USPSTF推荐妊娠24周后进行糖筛

根据美国预防服务工作组(USPSTF)的最终推荐声明，所有孕妇均应在怀孕24周后接受妊娠期糖尿病(GDM)筛查。该声明 1月13日在线发表在《内科学年鉴》杂志上。

USPSTF主席Virginia A. Moyer博士称，新声明体现了“对孕产期预防产伤、先兆子痫以及巨大儿等并发症整体受益重要性看法的转变”。


Virginia A. Moyer博士
 
Moyer博士代表工作组指出：“USPSTF确认，孕妇24周后接受GDM筛查和治疗，可使先兆子痫、巨大儿以及肩难产总体下降，从而与母婴健康中度改善相关，而筛查和治疗导致的损伤被认为非常有限。因此，工作组基本确定有中度的总体净获益。”

基于对文献的系统综述， 24周后筛查推荐意见被列为“B级推荐”。该最终推荐意见是对2008推荐意见的更新。当时，工作组认为推荐无症状孕妇进行筛查缺少充分证据，因此将其列为“I级推荐”。

推荐声明指出，因患者人口统计资料和诊断阈值不同，美国GDM患病率介于1%~25%。

Moyer博士在接受采访时称，GDM女性发展为2型糖尿病的风险增加，产后5~15年内罹患2型糖尿病的比例为15%~60%。“妊娠24周筛查有助于早期诊断，患者与医生可共同决定是否有必要进行治疗。证据表明，GDM治疗可减少并发症的发生。”

USPSTF评价证据显示，初级保健医生可通过二步法准确诊断孕24周后GDM，即如果50 g葡萄糖负荷试验达到或超过筛查阈值[130、135或140 mg/dl(7.21、7.49或7.77 mmol/L)]，则再进行口服葡萄糖耐量试验。

2013年，美国妇产科医师协会(ACOG)推荐采用二步法50 g葡萄糖负荷试验。尽管美国糖尿病学会(ADA)支持一步法75 g 2小时口服葡萄糖耐量试验，但NIH共识制定项目独立专家组发布的声明草案认为采用一步法的证据不足。

美国家庭医师协会(AAFP)和内分泌学会(ES)的推荐指南与这次更新后的USPSTF 推荐意见一致。

Moyer博士称：“现在有很好的证据支持临床医生对妊娠24周后的孕妇进行筛查。”

虽然高危女性可在妊娠24周前进行筛查，不过有关无症状女性早期筛查受益是否大于风险的评估证据仍然不足，因此，工作组将其列为“I级声明”。

Moyer博士报告称无相关利益冲突。

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By: SHARON WORCESTER, Clinical Endocrinology News Digital Network

All pregnant women should be screened for gestational diabetes after 24 weeks of gestation, according to a final recommendation statement from the U.S. Preventive Services Task Force.

The updated statement, published online Jan. 13 in Annals of Internal Medicine, represents "a change in thinking about how the collective benefits of preventing complications during pregnancy and birth – such as birth injuries, preeclampsia, and babies growing too large in the womb – are important according to Dr. Virginia A. Moyer, task force chair.
 
"The USPSTF determined that screening for and treatment of GDM [gestational diabetes] in women after 24 weeks of gestation are associated with moderate health improvements in the mother and infant through the collective reduction in preeclampsia, macrosomia, and shoulder dystocia. The harms of screening or treatment are considered no greater than small. Therefore, the USPSTF concludes with moderate certainty that the overall net benefit is moderate," Dr. Moyer wrote on behalf of the task force.

The recommendation to screen after 24 weeks is a "B recommendation," based on a systematic review of the literature.

The final recommendation updates the task force’s 2008 recommendation. At that time, USPSTF found insufficient evidence to recommend screening of asymptomatic women, and issued an "I recommendation."

GDM prevalence in the United States is between 1% and 25%, depending on patient demographics and diagnostic thresholds, according to the statement.

Women with GDM are at increased risk for developing type 2 diabetes mellitus, with 15%-60% developing type 2 diabetes within 5-15 years of delivery, Dr. Moyer said in an interview.

"Screening women after 24 weeks of pregnancy helps to identify the disease in women earlier so that they can work with their doctors to identify whether treatment is needed," she added, noting that evidence demonstrates that treatment for gestational diabetes reduces complications.

Evidence reviewed by USPSTF indicates that primary care providers can accurately detect GDM after 24 weeks’ gestation using the two-step 50-g oral glucose challenge test, followed by the oral glucose tolerance test if the screening threshold is met or exceeded (130 mg/dL, 135 mg/dL, or 140 mg/dL [7.21, 7.49, or 7.77 mmol/L]).

In 2013, the American Congress of Obstetricians and Gynecologists recommended use of the two-step approach using the 50-g oral glucose challenge test. Although the American Diabetes Association endorsed the one-step 75-g, 2-hour oral glucose tolerance test, an independent panel supported by the National Institute of Health Consensus Development Program released a draft statement that evidence is insufficient for adopting the one-step approach.

Recommendations of the American Academy of Family Physicians and the Endocrine Society are in line with the updated USPSTF recommendation.

"Clinicians now have good evidence to support continuing to screen pregnant women for diabetes after 24 weeks of pregnancy," Dr. Moyer said.

Although high-risk women can be screened earlier than 24 weeks, the evidence regarding earlier screening remains insufficient for assessing the balance of benefits and risks asymptomatic women, thus the task force issued an "I statement."

Dr. Moyer reported no relevant conflicts of interest.