动态血糖监测和自我血糖监测在妊娠合并糖尿病患者血糖监测中的临床价值

Clinical use of continuous glucose monitoring system in gestational diabetes mellitus and type 2 diabetes complicated with pregnancy

目的 评估动态血糖监测（CGMS）及自我血糖监测（SMBG）两种方法对妊娠期糖尿病（GDM）及2型糖尿病合并妊娠患者血糖监测的临床价值.方法 选取2012年8月至2013年4月于北京大学第一医院就诊患者共99例,其中70例为GDM患者（GDM组）,29例为2型糖尿病合并妊娠患者（2型糖尿病组）.对两组患者进行72 h的CGMS,期间每日进行7次末梢血糖的SMBG,对比两种不同血糖监测方法测得的血糖最大值、最小值、平均值及其出现的时间;对两种方法测得的血糖水平及其与糖化血红蛋白（HbA1c）水平的相关性进行分析,记录两组患者胰岛素用量.结果 （1）GDM组患者SMBG血糖最大值、最小值、平均值分别为（8.7±1.2）、（4.5±0.6）、（6.3±0.6）mmol/L,CGMS血糖最大值、最小值、平均值分别为（10.1±1.7）、（3.1±0.7）、（6.0±0.6） mmol/L;2型糖尿病组患者SMBG最大值、最小值、平均值分别为（10.1±2.2）、（4.5±1.0）、（6.9±1.1） mmol/L,CGMS最大值、最小值、平均值分别为（12.2±2.6）、（2.8±0.8）、（6.6±1.1） mmol/L.两组患者SMBG及CGMS的最大值及平均值分别比较,差异均有统计学意义（P＜0.01）;两组患者SMBG及CGMS的最小值分别比较,差异均无统计学意义（P＞0.05）.（2）GDM组患者CGMS平均值与SMBG平均值有显著相关性（r=0.864,P＜0.01）,CGMS最大值与SMBG最大值有显著相关性（r=0.734,P＜0.01）,但CGMS最小值与SMBG最小值无相关性（r=0.138,P＞0.05）;2型糖尿病组患者CGMS平均值与SMBG平均值有显著相关性（r=0.962,P＜0.01）,CGMS最大值与SMBG最大值有显著相关性（r=0.831,P＜0.01）,CGMS最小值与SMBG最小值也有相关性（r=0.460,P＜0.05）.（3）GDM组患者CGMS平均值与HbA1c水平有相关性（r=0.400,P＜0.01）,SMBG平均值与HbA1c水平有相关性（r=0.031,P＜0.05）;2型糖尿病组患者CGMS平均值与HbA1c水平有显著相关性（r=0.695,P＜0.01）,SMBG平均值与HbA1c水平有显著相关性（r=0.673,P＜0.01）.（4）GDM组中37％（26/70）的患者,其SMBG最小值出现在早餐前30 min,34％（24/70）出现在午餐前30 min; 86％ （60/70）的患者SMBG最大值分布于三餐后2h.2型糖尿病组中41％（12/29）的患者SMBG最小值出现在午餐前30 min,出现在早餐前30 min及晚餐前30 min分别为21％（6/29）及14％ （4/29）;30％左右的患者,其SMBG最大值分别出现在三餐后2h.（5）GDM组中23％（16/70）的患者CGMS最小值出现在夜间0：00～2：59,全天其他时间段最小值除18：00～ 20：59占3％（2/70）以外,为平均分布;43％（30/70）的患者,其CGMS最大值出现在6：00～ 8：59,其他时间段除0：00～ 2：59及21：00～ 23：59较少[分别占1％（1/70）及3％（2/70）]外为平均分布.2型糖尿病组中34％ （10/29）的患者,其CGMS最小值出现在夜间0：00～2：59,14％（4/29）的患者最小值出现在9：00～11：59及15：00～ 17：59.45％（13/29）的患者,其CGMS最大值出现在6：00～8：59,其他时间段除21：00～23：59、0：00～ 2：59、3：00～5：59无最大值外,其余为平均分布.（6）GDM组患者中,不需应用胰岛素治疗者占64％（45/70）,应用胰岛素治疗者占36％ （25/70）;在应用胰岛素治疗的患者中,64％（16/25）经CGMS后,根据血糖水平修正了胰岛素用量.2型糖尿病组患者中,不需应用胰岛素治疗者占14％（4/29）,应用胰岛素治疗者占86％（25/29）,其中60％（15/25）的患者经CGMS后,根据血糖水平修正了胰岛素用量.结论 CGMS及SMBG两种血糖监测方法均能准确反映患者的血糖水平.2型糖尿病合并妊娠患者的血糖水平较GDM患者更难以控制.CGMS较SMBG方法可以更好地发现患者餐后高血糖及夜间低血糖的情况.

Objective To compare the clinical use of continuous glucose monitoring system （CGMS） and self-monitoring blood glucose （SMBG） when monitoring blood glucose level of patients with gestational diabetes mellitus （GDM） or type 2 diabetes mellitus （DM） complicated with pregnancy.Methods A total of 99 patients with GDM （n=70） and type 2 DM complicated with pregnancy （n=29） that whether hospitalized or in clinical of Peking University First Hospital were recruited from Aug 2012 to Apr 2013.The CGMS was used to monitor their blood glucose level during the 72-hour time period,while the SMBG was also taken seven times daily.The correlation between these blood glucose levels and their glycosylated hemoglobin （HbA1c） levels were analyzed by comparing the average value,the maximum and the minimum value of blood glucose,and the appeared time of these extremum values in these two monitoring methods,and the amount of insulin usage was recorded as well.Results （1） The maximum,minimum and the average blood glucose value in the GDM group were （8.7± 1.2）,（4.5 ±0.6） and （6.3 ± 0.6） mmol/L of SMBG vs.（10.1±1.7）,（3.1±0.7）,（6.0±0.6） mmol/L of CGMS.These values in DM group were （10.1±2.2）,（4.5±1.0）,（6.9±1.1） mmol/L of SMBG vs.（12.2±2.6）,（2.8±0.8）,（6.6±1.1） mmol/L of CGMS.By using the two methods,the maximum and the average value of the two groups showed significant differences （P＜0.01） while the minimum value showed no significant differences （P＞0.05）.（2） In the GDM group,the average blood glucose values of CGMS and SMBG were significantly correlated （r=0.864,P＜0.01）.The maximum values presented the same result （r=0.734,P＜0.01）.Correlation was not found in the minimum values of CGMS and SMBG （r=0.138,P＞0.05）.In the DM group,the average valves of two methods were significantly correlated （r=0.962,P＜0.01）,the maximum values showed the same result （r=0.831,P＜0.01）.It can also be observed in the minimum values （r=0.460,P＜0.05）.（3） There was significant correlation between the average value of CGMS and HbA1c level （r=0.400,P＜0.01）,and the average value of SMBG and HbA1c level were correlated （r=0.031,P＜0.05） in the GDM group; the average values of CGMS （r=0.695,P＜0.01） and SMBG （r=0.673,P＜0.01） were both significantly correlated with the HbA1c level in the DM group.（4） In the GDM group,37％ （26/70） of the minimum values of SMBG appeared 30 minutes before breakfast,while 34％（24/70） of them appeared 30 minutes before lunch; 86％（60/70） of the maximum values of SMBG were evenly distributed 2 hours after each of the three meals.In the DM group,41％（12/29） of the minimum values of SMBG presented 30 minutes before lunch,while 21％（6/29） and 14％（4/29） of them were showed 30 minutes before breakfast and dinner respectively; about 30％ of the maximum values of SMBG appeared 2 hours after each of the three meals.（5） In the GDM group,23％（16/70） of the minimum values of CGMS occurred between 0：00-2：59 am.,and most of the other minimum values of CGMS were evenly distributed in the rest of the day,except for 3％（2/70） of them were found during 18：00-20：59 pm.43％（30/70） of the maximum values of CGMS appeared during 6：00-8：59 am.,only 1％（1/70） and 3％（2/70） of them presented during 0：00-2：59 am.and 21：00-23：59 pm.,and the rest were evenly distributed for the other times of the day.In the DM group,34％（10/29） of the minimum values of CGMS were found during 0：00-2：59 am.,14％（4/29） of them appeared during 9：00-11：59 am.and 15：00-17：59 pm.,45％（13/29） of the maximum values of the CGMS presented during 6：00-8：59 am.,none was found during 21：00-23：59 pm.,0：00-2：59 am.and 3：00-5：59 am.,and the rest were evenly distributed for the other times of the day.（6） 64％（45/70） of the patients in the GDM group did not require for insulin treatment,while 36％（25/70） of them did.For those patients who received insulin treatment,after CGMS,64％（16/25） of them adjusted the insulin dosage according to their blood glucose levels.In the DM group,14％（4/29） of them did not receive insulin treatment,while for the others who did（86％,25/29）; 60％ （15/25） of them adjusted the insulin dosage according to their blood glucose levels after CGMS.Conclusions Both CGMS and SMBG could correctly reflect patients＇ blood glucose levels.It was more difficult to control the blood glucose levels in patients with type 2 DM complicated with pregnancy than the GDM patients.Compared with SMBG,CGMS could detect postprandial hyperglycemia and nocturnal hypoglycemia more effectively.