妊娠合并糖代谢异常孕妇的妊娠结局分析

目的 探讨妊娠合并糖代谢异常孕妇的发生率变化趋势及经规范治疗后的不同类型糖代谢异常的母、儿结局。方法 1995年1月至2004年12月,在北京大学第一医院妇产科分娩的妊娠合并糖代谢异常患者共1490例,按照糖代谢异常情况分为糖尿病合并妊娠79例（DM组）,妊娠期糖尿病777例（GDM组,其中A1型355例,A2型316例,分型不明106例）,妊娠期糖耐量异常634例（GIGT组）。采用回顾性分析的方法对3组的母、儿结局进行分析,并对糖代谢异常孕妇的发生率进行统计。同期分娩的19013例糖代谢正常孕妇作为对照组。结果 （1）妊娠合并糖代谢异常的总发生率为7．3％,呈逐年上升的趋势。第一阶段即1995年1月至1999年12月,发生率呈缓慢增长,平均为4．3％（376／8739）;第二阶段即2000年1月至2001年12月,发生率呈快速增长趋势,平均为10．8％（445／4133）;第三阶段为2002年1月至2004年12月,基本稳定于8．9％（678／7640）。（2）3组糖代谢异常孕妇总的巨大胎儿、子痫前期、早产的发生率分别为12．1％（180／1490）、9．5％（141／1490）和9．4％（140／1490）,均明显高于对照组孕妇（P〈0．01）。3组糖代谢异常孕妇子痫前期、早产、宫内感染、羊水过多、酮症的发生率相互比较,差异有统计学意义（P〈0．05）,而3组的巨大儿发生率比较,差异无统计学意义（P〉0．05）。（3）3组糖代谢异常孕妇围产儿总死亡率为1．19％（18／1513）,其中,DM组为4．93％（4／81）,显著高于GDM组的1．14％（9／787）和GIGT组的0．78％（5／645）（P〈0．05）。而且,DM组新生儿窒息、低血糖及转诊的发生率均高于GDM组和GIGT组（P〈0．01）。（4）3组1505例新生儿中仅有0．6％（9／1505）发生呼吸窘迫综合征（RDS）,均发生于早产儿。结论 （1）妊娠合并糖代谢异常的发生率逐年上升,应重视提高对孕期糖尿病的筛查、诊断和处理。（2）经过孕期规范化管理,巨大儿、子痫前期和早产仍是糖代谢异常孕妇最常见的并发症,DM孕妇的母、儿合并症显著高于GDM和GIGT孕妇,今后应进一步加强该类型糖尿病孕妇管理。（3）新生儿RDS已不再是新生儿的主要合并症。

Maternal and fetal outcomes in pregnant women with abnormal glucose metabolism

OBJECTIVE: To understand the incidence of abnormal glucose metabolism during pregnancy and the maternal and neonatal outcomes after standard management. METHODS: A retrospective study of maternal and neonatal outcomes was conducted in 1490 pregnant women who were diagnosed and treated for abnormal glucose metabolism and delivered in the Department of Obstetrics and Gynecology of First Hospital of Peking University from Jan 1995 to Dec 2004 by reviewing the medical records. The selected cases consisted of 79 women with diabetes mellitus (DM group), 777 with gestational diabetes mellitus (GDM group), including 355 cases of A1, 316 with A2 and 106 cases unclassified, and 634 with gestational impaired glucose test (GIGT group). Maternal and fetal outcomes were analysed in comparison with the controls of 19 013 pregnant women with normal glucose metabolism who delivered during the same period. RESULTS: (1) The total incidence of gestational abnormal glucose metabolism was 7.3% and increased gradually from 1995 to 2004. The first stage, from Jan 1995 to Dec 1999, saw a slow increase in the incidence 4.3% (376/8739)]; the second stage, from Jan 2000 to Dec 2001, showed a fast increasing trend. The average incidence was 10.8% (445/4133). The incidence in the third stage kept stable at 8.9% (678/7640) from Jan 2002 to Dec 2004. (2) The incidence of macrosomia, preeclampsia and preterm birth were 12.1% (180/1490), 9.5% (141/1490) and 9.4% (140/1490), which were significantly higher than those women with normal glucose metabolism (P < 0.01). A significant difference was found in the incidence of preeclampsia, preterm birth, intrauterine infection, polyhydramnios and ketonuria among the three groups (P < 0.05), but not in the incidence of macrosomia (P > 0.05). (3) The perinatal mortality rate (PMR) of abnormal glucose metabolism group was 1.19% (18/1513) which was significantly higher in the DM group (4.93%) than GDM (1.14%) and GIGT groups (0.78%, P < 0.01), while the incidence of neonatal asphyxia, hypoglycemia, malformation and admission to NICU in the DM group were all higher than GDM and GIGT groups (P < 0.01). (4) NRDS was found in 9 cases among 1505 neonates (0.6%) and all were delivered preterm. CONCLUSIONS: (1) The incidence of gestational abnormal glucose metabolism is increasing and the screening and diagnosis of diabetes in pregnancy should be strengthened. (2) Macrosomia, preeclampsia and preterm birth remain the first three common complications even after standardized glycemic management, but the maternal and neonatal complications are reduced in the GIGT group except for macrosomia. Those women in the DM group has a higher rate of maternal and neonatal complications than those in GDM and GIGT groups, so management in these patients should be strengthened. (3) NRDS is no longer a primary neonatal complication provided proper management is performed.