有妊娠期糖尿病史者再次妊娠发生糖代谢异常的危险因素

Risk factors for abnormal glucose metabolism in pregnant women with a history of gestational diabetes mellitus

目的分析有妊娠期糖尿病(gestational diabetes mellitus,GDM)史者再次妊娠时发生糖代谢异常的危险因素。方法本研究为回顾性研究。研究对象为2011年1月至2019年5月在中山大学附属第一医院连续2次分娩,且前次妊娠合并GDM的孕妇。收集研究对象2次妊娠的一般资料,以及早孕期空腹血糖、孕24~28周的75 g口服葡萄糖耐量试验(oral glucose tolerance test,OGTT)、糖化血红蛋白及血脂等临床资料。分析有GDM史者再次妊娠糖代谢异常的发生情况及危险因素。采用方差分析、Kruskal-Wallis检验、SNK-q法或LSD-t法、卡方检验等分析数据。采用单因素logistic回归分析筛选高危因素,多因素logistics逐步回归拟合模型。采用coldiag2命令进行变量共线性分析。结果(1)共455例符合条件,纳入研究。按再次妊娠时早孕期空腹血糖和75 g OGTT的结果分为OGTT正常组240例、GDM组189例和孕前糖尿病(pregestational diabetes mellitus,PGDM)组26例。有GDM史者再次妊娠时糖代谢异常的发生率为47.2%(215/455)。(2)有GDM史者再次妊娠时孕前体重、剖宫产率和新生儿出生体重高于前次妊娠[(55.6±8.5)与(53.3±7.9)kg,t=-4.059;47.9%(218/455)与33.0%(150/455),χ^(2)=20.481;(3177±463)与(3114±460)g,t=-2.044];孕期增重和分娩孕周小于前次妊娠[(11.2±4.2)与(12.5±4.4)kg,t=4.435;(38.6±1.3)与(38.8±1.3)周,t=2.288;P值均<0.05]。(3)再次妊娠时,PGDM组孕妇OGTT服糖后2 h血糖大于前次妊娠[(11.4±1.1)与(9.9±1.7)mmol/L,t=-3.299,P=0.002]。(4)PGDM组孕妇再次妊娠的早孕期空腹血糖明显高于GDM组,GDM组又高于OGTT正常组[4.6 mmol/L(4.2~7.6 mmol/L)、4.3 mmol/L(4.0~4.6 mmol/L)与4.1 mmol/L(3.8~4.4 mmol/L),χ^(2)=34.498,P<0.001]。PGDM组孕妇产后体重滞留小于OGTT正常组,OGTT正常组又小于GDM组[(1.2±3.9)、(1.6±3.9)与(2.6±4.9)kg,F=3.086,P<0.05]。(5)多因素logistic回归分析显示,产后体重滞留、前次妊娠75 g OGTT服糖后1 h和2 h血糖是有GDM史者再次妊娠发生糖代谢异常的独立危险因素(产后体重滞留:OR=1.054,95%CI:1.005~1.106;服糖后1 h血糖:OR=1.284,95%CI:1.087~1.516;2 h血糖:OR=1.272,95%CI:1.071~1.511)。结论有GDM史者再次妊娠时,糖代谢异常可能与前次妊娠OGTT服糖后血糖和产后体重滞留等因素有关。

Objective To study the risk factors for abnormal glucose metabolism in pregnant women with a history of gestational diabetes mellitus(GDM).Methods A retrospective analysis was performed on pregnant women who had two consecutive deliveries and were was complicated by GDM in the previous pregnancy at the First Affiliated Hospital of Sun Yat-sen University from January 2011 to May 2019.Clinical data of both pregnancies were collected,including general information,fasting blood glucose in early pregnancy and 75 g oral glucose tolerance test(OGTT)results,glycosylated hemoglobin A1c and blood lipid profile at 24-28 gestational weeks.The incidence and risk factors of abnormal glucose metabolism in these cases during the present pregnancy were analyzed.Analysis of variance,Kruskal-Wallis test,SNK-q or LSD-t-test,and Chi-square test were used for data analysis.Single-factor logistic regression analysis was used to analyze the high-risk factors,and multifactor logistic regression analysis was performed to fit the model.Variable collinearity diagnosis was performed using the coldiag2 command.Results(1)A total of 455 cases were enrolled in the study.According to the fasting glucose level in the first trimester and the OGTT results in the present pregnancy,they were divided into three groups:normal OGTT group(n=240),GDM group(n=189),and pre-gestational diabetes mellitus group(PGDM,n=26).The incidence of abnormal glucose metabolism in these patients during the present pregnancy was 47.2%(215/455).(2)Those with a history of GDM had higher pre-pregnancy weight,lower weight gain,higher cesarean section rate,smaller gestational age at delivery,and higher neonatal birth weight in the present pregnancy than those in the previous pregnancy[(55.6±8.5)vs(53.3±7.9)kg,t=-4.059;(11.2±4.2)vs(12.5±4.4)kg,t=4.435;47.9%(218/455)vs 33.0%(150/455),χ^(2)=20.481;(38.6±1.3)vs(38.8±1.3)weeks,t=2.288;(3177±463)and(3114±460)g,t=-2.044;all P<0.05].(3)In the PGDM group,the 2-h plasma glucose level after 75 g OGTT was higher than that in the previous pregnancy[(11.4±1.1)vs(9.9±1.7)mmol/L,t=-3.299,P=0.002].(4)In the present pregnancy,the PGDM group had the highest fasting blood glucose in early pregnancy,followed by the GDM group and the normal OGTT group[4.6 mmol/L(4.2-7.6 mmol/L),4.3 mmol/L(4.0-4.6 mmol/L)and 4.1 mmol/L(3.8-4.4 mmol/L),χ^(2)=34.498,P<0.001].The PGDM group had the least postpartum weight retention,followed by the normal OGTT group and the GDM group[(1.2±3.9),(1.6±3.9),and(2.6±4.9)kg,F=3.086,P<0.05].(5)Multivariate logistic regression analysis showed postpartum weight retention and the 1-h and 2-h plasma glucose levels after 75 g OGTT in the previous pregnancy were independent risk factors for abnormal glucose metabolism in pregnant women with a history of GDM(postpartum weight retention:OR=1.054,95%CI:1.005-1.106;1-h plasma glucose:OR=1.284,95%CI:1.087-1.516;2-h plasma glucose:OR=1.272,95%CI:1.071-1.511).Conclusions The incidence of abnormal glucose metabolism is higher in subsequent pregnancy in women with GDM history,which may be related to various factors,such as postpartum weight retention and plasma glucose after 75 g OGTT in the previous pregnancy.