Gestational hyperglycaemia in Malaysia: early screening and intervention to improve outcomes of pregnancy

妊娠期高血糖或妊娠期糖尿病(GDM)是妊娠期最常见的疾病之一。它会对孕妇和她的孩子造成伤害。妊娠期糖尿病影响了10%-15%的马来西亚女性。现在越来越多的女性被诊断为妊娠期糖尿病，因为血糖水平较低被用来诊断妊娠期糖尿病。如果不进行治疗，妊娠期糖尿病会导致妊娠高血压、剖腹产增加、焦虑和抑郁。患有妊娠期糖尿病的女性一生罹患2型糖尿病(T2 DM)的风险要高出7-8倍。孩子们也面临着风险。它们可能太大，也可能太小。如果太大，他们的肩膀可能会在分娩过程中受损。他们的血糖在出生后可能会降得太低。他们可能在出生后不久就出现黄疸，或者呼吸困难。极少数人可能会在出生前死亡(死产)。从长远来看，这些孩子超重和患糖尿病的风险更高。妊娠期糖尿病的诊断通常是在怀孕24-28周期间使用被称为口服葡萄糖耐量测试(OGTT)的葡萄糖饮料测试来诊断的。虽然治疗可以改善妊娠结局，但一些损害可能已经对未出生的婴儿造成了。因此，在怀孕早期进行筛查以检测高血糖水平可能更好。然而，筛查既有好处也有坏处。正如《英国医学杂志》最近的一篇文章所说：“妊娠期糖尿病的标签带来了一系列干预措施，包括血糖监测、额外的诊所就诊、更多的产科监测和更大可能性的引产、手术分娩和婴儿进入特殊护理，最后对母亲来说，标签是糖尿病的高风险标签。”目前，马来西亚所有孕妇都应该接受GDM筛查，因为该人群被认为是高危人群。然而，做OGTT可能是具有挑战性的。这项测试要求孕妇来实验室至少8小时内没有进食任何东西。在包括英国在内的许多国家，女性是基于体重较高和年龄较大等风险因素而被选为OGTT的。然而，根据这些因素选择女性可能会错过多达一半的妊娠期糖尿病女性。另一种简单的手指刺法(称为HbA1c)进行的血糖测试可能会起作用。这将在第一次产前诊所就诊时进行。HbA1c是一步检测，患者不需要禁食。然而，HbA1c检测在马来西亚妇女中的价值尚不清楚。这项研究的目的是找出第一次产前就诊时检测HbA1c是否可以预测以后的妊娠期糖尿病，以及是否有一个水平可以排除以后的妊娠期糖尿病。我们还想将检测所有孕妇与只检测那些有风险因素的孕妇进行比较。我们将进行一项试验，看看一种名为二甲双胍的药物是否可以防止女性患上妊娠期糖尿病。二甲双胍在怀孕期间是安全的。准确的HbA1c水平可以安全地排除低风险妇女中的妊娠期糖尿病，这将有助于孕妇。他们可以放心了。避免使用OGTT将为他们节省时间和金钱。相比之下，如果糖化血红蛋白水平确定他们是高危人群，健康饮食和生活方式建议可以降低他们患妊娠期糖尿病的风险。除了对母亲和她们的孩子有益外，这项研究也将对马来西亚提供医疗保健的人有用。他们可以更多地关注高危女性。这一结果可以被其他国家使用。

High blood glucose levels in pregnancy or gestational diabetes mellitus (GDM) is one of the most common medical conditions during pregnancy. It can cause harm to the pregnant woman and her child. GDM affects 10-15% of Malaysian women. More women are being diagnosed with GDM now because a lower level of blood glucose is being used to diagnose GDM.If not treated, GDM can cause high blood pressure in pregnancy, increased numbers of caesarean deliveries, anxiety and depression. Women who have had GDM have 7-8 times higher life-time risk of type 2 diabetes mellitus (T2DM). There are risks to the children too. They may be too big or too small. If too big, they can have shoulders damaged during the birth. Their blood glucose may fall too low after birth. They may get jaundice soon after birth, or have difficulty in breathing. A very few may die before birth (stillbirth). In the long term, these children are at higher risk of becoming overweight and diabetic.The diagnosis of GDM is usually made between 24-28 weeks of pregnancy using a glucose drink test called an oral glucose tolerance test (OGTT). Although treatment can improve pregnancy outcomes, some of the damage may have already been done to the unborn baby. So screening to detect high glucose levels earlier in pregnancy may be better. However, there can be harms as well as benefits from screening. As a recent British Medical Journal article said:"a label of gestational diabetes brings with it an intervention package that includes glucose monitoring, extra clinic visits, more obstetric monitoring with greater likelihood of labour induction, operative delivery and admission of the baby to special care, and finally for the mother a label of high risk for diabetes". At present, all pregnant women in Malaysia are supposed to be screened for GDM because the population is considered to be high-risk. However, doing OGTTs can be challenging. The test requires pregnant women to come to a laboratory having not eaten anything for at least 8 hours. In many countries, including the UK, women are selected for OGTT based on risk factors such as higher body weight and older age. However, selecting women based on these factors can miss up to half of all women with GDM. Another blood glucose test done by a simple finger prick (called HbA1c) might do instead. It would be done at the first antenatal clinic visit. The HbA1c is a one-step test and patients do not need to fast. However, the value of HbA1c testing is not yet known in Malaysian women.The aims of this study is to find out whether HbA1c testing at first antenatal clinic visit can predict later GDM and if there is a level that can rule out later GDM. We also want to compare testing all pregnant women with testing only those with risk factors. We will do a trial to see if a drug called metformin can prevent women developing GDM. Metformin is safe in pregnancy.An accurate HbA1c level that can safely rule out GDM in women at low risk would help pregnant women. They can be reassured. Avoiding the need for OGTT would save them time and money. In contrast, if the HbA1c level identifies them as at high-risk, healthy eating and lifestyle advice can reduce their risk of getting GDM. In addition to the benefit to mothers and their children, this study will also be useful to people who provide health care in Malaysia. They can focus care more on women at high risk. The results could be used by other countries.