摘要
目的应用持续性动态血糖监测系统（CGMS）监测妊娠期糖尿病（GDM）患者血糖水平,并探讨GDM患者血糖波动与新生儿出生体重、母体及新生儿不良妊娠结局的相关性。方法选取2011年4月至2012年8月于广东省妇幼保健院门诊定期产前检查的189例GDM患者为研究对象。本组GDM患者的诊断符合2011年美国糖尿病协会（ADA）推荐的GDM诊断标准。对本组患者于入组第1周,进行第1次CGMS 72h血糖监测。对其采取个体化血糖控制4周后,即入组第5周时,进行第2次CGMS72h血糖监测。收集189例GDM患者的年龄、身高、孕产史、孕前体重、空腹血糖水平、口服葡萄糖耐量试验（OGTT）1h血糖（OGTT-GLU1h）、OGTT 2h血糖（OGTTGLU2h）、OGTT日糖化血红蛋白（HbA1c）水平、入组第1及第5周平均血糖水平（MBG）、血糖水平标准差（SDBG）、平均血糖波动幅度（MAGE）及日间血糖平均绝对差（MODD）,以及新生儿体重、母体与新生儿不良妊娠结局等指标。采用多重线性回归分析方法对GDM患者上述指标与新生儿出生体重,进行相关性分析。采用非条件多因素logistic回归分析方法,对GDM患者上述指标与母体及新生儿不良妊娠结局的关系进行分析。本研究遵循的程序符合广东省妇幼保健院人体试验委员会制定的伦理学标准,得到该委员会批准。结果 1本组189例GDM患者入组第5周时,MBG、SDBG、MAGE、MODD、高血糖水平（≥7.8mmol/L）时间及低血糖水平（≤3.3mmol/L）时间分别为（5.7±0.7）mmol/L、（1.1±0.4）mmol/L、（2.4±0.9）mmol/L、（1.2±0.3）mmol/L、60 min/d（0~380min/d）及0min/d（0~270min/d）,均分别显著低于入组第1周时的（6.1±0.9）mmol/L、（1.3±0.4）mmol/L、（3.1±0.9）mmol/L、（1.5±0.4）mmol/L、100 min/d（0~760 min/d）及0 min/d（0~470min/d）,并且差异均有统计学意义（χ~2=4.197,P〈0.001;χ~2=7.028,P〈0.001;χ~2=7.691,P〈0.001;χ~2=12.986,P〈0.001;Z=-4.992,P〈0.001;Z=-2.601,P=0.009）。2本组189例GDM患者中,因自然流产（1例）及胎死宫内（2例）,共计186例新生儿出生,出生体重为（3 345±508）kg。其中,母体不良妊娠结局包括：1例（0.5%）自然流产,2例（1.1%）胎死宫内,19例（10.1%）合并子痫前期,88例（46.6%）初次剖宫产,36例再次剖宫产（19.0%）。新生儿不良妊娠结局包括：1例（0.5%）产伤,20例（10.8%）巨大儿,48例（25.8%）大于胎龄儿,5例（2.7%）小于胎龄儿,26例（14.0%）合并低血糖,18例（9.7%）合并高胆红素血症,11例（5.9%）合并呼吸窘迫综合征,共计92例（49.5%）新生儿发生不良妊娠结局。3GDM患者入组第1周的MBG及入组第5周的MAGE,均与新生儿出生体重呈正相关关系（b=104.709,P=0.013;b=87.804,P=0.035）。4GDM患者入组第1周的MBG与初产妇,均为初次剖宫产的独立危险因素（OR=1.728,95%CI：1.160~2.573,P=0.007;OR=5.208,95%CI：2.677~10.133,P=0.000）。GDM患者入组第1周的MAGE与MBG,为大于或小于胎龄儿的独立危险因素（OR=1.632,95%CI：1.137~2.343,P=0.008;OR=1.992,95%CI：1.269~3.128,P=0.003）。GDM患者入组第1周的MAGE、MBG及入组第5周的MAGE,均为巨大儿的独立危险因素（OR=1.800,95%CI：1.107~2.925,P=0.018;OR=1.987,95%CI：1.038~3.803,P=0.038;OR=1.885,95%CI：1.063~3.341,P=0.030）。GDM患者入组第1周的MAGE为新生儿不良妊娠结局的独立危险因素（OR=1.452,95%CI：1.050~2.008,P=0.024）。结论 GDM患者血糖波动异常,可能导致母体及新生儿的不良妊娠结局,因此除了对GDM患者每天监测7次瞬时血糖水平外,还应同时监测其血糖波动情况。
Objective To analyze the glycemic variability in patients with gestational diabetes mellitus（GDM）by using continuous glucose monitoring system（CGMS）and to explore the relationship between GDM glycemic variability and infant birth weight and maternal and neonatal adverse pregnancy outcomes.Methods From April 2011 to August 2012,189 cases of patients with GDM who were ready to regularly receive prenatal examination in the Department of Obstetrics of Guangdong Women and Children Hospital were enrolled in this study.All the GDM patients in this research met the GDM diagnostic criteria recommended by American Diabetes Association.They were instructed to wear the CGMS for 72 consecutive hours in the first week of this study.After four weeks of individual glucose control following strictly with doctors′advice,all the patients wear the CGMS for72 consecutive hours for the second time in the fifth week of this study The parameters of glycemic variability which included mean blood glucose（MBG）,the standard deviation of blood glucose（SDBG）,mean amplitude of glycemic excursions（MAGE）,and the mean of daily differences（MODD）were measured in the first and fifth weeks of this study.The maternal and neonatal adverse pregnancy outcomes and infant birth weight were collected.The relationship between infant birth weight and GDM patients′age,height,pregnancy history,body weight before pregnancy,fasting blood glucose level,oral glucose tolerance test（OGTT）1hglucose（OGTT-GLU1h）,OGTT 2h glucose（OGTT-GLU2h）and level of glycosylated hemoglobin A1c（HbA1c）on OGTT day,and MBG,SDBG,MAGE,MODD in the first and fifth weeks of this study were analyzed by multiple linear regression analysis. The relationship between maternal and neonatal adverse pregnancy outcomes and those above indexes of GDM patients in the first and fifth weeks of this study were analyzed by multiple logistic regression analysis.The study protocol was approved by the Ethical Review Board of Investigation in Human Being of Guangdong Women and Children Hospital.Results 1The MBG,SDBG,MAGE,MODD,duration of hyperglycemia level（≥7.8mmol/L）and duration of hypoglycemia level（≤3.3mmol/L）of GDM patients in the fifth week of this study were（5.7±0.7）mmol/L,（1.1±0.4）mmol/L,（2.4±0.9）mmol/L,（1.2±0.3）mmol/L,60 min/d（0-380min/d）and 0 min/d（0~270 min/d）respectively,which all were significantly lower than those（6.1±0.9）mmol/L,（1.3±0.4）mmol/L,（3.1±0.9）mmol/L,（1.5±0.4）mmol/L,100min/d（0~760min/d）and 0min/d（0~470min/d）in the first week of this study respectively,and all the differences were statistically significant（χ~2=4.197,P〈0.001;χ~2=7.028,P〈0.001;χ~2=7.691,P〈0.001;χ~2=12.986,P〈0.001;Z=-4.992,P〈0.001;Z=-2.601,P=0.009）.2189 women with GDM delivered 186 living infants,as 1woman miscarried and 2women experienced intrauterine fetal death.The average birth weight of infants was（3 345±508）kg.The maternal adverse pregnancy outcomes included：1（0.5%）miscarriage,2（1.1%）intrauterine fetal deaths,19（10.1%）combined with preeclampsia,88（46.6%）primary cesarean delivery,36（19.0%）repeat cesarean delivery.The neonatal adverse pregnancy outcomes included：1（0.5%）obstetric trauma,20（10.8%）macrosomia,48（25.8%）large for gestational age,5（2.7%）small for gestational age,26（14.0%）combined with hypoglycemia,18（9.7%）combined with hyperbilirubinemia,11（5.9%）combined with respiratory distress syndrome.In total,92（49.5%）infants suffered adverse pregnancy outcomes.3MBG in the first week and MAGE in the fifth week were strongly associated with infant birth weight（b=104.709,P=0.013;b=87.804,P=0.035）.4 MBG in the first week of GDM patients and primipara were independent risk factors for primary cesarean delivery（OR=1.728,95% CI：1.160-2.573,P=0.007;OR=5.208,95% CI：2.677-10.133,P=0.000）.MAGE and MBG in the first week of GDM patients were independent risk factors for large or small for gestational age（OR=1.632,95% CI：1.137-2.343,P=0.008;OR=1.992,95% CI：1.269-3.128,P=0.003）.MAGE,MBG in the first week and MAGE in the fifth week of GDM patients were independent risk factors for macrosomia（OR=1.800,95% CI：1.107-2.925,P=0.018;OR=1.987,95% CI：1.038-3.803,P=0.038;OR=1.885,95% CI：1.063-3.341,P=0.030）.MAGE in the first week of GDM patients was independent risk factor for neonatal adverse pregnancy outcome（OR=1.452,95% CI：1.050-2.008,P=0.024）.Conclusions Abnormal glycemic variability in patients with GDM may lead to maternal and neonatal adverse pregnancy outcomes.Therefore,seven times of measurements for glucose levels per day may be not enough for GDM.Monitoring for glycemic variability is also recommended.
出处
《中华妇幼临床医学杂志（电子版）》
CAS
2016年第3期305-311,共7页
Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition)
基金
广东省社会发展项目(2011B31800264)~~
关键词
糖尿病
妊娠
血糖波动
妊娠结局
动态血糖监测系统
Diabetes
gestational
Glycemic variability
Pregnancy outcome
Continuous glucose monitoring system
