早孕期代谢指标对不同孕前体重妊娠期糖尿病预测的价值探讨

The values of early pregnancy glucose and lipid metabolism indexes in predicting gestational diabetes mellitus with different pre-pregnancy body mass index

目的探讨早孕期空腹血糖(FPG)、血脂、血压等常用临床指标对不同孕前体重妊娠期糖尿病(GDM)的预测价值,并建立GDM早孕期预测模型。方法前瞻性病例对照研究。收集2017年9月至2018年6月早孕期在北京大学第一医院就诊的单胎孕妇1471名建立随访队列,以孕前体重、早孕期血压、FPG、血脂谱资料完整者作为研究对象,根据中孕期75g口服葡萄糖耐量试验(OGTT)结果,参照国际糖尿病与妊娠研究组诊断标准,其中GDM组222例、糖耐量正常(NGT)组420例进入病例对照研究。收集两组相关资料并根据孕前体重指数(BMI)分为体重正常及超重、肥胖组。采用logistic回归分析建立不同孕前体重GDM预测模型,采用受试者工作特性(ROC)曲线分析模型预测价值。结果与NGT组相比,GDM组妊娠年龄更大,糖尿病家族史、GDM史比例更高,甘油三酯(TG)、总胆固醇、低密度脂蛋白胆固醇(LDL-C)水平均更高,中孕期75g OGTT FPG、1 h血糖(1 hPG)、2 h血糖(2 hPG)亦更高,差异均有统计学意义(P<0.05)。妊娠年龄>31.2岁、早孕期FPG>5.42 mmol/L、TG>1.00 mmol/L、LDL-C>2.49 mmol/L、舒张压>72.5 mmHg(1 mmHg=0.133 kPa)和糖尿病家族史均为GDM的独立预测指标。孕前体重正常的孕妇,妊娠年龄、早孕期舒张压和FPG是GDM的独立预测指标;孕前超重、肥胖的孕妇,妊娠次数、糖尿病家族史、早孕期舒张压、FPG和TG对GDM有独立预测价值。TG预测价值大于FPG和舒张压(ROC下面积分别为0.718、0.640和0.648),联合预测准确度更高(ROC曲线下面积达0.793)。结论GDM虽在中晚孕期诊断,但早孕期即显示更高的FPG、TG、LDL-C及舒张压。正常体重者年龄、FPG及舒张压具有预测作用;超重、肥胖者,除FPG及舒张压外,TG、妊娠次数多、DM家族史也对GDM有独立预测作用,TG预测价值大于FPG,多指标联合可提高预测准确性。

Objective To explore the predictive values of early pregnancy fasting plasma glucose(FPG),lipid profiles and blood pressure,and establish prediction models for gestational diabetes mellitus(GDM)of different pre-pregnancy body mass index(p-BMI)ranges.Methods This is a prospective case-control study.From September 2017 to June 2018,1471 singleton pregnant women in our hospital were prospectively enrolled.We chose women with intact data of p-BMI,early pregnancy blood pressure,FPG and lipid profiles as objectives.According to the International Diabetes and Pregnancy Study Group(IADPSG)criteria,222 women diagnosed with GDM,and 420 women diagnosed with normal glucose tolerance(NGT)were enrolled into case-control study.The relevant data were collected.Objectives were divided into normal weight group and overweight/obese group basing on p-BMI,then logistic regression was used to establish GDM prediction models,and ROC was used to analyze the predictive values.Results(1)Compared with the NGT group,the GDM group were older at gestation,had higher proportions of diabetes mellitus(DM)family history,and GDM history.Pre-pregnancy weight,BMI,early pregnancy systolic and diastolic blood pressure(SBP and DBP),FPG,triglycerides(TG),total cholesterol(TCHO),and low-density lipoprotein cholesterol(LDL-C)of the GDM group were all significantly higher.Seventy five g OGTT FPG,1 hour plasma glucose(1 hPG),2 hour plasma glucose(2 hPG)during middle pregnancy were also significantly higher in the GDM group(P<0.05).(2)The age at gestation higher than 31.2 years,early pregnancy FPG higher than 5.42 mmol/L,TG higher than 1.00 mmol/L,LDL-C higher than 2.49 mmol/L,DBP higher than 72.5 mmHg(1 mmHg=0.133 kPa)and DM family history were independent predictors of GDM.(3)For pre-pregnancy normal weight women,GDM can be predicted using age at gestation,early pregnancy FPG and DBP.For pre-pregnancy overweight/obese women,besides early pregnancy FPG and DBP,TG,times of pregnancy and DM family history were all independent predictors.The predictive value of TG was higher than that of FPG or DBP(area under curve were 0.718,0.640 and 0.648).The prediction model combining above independent predictors had improved predictive value(area under curve was 0.793).Conclusions While GDM was diagnosed during middle or late pregnancy,higher levels of FPG,TG,LDL-C and DBP have emerged during early pregnancy.Women with different p-BMI have different predictive indicators in early pregnancy.Age at gestation,FPG and DBP were independent predictors for normal-weight women.For pre-pregnancy overweight/obese women,besides early pregnancy FPG and DBP,TG,times of pregnancy and DM family history were all independent predictors.The predictive value of TG was higher than that of FPG or DBP.The prediction model combining above independent predictors had improved predictive value.