【作者】 张薇；

【导师】 陈丹青；

【作者基本信息】 浙江大学 ， 妇产科学， 2009， 硕士

【摘要】 妊娠期糖尿病(gestational diabetes mellitus,GDM)是指妊娠期间首次发生或发现的糖代谢异常,是一种常见的妊娠合并症,发病率为5%-6%,严重威胁着母婴健康。近年来,随着生活水平的提高,其发病率有逐年升高的趋势。多数GDM患者分娩后血糖逐可渐恢复正常,但长期随访观察也发现,GDM患者会成为2型糖尿病的高危人群,甚至有学者认为GDM是2型糖尿病的早期阶段,会改变子宫内代谢环境,近期可致围产儿的发病率和死亡率显著高于普通人群,远期可影响智力发育,增加青春期肥胖等疾病的发病率,因而日益引起人们的关注。妊娠可使隐性糖尿病显性化,使无糖尿病者发生GDM,使原有糖尿病患者病情加重,由于妊娠期糖代谢的复杂变化,如不能及时调整胰岛素用量,部分患者可能会出现低血糖,严重者甚至导致饥饿性酮症酸中毒、低血糖性昏迷等,妊娠合并糖尿病对母儿有严重的影响,影响程度与病情及血糖控制情况密切相关,对孕妇的影响主要表现在:孕早期自然流产发病率增加,达15%-30%,多见于血糖未及时控制患者,高血糖可使胚胎发育异常甚至死亡;易并发子痫前期,为正常孕妇的3-5倍,伴有血管广泛病变的糖尿病孕妇,多有小血管内皮细胞增厚及管腔变窄,组织血供不足,尤其糖尿病孕妇并发肾血管病变时,子痫前期发生率高达50%以上,糖尿病一旦并发子痫前期,病情及其复杂,临床较难控制,对母儿极不利;糖尿病孕妇抵抗力下降,易合并,以泌尿系统感染最为常见;羊水过多的发病率较非糖尿病孕妇多10倍,其发生与畸形无关,可能与胎儿高血糖、高渗性利尿致胎儿尿量增多有关;巨大儿明显增多,难产、产道损伤、手术产几率增高;易发生糖尿病酮症酸中毒。对胎儿的影响主要表现在:巨大胎儿的发生率高达25%-40%;胎儿宫内发育迟缓发生率为21%,见于严重糖尿病伴有血管病变时;早产发生率为10%-25%;胎儿畸形率为6%-8%,高于非糖尿病孕妇。对新生儿的影响主要表现在:新生儿呼吸窘迫综合征发生率增加,孕妇高血糖持续经胎盘达到胎儿体内,刺激胎儿胰岛素分泌增加,形成高胰岛素血症,后者具有拮抗糖皮质激素促进肺泡Ⅱ型细胞表面活性物质合成及释放的作用,使胎儿肺表面活性物质产生及分泌减少,胎儿肺成熟延迟;新生儿低血糖,新生儿脱离母体高血糖环境后,高胰岛素血症仍存在,若不及时不从糖,易发生低血糖,严重时未及新生儿生命。研究表明肥胖是妊娠期糖尿病发病的高危因素之一,亦有文章报道妊娠前肥胖及妊娠期体重增加过多会对妊娠结局产生不良影响。但对于GDM孕妇的妊娠前体重指数,以及妊娠期体重增长情况与围产结局的关系探讨较少。研究目的分析妊娠期糖尿病(GDM)孕妇妊娠前体重指数(BMI)及妊娠期体重指数增幅与围产结局的关系。研究方法选择2006年1月至2007年12月间在浙江大学医学院附属妇产科医院产科门诊行常规检查并确诊为GDM的238例患者,按妊娠前体重指数分为正常组(18.5≤BMI＜23)、超重组(23≤BMI＜25)、肥胖组(BMI≥25),按早孕至终止妊娠前BMI的总增幅,分为A组(BMI总增幅＜4),B组(4≤BMI总增幅≤6),C组(BMI总增幅＞6),比较分析各组间围产结局的差异。研究结果1、肥胖组子痫前期、早产发生率均(26.0%,32.7%)显著高于正常组(11.9%,8.3%)及超重组(10.8%,3.7%),差异均有统计学意义(P＜0.05)。2、3组孕妇羊水过多和胎膜早破发生率差异均无统计学意义。正常组孕妇胎儿窘迫发生率(8.3%)显著低于超重组(23.5%)和肥胖组(23.1%),差异有统计学意义(p＜0.05),而超重组与肥胖组相比差异无统计学意义。3、B组子痫前期(10.4%)、羊水过多(10.4%)、胎膜早破(10.4%)、胎儿窘迫(11.3%)和早产(8.0%)的发生率均明显低于C组(22.2%,23.8%,25.3%,30.2%,30.2%)差异均有统计学意义(P均＜0.05),但与A组相比差异均无统计学意义。C组除胎膜早破发生率明显高于A组外,其余各并发症发生率与A组相比,差异均无统计学意义。4、C组巨大儿的发生率(25.4%)明显高于A组(6.0%)和B组(12.0%),差异均有统计学意义(P均＜0.05)。C组新生儿低血糖的发生率(28.6%)明显高于B组(16.0%),差异有统计学意义(P＜0.05),但与A组相比,差异无统计学意义。3组新生儿窒息、高胆红素血症和湿肺发生率差异均无统计学意义。结论妊娠前肥胖及妊娠期体重增加过多可增加GDM孕妇发生不良妊娠结局的危险性,GDM孕妇妊娠期体重指数总增幅应控制在合适的范围内以减少不良妊娠结局的发生。更多还原

【Abstract】 Gestational diabetes mellitus(GDM) is defined as carbohydrate intolerance of variable severity with onset or first recognition during pregnancy.It’s a common complication of pregnancy,the morbidity is 5%-6%and is increasing recently.The level of blood glucose of most gestational diabetes patients will restore normal,but some long term follow-up research finding gestational diabetes patients will become high-risk group of type-2 diabetes mellitus.Some scholars even think GDM is early stages of type 2 diabetes,it will change the metabolism of intra-uterine environment and cause the recently perinatal morbidity and mortality significantly higher than the general population,also affect the mental development in long-term,and increase the morbidity of adolescent obesity.So more and more scholars begin to pay attention to this disease.Pregnancy is associated with increased tissue resistance to insulin,resulting in increased levels of blood insulin as well as glucose and triglycerides.Gestational diabetes has a serious impact on mother and fetus,the major impact on pregnant women including:Increasing the incidence of spontaneous abortion at early pregnancy, especially in patients with bad blood glucose control;Increasing the morbidity of pre-eclampsia.In particular,pregnant women complicated with diabetic renal vascular lesions,the incidence of pre-eclampsia will up to more than 50%;The rates of infection, polyhydramnios,macrosomia,DKA are higher than that in normal pregnant women. The major impact on fetus including:Increasing the incidence of neonatal respiratory distress syndrome and neonatal hypoglycemia.Study shows that obesity is one of the high risk factors of gestational diabetes. Articles also reported that pro-pregnancy obesity and excessive weight gain during pregnancy will have a negative impact on pregnancy outcome.In this study,we want to estimate the effect of matemal pre-pregnancy body mass index(BMI) and BMI gain during pregnancy on obstetric outcomes of gestational diabetes mellitus(GDM) women.MethodsThis study is a register-based prospective cohort study.238 pregnant women diagnosed with GDM at our institution between 2006 and 2007 were enrolled,all the women were instructed in the use of diet therapy to achieved targeted levels of glycemic control.Perinatal outcomes were observed and analyzed according to maternal prepregnancy body mass index(BMI,kg/m~2) categories(normal weight group, overweight group,obese group) and BMI gain during pregnancy categories:A group(BMI gain＜4),B group(4≤BMI gain≤6),C group(BMI gain＞6).Results1、The rates of preeclampsia and preterm delivery in obese group(26.0%,32.7%) were significantly higher than that in normal weight group(11.9%,8.3%) and obese group (10.8%,3.7%)(P＜0.05).2、There was no significant differences about polyhydramnios and premature rupture of membrane in three groups(P＞0.05).The normal weight group have less fetus distress(8.3%)than overweight group(23.5%)and obese group(23.1%)(P＜0.05).3、In B group,there was significantly more preeclampsia(10.4%),polyhydramnios (10.4%),premature rupture of membrane(10.4%),fetus distress(11.3%), preterm delivery(8.0%) compared with the C group(22.2%,23.8%,25.3%, 30.2%,30.2%).4、The rates of fetal macrosomia in C group(25.4%) were higher than that in A (6.0%) and B group(12.0%)(P<0.05).The newborn of C group(28.6%) have more hypoglycemia than B group(16.0%)(P<0.05).Among the A,B and C groups, the rates of neonatal distress,jaundice and wet lung had no statistical differences (P>0.05).ConclusionThe obese GDM women with BMI≥25 and BMI gain>6 during pregnancy would have higher risk of adverse prenatal outcome such as preterm delivery,preeclampsia and fetus distress.The BMI gain during pregnancy of GDM women should be suitably controlled,then the prenatal outcome would be enhanced.更多还原