母亲妊娠期糖尿病对胎儿和婴儿心功能的影响

Follow-up of cardiac function in infants of mothers with gestational diabetes mellitus

目的探讨妊娠期糖尿病（gestational diabetes mellitus，GDM）母亲的子代婴儿期心脏解剖和功能的变化。方法选择2007年1月至8月在复旦大学附属妇产科医院行产前检查并分娩的GDM孕妇18例为GDM组，选择同期24例孕周匹配的正常妊娠孕妇作为对照组，均在妊娠晚期接受胎儿超声心动图检查，测量胎儿心脏大小和功能各项指标，组间比较采用两独立样本t检验。GDM组孕妇的子代于2～3月龄时接受小儿超声心动图随访，选择同期24例月龄匹配的正常妊娠的健康婴儿为对照组，再次评价和比较婴儿心脏大小和功能各项指标，组间差异比较采用方差分析及两两检验。结果GDM组18例胎儿中出生6例大于胎龄儿（large for gestational age，LGA），占33．3％，12例（66．7％）适于胎龄儿（appropriate for gestational age，AGA）；对照组24例胎儿中出生2例LGA（8．3％）和22例（91．7%）AGA（Х^2=3．840，P=0．05）。GDM组胎儿的左室壁和室间隔收缩末期厚度大于对照组（P均〈0．05）；至婴儿期室壁厚度未再增加，而LGA婴儿的左室壁收缩末期厚度[（4．55±0．37）mm]和左心室舒张末期长径[（37．3±2．3）mm]仍大于对照组[分别为（4．13±0．39）mm和（34．6±2．6）mm]（P均〈0．05）。GDM组胎儿的主、肺动脉峰速和左心输出量均大于对照组胎儿（P均〈0．01），右心／左心输出量值小于对照组（分别为1．1984-0．206和1．430±0．321，t=-2．668，P=0．011）；至婴儿期，GDM组仅AGA婴儿的右心／左心输出量值大于对照组（P〈0．05）。GDM组胎儿左房缩短分数，三尖瓣E峰、A峰速度和E／A比值小于对照组（P均〈0．05）；至婴儿期，GDM组仅左房缩短分数（0．356±0．040）仍小于对照组（0．386±0．041）（t=-2．332，P=0．025）。GDM组胎儿的左、右心室Tel指数分别为0．482±0．129和0．414±0．094，均大于对照组（分别为0．309±0．074和0．283±0．072）（t分别=5．075和5．129，P均=0．000）；至婴儿期，GDM组LGA和AGA婴儿的左、右心室Tei指数均较胎儿期明显降低，并与对照组婴儿差异无统计学意义。结论血糖控制良好的GDM母亲分娩的婴儿在2～3月龄时，心脏的解剖和功能指标均较胎儿期更接近健康婴儿。

Objective To follow up the changes of postnatal cardiac sizes and function in infants of mothers with gestational diabetes mellitus （GDM）. Methods Eighteen GDM mothers with euglycemia （GDM group） and 24 gestational age matched normal pregnant women （control group）, having prenatal examination and delivered in Women＇s Hospital of Fudan University from January to August in 2007, received fetal echocardiographic examination in late pregnancy. Infants of these GDM mothers and 24 age-matched healthy infants of normal pregnancy （control group） received sonographic follow up. Cardiac sizes and function were evaluated and compared. Results At birth, there were six （33.3%） infants of large for gestational age （LGA） and 12（66.7%） appropriate for gestational age（AGA） in GDM group, while in the control group, there were two LGA （8.3%） and 22（91.7%） AGA infants （Х^2 =3. 840, P=0.05）. Both the interventricular septum and left ventricular walls in GDM fetuses were thicker than in control fetuses （P 〈 0.05）. No increase in the thickness of ventricular walls was observed till infantile period. However, the end-systolic thickness of left ventricular walls in LGA infants was still larger than in control infants [（4.55 ± 0. 37） mm vs （4.13±0.39） mm, P〈0.05], and end-diastolic left ventricular long-diameters were also larger [（37. 3±2. 3） mmvs （34.6±2.6） mm] （P〈0.05）. In GDM fetuses, the peak velocities of aorta and pulmonary artery and left cardiac output were higher than in the controls （P〈 0.01）, and right/left cardiac outputs ratios were lower （1.198±0.206 vs 1.430±0.321, t= 2.668,P=0.011）. Till infantile period, only right/left cardiac outputs ratios in AGA infants of GDM group were larger than in controls （P〈0.05）. GDM fetuses＇ left atrial shortening fraction and tricuspid E/A ratios were smaller （P〈0. 05）. In infantile period, only left atrial shortening fraction in GDM infants was still smaller than in controls （0.356±0.040 vs 0.386±0.041, t=-2.332, P=0.025）. Left and right ventricular Tel index in GDM fetuses were 0. 482±0. 129 and 0. 414±0. 094, both larger than those of control fetuses （0.309±0.074 and 0.283±0.072）（t=5.075 and 5. 129, P=0.000）. Till infantile period they both became significantly lower and no differences were found among LGA, AGA and control infants. Conclusions The cardiac sizes and function at 2-3 months of age, in infants of GDM mothers with good glucose control, became better than that in uterus.