不同亚型妊娠期糖尿病患者胰岛素水平的交互作用及对出生体质量的影响

The interaction of insulin levels on birth weight in different subtypes of gestational diabetes mellitus

目的 探讨不同亚型妊娠期糖尿病(GDM)患者胰岛素水平的交互作用,并分析其对新生儿出生体质量的影响,为GDM的血糖管理提供循证依据。方法 采用前瞻性队列研究设计,选取2022年1月—2023年5月在舟山市妇女儿童医院进行围生保健并住院分娩的孕产妇及新生儿为研究对象。根据空腹血糖和葡萄糖耐量试验检测结果,将GDM患者分为空腹血糖增高型、餐后负荷增高型、空腹和餐后负荷均增高型3种亚型,再根据不同时点胰岛素水平,将各亚型分为胰岛素分泌减少型和胰岛素抵抗型。采用二分类logistic回归模型分析胰岛素不同指标与出生体质量(分类变量)的关联;采用多因素logistic回归模型分析胰岛素不同指标与出生体质量(连续变量)的关联及GDM与胰岛素交互作用对出生体质量的影响。结果 共纳入1 465例孕妇,其中血糖正常1 192例,空腹血糖增高型88例,餐后负荷增高型154例,空腹和餐后负荷均增高型31例。GDM不同亚型孕妇的新生儿出生体质量比较,差异无统计学意义(P>0.05);胰岛素抵抗组孕妇的孕前体质量指数(BMI)和新生儿出生体质量高于胰岛素非抵抗组,差异有统计学意义(P<0.05)。调整年龄、分娩孕周、是否有妊娠史及产次等因素后,多因素logistic回归模型分析结果显示,胰岛素水平、胰岛素抵抗指数与出生体质量呈正相关关系(β=3.01,P<0.05;β=14.99,P<0.05),但进一步调整孕前BMI和孕期增重后未见统计学关联;胰岛素分泌指数在调整孕前BMI、孕期增重后与出生体质量呈负相关关系(β=-0.06,P<0.05)。二分类logistic回归模型分析结果显示,胰岛素水平、胰岛素抵抗指数及胰岛素分泌指数与低出生体质量未见统计学关联。调整年龄、分娩孕周、是否有妊娠史及产次及孕前BMI等因素后,胰岛素水平>75%分位数和胰岛素抵抗指数>75%分位数均与巨大儿呈正相关关系(OR=2.39,95%CI:1.35~4.23;OR=3.37,95%CI:1.91~5.95)。在GDM孕妇中,调整年龄、分娩孕周、是否有妊娠史及产次等因素后,多因素logistic回归模型分析结果显示,胰岛素>75%水平和胰岛素抵抗指数>75%水平均与出生体质量呈正相关关系(β=118.02,P<0.05;β=120.752,P<0.05),但进一步调整孕前BMI和孕期增重后均未见统计学关联。调整年龄、分娩孕周、是否有妊娠史及产次等因素后,多因素logistic回归模型分析结果显示,非GDM和胰岛素抵抗相互作用与出生体质量呈正相关关系(β=90.97,P<0.05);空腹和餐后血糖均增高型和胰岛素分泌指数交互作用与出生体质量呈正相关关系(β=208.24,P<0.05),但进一步调整孕前BMI和孕期增重后未见统计学关联。结论 胰岛素不同水平与不同亚型GDM对出生体质量可能存在交互作用,建议在围生期行葡萄糖耐量试验筛查GDM时,重视不同时点的胰岛水平检测,并针对不同亚型的GDM患者进行针对性的干预和指导,最大限度改善妊娠结局,促进母婴健康。

Objective To exploe the interaction of insulin levels in patients with different subtypes of gestational diabetes mellitus(CDM),and analyze its effects on birth weight of newborns,so as to provide evidence-based evidence for blood glucose management of GDM.MethodsThe study used a prospective cohort design.Pregnant women and newborns who received perinatal health care and hospitalized delivery in Zhoushan Women and Children Hospital from January 2022 to May 2023 were selected as the study objects.According to the results of fasting blood glucose and glucose tolerance tests,GDM patients were divided into three subtypes:increased fasting blood glucose type,increased postprandial load type,and increased fasting and postprandial load type.According to the insulin levels at dfferent time points,each subtype was divided into reduced insulin secretion type and insulin resistance type.Binary logistic regression model was used to analyze the correlation between different insulin indexes and birth weight(categorical variable).Mulivariate logistic regression model was used to analyze the association between dfferent insulin indexes and birth weight(continuous variable)and the influence of interaction between GDM and insulin on birth weight.Results A total of 1465 pregnant women were included in this study,including 1192 patients with normal blood glucose,88 patients with increased fasting blood glucose,154 patients with increased postprandial load,and 31 patients with increased fasting and postprandial load.There was no significant diference in birth weight among pregnant women with different subtypes of GDM(P>0.05).The pre-pregnancy BMI and birth weight of the pregnant women in the insulin resistance group were higher than those in the non-insulin resistance group,and the difference was statistically significant(P<0.05).After adjusting for age,gestational age,gestational history and second birth,the results of multivariate logistic regression model showed that insulin level and insulin resistance index were positively correlated with birth weight(β=3.01,P<0.05;β=14.99,P<0.05),but there was no statistical association between BMI be fore pregnancy and weight gain during pregnancy afer further adjustment;Insulin secretion index was negatively correlated with birth weight after adjusting pre-pregnancy BMI and pregnancy weight gain(β=-0.06,P<0.05).Binary logistic regression model analysis showed that there was no statistical correlation between insulin level,insulin resistance index and insulin secretion index and low birth weight.After adjusting for age,gestational age,gestational history,birth time and pre-pregnancy BMI,insulin level>75%quantile and insulin resistance index>75%quantile were positively correlated with macrosomia(OR=2.39,95%Cl:1.35-4.23;OR=3.37,95%Cl:1.91-5.95).In GDM pregnant women,after adjusting for age,gestational age,gestational history and second birth,the results of multivariate logistic regression model showed that insulin>75%and insulin resistance index>75%were positively correlated with birth weight(β=118.02,P<0.05;β=120.752,P<0.05),but there was no statistical ssociation between pre-pregnancy BMI and pregnancy weight gain after further adjustment.Ater adjusting for age,gestational age,gestational history and birth rank,the results of multivariate logistic regression model showed that the interaction between non-GDM and insulin resistance was positively correlated with birth weight(β=90.97,P<0.05).The interaction between fasting and postprandial hyperglycemia and insulin secretion index was positively correlated with birth body mass(β=208.24,P<0.05),but no statistical association was found after further adjustment of pre-pregnancy BMI and pregnancy weight gain.ConclusionDiferent levels of insulin and diferent subtypes of gestational diabetes may interact with birth weight.During perinatal glucose tolerance test screening for GDM,attention should be paid to islet level detection at different time points,and targeted intervention and guidance should be carried out for dfferent subtypes of gestational diabetes,so as to maximize pregnancy outcome and promote maternal and child health.