有妊娠期糖尿病史女性再次妊娠时的孕期增重及围产结局

Gestational weight gain and pregnancy outcome in women with a history of gestational diabetes mellitus

目的探讨有妊娠期糖尿病(gestational diabetes mellitus,GDM)史女性再次妊娠时孕期总增重、不同时期增重及其与不良妊娠结局的关系。方法本研究为回顾性队列研究,选择2017年1月至2018年12月在首都医科大学附属北京妇产医院分娩的441例有GDM史的单胎经孕妇作为GDM史组,从同时期在本院分娩的无GDM史的单胎经产妇中采用机械抽样的方法筛选出1637例作为无GDM史组。采用独立样本t检验和χ2检验,比较2组孕妇的一般情况、孕期增重及围产结局的差异。根据美国医学研究所推荐的增重适宜值将2组孕妇分别分为增重不足、增重适宜和增重过多,采用多变量logistic回归分析比较妊娠不同时期同一增重情况2组孕妇的妊娠结局。结果(1)GDM史组孕妇行75 g口服葡萄糖耐量试验(oral glucose tolerance test,OGTT)前、OGTT后增重及孕期总增重均显著低于无GDM史组[(6.3±3.3)与(7.9±3.7)kg、(4.8±2.6)与(5.6±2.6)kg及(11.8±4.6)与(14.4±4.6)kg,t值分别为8.074、5.183及10.277,P值均<0.001]。GDM史组此次妊娠GDM、妊娠期高血压及大于胎龄儿的发生率均高于无GDM史组[46.5%(205/441)与18.1%(296/1637)、8.4%(37/441)与5.4%(88/1637)、12.9%(57/441)与9.7%(158/1637),χ^(2)值分别为153.181、5.583及4.013,P值均<0.05]。(2)行OGTT前:不同增重类别的GDM史孕妇发生GDM的风险较高[增重不足、适宜、过多者OR值及95%CI分别为4.02(2.35~6.88)、3.92(2.65~5.79)及3.33(2.11~5.25),P值均<0.001];除增重不足者,GDM史孕妇发生子痫前期的风险亦较高[增重适宜、过多者OR值及95%CI分别为3.62(1.47~9.23)和2.22(1.07~5.57),P值均<0.05]。行OGTT后:不同增重类别的GDM史孕妇发生GDM的风险较高[增重不足、适宜、过多者OR值及95%CI分别为2.48(1.60~3.84)、4.63(2.92~7.35)及4.22(2.73~6.51),P值均<0.001];增重过多的GDM史孕妇子痫前期的发生风险增加(OR=2.46,95%CI:1.10~5.51,P<0.05)。整个孕期:不同增重类别的GDM史孕妇发生GDM的风险均较高[增重不足、适宜、过多者OR值及95%CI分别为3.02(2.00~4.59)、4.08(2.76~6.04)及2.66(1.54~4.59),P值均<0.001];GDM史增加增重不足者大于胎龄儿及增重过多者产后出血发生风险[OR值及95%CI分别为1.94(1.09~4.21)和2.93(1.31~6.55),P值均<0.05]。结论有GDM史女性再次妊娠时不同时期增重及孕期总增重均低于无GDM史者,但不良结局的发生风险较高。即使在同一增重类别中GDM史也会增加GDM和子痫前期等不良妊娠结局的发生风险。

Objective To explore the association of the total gestational weight gain(GWG)and GWG in different trimesters with adverse pregnancy outcomes during the second pregnancy in women with history of gestational diabetes mellitus(GDM).Methods This retrospective cohort study recruited 441 singleton pregnant women with a history of GDM who gave birth at Beijing Obstetrics and Gynecology Hospital of Capital Medical University from January 2017 to December 2018 as the GDM history group.Another 1637 singleton pregnant women without a history of GDM who gave birth at the same period were selected through the mechanical sampling method as the control group.Independent sample t-test and Chi-square test were used to compare the differences in general conditions,GWG and perinatal outcomes between the two groups.Based on the Institute of Medicine guidelines for GWG,the subjects were further divided into three subgroups:inadequate GWG,adequate GWG and excessive GWG groups.Multivariate logistic regression analysis was used to compare the pregnancy outcome in women with the same GWG in different periods of pregnancy between the two groups.Results(1)Women with GDM history had lower GWG before and after oral glucose tolerance test(OGTT)and the whole pregnancy than those without[(6.3±3.3)vs(7.9±3.7)kg,(4.8±2.6)vs(5.6±2.6)kg,(11.8±4.6)vs(14.4±4.6)kg;t=8.074,5.183,10.277;all P<0.001].The incidence of GDM,gestational hypertension,and large for gestational age(LGA)in the GDM history group were higher than those in the control group[46.5%(205/441)vs 18.1%(296/1637),8.4%(37/441)vs 5.4%(88/1637),12.9%(57/441)vs 9.7%(158/1637);χ2=153.181,5.583,4.013;all P<0.05].(2)Before OGTT:pregnant women with GDM history of different GWG categories had a higher risk of developing GDM[OR and 95%CI for inadequate,adequate and excessive GWG were 4.02(2.35-6.88),3.92(2.65-5.79)and 3.33(2.11-5.25),respectively,all P<0.001].Except for women with inadequate GWG,pregnancy with a history of GDM also had a higher risk of preeclampsia[OR and 95%CI were 3.62(1.47-9.23)and 2.22(1.07-5.57)for adequate and excessive GWG,respectively,both P<0.05].After OGTT:pregnant women with GDM history of different GWG categories had a higher risk of developing GDM[OR and 95%CI for inadequate,adequate and excessive GWG were 2.48(1.60-3.84),4.63(2.92-7.35)and 4.22(2.73-6.51),respectively,all P<0.001].Pregnant women with a history of GDM with excessive GWG had an increased risk of preeclampsia(OR=2.46,95%CI:1.10-5.51,P<0.05).During pregnancy:pregnant women with GDM history of different GWG categories had a higher risk of developing GDM[OR and 95%CI were 3.02(2.00-4.59),4.08(2.76-6.04)and 2.66(1.54-4.59)for inadequate,adequate and excessive GWG,respectively,all P<0.001].Women with GDM history had an increased risk of large for gestational age(LGA)in those with inadequate GWG and postpartum hemorrhage in those with excessive GWG[OR and 95%CI were 1.94(1.09-4.21)and 2.93(1.31-6.55),respectively,both P<0.05].Conclusions The total GWG and GWG in different periods during the second pregnancy in women with a history of GDM are lower than those without,but with a higher risk of adverse outcomes.Even in women with the same range of GWG,GDM history still increases the risk of adverse pregnancy outcomes.