孕期营养干预和代谢性危险因素对妊娠结局的影响

Effect of diet consultation and metabolic risk factors during pregnancy on gestational outcomes

目的探讨孕期营养干预和孕期代谢性危险因素对妊娠结局的影响。方法研究对象为上海市国际和平妇幼保健院2010年5月至2012年4月接受常规产检并且分娩的孕妇。采用回顾性队列研究，在确诊为妊娠糖尿病（GDM）的孕妇中比较膳食干预组（接受膳食咨询）和对照组（未接受膳食咨询）不良妊娠结局的差异，GDM诊断采用2010年国际糖尿病与妊娠研究组推荐标准。采用Logistics逐步回归分析母亲孕期危险因素对巨大儿发生的影响及作用大小。结果①10421名孕妇的围生期信息进入数据分析。孕妇初诊时平均孕周20．8（19．4—22．4）周，初诊时空腹血糖（FBS）、三酰甘油（TG）和总胆固醇（CHOL）平均水平分别为（4．3±0．4）、（1．3±0．6）和（4．7±0．8）mmol·L^-1，收缩压和舒张压的平均水平分别为（111．3±11．5）和（67．9±13．3）mmHg。高危孕妇的GDM的患病率为15．8％。新生儿平均出生体重（3355．4±426．0）g，巨大儿发生率6．2％。@812名GDM孕妇中，干预组570例，对照组242例。两组孕妇年龄、文化程度、孕20周体重、初诊时血糖、血脂等基线水平均衡可比。干预组的新生儿出生体重、巨大儿发生率和妊娠期高血压发生率均低于对照组，分别为（3347．4±19．6）傩（3450．3±35．6）g（P=0．007）、6．7％vs15．6％（P=0．001）和26．3％w47．9％（P〈0．001）。随着营养干预次数的增加，孕中晚期体重增长量和新生儿出生体重均呈下降趋势（r=-0．126，P=0．003；r=-0．112，P=0．002），巨大儿的发生率也依次降低。③Logistic逐步回归分析显示，孕20周时体重（OR=1．08，95％CI：1．07—1．09）、孕中晚期体重增长量（OR=1．10，95％CI：1．07～1．12）和GDM（OR=1．63，95％CI：1．22～2．19）是巨大儿发生的危险因素。结论对高危孕妇应考虑进行更早期的孕期危险因素管理以及膳食指导干预，控制孕期体重合理增长，有望减少不良妊娠结局的发生。

Objective To investigate the effect of diet consultation and metabolic risk factors during pregnancy on gestational outcomes. Methods Subjects were consecutive pregnant women who accepted routine prenatal examination and delivery in the International Peace Maternity and Childreng Health Hospital of China Welfare Institute in Shanghai from May 2010 to April 2012. The retrospective cohort was analyzed to evaluate the effect of diet consultation intervention on gestational complications among women with gestational diabetes mellitus （GDM）. Stepwise logistic regressions analysis was used to evaluate the effect of metabolic risk factors on birth weight and macrosomia, respectively. Results @Analyses were performed among 10 421 subjects. The mean of gestational week at the first prenatal visit was 20. 8 （ 19.4 ± 22.4 ） weeks. The mean of fasting blood glucose （ FBS）, triglyceride （TG） and total cholesterol（CHOL） was （4.4 ±0.4）, （ 1.4 ±0.6） and （4.7±0.8） mmol · L^-1 , respectively. The mean of SBP and DBP was （ 111.3 ±11.5 ） and （67.9 ±13.3 ） mmHg. The prevalence of GDM was 15.8%. The mean of birth weight was （3 355.4 ± 426.0） g and the prevalence of macrosomia was 6.2%. ②Among 812 pregnant women with diagnosed GDM, 570 accepted diet consultation at least once and the rest of 242 women never went to the diet consultation. No significant between-group differences were observed in variables in the baseline characteristics, including age, education, weight in 20th gestational week and biochemical tests at first prenatal visit. Compared with the control group the mean of birth weight, the prevalence of macrosomia and gestational hypertension in intervention group were reduced, （3 347.4 -＋ 19.6 g vs 3 450.3 ＋ 35.6 g, P =0. 007 ; 6.7% vs 15.6%, P -- 0. 001 ; 26.3% vs 47.9%, P 〈 0. 001 ）, respectively. With the increase of times of visiting nutrition intervention, the mean of maternal gestational weight gain and birth weight declined （r = -0. 126, P = 0. 003; r = - 0. 112, P = 0. 002） , and the prevalence of macrosomia was also decreased. ③Stepwise multiple logistic regressions showed the body weight at 20th gestational week（ OR = 1.08, 95% CI ： 1.07 - 1.09）, gestational weight gain （ OR = 1.10, 95% CI ： 1.07 - 1. 12） and GDM （OR = 1. 63, 95% CI： 1. 22 -2. 19） significantly increased the risk of the neonatal macrosomia. Conclusion The findings show that the elevated metabolic risk factors in pregnancy increase the risk of adverse gestional outcomes, diet consultation help improve the neonatal outcomes. The findings call for the urgent need for early and throughout management of metabolic risk factors and diet consultation among pregnant women during pregnancy to achieve better control the adverse gestation outcomes.