早孕期空腹血浆血糖与妊娠期糖代谢异常的相关性

目的 探讨早孕期空腹血浆血糖(fasting plasma glucose,FPG)与妊娠期糖代谢异常的相关性.方法 选取2009年1月1日至2009年5月31日在北京大学第一医院妇产科产前保健及分娩的单胎非孕前糖尿病且早孕期5～13周检测FPG、资料齐全的孕妇656例,对其早孕期FPG孕24周后50 g葡萄糖负荷试验结果(glucose challenge test,GCT)、75 g葡萄糖耐量试验结果(oral glucose tolerance test,OGTT)、妊娠期糖尿病(gestational diabetes mellitus,GDM)和妊娠期糖耐量受损(gestational impaired glucose tolerance,GIGT)发病情况进行受试者工作特性(receiver operating characteristic,ROC)分析.结果 (1)早孕期FPG与孕24周后GCT的ROC分析:最大曲线下面积0.539,95%CI:0.493～0.586,两者无明显相关性(P=0.057).(2)早孕期FPG与孕24周后FPG异常的ROC分析:最大曲线下面积0.796(95%CI:0.672～0.920),如取5.05 mmol/L为界值,敏感性为54.5%,特异性为83.2%,两者存在相关性(r=0.432,P=0.000).(3)早孕期FPG与孕24周后OGTT 1、2、3 h血糖无相关性(r=0.093、0.036和0.107,P=0.122、0.549和0.074),OGTT服糖前与服糖后1、2、3 h血糖分别呈正相关(r=0.493、0.421和0.368,P均=0.000).(4)本研究中共656例早孕期孕妇的FPG值均＜6.1 mmol/L,诊断GDM 22例,GIGT 27例,早孕期FPG对预测最终发生GDM及GIGT无相关性.结论 早孕期FPG不能取代现有的50 g GCT作为孕期糖代谢异常的早期筛查指标,但早孕期FPG的检测是必要的.

Abstract：

Objective To investigate the relationship between early pregnancy fasting plasma glucose (FPG) and gestational glucose metabolism disorders. Methods Six hundred and fifty-six pregnant women who were singleton, non-diabetes before pregnancy and had FPG examined during 5-13 weeks of pregnancy were admitted into this study from January 1, 2009 to May 31, 2009. All these subjects had routine prenatal examination and finally delivered in the Department of Obstetrics of Peking University First Hospital. The FPG, 50 g glucose challenge test (GCT) after 24 weeks of pregnancy, 75 g oral glucose tolerance test (OGTT), gestational diabetes mellitus (GDM),gestational impaired glucose tolerance (GIGT) were analyzed with receiver operating characteristic (ROC) curve. Results (1) Relationship between FPG and GCT were analyzed with ROC curve.The maximum area under curve was 0. 539 (95% CI: 0. 493-0. 586) and there was no correlation between the FPG and GCT results(P=0. 057). (2) Relationship between early pregnancy FPG and abnormal FPG examined after 24 gestational weeks were also analyzed . The maximum area under curve was 0. 796(95% CI: 0. 672-0. 920). If 5. 05 mmol/L was taken as the cutoff value, the sensitivity and specificity was 54. 5% and 83. 2%, respectively. There was significant relationship between the two values (r=0. 432, P=0. 000). (3) There were no relationship between early pregnancy FPG and the blood glucose value of 1, 2 and 3 h in 75 g OGTT (r=0. 093, 0. 036 and 0. 107, P=0.122, 0. 549 and 0. 074 respectively). OGTT 0 h value was positively related to OGTT 1, 2 and3 h glucose level (r=0.493, 0.421 and 0.368, P=0.000, respectively). (4) All early pregnant FPG values in this study were under 6.1 mmol/L. Twenty-two GDM and 27 GIGT patients were diagnosed in this study. Early pregnancy FPG did not relate to the GDM and GIGT diagnosis.Conclusions Early pregnancy FPG could not replace 50 g GCT as an early screening for glucose metabolic abnormality in pregnancy, but FPG during early pregnancy is necessary.     

血糖控制满意的妊娠期糖尿病孕妇血清性激素结合球蛋白水平与妊娠结局的关系

目的 探讨血糖控制满意的妊娠期糖尿病(GDM)孕妇血清性激素结合球蛋白(SHBG)水平与妊娠结局的关系.方法 选择2005年3月至2010年3月在中国医科大学附属盛京医院产科门诊确诊的妊娠24～28周GDM孕妇251例,其中经单纯饮食控制(169例)或加用胰岛素治疗(47例)后血糖控制满意的216例为血糖控制满意组;经单纯饮食控制或加用胰岛素治疗后血糖控制不满意的35例为血糖控制不满意组.选取同期妊娠24～28周的192例健康孕妇为健康对照组.分别于妊娠24～28周和妊娠＞36周两次测定孕妇血清SHBG水平和稳态模型的胰岛素抵抗(HOMA-IR)指数.依据美国糖尿病资料小组的GDM诊断标准采用"两步法"诊断GDM.记录并观察3组孕妇的妊娠结局.测定孕妇空腹血糖(FPG)和空腹胰岛素(FINS)水平.结果 (1)妊娠结局比较:血糖控制满意组孕妇的妊娠期高血压疾病(10.6%,23/216)、早产(8.3%,18/216)、大于胎龄儿(8.8%,19/216)、新生儿窒息(3.7%,8/216)和新生儿低血糖(2.3%,5/216)的发生率明显低于血糖控制不满意组[分别为42.9%(15/35)、34.3%(12/35)、31.4%(11/35)、22.9%(8/35)和11.4%(4/35)],两组分别比较,差异均有统计学意义(P＜0.05或P＜0.01);而两组孕妇羊水过多、产褥感染、产后出血和新生儿高胆红素血症的发生率比较,差异均无统计学意义(P＞0.05).血糖控制满意组孕妇早产、产褥感染(3.2%,7/216)、产后出血(5.1%,11/216)、新生儿窒息(3.7%,8/216)和新生儿低血糖(2.3%,5/216)的发生率,与健康对照组[分别为7.3%(14/192)、2.1%(4/192)、4.2%(8/192)、2.1%(4/192)和1.6%(3/192)]比较,差异均无统计学意义(P＞0.05).(2)妊娠24～28周与妊娠＞36周孕妇血清SHBG等项指标检测结果比较:血糖控制满意组孕妇血清SHBG水平[分别为(384±88)及(457±48)nmo]/L]均明显高于血糖控制不满意组[分别为(313±45)及(401±73)nmol/L];血糖控制满意组孕妇HOMA-IR指数(分别为5.3±1.1及5.5±1.1)均明显低于血糖控制不满意组(分别为7.0±1.3及7.6±1.7),两组分别比较,差异均有统计学意义(P＜0.01);血糖控制满意组孕妇血清SHBG水平均明显低于健康对照组[分别为(492±95)及(565±40)nmol/L];而HOMA-IR指数均明显高于健康对照组(分别为3.6±0.6及3.9±0.5),两组分别比较,差异均有统计学意义(P＜0.01);血糖控制满意组孕妇FPG水平[分别为(5.84±0.28)及(5.16±0.13)mmol/L]明显低于血糖控制不满意组[分别为(6.13±0.16)及(5.68±1.14)mmol/L],两组分别比较,差异均有统计学意义(P＜0.01);血糖控制满意组孕妇FINS水平[分别为(20.4±2.1)及(24.1±4.2)mmol/L]明显低于血糖控制不满意组[分别为(24.7±4.5)及(29.9±2.7)mmol/L],两组分别比较,差异均有统计学意义(P＜0.01).(3)相关性分析:妊娠24～28周时,3组孕妇(共443例)血清SHBG水平与HOMA-IR指数呈负相关(r=-0.952,P＜0.01);其中血糖控制满意组216例孕妇血清SHBG水平与HOMA-IR指数也呈负相关(r=-0.903,P＜0.01).结论 血糖控制满意的GDM孕妇并不能完全改善妊娠结局,GDM孕妇血清SHBG水平降低和高IR对其妊娠结局有一定影响.

Abstract：

Objective To explore the relationship between sex hormone-binding globulin (SHBG) of gestational diabetes mellitus ( GDM ) pregnant women with well-controlled glucose and pregnancy outcomes. Methods Two hundred and fifty-one GDM pregnant women of 24 - 28 weeks in Shengjing Hospital of China Medical University were recruited from Mar. 2005 to Mar. 2010. Two hundred and sixteen cases of GDM with well-controlled glucose were defined as glycemic satisfied group, and they were treated by diet therapy ( 169 cases) or insulin therapy (47 cases) . Thirty-five cases with unsatisfied glucose were defined as glycemic unsatisfied group. One hundred and ninety-two healthy pregnant women of 24 - 28 weeks were defined as healthy control group. Serum SHBG and homeostasis model analysis of insulin resistance ( HOMA-IR) at 24 - 28 weeks and above 36 weeks were measured. GDM was diagnosed by " two-step" method according to the National Diabetes Data Group ( NDDG) criteria. The pregnancy outcomes and complications of the three groups were recorded. Results ( 1 ) Comparison of pregnancy outcomes and complications: glycemic satisfied group was less likely to develop hypertensive disorders in pregnancy ( 10. 6% ) , premature birth(8. 3% ) ,large for gestational age ( LGA) (8. 8% ) , neonatal asphyxia(3. 7% ) and neonatal hypoglycemia ( 2. 3% ) compared to glycemic unsatisfied group ( 42. 9% , 34. 3% , 31. 4% , 22. 9% and 11. 4% ,respectively). And the difference was statistically significant (P ＜0. 05 or P ＜0. 01). There was no significant difference for incidence of polyhydramnios, pueperal infection, postpartum hemorrhage, neonatal hyperbilirubinemia between the two groups ( P＞ 0. 05 ) . When compared to healthy control group(7. 3% ,2. 1% ,4. 2% ,2. 1% and 1. 6% ) ,no significant difference was found for incidence of premature birth( 8. 3% ) , pueperal infection ( 3. 2% ) , postpartum hemorrhage (5. 1% ) , neonatal asphyxia (3. 7% )and neonatal hypoglycemia(2. 3% ,P ＞0. 05). (2) Comparison of results of 24 - 28 weeks and above 36 weeks: serum SHBG of glycemic satisfied group [( 384 ± 88 ) , (457 ± 48 ) nmol/L]was significantly higher than that of glycemic unsatisfied group[(313 ±45) ,(401 ±73) nmol/L];HOMA-IR of glycemic satisfied group (5. 3 ±1.1,5.5 ±1.1) was significantly lower than that of glycemic unsatisfied group (7. 0 ± 1. 3 ,7. 6 ± 1. 7 ; P ＜ 0. 01). Serum SHBG of glycemic satisfied group was significantly lower than that of healthy control group [( 492 ± 95 ) , (565 ± 40 ) nmol/L]; and HOMA-IR of glycemic satisfied group(5. 3 ± 1. 1,5. 5 ± 1. 1) was significantly higher than that of healthy control group (3. 6 ±0. 6,3. 9 ± 0. 5 ;P ＜ 0. 01 ) . FPG of glycemic satisfied group [( 5. 84 ± 0. 28 ) , ( 5. 16 ± 0. 13 ) mmol/L]was significantly lower than that of glycemic unsatisfied group [(6. 13 ± 0. 16 ) , ( 5. 68 ± 1. 14) mmol/L; P ＜ 0. 01]. FINS of glycemic satisfied group [( 20. 4 ± 2. 1 ) , ( 24. 1 ± 4. 2 ) mmol/L]was significantly lower than that of glycemic unsatisfied group [(24. 7 ± 4. 5 ) , ( 29. 9 ± 2. 7 ) mmol/L; P ＜ 0. 01]. ( 3 ) Correlation analysis. Between 24 - 28 weeks, SHBG was negatively correlated with HOMA-IR in the three groups ( r = -0. 952, P ＜0. 01) ; and SHBG was negatively correlated with HOMA-IR in glycemic satisfied group ( r = -0. 903, P ＜0. 01). Conclusions Well-controlled glucose can not completely improve maternal and fetal outcomes of GDM pregnant women. High insulin resistance and low serum SHBG can influence pregnancy outcomes.     

妊娠早期空腹血浆葡萄糖水平与妊娠期糖尿病诊断的相关性

目的 探讨妊娠早期空腹血浆葡萄糖(fasting plasma glucose,FPG)水平与妊娠期糖尿病(gestational diabetes mellitus,GDM)诊断的关系,分析国际糖尿病与妊娠研究组(InternationalAssociation of Diabetes and Pregnancy Study Groups,IADPSG)新GDM诊断标准中妊娠早期FPG作为GDM诊断标准的适用性. 方法 收集2011年4月1日至12月31日在北京大学第一医院行产前检查的非孕前糖尿病孕妇2761例临床资料,比较GDM与非GDM 2组孕妇妊娠早期FPG水平;同时依据妊娠早期FPG水平分为FPG＜5.1 mmol/L组(2431例)和FPG≥5.1 mmol/L组(330例),比较GDM发生率.采用t或x 2检验比较各组妊娠结局,FPG对GDM发生风险的预测行Logistic回归分析及受试者工作特性曲线分析. 结果 (1) 2761例孕妇中,诊断GDM 515例,发生率18.7％.GDM组妊娠早期FPG水平显著高于非GDM组[(4.84±0.46) mmol/L与(4.57±0.35) mmol/L,t=11.924,P=0.000],妊娠早期FPG每升高1 mmol/L,发生GDM风险增加7.984倍(OR=8.984,95％CI:6.605～12.220).(2)FPG＜5.1 mmol/L组与≥5.1 mmol/L组在妊娠中晚期被诊断GDM的比例分别是15.2％ (370/2431)和43.9％(145/330),差异有统计学意义(x2=123.976,P=0.000).FPG≥6.1 mmol/L者共5例,均于妊娠中期诊断GDM.(3)妊娠早期FPG与GDM诊断的受试者工作特性曲线分析:最大曲线下面积0.718,95％CI:0.690～0.747;以4.795 mmol/L和4.785 mmol/L为界值时,诊断GDM的敏感性和特异性分别是0.600、0.612和0.735、0.726.(4)2761例孕妇中已分娩1208例,其中GDM 227例,非GDM981例,2组剖宫产率分别为54.2％(123/227)和39.2％(385/981),差异有统计学意义(x2=16.884,P=0.000),巨大儿、新生儿高胆红素血症、低出生体重儿、早产、胎儿生长受限、子痫前期的发生率差异均无统计学意义(P均＞0.05);FPG＜5.1 mmol/L组和≥5.1 mmol/L组中GDM分别为173例和54例,早产发生率分别是5.8％(10/173)和14.8％(8/54),≥5.1 mmol/L组显著升高(x2 =4.601,P＜0.05),剖宫产、胰岛素应用、巨大儿、子痫前期的发生率差异均无统计学意义(P均＞0.05). 结论 妊娠早期以FPG≥5.1 mmol/L作为GDM诊断标准会出现过度诊断,不建议推广,但有评估发生GDM风险的价值,值得临床重视.     

胎儿生长受限大鼠胰岛素敏感性的动态变化

目的 探讨胎儿生长受限(fetal growth restriction,FGR)大鼠胰岛素敏感性的变化规律.方法 母鼠受孕后第1天始随机分为对照组和低蛋白组,各10只.低蛋白组孕鼠采用低蛋白饮食法建立FGR模型.低蛋白组仔鼠中出生体重低于对照组仔鼠平均出生体重两个标准差者定为FGR鼠.测定对照组和FGR仔鼠(每组雌雄各8只)生后3、7、14、30、60及90 d空腹血浆血糖(fasting plasma glucose,FPG)及空腹血清胰岛索(fasting serum insulin,FINS),计算胰岛素抵抗指数及胰岛素敏感指数.90 d时测定血甘油三酯、低密度脂蛋白胆固醇、高密度脂蛋白胆固醇和糖化血红蛋白,同时行腹腔葡萄糖耐量实验.结果 (1)低蛋白组仔鼠平均出生体重为(4.92±0.36)g,低于对照组的(6.43±0.59)g,差异有统计学意义(t=14.73,P＜0.05).(2)雄性FGR鼠生后60 d时FPG高于对照组[(9.38±1.57)mmol/L与(5.58士1.24)mmol/L],直至90 d[(8.95±1.83)mmol/L与(6.21±1.14)mmol/L],差异有统计学意义(t=-3.291,P＜0.05);雌性FGR鼠90 d时FPG为(9.08±1.65)mmol/L,高于对照组的(6.73土0.67)mmol/L,差异有统计学意义(t=-3.226,P＜0.05);雄性FGR鼠FINS 30 d时开始高于对照组,直至90 d时;雌性FGR鼠60及90 d时FINS 高于对照组,差异均有统计学意义(P＜0.05);雄性及雌性FGR鼠胰岛素抵抗指数及胰岛素敏感指数分别于30 d及60 d始与对照组相比出现改变,直至90 d,差异有统计学意义(P均＜0.05).腹腔葡萄糖耐量实验结果显示,从0 min始各时间点雄性和雌性FGR鼠血糖均高于对照组,差异均有统计学意义(P＜0.05).(3)生后90 d时,雄性FGR鼠糖化血红蛋白为(7.03±0.54)%,高于对照组的(4.37±0.64)%,差异有统计学意义(t=-8.028,P＜0.05).无论雄性或雌性仔鼠,2组血脂水平差异均无统计学意义(P均＞0.05).结论 FGR鼠在生后早期尚能维持正常的FPG和FINS水平,随着日龄增加,胰岛素敏感性从青年期逐渐降低,直至成年期,而且雄性FGR鼠更易发生胰岛素抵抗.

Abstract：

Objective To investigate the regular pattern of dynamic changes of insulin sensitivity in fetal growth restriction (FGR) rats. Methods Twenty pregnant female rats were randomly divided into two groups as normal-protein group (NP) and low-protein group (LP), which respectively received normal protein diet (20% protein) and low protein diet (8% protein) during pregnancy. Weights of newborns were measured within 6 hours after birth, and the LP offspring whose birth weights were at least 2 standard deviations below the mean of NP offspring (≤2 standard deviations) were defined as FGR rats. At day 3, 7, 14, 30, 60 and 90 after birth, rats were fasted for 12 hours and then angular vein blood was collected to measure fasting plasma glucose (FPG) and fasting serum insulin (FINS) level. At 90 days of age, intraperitoneal glucose tolerance test (IPGTT)was performed; and blood triglyceride ( TG ), low-density lipoprotein cholesterol ( LDL-C ),high-density lipoprotein cholesterol (HDL-C) and glycosylated hemoglobin Alc (HbAlc) were measured. Insulin sensitivity was evaluated by FINS, insulin resistance index (HOMA-IR), insulin sensitivity index (ISI) and IPGTT. Results (1) Birth weights of LP offspring [(4. 92 ± 0. 36) g]were significantly lower than those of NP ones [(6. 43 ± 0. 59) g] (t = 14. 73, P＜0. 05). The incidence of FGR in LP was 88. 2% ; and for the male and female rats, the FGR rate was 94. 1% and 83. 1%, respectively. (2) FPG levels in the male FGR rats were significantly higher than in the NP from the age of 60 days [(9.38 ± 1.57) mmol/L vs (5. 58 ± 1.24) mmol/L] to 90 days [(8. 95 ±1.83) mmol/L vs (6. 21± 1.14) mmol/L] (t=-3. 291, P＜0. 05), while FPG levels in female FGR rats increased significantly only at 90 days of age [(9. 08±1.65) mmol/L vs (6.73±0. 67) mmol/L](t=-3. 226,P＜0. 05). FINS levels were significantly higher in FGR rats than in the NP from the age of 30 days (male FGR rats) or 60 days (female FGR rats) to 90 days (P＜0. 05, respectively).Similarly, HOMA-IR was significantly higher in FGR rats than in the NP at the age of 30 days (male FGR rats) or 60 days (female FGR rats) to 90 days (P＜0. 05, respectively). ISI in male FGR rats showed a reduction in comparison with the NP from the age of 30 to 90 days, while as to the female FGR rats it was significantly lower than in the NP only at 60 days of age and continued to 90 days (P＜0. 05, respectively). IPGTT showed that after injection of glucose, blood glucose at all four points (from 0 min to 120 min) in both male and female FGR rats were higher than that in the NP (P＜0. 05). (3) No significant difference was observed in TG, LDL-C and HDL-C at 90 days of age between the FGR rats and NP ones, while HbA1c in the male FGR rats was significantly higher than that in the NP [(7. 03±0. 54) % vs (4. 37±0. 64)%,t= -8. 028, P＜0. 05]. Conclusions FGR rats are able to maintain glucose balance and normal insulin levels during their earlier age, while insulin sensitivity decreased from adolescence to adulthood. The change of insulin sensitivity is different between male and female FGR rats, and male FGR rats are more likely to develop insulin resistance.     

妊娠期血小板减少程度对母儿结局的影响

Objective To investigate the perinatal outcomes of pregnancies complicated with varying degrees of thrombocytopenia.Methods Clinical data of 305 pregnant women with thrombocytopenia,who admitted to Peking University People's Hospital from January 1,2000 to January 31,2010 were retrospectively analyzed.The etiological diagnosis of them were gestational thrombocytopenia (GT),idiopathic thrombocytopenic purpura (ITP) or undetermined.The patients were divided into 4 groups according to the minimal level of platelets in pregnancy ( platelets count was lower than 100 ×109/L at least twice) : groupⅠ,(50-100) ×109/L (n=101) ; group Ⅱ,(30-50) × 109/L (n = 85); group Ⅲ,(10-30) × 109/L (n = 87); group Ⅳ,< 10 × 109/L (n = 32).Demographic data such as pregnancy complications,treatment,neonates and follow-up results of the patients in each group were compared with ANOVA,Spearman rank correlation analysis,Chirsquare test and Chi-square trend test in SPSS 17.0.Results Medical complications in pregnancy of these patients included hypertensive disorder complicating (n = 35,11.48%) and abnormal glucose metabolism (n=23,7.54%),no difference was found in the incidence of these diseases among the four groups.There were 68 patients complicated with anemia (22.30%),40 preterm delivery (13.11%),60 postpartum hemorrhage (19.67%); there were significant differences in the incidence among the four groups (P＜0.05),the incidence increased with the aggravation of thrombocytopenia (P＜0.05).There were 2 cases of puerperal infection (0.66%),no maternal deaths.Fifty-one patients (16.72%) accepted treatment of corticosteroids or Gamma globulin during pregnancy.There were 116 cases (38.03%) of vaginal delivery and 189 cases (61.97%) of cesarean section.The postpartum bleeding amount within 24 hours increased with the aggravation of thrombocytopenia.Two hundred and eleven (69.18%) patients were followed up and platelet count regained normal,among which 152 cases recovered within six months after delivery.The recovery rates were 90.59% (77/85),82.36% (42/51),46.16% (24/52) and 39.13% (9/23) from group Ⅰ to group Ⅳ,as declined with the aggravation of thrombocytopenia in pregnancy ( x2trend = 42.616,Ptrend =0.000).Among the 306 perinatal fetuses,neonatal outcomes included 301 live births,5 fetal deaths,4 early neonatal deaths,4 low birth-weight infants after term birth,1 intracranial hemorrhage and 18 (5.98%) neonatal thrombocytopenia cases.Incidence of neonatal thrombocytopenia increased with the aggravation of maternal thrombocytopenia.Sixteen cases of neonatal thrombocytopenia recovered at 3-8 weeks after birth,but two cases did not recover within three years during followed up.Conclusions The perinatal outcomes are different in pregnancies complicated with varying degrees of thrombocytopenia.As thrombocytopenia in pregnancy become worse,the risk of anemia,premature delivery,postpartum hemorrhage and neonatal thrombocytopenia increases.While,perinatal outcomes may be better under close perinatal care.     

妊娠期血小板减少程度对母儿结局的影响

Objective To investigate the perinatal outcomes of pregnancies complicated with varying degrees of thrombocytopenia.Methods Clinical data of 305 pregnant women with thrombocytopenia,who admitted to Peking University People's Hospital from January 1,2000 to January 31,2010 were retrospectively analyzed.The etiological diagnosis of them were gestational thrombocytopenia (GT),idiopathic thrombocytopenic purpura (ITP) or undetermined.The patients were divided into 4 groups according to the minimal level of platelets in pregnancy ( platelets count was lower than 100 ×109/L at least twice) : groupⅠ,(50-100) ×109/L (n=101) ; group Ⅱ,(30-50) × 109/L (n = 85); group Ⅲ,(10-30) × 109/L (n = 87); group Ⅳ,< 10 × 109/L (n = 32).Demographic data such as pregnancy complications,treatment,neonates and follow-up results of the patients in each group were compared with ANOVA,Spearman rank correlation analysis,Chirsquare test and Chi-square trend test in SPSS 17.0.Results Medical complications in pregnancy of these patients included hypertensive disorder complicating (n = 35,11.48%) and abnormal glucose metabolism (n=23,7.54%),no difference was found in the incidence of these diseases among the four groups.There were 68 patients complicated with anemia (22.30%),40 preterm delivery (13.11%),60 postpartum hemorrhage (19.67%); there were significant differences in the incidence among the four groups (P＜0.05),the incidence increased with the aggravation of thrombocytopenia (P＜0.05).There were 2 cases of puerperal infection (0.66%),no maternal deaths.Fifty-one patients (16.72%) accepted treatment of corticosteroids or Gamma globulin during pregnancy.There were 116 cases (38.03%) of vaginal delivery and 189 cases (61.97%) of cesarean section.The postpartum bleeding amount within 24 hours increased with the aggravation of thrombocytopenia.Two hundred and eleven (69.18%) patients were followed up and platelet count regained normal,among which 152 cases recovered within six months after delivery.The recovery rates were 90.59% (77/85),82.36% (42/51),46.16% (24/52) and 39.13% (9/23) from group Ⅰ to group Ⅳ,as declined with the aggravation of thrombocytopenia in pregnancy ( x2trend = 42.616,Ptrend =0.000).Among the 306 perinatal fetuses,neonatal outcomes included 301 live births,5 fetal deaths,4 early neonatal deaths,4 low birth-weight infants after term birth,1 intracranial hemorrhage and 18 (5.98%) neonatal thrombocytopenia cases.Incidence of neonatal thrombocytopenia increased with the aggravation of maternal thrombocytopenia.Sixteen cases of neonatal thrombocytopenia recovered at 3-8 weeks after birth,but two cases did not recover within three years during followed up.Conclusions The perinatal outcomes are different in pregnancies complicated with varying degrees of thrombocytopenia.As thrombocytopenia in pregnancy become worse,the risk of anemia,premature delivery,postpartum hemorrhage and neonatal thrombocytopenia increases.While,perinatal outcomes may be better under close perinatal care.     

妊娠期糖尿病母鼠血清晚期糖基化终产物与子鼠心脏发育异常的关系

Objective To explore the effect of advanced glycation end product(AGE) in serum of maternal rats with gestational diabetes mellitus (GDM) on the heart development of their offsprings. Methods Fifty-four SD rats were randomly assigned into control group (n= 24) and GDM group (n=30) which were established by administration of streptozotocin intra-abdominally. On the gestational age of 13, 16, 19 days, all rats underwent hysterectomy to obtain the fetal heart tissues. Serum level of AGE and blood glucose level of maternal rats were tested. The expression of receptor AGE (RAGE) in fetal cardiac tissue were detected by immunohistoehemistry. Results The incidence of fetal heart defect in GDM group was significantly higher than the control group at each time point (P<0.01). Rats in GDM group had higher blood glucose level at each time point (P<0.01). The AGE levels of GDM group on gestational age of 13, 16 and 19 day [(5.72±0.68) U/mgpr, (7.31±0.29) U/mgpr and (7.77±0.39) U/mgpr] were significantly higher than those of the control group [(4.45±0.27) U/mgpr, (4.71±0. 35) U/mgpr and (4. 37±0. 44) U/rngpr] (t=6. 142, 16. 295, 0. 399,P<0. 01). The number of heart malformation in fetal rats (r=0.994,P=0. 000) and blood glucose (r=0. 717,P=0. 000) had the positive relationship with the maternal serum AGE level. The expression of RAGE in fetal heart was positively related with the number of fetal heart malformation (r= 0. 638,P= 0. 004). Conclusions The increased maternal serum AGE level in GDM rats may be an important factor in fetal heart dysplasia.     

妊娠期糖尿病母鼠血清晚期糖基化终产物与子鼠心脏发育异常的关系

Objective To explore the effect of advanced glycation end product(AGE) in serum of maternal rats with gestational diabetes mellitus (GDM) on the heart development of their offsprings. Methods Fifty-four SD rats were randomly assigned into control group (n= 24) and GDM group (n=30) which were established by administration of streptozotocin intra-abdominally. On the gestational age of 13, 16, 19 days, all rats underwent hysterectomy to obtain the fetal heart tissues. Serum level of AGE and blood glucose level of maternal rats were tested. The expression of receptor AGE (RAGE) in fetal cardiac tissue were detected by immunohistoehemistry. Results The incidence of fetal heart defect in GDM group was significantly higher than the control group at each time point (P<0.01). Rats in GDM group had higher blood glucose level at each time point (P<0.01). The AGE levels of GDM group on gestational age of 13, 16 and 19 day [(5.72±0.68) U/mgpr, (7.31±0.29) U/mgpr and (7.77±0.39) U/mgpr] were significantly higher than those of the control group [(4.45±0.27) U/mgpr, (4.71±0. 35) U/mgpr and (4. 37±0. 44) U/rngpr] (t=6. 142, 16. 295, 0. 399,P<0. 01). The number of heart malformation in fetal rats (r=0.994,P=0. 000) and blood glucose (r=0. 717,P=0. 000) had the positive relationship with the maternal serum AGE level. The expression of RAGE in fetal heart was positively related with the number of fetal heart malformation (r= 0. 638,P= 0. 004). Conclusions The increased maternal serum AGE level in GDM rats may be an important factor in fetal heart dysplasia.     

妊娠期糖尿病母鼠血清晚期糖基化终产物与子鼠心脏发育异常的关系

Objective To explore the effect of advanced glycation end product(AGE) in serum of maternal rats with gestational diabetes mellitus (GDM) on the heart development of their offsprings. Methods Fifty-four SD rats were randomly assigned into control group (n= 24) and GDM group (n=30) which were established by administration of streptozotocin intra-abdominally. On the gestational age of 13, 16, 19 days, all rats underwent hysterectomy to obtain the fetal heart tissues. Serum level of AGE and blood glucose level of maternal rats were tested. The expression of receptor AGE (RAGE) in fetal cardiac tissue were detected by immunohistoehemistry. Results The incidence of fetal heart defect in GDM group was significantly higher than the control group at each time point (P<0.01). Rats in GDM group had higher blood glucose level at each time point (P<0.01). The AGE levels of GDM group on gestational age of 13, 16 and 19 day [(5.72±0.68) U/mgpr, (7.31±0.29) U/mgpr and (7.77±0.39) U/mgpr] were significantly higher than those of the control group [(4.45±0.27) U/mgpr, (4.71±0. 35) U/mgpr and (4. 37±0. 44) U/rngpr] (t=6. 142, 16. 295, 0. 399,P<0. 01). The number of heart malformation in fetal rats (r=0.994,P=0. 000) and blood glucose (r=0. 717,P=0. 000) had the positive relationship with the maternal serum AGE level. The expression of RAGE in fetal heart was positively related with the number of fetal heart malformation (r= 0. 638,P= 0. 004). Conclusions The increased maternal serum AGE level in GDM rats may be an important factor in fetal heart dysplasia.     

妊娠期糖尿病母鼠血清晚期糖基化终产物与子鼠心脏发育异常的关系

Objective To explore the effect of advanced glycation end product(AGE) in serum of maternal rats with gestational diabetes mellitus (GDM) on the heart development of their offsprings. Methods Fifty-four SD rats were randomly assigned into control group (n= 24) and GDM group (n=30) which were established by administration of streptozotocin intra-abdominally. On the gestational age of 13, 16, 19 days, all rats underwent hysterectomy to obtain the fetal heart tissues. Serum level of AGE and blood glucose level of maternal rats were tested. The expression of receptor AGE (RAGE) in fetal cardiac tissue were detected by immunohistoehemistry. Results The incidence of fetal heart defect in GDM group was significantly higher than the control group at each time point (P<0.01). Rats in GDM group had higher blood glucose level at each time point (P<0.01). The AGE levels of GDM group on gestational age of 13, 16 and 19 day [(5.72±0.68) U/mgpr, (7.31±0.29) U/mgpr and (7.77±0.39) U/mgpr] were significantly higher than those of the control group [(4.45±0.27) U/mgpr, (4.71±0. 35) U/mgpr and (4. 37±0. 44) U/rngpr] (t=6. 142, 16. 295, 0. 399,P<0. 01). The number of heart malformation in fetal rats (r=0.994,P=0. 000) and blood glucose (r=0. 717,P=0. 000) had the positive relationship with the maternal serum AGE level. The expression of RAGE in fetal heart was positively related with the number of fetal heart malformation (r= 0. 638,P= 0. 004). Conclusions The increased maternal serum AGE level in GDM rats may be an important factor in fetal heart dysplasia.     

母亲妊娠期糖尿病对胎儿和婴儿心功能的影响

目的 探讨妊娠期糖尿病(gestational diabetes mellitus,GDM)母亲的子代婴儿期心脏解剖和功能的变化.方法 选择2007年1月至8月在复旦大学附属妇产科医院行产前检查并分娩的GDM孕妇18例为GDM组,选择同期24例孕周匹配的正常妊娠孕妇作为对照组,均在妊娠晚期接受胎儿超声心动图检查,测量胎儿心脏大小和功能各项指标,组间比较采用两独立样本t检验.GDM组 孕妇的子代于2～3月龄时接受小儿超声心动图随访,选择同期24例月龄匹配的正常妊娠的健康婴儿为对照组,再次评价和比较婴儿心脏大小和功能各项指标,组间差异比较采用方差分析及两两检验.结果 GDM组18例胎儿中出生6例大于胎龄儿(1arge for gestational age,LGA),占33.3%,12例(66.7%)适于胎龄儿(appropriate for gestational age,AGA);对照组24例胎儿中出生2例LGA(8.3%)和22例(91.7%)AGA(x2=3.840,P=0.05).GDM组胎儿的左室壁和室间隔收缩末期厚度大于对照组(P均＜0.05);至婴儿期室壁厚度未再增加,而LGA婴儿的左室壁收缩末期厚度[(4.55±0.37)mm]和左心室舒张末期长径[(37.3±2.3)mm]仍大于对照组[分别为(4.13±0.39)mm和(34.6±2.6)mm](P均＜0.05).GDM组胎儿的主、肺动脉峰速和左心输出量均大于对照组胎儿(P均＜0.01),右心/左心输出量值小于对照组(分别为1.198±0.206和1.430±0.321,t=-2.668,P=0.011);至婴儿期,GDM组仅AGA婴儿的右心/左心输出量值大于对照组(P＜0.05).GDM组胎儿左房缩短分数,三尖瓣E峰、A峰速度和E/A比值小于对照组(P均＜0.05);至婴儿期,GDM组仅左房缩短分数(0.356±0.040)仍小于对照组(0.386±0.041)(t=-2.332,P=0.025).GDM组胎儿的左、右心室Tei指数分别为0.482±0.129和0.414±0.094,均大于对照组(分别为0.309±0.074和0.283±0.072)(t分别=5.075和5.129,P均=0.000);至婴儿期,GDM组LGA和AGA婴儿的左、右心室 Tei指数均较胎儿期明显降低,并与对照组婴儿差异无统计学意义.结论 血糖控制良好的GDM母亲分娩的婴儿在2～3月龄时,心脏的解剖和功能指标均较胎儿期更接近健康婴儿.     

Screening for gestational diabetes mellitus in southern Asian women

AIM: To compare fasting plasma glucose (FPG) against 2-h postprandial plasma glucose (PPPG), following a carbohydrate meal, for screening of gestational diabetes mellitus (GDM) in southern Asian women with one or more risk factors. METHODS: A comparative study was conducted at a university obstetric unit in Sri Lanka. Two hundred and seventy one women undergoing oral glucose tolerance test (OGTT) according to the WHO criteria of 1999 had a 2-h PPPG performed within the following week. Sensitivity, specificity, predictive values and correlation coefficients for predicting a diagnosis of GDM and areas under receiver-operator curves (ROC) were calculated for FPG and PPPG. The ability to predict GDM and to reduce the need for OGTT were the main outcome measures. RESULTS: The mean period of gestation was 26.43 weeks (SD = 5.4) Seventy-five (27.7%) women were diagnosed with GDM. The optimal threshold for FPG was 4.4 mmol/L and for PPPG 4.7 mmol/L. At these, sensitivity was 92.0% and 90.7%, specificity 48.7% and 25.4% and the areas under the ROC 0.82 and 0.73 for FPG and PPPG, respectively. Nine (12%) women could be diagnosed as having GDM on the basis of the FPG being above the threshold. CONCLUSIONS: FPG is superior to 2-h PPPG for screening high-risk women for GDM. Nine women were diagnosed as having GDM on the basis of having an FPG above 7 mmol/L. FPG could reduce the number of OGTT needed by 40.9%, compared to 20.6% by PPPG. FPG is a less cumbersome and cost-effective screening test.     

妊娠期糖尿病孕妇血清及皮下脂肪组织中视黄醇结合蛋白4的表达及其与胰岛素抵抗的关系

目的 探讨妊娠期糖尿病孕妇血清及皮下脂肪组织中视黄醇结合蛋白4(RBP-4)的表达变化及其与胰岛素抵抗的关系.方法 选择2008年5月至2009年4月在青岛大学医学院附属医院产科行选择性剖宫产术的妊娠期糖尿病孕妇32例为妊娠期糖尿病组,同期行选择性剖宫产术的糖耐量正常孕妇30例为对照组.采用酶联免疫吸附试验检测两组孕妇血清中RBP-4水平,放射免疫法榆测两组孕妇空腹胰岛素(FINS)水平,匍萄糖氧化酶法检测两组孕妇空腹血糖(FPG)水平,并计算稳态模型的胰岛索抵抗指数(HOMA-IR).采用半定量RT-PCR技术及蛋白印迹法检测两组孕妇皮下脂肪组织中RBP-4 mRNA和蛋白表达水平,并对妊娠期糖尿病组孕妇皮下脂肪组织中RBP-4mRNA和蛋白表达水平与血清中RBP-4水平及HOMA-IR行相关性分析.结果 (1)妊娠期糖尿病组孕妇血清中RBP-4、FINS、FPG水平及HOMA-IR分别为(27.0±1.2)mg/l、(12.1±1.4)mU/L、(5.3±019)mmol/L及2.5±0.2,对照组分别为(19.4 ±1.8)mg/L、(8.3±0.8)mU/L、(4.1±0.6)mmol/L及1.5±0.1,妊娠期糖尿病组孕妇以上4项指标均显著高于对照组(P均<0.05).(2)妊娠期糖尿病组孕妇皮下脂肪组织中RBP-4 mRNA和蛋白表达水平分别为0.76 ±0.12和0.74 ±0.09,显著高于对照组的0.53±0.06和0.54±0.06,两组分别比较,差异有统计学意义(P均<0.05).(3)妊娠期糖尿病组孕妇皮下脂肪组织中RBP-4 mRNA和蛋白表达水平与HOMA-IR均呈明显正相关关系(r=0.575、0.851,P均<0.05);血清巾RBP-4水平与HOMA-IR呈明显正相关关系(r=0.635,P<0.05);皮下脂肪组织中RBP-4 mRNA和蛋白表达水平与血清中RBP-4水平无明显相关性(P>0.05).结论 妊娠期糖尿病孕妇出现的皮下脂肪组织中RBP-4 mRNA高表达及血清中RBP-4高水平的变化,可能是妊娠期糖尿病孕妇发生胰岛素抵抗的机制之一.     

Effects of intervention to mild GDM on outcomes

Objective: To evaluate pregnancy outcomes in women with gestational diabetes mellitus (GDM) diagnosed by the IADPSG criteria at 24–28 weeks of gestation but with fasting plasma glucose (FPG) less than 4.4?mmol/L.

Research design and methods: A retrospective study was conducted. Medical records of 25?674 pregnant women attending the Peking University First Hospital (PUFH) were analyzed. Women with FPG value <4.4?mmol/L were segregated into those with and without GDM based on the IADPSG criteria. Pregnancy outcomes in the form of birth weight, neonatal hypoglycemia and cesarean delivery were compared between the two groups.

Results: The incidence of macrosomia between GDM 7.1% (treated 6.9%; untreated 7.2%) was not different from the non GDM group 6.3%, similarly neonatal hypoglycemia 1.9% (treated 2.0%; untreated 1.7%) was were not significantly different from the non GDM group 1.1%. Rate of cesarean delivery in the untreated GDM group 59.7% was significantly higher compared to both with treated GDM (48.4%) and the non GDM group (47.6%).

Conclusions: There is no difference in the incidence of select adverse pregnancy outcomes amongst Chinese women with mild GDM (FPG<4.4?mmol/L) with or without intervention compared to women without GDM.     

磷脂酰肌醇-3激酶的表达及其活性变化与妊娠期糖尿病胰岛素抵抗的关系

目的 研究磷脂酰肌醇-3激酶(phosphatidyl inositol-3 kinase,PI-3K)在妊娠期糖尿病(gestational diabetes mellitus,GDM)患者脂肪组织中的表达及其活性变化,分析其与GDM胰岛素抵抗(insulin resistance,IR)的关系.方法 采用Western印迹法、RT-PCR法分别检测20例GDM孕妇(GDM组)和20例正常妊娠晚期孕妇(正常妊娠组)脂肪组织中PI-3K p85α蛋白质和mRNA的表达,采用ELISA法检测两组孕妇脂肪组织中PI-3K的活性,葡萄糖氧化酶法和放射免疫法检测两组孕妇空腹血糖(fasting plasma glucose,FPG)及空腹胰岛素(fasting insulin,FIN)水平,并采用稳态模型(homeostasis model assessment,HOMA)计算IR指数.结果 (1)PI-3K p85a蛋白的表达GDM组高于正常妊娠组(0.93±0.04和0.71±0.06,P＜0.01).(2)GDM组PI-3K p85emRNA表达高于正常妊娠组(0.83±0.03和0.53±0.07,P＜0.01).(3)GDM组PI-3K的活性为正常妊娠组的30%,明显降低(1.7±0.6和5.2±0.5,P＜0.01)(4)GDM组FPG、FINS、HOMA-IR分别为(5.8±0.2)mmol/L、(14.8±0.2)mmol/L和1.3±0.4,正常晚孕组分别为(4.7±0.3)mmol/L、(11.2±0.3)mmol/L和0.9±0.3,两组间各指标比较均有统计学意义(P＜0.01).PI-3K活性与HOMA-IR呈负相关(r=-0.68,P＜0.01).结论 GDM患者脂肪组织中PI-3K活性降低是其发生胰岛素抵抗的分子机制之一.     

糖化血红蛋白联合空腹血糖检测在妊娠期糖尿病诊断中的应用价值

目的：建立天津市中心妇产科医院（我院）孕妇孕中期糖化血红蛋白（HbA1c）的正常参考区间,并探讨HbA1c联合空腹血糖（FPG）检测在妊娠期糖尿病（GDM）诊断中的应用价值。方法：依据2010年国际妊娠合并糖尿病研究组织（IADPSG）推荐的GDM诊断标准,从2016年5-12月期间在我院行75 g口服葡萄糖耐量试验（OGTT）产前检查的孕24～28周的孕妇中筛查出196例GDM孕妇作为GDM组,以同期健康孕妇320例作为对照组（健康孕妇组）,同时收集其相关的临床资料。采用高效液相色谱法检测HbA1c水平,采用受试者工作特征（ROC）曲线分析HbA1c联合FPG用于筛查GDM的价值。结果：①GDM组的年龄、孕前体质量和孕前体质量指数（BMI）均高于健康孕妇组（P＜0.01）,2组孕妇的孕周和身高比较差异无统计学意义（P＞0.05）;②GDM组HbA1c水平和OGTT各时点血糖水平均高于健康孕妇组,差异有统计学意义（P＜0.01）;③320例健康孕妇HbA1c水平符合正态分布,其孕中期HbA1c水平的正常参考区间（取其第2.5～97.5百分位数）为4.4%～5.8%;④当HbA1c为5.35%时,其预测GDM的敏感度（44.9%）和特异度（77.5%）最高,此时HbA1c诊断GDM的ROC曲线下面积（AUC）为0.665（95%CI：0.617～0.713）;HbA1c（≥5.35%）联合FPG（≥5.1 mmol/L）诊断GDM的AUC为0.933（95%CI：0.909～0.957）。结论：建立了我院孕妇孕中期HbAlc的正常参考区间。HbAlc联合FPG检测简单、方便,有望成为GDM诊断的有力补充。     

Gestational diabetes: an alternative, patient-friendly approach for using the diagnostic 100-g OGTT in high-risk populations

Objective: To simplify the 100-g oral glucose tolerance test (OGTT) for making a diagnosis of gestational diabetes mellitus (GDM). Methods: During a 6-year period, 6,801 pregnant women underwent the 3-h, 100-g OGTT in a high-risk, multiethnic population. All these women had either a positive glucose challenge test/clinical history or were part of a universal screening protocol. The area (AUC) under the receiver-operating characteristic curve was used to compare the performance of the fasting plasma glucose (FPG), 1-h, 2-h and 3-h glucose values for GDM diagnosis. Ideal cut-offs of the best performing glucose value alone and in combination were used to find the best predictor for GDM with minimal loss of sensitivity and specificity. Results: Using the American Diabetes Association criteria, 2,127 (31.3%) women were classified as having GDM. The 2-h value was the best performing (AUC 0.933) glucose value; at an optimal cut-off of ≥8.6 mmol/l, the sensitivity was 83.6% with a specificity of 92.8%. It did not achieve sufficient collective specificity and sensitivity at various thresholds to be useful. However, in combination with FPG (either FPG ≥5.3 mmol/l or 2-h ≥8.6 mmol/l) or (either FPG ≥5.6 mmol/l or 2-h ≥8.6 mmol/l), the sensitivity/specificity were 98.5%/84.7% and 92.5%/89.3%, respectively. Conclusion: An abbreviated 100-g OGTT, using only the FPG and 2-h glucose value, may be a useful alternative in high-risk populations to make a diagnosis of GDM by being cost-effective and patient-friendly.