妊娠期糖尿病合并慢性高血压孕妇胰岛素抵抗水平及其对妊娠结局的影响

目的探讨妊娠期糖尿病(gestational diabetes mellitus,GDM)合并慢性高血压(chronic hypertension,CHT)孕妇的胰岛素抵抗(insulin resistance,IR)水平及其对妊娠结局的影响。方法本研究为回顾性病例对照研究。纳入2014年1月1日至2016年12月31日在北京大学第一医院规律产前检查并参加GDM一日门诊的单胎妊娠GDM孕妇2457例。回顾临床资料,采用稳态模型评估IR水平(homeostasis model assessment insulin resistance,HOMA-IR)。根据GDM孕妇是否合并CHT分为GDM合并CHT组(n=47)和GDM未合并CHT组(n=2410),并进一步根据孕前体重指数(body mass index,BMI)分为孕前BMI正常组(n=1590)及孕前超重和肥胖组(n=863)进行分层分析。采用两独立样本t检验、χ2检验分析组间孕妇年龄、HOMA-IR、孕前BMI、孕期增重、血糖等临床特征的差异。采用logistic回归模型分析HOMR-IR水平对妊娠结局的影响。结果合并CHT的GDM孕妇HOMA-IR(3.5±1.8与2.6±1.5,t=-3.290)、空腹血浆葡萄糖(5.4±0.5)与(5.2±0.5)mmol/L,t=-3.005]、孕前BMI(26.7±4.7)与(23.3±3.4)kg/m2,t=-4.842]以及发生子痫前期的比例14.9%(7/47)与2.5%(61/2410),χ2=21.790]高于未合并CHT的GDM孕妇,但孕期增重少于未合并CHT者(9.6±5.8)与(12.2±4.7)kg,t=3.790](P值均<0.01)。根据孕前BMI分层后,超重和肥胖孕妇中,GDM合并CHT组子痫前期的比例高于GDM未合并CHT组15.2%(5/33)与4.2%(35/830),χ2=6.290,P=0.012],但HOMA-IR差异无统计学意义(P>0.05);而对于孕前BMI正常的孕妇,GDM合并CHT组HOMA-IR(3.0±1.5与2.3±1.2,t=-2.217)、空腹血浆葡萄糖(5.4±0.5)与(5.1±0.5)mmol/L,t=-2.299]和子痫前期的比例2/14与1.6%(26/1576),χ2=6.545]均高于未合并CHT组(P值均<0.05)。对于GDM合并CHT孕妇,HOMA-IR水平不会增加剖宫产、早产、大于胎龄儿、小于胎龄儿和巨大儿的发生风险(P值均>0.05)。控制年龄、空腹血浆葡萄糖、孕前BMI、孕期增重后,对于未合并CHT的GDM孕妇,HOMA-IR水平的增加会使早产的发生风险增加(OR=1.223,95%CI:1.093~1.369,P<0.001)。结论GDM合并CHT孕妇胰岛素抵抗程度更重,子痫前期的发病率更高,但其他不良妊娠结局的发生风险未见增加。

Insulin resistance and pregnancy outcomes in gestational diabetes mellitus gravida complicated by chronic hypertension

Objective To analyze insulin resistance(IR)level and pregnancy outcomes in women with gestational diabetes mellitus(GDM)complicated by chronic hypertension(CHT).Methods This is a retrospective case-control study involving 2457 singleton pregnant women complicated by GDM who received regular prenatal examinations and participated in the one-day-care clinic of GDM in Peking University First Hospital from January 1,2014 to December 31,2016.Clinical data were collected and homeostasis model assessment insulin resistance(HOMA-IR)was calculated.All subjects were divided into two groups:GDM with CHT group(CHT group,n=47)and GDM without CHT group(non-CHT group,n=2410).Based on their pre-pregnancy body mass index(BMI),they were also grouped into normal pre-pregnancy BMI group(n=1590)and overweight and obese group(n=863).Two-sample independent t test and Chi-square test were used to compared the age,HOMA-IR,pre-pregnancy BMI,weight gain during pregnancy and glucose levels between groups,and logistic regression model was used to analyze the effects of HOMA-IR on pregnancy outcomes.Results HOMA-IR(3.5±1.8 vs 2.6±1.5,t=-3.290),fasting plasma glucose(5.4±0.5)vs(5.2±0.5)mmol/L,t=-3.005],pre-pregnancy BMI(26.7±4.7)vs(23.3±3.4)kg/m2,t=-4.842]and the incidence of preeclampsia14.9%(7/47)vs 2.5%(61/2410),χ2=21.790]were significantly higher in GDM women with CHT than those without(all P<0.01).The weight gain during pregnancy was less(9.6±5.8)vs(12.2±4.7)kg,t=3.790,P<0.001].The incidence of preeclampsia was higher in GDM with CHT group than the non-CHT group15.2%(5/33)vs 4.2%(35/830),χ2=6.290,P=0.012]among overweight and obese pregnant women,but no significant difference in HOMA-IR was shown(P>0.05).For pregnant women with normal pre-pregnancy BMI,HOMA-IR(3.0±1.5 vs 2.3±1.2,t=-2.217),fasting plasma glucose(5.4±0.5)vs(5.1±0.5)mmol/L,t=-2.299]and the incidence of preeclampsia2/14 vs 1.6%(26/1576),χ2=6.545]were higher in the CHT group than the non-CHT group(all P<0.05).HOMA-IR did not significantly increase the risk of caesarean section,premature birth,large for gestational age,small for gestational age or macrosomia in the CHT group(all P>0.05).After adjusting for age,fasting plasma glucose,pre-pregnancy BMI and weight gain during pregnancy,the elevated HOMA-IR level increased the risk of preterm birth(OR=1.223,95%CI:1.093-1.369,P<0.001)in GDM women without CHT.Conclusions GDM gravida complicated by CHT have severe insulin resistance and a higher incidence of preeclampsia,but the risk of other pregnancy outcomes are not increased.