. Hou S. Historical perspective of pregnancy in chronic kidney disease. Adv Chronic Kidney Dis 2007; 14:116.
  44. Reece EA, Coustan DR, Hayslett JP, et al. Diabetic nephropathy: pregnancy performance and fetomaternal outcome. Am J Obstet Gynecol 1988; 159:56.
  45. Reece EA, Winn HN, Hayslett JP, et al. Does pregnancy alter the rate of progression of diabetic nephropathy? Am J Perinatol 1990; 7:193.
  46. Rossing K, Jacobsen P, Hommel E, et al. Pregnancy and progression of diabetic nephropathy. Diabetologia 2002; 45:36.
  47. Nielsen LR, Damm P, Mathiesen ER. Improved pregnancy outcome in type 1 diabetic women with microalbuminuria or diabetic nephropathy: effect of intensified antihypertensive therapy? Diabetes Care 2009; 32:38.
  48. Leguizamon G, Reece EA. Effect of medical therapy on progressive nephropathy: influence of pregnancy, diabetes and hypertension. J Matern Fetal Med 2000; 9:70.
  49. American Diabetes Association. (12) Management of diabetes in pregnancy. Diabetes Care 2015; 38 Suppl:S77.
  50. Bakris GL, Weir MR, Secic M, et al. Differential effects of calcium antagonist subclasses on markers of nephropathy progression. Kidney Int 2004; 65:1991.
  51. Abalos E, Duley L, Steyn DW. Antihypertensive drug therapy for mild to moderate hypertension during pregnancy. Cochrane Database Syst Rev 2014; :CD002252.
  52. Cockburn J, Moar VA, Ounsted M, Redman CW. Final report of study on hypertension during pregnancy: the effects of specific treatment on the growth and development of the children. Lancet 1982; 1:647.
  53. American College of Obstetricians and Gynecologists, Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Obstet Gynecol 2013; 122:1122.
  54. Molvi SN, Mir S, Rana VS, et al. Role of antihypertensive therapy in mild to moderate pregnancy-induced hypertension: a prospective randomized study comparing labetalol with alpha methyldopa. Arch Gynecol Obstet 2012; 285:1553.
  55. Yakoob MY, Bateman BT, Ho E, et al. The risk of congenital malformations associated with exposure to β-blockers early in pregnancy: a meta-analysis. Hypertension 2013; 62:375.
  56. Lydakis C, Lip GY, Beevers M, Beevers DG. Atenolol and fetal growth in pregnancies complicated by hypertension. Am J Hypertens 1999; 12:541.
  57. Magee LA, Duley L. Oral beta-blockers for mild to moderate hypertension during pregnancy. Cochrane Database Syst Rev 2003; :CD002863.
  58. Magee LA, Cham C, Waterman EJ, et al. Hydralazine for treatment of severe hypertension in pregnancy: meta-analysis. BMJ 2003; 327:955.
  59. Collins R, Yusuf S, Peto R. Overview of randomised trials of diuretics in pregnancy. Br Med J (Clin Res Ed) 1985; 290:17.
  60. Hod M, van Dijk DJ, Karp M, et al. Diabetic nephropathy and pregnancy: the effect of ACE inhibitors prior to pregnancy on fetomaternal outcome. Nephrol Dial Transplant 1995; 10:2328.
  61. Bar J, Chen R, Schoenfeld A, et al. Pregnancy outcome in patients with insulin dependent diabetes mellitus and diabetic nephropathy treated with ACE inhibitors before pregnancy. J Pediatr Endocrinol Metab 1999; 12:659.
  62. Cooper WO, Hernandez-Diaz S, Arbogast PG, et al. Major congenital malformations after first-trimester exposure to ACE inhibitors. N Engl J Med 2006; 354:2443.
  63. Caritis S, Sibai B, Hauth J, et al. Low-dose aspirin to prevent preeclampsia in women at high risk. National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units. N Engl J Med 1998; 338:701.
  64. Hayslett JP, Reece EA. Managing diabetic patients with nephropathy and other vascular complications. Baillieres Clin Obstet Gynaecol 1994; 8:405.