孕期不同时期增重对妊娠并发症的影响

Effects of gestational weight gain at different stages on pregnancy complications

目的探讨孕期不同时期增重对子痫前期、妊娠期高血压、妊娠期糖尿病、小于胎龄儿(small for gestational age,SGA)和大于胎龄儿等妊娠并发症的影响。方法本研究为前瞻性纵向队列研究。于2017年1月至2019年11月在南京大学医学院附属鼓楼医院招募孕11~13周^(+6)单胎妊娠孕妇,分别于孕19~23周^(+6)、29~34周^(+6)、35~40周^(+6)进行3次面访,现场测量孕妇的身高、体重、血压、超声指标等,并随访妊娠结局。依据早孕期体重指数将孕妇分为偏瘦组(<18.50 kg/m^(2))、正常组(18.50~23.99 kg/m^(2))和超重/肥胖组(≥24.00 kg/m^(2))。采用χ2检验和秩和检验进行组间比较。将周增重转化为Z分数,Z<-1定义为增重不足,-1≤Z≤1定义为增重适宜,Z>1定义为增重过度。利用二元logistic回归计算孕期不同时期周增重对妊娠并发症的影响。结果4143例孕妇进入队列,排除327例,最终3816例纳入分析,其中偏瘦组394例,正常组2668例,超重/肥胖组754例。中孕早期周增重过度是大于胎龄儿的危险因素(aOR=1.78,95%CI:1.31~2.42,P<0.001)。中孕晚期周增重过度是早产型子痫前期(aOR=3.00,95%CI:1.26~7.10,P=0.013)、妊娠期高血压(aOR=2.38,95%CI:1.44~3.94,P=0.001)和大于胎龄儿(aOR=1.59,95%CI:1.15~2.22,P=0.005)的危险因素。晚孕期增重过度是足月产型子痫前期(aOR=2.70,95%CI:1.61~4.54,P<0.001)和妊娠期高血压(aOR=1.84,95%CI:1.05~3.21,P=0.033)的危险因素。晚孕期增重不足是SGA的危险因素(aOR=1.58,95%CI:1.01~2.48,P=0.045),是足月产型子痫前期的保护因素(aOR=0.37,95%CI:0.14~0.97,P=0.041)。中孕早期周增重不足和过度对妊娠期糖尿病的发生无影响(P值均>0.05)。结论孕期不同时期增重对妊娠并发症的影响不同。适当放宽中孕早期增重,相对严格控制中孕晚期和晚孕期增重,可能是既有利于预防早产型子痫前期又不增加SGA发生率的合理选择。

Objective To investigate the effects of gestational weight gain(GWG)at different stages on pregnancy complications such as preeclampsia,gestational hypertension,gestational diabetes mellitus(GDM),small for gestational age(SGA),and large for gestational age(LGA).Methods This was a prospective longitudinal cohort study.Singleton pregnancies at 11-13^(+6) weeks of gestation in the Affiliated Drum Tower Hospital,Medical School of Nanjing University from January 2017 to November 2019 were recruited.The maternal height,weight,blood pressure,and fetal ultrasonic parameters were measured at 19-23^(+6),29-34^(+6),and 35-40^(+6) weeks of gestation by face-to-face interview and the pregnancy outcomes were followed up.All participants were grouped by body mass index(BMI)in the first trimester,with<18.50 kg/m^(2) as underweight group,18.50-23.99 kg/m^(2) as normal group,≥24.00 kg/m^(2) as overweight/obesity group.Chi-square test and rank-sum test were adopted for comparison among groups.Weekly weight gain was converted into Z scores,and insufficient,appropriate,and excessive weight gain were respectively defined when Z<-1,-1≤Z≤1,and Z>1.The effect of weekly weight gain at different gestational trimesters on pregnancy complications was analyzed by binary logistic regression.Results Totally,4143 pregnant women entered the cohort.After excluding 327 cases,3816 were finally included in the analysis,with 394 in underweight group,2668 in normal group,and 754 in overweight/obesity group.Excessive weekly weight gain in the early second trimester was a risk factor for LGA(aOR=1.78,95%CI:1.31-2.42,P<0.001),and in the later second trimester it was associated with preterm preeclampsia(aOR=3.00,95%CI:1.26-7.10,P=0.013),gestational hypertension(aOR=2.38,95%CI:1.44-3.94,P=0.001),and LGA(aOR=1.59,95%CI:1.15-2.22,P=0.005).In the third trimester,excessive weekly weight gain was associated with higher risks of term preeclampsia(aOR=2.70,95%CI:1.61-4.54,P<0.001)and gestational hypertension(aOR=1.84,95%CI:1.05-3.21,P=0.033);while insufficient weekly weight gain was a risk factor for SGA(aOR=1.58,95%CI:1.01-2.48,P=0.045),but a protective factor for term preeclampsia(aOR=0.37,95%CI:0.14-0.97,P=0.041).Insufficient and excessive weekly weight gain in the early second trimester were not related to GDM(both P>0.05).Conclusions GWG at different stages has different effects on pregnancy complications.A more relaxed control of GWG in the early second trimester combined with strict control in both the later second trimester and the third trimester may be a reasonable strategy to reduce the risk of preeclampsia without increasing the risk of SGA.