年龄匹配设计的初产孕妇妊娠期糖尿病发病危险因素的病例对照研究

An age matched case-control study on the risk factors for the gestational diabetes mellitus among primiparous women

目的:妊娠期糖尿病(gestational diabetes mellitus,GDM)是临床上常见的妊娠合并症,对母婴近期或远期的健康均会产生不良的影响。GDM的危险因素复杂、多样,孕妇年龄越大、产次越多,GDM发病风险也越高。若这两个已知的独立危险因素在各组间的分布不均衡,可能会掩盖其他危险因素的作用。因此,本研究以初产孕妇为研究对象,采用年龄1:1配对设计的病例对照方法探究GDM发病的危险因素,旨在对存在高危因素的孕妇进行早期干预,以降低其在孕中后期发生GDM的可能性,促进母婴健康。方法:回顾性收集2018年8月至2019年10月在厦门大学附属妇女儿童医院产科或营养科门诊定期行产检、营养咨询的2425例孕妇的临床资料,根据纳入和排除标准,共2287例孕妇进入研究。在孕24~28周经口服葡萄糖耐量试验(oral glucose tolerance test,OGTT)确诊为GDM且资料完整的231例孕妇纳入GDM组。在糖耐量正常且资料完整的孕妇中,以GDM组年龄段为匹配因素进行1:1配对,用随机数字方法随机选择231例孕妇作为对照组进入研究。受试者总体年龄22~45(28.82±4.03)岁。收集患者孕前BMI,孕早期尿酸、空腹血糖(fasting blood glucose,FBG)、血脂指标及糖化血红蛋白(glycosylated hemoglobin,HbA1c)水平,孕13周前及孕24周前体重增长,流产次数,乙肝表面抗原是否阳性,父、母是否患有糖尿病、高血压等资料。比较2组孕前BMI、孕早期尿酸水平、孕早期FBG水平、孕13周前及孕24周前体重增长、早期血脂指标及HbAlc水平等资料。采用logistic回归分析研究GDM的危险因素。对2组孕妇孕24周前体重增长进行分层分析。结果:GDM组孕前BMI、孕早期尿酸水平、孕早期FBG水平、孕13周前及孕24周前体重增长均高于对照组,差异均有统计学意义(均P<0.05)。GDM组孕早期LDL水平高于对照组,而HDL水平则低于对照组,差异均有统计学意义(均P<0.05)。GDM组流产超过2次、孕前超重或肥胖、孕早期FBG超过5.1 mmol/L的比例均高于对照组,差异均有统计学意义(均P<0.05)。随着孕24周前体重增长切点值的上升,GDM发病风险也逐渐增加,当切点值达到10 kg时,差异具有统计学意义(OR=1.988,P=0.004)。孕早期HDL≥1.6 mmol/L是GDM的保护因素(OR=0.460,P=0.016),而孕24周前体重增长超过10 kg(OR=1.743,P=0.032)、孕早期FBG超过5.1 mmol/L(OR=3.488,P=0.001)、孕早期LDL≥2.50 mmol/L(OR=2.179,P=0.032)是GDM的危险因素。其中,孕早期FBG超过5.1 mmol/L对增加孕中后期发生GDM风险的影响最大。结论:在初产孕妇中,排除年龄的影响后,孕早期FBG及孕早期LDL水平越高,孕中后期发生GDM的风险越高。孕妇应当及早控制饮食,将孕24周前体重增长控制在10 kg以内,以降低发生GDM的风险。

Objective:Gestational diabetes mellitus(GDM)is one of the most common complications of pregnancy.It is associated with a wide range of short and long term adverse health consequences for both mother and offspring.As we know,the risk factors of the GDM are complex and diverse,and the incidence of GDM is directly correlated with the age and the times of women delivery.In the process of exploring the risk factors of GDM,if the 2 known independent risk factors are unevenly distributed among groups,the effects of other risk factors may be concealed.To avoid the influence of the 2 factors on the research results,we collected primiparous women as the participants through the method of the casecontrol study of age 1:1 paired design.Through this way,we want to provide early intervention for the pregnant women with the high risk factors so as to reduce the possibility of the GDM during the pregnancy and promote the maternal and infant’s health.Methods:This study was a retrospective study.A total of 2425 pregnant women were collected as the participants,who accepted the regular prenatal examination or nutrition health guidance in the Department of Obstetrics or Nutrition in the Women and Children’s Hospital,School of Medicine,Xiamen University from August 2018 to October 2019.According to the inclusion and exclusion criteria,2287 pregnant women were included in the study.Among them,231 pregnant women with the complete information were collected as a case group because of the abnormal results of the oral glucose tolerance test(OGTT)that executed between the 24 th and 28 th weeks during the pregnancy.Meanwhile,among the participants with the normal results of the OGTT,231 pregnant women with the complete information were selected randomly as a control group through the method of the age 1:1 paired with the case group.The age range of the all subjects was 22 to 45(28.82±4.03)years old.We collected their clinical and basic data retrospectively,including the BMI before pregnancy,the level of uric acid,fasting blood glucose,serum lipid index,and glycosylated hemoglobin(Hb A1 c)in the early pregnancy,the body weight gain before the13 th and 24 th weeks during the pregnancy,the times of the abortions,the positive of HBs Ag,the family history of diabetes or hypertension etc.The differences in these indexes were compared between the 2 groups.The logistic regression analysis was used to explore the risk factors for GDM and the stratified analysis was used to explore the difference of the body weight gain before the 24 th week during the pregnancy between the 2 groups.Results:The BMI before pregnancy,the uric acid,the fasting blood glucose,the body weight gain before the 13 th and 24 th weeks during the pregnancy in the GDM group were higher than those in the control group,and the differences were significant(all P<0.05).The LDL level in the early pregnancy of the GDM group was higher than that of the control group,however,the HDL level in the early pregnancy of the GDM group was lower than that of the control group,and the differences were significant(both P<0.05).The rates of the pregnant women in the GDM group with more than 2 abortions,obesity or overweight before pregnancy,the fasting blood glucose in the early pregnancy over 5.1 mmol/L were significantly higher than those in the control group(all P<0.05).With the uptrend of the cut-off point of the body weight gain before the 24 th week during the pregnancy,the risk of the GDM was gradually increasing.When the cut-off point reached at 10 kg,the difference was significant(OR=1.988,P=0.004).The level of HDL in the early pregnancy over 1.6 mmol/L was the protective factor for GDM(OR=0.460,P=0.016).Meanwhile,the body weight gain over 10 kg before the 24 th week during the pregnancy(OR=1.743,P=0.032),the fasting blood glucose in the early pregnancy over 5.1 mmol/L(OR=3.488,P=0.001),the LDL in the early pregnancy over 2.5 mmol/L(OR=2.179,P=0.032)were the risk factors for the GDM.Among them,the fasting blood glucose in the early pregnancy over 5.1 mmol/L had the greatest impact on the increase of risk for the GDM.Conclusion:After excluding the influence of the age,for primiparous women,the higher level of the LDL and the fasting blood glucose in the early pregnancy,the higher possibility to be the GDM.Meanwhile,the pregnant women should control their diet as soon as possible to control the body weight gain within 10 kg before the 24 th week during the pregnancy so as to reduce the possibility of being GDM.