血糖控制满意的妊娠期糖尿病孕妇血清性激素结合球蛋白水平与妊娠结局的关系

Sex hormone-binding globulin of gestational diabetes mellitus pregnant women with well-controlled glucose and pregnancy outcomes

目的探讨血糖控制满意的妊娠期糖尿病（GDM）孕妇血清性激素结合球蛋白（SHBG）水平与妊娠结局的关系。方法选择2005年3月至2010年3月在中国医科大学附属盛京医院产科门诊确诊的妊娠24—28周GDM孕妇251例，其中经单纯饮食控制（169例）或加用胰岛素治疗（47例）后血糖控制满意的216例为血糖控制满意组；经单纯饮食控制或加用胰岛素治疗后血糖控制不满意的35例为血糖控制不满意组。选取同期妊娠24～28周的192例健康孕妇为健康对照组。分别于妊娠24～28周和妊娠〉36周两次测定孕妇血清SHBG水平和稳态模型的胰岛素抵抗（HOMA—IR）指数。依据美国糖尿病资料小组的GDM诊断标准采用“两步法”诊断GDM。记录并观察3组孕妇的妊娠结局。测定孕妇空腹血糖（FPC）和空腹胰岛素（FINS）水平。结果（1）妊娠结局比较：血糖控制满意组孕妇的妊娠期高血压疾病（10．6％，23／216）、早产（8．3％，18／216）、大于胎龄儿（8．8％，19／216）、新生儿窒息（3．7％，8／216）和新生儿低血糖（2．3％，5／216）的发生率明显低于血糖控制不满意组[分别为42．9％（15／35）、34．3％（12／35）、31．4％（11／35）、22．9％（8／35）和11．4％（4／35）]，两组分别比较，差异均有统计学意义（P〈0．05或P〈0．01）；而两组孕妇羊水过多、产褥感染、产后出血和新生儿高胆红素血症的发生率比较，差异均无统计学意义（P〉0．05）。血糖控制满意组孕妇早产、产褥感染（3．2％，7／216）、产后出血（5．1％，11／216）、新生儿窒息（3．7％，8／216）和新生儿低血糖（2．3％，5／216）的发生率，与健康对照组[分别为7．3％（14／192）、2．1％（4／192）、4．2％（8／192）、2．1％（4／192）和1．6％（3／192）]比较，差异均无统计学意义（P〉0．05）。（2）妊娠24—28周与妊娠〉36周孕妇血清SHBG等项指标检测结果比较：血糖控制满意组孕妇血清SHBG水平[分别为（384±88）及（457±48）nmo]／L]均明显高于血糖控制不满意组[分别为（313±45）及（401±73）nmol／L]；血糖控制满意组孕妇HOMA—IR指数（分别为5．3±1．1及5．5±1．1）均明显低于血糖控制不满意组（分别为7．0±1．3及7．6-4-1．7），两组分别比较，差异均有统计学意义（P〈0．01）；血糖控制满意组孕妇血清SHBG水平均明显低于健康对照组[分别为（492±95）及（565±40）nmo]／L]；而HOMA—IR指数均明显高于健康对照组（分别为3．6±0．6及3．9±0．5），两组分别比较，差异均有统计学意义（P〈0．01）；血糖控制满意组孕妇FPG水平[分别为（5．84±0．28）及（5．16±0．13）mmol／L]明显低于血糖控制不满意组[分别为（6．13±0．16）及（5．68±1．14）mmo]／L]，两组分别比较，差异均有统计学意义（P〈0．01）；血糖控制满意组孕妇FINS水平[分别为（20．4±2．1）及（24．1±4．2）mmol／L]明显低于血糖控制不满意组[分别为（24．7±4．5）及（29．9±2．7）mmol／L]，两组分别比较，差异均有统计学意义（P〈0．01）。（3）相关性分析：妊娠24～28周时，3组孕妇（共443例）血清SHBG水平与HOMA—IR指数呈负相关（r=-0．952，P〈0．01）；其中血糖控制满意组216例孕妇血清SHBG水平与HOMA—IR指数也呈负相关（r=-0．903，P〈0．01）。结论血糖控制满意的GDM孕妇并不能完全改善妊娠结局，GDM孕妇血清SHBG水平降低和高IR对其妊娠结局有一定影响。

Objective To explore the relationship between sex hormone-binding globulin （SHBG） of gestational diabetes mellitus （GDM） pregnant women with well-controlled glucose and pregnancy outcomes. Methods Two hundred and fifty-one GDM pregnant women of 24 -28 weeks in Shengjing Hospital of China Medical University were recruited from Mar. 2005 to Mar. 2010. Two hundred and sixteen cases of GDM with well-controlled glucose wew defined as glycemic satisfied group, and they were treated by diet therapy （169 cases） or insulin therapy （47 cases）. Thirty-five cases with unsatisfied glucose were defined as glycemie unsatisfied group. One hundred and ninety-two healthy pregnant women of 24 -2g weeks were defined as healthy control group. Serum SHBG and homeostasis model analysis of insulin resistance （HOMA-IR） at 24 -28 weeks and above 36 weeks were measured. GDM was diagnosed by ＂two-step＂ method according to the National Diabetes Data Group （NDDG） criteria. The pregnancy outcomes and complications of the three groups were recorded. Results （ 1 ） Comparison of pregnancy outcomes and complications： glycemic satisfied group was less likely to develop hypertensive disorders in pregnancy （ 10. 6 % ）, premature birth （ 8.3 % ）, large for gestational age （LGA） （ 8.8 % ）, neonatal asphyxia （ 3.7 % ） and neonatal hypoglycemia （ 2. 3% ） compared to glycemic unsatisfied group （ 42. 9% , 34. 3% , 31.4% , 22. 9% and 11.4% , respectively）. And the difference was statistically significant （P 〈 0. 05 or P 〈0.01 ）. There was no significant difference for incidence of polyhydramnios, pueperal infection, postpartum hemorrhage, neonatal hyperbilirubinemia between the two groups （ P 〉 0. 05 ）. When compared to healthy control group（7.3% ,2. 1% ,4.2% ,2. 1% and 1.6% ） ,no significant difference was found for incidence of premature birth（ 8.3% ）, pueperal infection （ 3.2% ）, postpartum hemorrhage （ 5. 1% ）, neonatal asphyxia （3.7%） and neonatal hypoglycemia （2. 3% , P 〉 0. 05 ）. （2） Comparison of results of 24 - 28 weeks and above 36 weeks： serum SHBG of g]ycemic satisfied group [（384± 88）, （457 ± 48） nmo]/L] was significantly higher than that of glycemic unsatisfied group [ （ 313 ± 45 ）, （401 ±73 ） nmol/L ] ; HOMA-IR of glycemie satisfied group （ 5.3 ± 1.1,5.5 ±1.1 ） was significantly lower than that of glyeemie unsatisfied group （7.0 ±1.3,7.6 ±1.7 ; P 〈 0. 01 ）. Serum SHBG of glyeemic satisfied group was significantly lower than that of healthy control group [ （492 ±95 ） , （565 ±40 ） nmol/L ] ; and HOMA-IR of glyeemic satisfied group（5.3 ±1.1,5.5 ± 1.1 ） was significantly higher than that of healthy control group （3.6 ±0. 6,3.9 ±0.5;P 〈 0.01 ） . FPG of glyeemie satisfied group [（5.84 ±0.28）, （5. 16 ±0. 13） mmol/L] was significantly lower than that of glycemic unsatisfied group[ （6. 13 ±0. 16） , （5.68 ±1.14） mmol/L;P 〈 0. 011. FINS of glycemic satisfied group [ （20. 4 ±2. 1 ）, （ 24. 1 ± 4. 2 ） mmol/L ] was significantly lower than that of glyeemic unsatisfied group [ （ 24. 7 ± 4. 5 ）, （ 29.9 ±2. 7 ） mmol/L ; P 〈 0. 01 ]. （ 3 ） Correlation analysis. Between 24 -28 weeks, SHBG was negatively correlated with HOMA-IR in the three groups （r = -0. 952,P 〈0. 01） ; and SHBG was negatively correlated with HOMA-IR in glycemic satisfied group（r = -0. 903 ,P 〈 0. 01 ）. Conclusions Well-eomrolled glucose can not completely improve maternal and fetal outcomes of GDM pregnant women. High insulin resistance and low serum SHBG can influence pregnancy outcomes.