糖代谢异常孕妇胎婴儿丢失原因分析及预防

Cause analysis and preventive strategies for fetal or neonatal losses associated with abnormal glucose metabolism during pregnancy

目的探讨妊娠合并糖代谢异常孕妇的胎儿丢失及新生儿死亡情况,以期寻找更好的预防策略。方法1995年1月至2006年12月在北京大学第一医院产科分娩的妊娠合并糖代谢异常患者共2021例,其中妊娠合并糖耐量受损(GIGT)组865例,妊娠期糖尿病(GDM)组1028例,糖尿病合并妊娠(DM)组128例。所有患者中,血糖控制满意者1720例,未控制或控制不满意者301例。采用回顾性分析方法对所有孕妇的胎儿及新生儿结局进行分析。结果2021例孕妇中发生胎儿丢失22例,占1.1%(22/2021);DM组的胎儿丢失率为8.6%(11/128),显著高于GDM组(0.9%)和GIGT组(0.2%),P=0.000。新生儿死亡19例,占0.9%(19/2021)。新生儿死亡的首要原因为先天畸形,占52.6%;其次为新生儿呼吸窘迫综合征(NRDS),占21.1%。共有74例先天畸形,占3.7%(74/2021)。胎儿畸形种类涉及全身各个系统,心血管系统畸形最为常见,占60.8%(45/74)。DM组先天畸形的发生率14.1%(18/128),显著高于GDM组的3.1%和GIGT组的2.8%,P=0.000。结论DM患者胎儿丢失及先天畸形发生率较高,应加强DM患者的孕前管理,在孕前将血糖控制在理想范围,降低自然流产及胎儿畸形的发生率,进而减少胎儿丢失率及新生儿死亡率。血糖控制不满意者,NRDS的发生率明显增加。

Objective To find out preventive strategies for fetal loss or newborns death in pregnant women with abnormal glucose metabolism based on the current data. Methods Between Jan 1995 and Dec 2006, 2021 pregnant women with abnormal glucose metabolism were diagnosed in the First Hospital of Peking University, among which 865 were gestational impaired glucose tolerance（ GIGT）, 1028 were gestational diabetes mellitus（GDM）, and 128 were pre-pregnant diabetes （DM）. Out of the 2021 women, 1720 women achieved euglyeemia and 301 did not. The fetal or newborns outcomes were retrospectively analyzed for all pregnant women. Results Among the 2021 women, 22 fetal losses （1.1%） and 19 new-born deaths （0.9%） werereported. Congenital abnormalities （CA） were found in 74 babies （3.7%） and all systems were involved dominated by cardiovascular malformations （60.8%, 45/74）. The CA rate in DM group was significantly higher than that of the GIGT and GDM group （ 14.1%, 18/128 vs 2.8% and 3.1% ,P =0.000）. All 13 cases with NRDS were preterm babies, among which 4 dead （30.8%）. The incidence of NRDS in euglycemia group was lower than the non-euglycemia group （0.4%, 7/1720 vs 2.0%, 6/301 ,P = 0.038）. Conclusion Management of DM should be started before conception. Those who are planning to conceive are better to achieve euglycemia in order to reduce the incidence of spontaneous abortion and fetal abnormalities, eventually to reduce fetal loss or newborn death. Prenatal screening and prenatal diagnosis can not only reduce the birth rate of those babies with birth defect, but also improve the quality of life for the defected babies. Pregnancies with abnormal glucose metabolism do not increase the rate of NRDS if euglycemia were achieved.