【作者】 周旋；

【导师】 班博；

【作者基本信息】 天津医科大学 ， 内科学 内分泌与代谢病（专业学位）， 2018， 硕士

【摘要】 目的:肥胖是妊娠期糖尿病(Gestational diabetes mellitus,GDM)的独立危险因素,而且在育龄妇女中普遍存在。已有较多研究证实,妊娠期糖尿病和肥胖可导致大于胎龄儿(Large for gestational age,LGA)、早产、肩难产等不良结局,而且孕期营养状态也越来越受重视。已有较多关于孕前体重指数和孕期增重与不良妊娠结局的研究,尤其是子代不良结局的研究,但是针对GDM女性的研究较少。而且2009年美国国家医学科学院(the Institute of Medicine,IOM)推荐了国际上通用的妊娠期妇女体重增加范围。基于上述研究背景,本研究通过对临床病例资料的收集、整理、归纳,试图分析孕前体重指数和孕期增重对妊娠期糖尿病子代不良结局的影响,以指导妊娠期糖尿病女性的体重管理。方法:以2017年1月至2017年8月就诊于济宁医学院附属医院例行产前检查及分娩的妊娠期女性为研究对象,所有妊娠期女性均在孕24-28周进行75g口服葡萄糖耐量试验(oral glucose tolerance test,75gOGTT)。参考美国糖尿病学会(American Diabetes Association,ADA)2011年研究发表的GDM诊断标准:空腹血糖(fasting glucose,FPG)≥5.1 mmol/L,服糖后1小时血糖(1 hour plasma glucose)≥10.0 mmol/L,2小时血糖(2 hour plasma glucose)≥8.5 mmol/L,若其中任1点的血糖值高于正常则可诊断为GDM。经以上糖耐量筛查试验诊断为GDM者1425例。收集年龄、产次、糖化血红蛋白(glycated hemoglobin A1c,HbA1c)、孕前体重、身高、分娩前体重、早产、SGA(Small for gestational age)、LGA、新生儿低血糖、新生儿高胆红素血症等临床资料。排除孕前即诊断为糖尿病或糖耐量异常、双胎、服用影响糖脂代谢药物、死胎、死产、合并慢性疾病等,共纳入GDM孕妇1123例。根据2016年中国超重/肥胖问题医学营养治疗专家共识将孕前体重指数(Bady mass index,BMI)如下分类:规定BMI<18.5体重过低;18.5≤BMI<24.0体重正常;24.0≤BMI<28.0超重;BMI≥28.0视为肥胖。孕期增重(gestational weight gain,GWG)为分娩前体重减孕前体重之差值。根据2009年美国国家医学科学院(IOM)推荐对应的GWG目标为:低体质量孕妇增重范围12.5~18 kg,正常体质量孕妇增重范围11.5~16 kg,超重孕妇增重范围7~11.5 kg,肥胖孕妇增重范围5~9 kg;依此分为增重不足、增重适宜和增重过多三组。分别对孕前BMI、孕期增重及糖化血红蛋白和孕期增重在BMI各组中进行分层分析等研究其对妊娠期糖尿病子代不良结局的影响以分析探讨GDM女性体重的管理。结果:1.GDM子代常见不良结局有早产、LGA、SGA。2.与孕前BMI正常的GDM孕妇相比,孕前超重和肥胖的GDM孕妇容易分娩LGA,危险系数分别为2.07和4.66,肥胖者风险高于超重者。但孕前肥胖的GDM患者分娩SGA的风险较低,危险系数为0.09。3.与孕期增重适宜的GDM孕妇相比,孕期增重过多者分娩LGA的风险高,调整混杂因素后危险系数为2.48;但是孕前增重过多的GDM孕妇发生新生儿早产的风险较低。4.在孕期增重各组中进行分层分析,发现孕期增重过多的GDM孕妇,糖化血红蛋白增高可能增加LGA的发生风险。5.在孕前BMI各组中进行分层分析发现,与正常体重、超重、肥胖的GDM孕妇相比,孕前低体重的GDM孕妇如孕期增重过多则发生LGA的风险较高。结论:GDM孕妇孕前超重、肥胖和孕期增重过多增加LGA的发生风险;孕前低体重的GDM孕妇如孕期增重过多则发生LGA的风险高于孕前体重正常、超重、肥胖的GDM孕妇;而孕期增重过多的GDM孕妇如糖化血红蛋白增高可能增加LGA的发生风险。更多还原

【Abstract】 Objective:Obesity is an independent risk factor for gestational diabetes and is common in women of child-bearing age.Many studies have confirmed that gestational diabetes and obesity can lead to more adverse outcomes than gestational age,premature birth,shoulder dystocia and other adverse outcomes.There have been many studies on pre-pregnancy body mass index,weight gain during pregnancy and adverse pregnancy outcomes,especially on adverse offspring outcomes,but few studies have been conducted on women with GDM.And in 2009,the Institute of Medicine(IOM)recommended an internationally accepted range of weight gain for pregnant women.Based on the above research background,this study based on clinical data collection,sorting,induction,tried to analyze pregnancy body mass index and weight gain during pregnancy on that the influence of adverse outcome of gestational diabetes to guide the weight management of gestational diabetes women.Methods:In January 2017 to August 2017 in jining medical college affiliated hospital routine antenatal examination women during pregnancy and childbirth as the research object,all the women during pregnancy in the 24 to 28 weeks of pregnancy for 75 g oral glucose tolerance test.Refer to the American diabetes association study,published in 2011 GDM diagnosis standard: fasting plasma glucose or greater tendency for 5.1 /L,1 hour after taking sugar glucose or greater tendency for 10.0 / L,2 hours blood glucose or greater tendency for 8.5 / L,if the term 1 point higher than normal blood glucose values can be diagnosed with GDM.The glucose tolerance screening test above diagnosed as GDM in 1425 cases.Collect age,production time,glycosylated hemoglobin(glycated hemoglobin A1 c,HbA1c),pregnancy weight,height,weight,premature birth,SGA before delivery,the LGA,neonatal hypoglycemia,neonatal clinical data,such as the high blood bilirubin.A total of 1123 cases were included in gdm23 cases,including diabetes mellitus or abnormal glucose tolerance,twins,taking drugs affecting glycolipid metabolism,stillbirth,stillbirth and chronic diseases,etc.,before pregnancy.According to the consensus of Chinese medical nutrition experts onoverweight/obesity in 2016,pre-pregnancy body mass index is classified as follows:BMI<18.5 is too low;BMI<24.0 is normal;24.0 or less BMI < 28.0 overweight;A BMI greater than or equal to 28.0 is considered obese.Weight gain during pregnancy is the difference between weight gain before birth and weight loss before pregnancy.According to the 2009 national academy of medical sciences(IOM)recommends corresponding GWG goal is: low body quality of pregnant women gain weight range 12.5 ~ 18 kg,normal body quality of pregnant women from 16 to 11.5kg,overweight pregnant 7 ~ 11.5 kg,obese pregnant women 5 ~ 9 kg;According to this,it was divided into three groups: insufficient weight gain,appropriate weight gain and excessive weight gain.Respectively for BMI,weight gain during pregnancy and glycosylated hemoglobin before childbirth and pregnancy increased emphasis on BMI between groups of hierarchical analysis to study the aderse outcome of gestational diabetes children to analyze the influence of GDM women weight management.Result:1.The common adverse outcomes of GDM offspring were premature birth,LGA and SGA.2.Compared with GDM pregnant women with normal BMI before pregnancy,overweight and obese GDM pregnant women are more likely to give birth to LGA,with risk factors of 2.07 and 4.66,respectively.However,patients with GDM who were obese before pregnancy had a lower risk of SGA delivery,with a risk coefficient of 0.09.3.Compared with GDM pregnant women who gain weight appropriately during pregnancy,those who gain too much weight during pregnancy have a higher risk of giving birth to LGA,and the risk factor after adjusting for confounding factors is 2.48.But women with GDM who gain too much weight before pregnancy have a lower risk of premature birth.4.Stratified analysis was carried out in each group that gained weight during pregnancy,and it was found that the increased glycosylated hemoglobin in GDM pregnant women who gained too much weight during pregnancy may increase therisk of LGA.5.Stratified analysis of BMI in each group before pregnancy revealed that compared with normal weight,overweight and obese GDM pregnant women,low-weight GDM pregnant women before pregnancy had a higher risk of LGA if they gained too much weight during pregnancy.Conclusion:GDM pregnant women who are overweight,obese and overweight before pregnancy and who gain too much weight during pregnancy increase the risk of LGA.The risk of LGA in low weight GDM pregnant women before pregnancy is higher than that in normal weight,overweight and obese GDM pregnant women before pregnancy if they gain too much weight during pregnancy.However,pregnant women with GDM who gain too much weight during pregnancy,such as increased hemoglobin a1 c,may increase the risk of LGA.更多还原