肝纤维化指标对妊娠期糖尿病患者不良妊娠结局的预测价值_陈玉花.pdf

妇女保健/论著肝纤维化指标对妊娠期糖尿病患者不良妊娠结局的预测价值陈玉花1，王海军21.延安市人民医院妇产科，陕西 延安 716000;2.延安市人民医院内分泌科基金项目:陕西省重点研发计划项目(2019SF193)通信作者:王海军，Email:dd100wwhj 摘要:目的分析肝纤维化指标对妊娠期糖尿病(GDM)患者不良妊娠结局的预测价值。方法选取 2017 年 1 月2021 年 3 月延安市人民医院妇产科收治的 294 例 GDM 患者为研究对象，按妊娠结局分为正常妊娠结局组和不良妊娠结局组。比较两组患者一般临床资料和肝纤维化指标(包括血清透明质酸、层粘连蛋白、型胶原、型前胶原及肝脏硬度)。采用多因素logistic 回归分析法获得 GDM 患者发生不良妊娠结局的危险因素，绘制肝纤维化相关指标预测 GDM 患者不良妊娠结局的 OC 曲线。结果正常妊娠结局组血清透明质酸、层粘连蛋白、型胶原、型前胶原及肝脏硬度分别为(289.534.5)ng/ml、(321.440.2)ng/ml、(103.632.4)ng/ml、(131.536.8)ng/ml 及(6.80.5)Kpa;不良妊娠结局组血清透明质酸、层粘连蛋白、型胶原、型前胶原及肝脏硬度分别为(339.648.9)ng/ml、(373.551.4)ng/ml、(148.442.5)ng/ml、(191.937.4)ng/ml 及(7.60.5)Kpa。不良妊娠结局组患者血清透明质酸、层粘连蛋白、型胶原、型前胶原及肝脏硬度均明显高于正常妊娠结局组，差异均有统计学意义(t=6.237，6.192，5.478，7.426，5.893，均 P0.05)。多因素 logistic 回归分析结果显示:年龄、血清透明质酸、层粘连蛋白、型胶原、型前胶原及肝脏硬度均是 GDM 患者发生不良妊娠结局的危险因素(均 P0.05)。OC 曲线显示:血清透明质酸、层粘连蛋白、型胶原、型前胶原、肝脏硬度以及联合检测对 GDM 患者不良妊娠结局均有一定的预测价值，其中联合检测的预测价值最高，曲线下面积(AUC)为 0.814，灵敏度和特异度分别为85.3%和 78.5%。结论年龄、血清透明质酸、层粘连蛋白、型胶原、型前胶原及肝脏硬度是 GDM 患者不良妊娠结局的危险因素，对 GDM 患者不良妊娠结局具有良好的预测价值。关键词:肝纤维化指标;妊娠期糖尿病;不良妊娠结局中国图书分类号:714.256文献标识码:A文章编号:1001-4411(2023)03-0397-04;doi:10.19829/j.zgfybj.issn.10014411.2023.03.003Predictive value of indicators of hepatic fibrosis for adverse pregnancyoutcome in patients with gestational diabetes mellitusCHEN Yuhua*，WANG Haijun*Department of Gynecology and Obstetrics，Yanan Peoples Hospital，Yanan，Shaanxi 716000，ChinaAbstract:ObjectiveTo analyze the predictive value of indicators of hepatic fibrosis for adverse pregnancy outcome in patients withgestational diabetes mellitus(GDM).MethodsA total of 294 patients with GDM treated in Department of Gynecology and Obstetrics，Yanan Peoples Hospital from January 2017 to March 2021 were selected as study object，then they were divided into normal pregnancy out-come group and adverse pregnancy outcome group according to pregnancy outcome.The general clinical data and indicators of hepatic fibrosis(including serum hyaluronic acid，laminin，type collagen，type procollagen，and liver hardness)in the two groups were com-pared.Multivariate logistic regression model was used to obtain the risk factors of adverse pregnancy outcome of GDM patients，OC curve ofindicators of hepatic fibrosis to predict adverse pregnancy outcome of GDM patients was drawn.esultsSerum hyaluronic acid，laminin，type collagen，type procollagen，and liver hardness in normal pregnancy outcome group were(289.534.5)ng/ml，(321.440.2)ng/ml，(103.632.4)ng/ml，(131.536.8)ng/ml，and(6.80.5)Kpa，respectively;serum hyaluronic acid，laminin，type collagen，type procollagen，and liver hardness in adverse pregnancy outcome group were(339.6 48.9)ng/ml，(373.5 51.4)ng/ml，(148.442.5)ng/ml，(191.937.4)ng/ml，and(7.60.5)Kpa，respectively.Serum hyaluronic acid，laminin，type collagen，type procollagen，and liver hardness in adverse pregnancy outcome group were statistically significantly higher than those in nor-mal pregnancy outcome group(t=6.237，6.192，5.478，7.426，5.893，all P0.05).Multivariate logistic regression analysis showed thatage，serum hyaluronic acid，laminin，type collagen，type procollagen，and liver hardness were risk factors of adverse pregnancy out-come in patients with GDM(all P0.05).OC curve showed that serum hyaluronic acid，laminin，type collagen，type procollagen，liver hardness，and joint detection had certain predictive value for adverse pregnancy outcome in patients with GDM，the value of joint detec-tion was the highest，the area under OC curve(AUC)was 0.814，the sensitivity and specificity were 85.3%and 78.5%，respectivelyConclusionAge，serum hyaluronic acid，laminin，type collagen，type procollagen，and liver hardness are risk factors of adversepregnancy outcome in patients with GDM，which have good predictive value for adverse pregnancy outcome of GDM patients.Keywords:Indicator of hepatic fibrosis;Gestational diabetesmellitus;Adverse pregnancy outcome793中国妇幼保健2023 年 2 月第 38 卷第 3 期Maternal and Child Health Care of China.February 2023，Vol.38，No.3妊娠期糖尿病(GDM)指妇女妊娠期间首次发现的糖耐量异常1。近年来，随着国民经济的发展和人们生活水平的提高，我国 GDM 发病率呈逐年上升的趋势2。目前，GDM 的病因尚未明确，一般认为与妊娠中后期孕妇胰岛素分泌不足、胰岛素抵抗及胰岛素受体缺陷等因素有关34。GDM 患者如不及时诊治，母体长期处于高血糖状态，会明显增加早产、自然流产、死胎、胎儿窘迫、巨大儿、新生儿窒息、新生儿畸形及新生儿高胆红素血症等不良妊娠结局的发生率，严重危害母体与胎儿生命安全56。因此，临床除需要对 GDM 患者进行及时、准确的诊断和监控外，还需了解 GDM 患者发生不良妊娠结局的危险因素，这对于降低不良妊娠结局的发生率也具有非常重要的意义。肝脏是糖代谢的重要器官，肝脏严重受损时会影响正常糖代谢，出现胰岛素抵抗和糖耐量异常，而长期的高血糖状态又能加重肝损伤和促进肝纤维化，机制可能与高血糖致肝星状细胞激活和增殖等有关78。基于此，本研究选择 2017 年 1 月2021 年 3 月延安市人民医院妇产科收治的 294 例GDM 患者为研究对象，通过检测肝纤维化相关指标，并随访记录其不良妊娠结局，探讨肝纤维化指标和GDM 患者发生不良妊娠结局的关系，旨在为降低GDM 患者不良妊娠结局发生率和指导个体精细化治疗提供依据。1资料与方法1.1资料来源选取2017 年1 月2021 年3 月延安市人民医院妇产科收治的 294 例 GDM 患者为研究对象。GDM 的诊断标准采用国际糖尿病和妊娠研究组协会(IADPSG)推荐的方法，即在妊娠 2428 周进行口服葡萄糖耐量试验，如空腹血糖5.1 mmol/L或口服葡萄糖 1 h 后血糖10.0 mmol/L 或口服葡萄糖2 h 后血糖8.5 mmol/L，以上条件满足 1 项即可诊断为 GDM。排除标准:妊娠前存在糖耐量异常或明确诊断为糖尿病;合并严重的自身免疫性疾病或血液系统疾病;合并多囊卵巢综合征;合并恶性肿瘤;长期服用糖皮质激素等可能影响糖代谢的药物;孕 28 周前便终止妊娠或院外分娩。本研究符合医学伦理学要求，经医院伦理委员会批准，患者均知情同意本研究。1.2方法1.2.1研究分组将所有纳入研究的 GDM 患者按妊娠结局分为正常妊娠结局组和不良妊娠结局组。不良妊娠结局指出现早产、自然流产、死胎、胎儿窘迫、巨大儿、低出生体质量儿、新生儿窒息、新生儿畸形、新生儿高胆红素血症及分娩并发症。正常妊娠结局组未出现以上情况。1.2.2临床资料收集收集患者一般临床资料，包括年龄、孕前体质指数、孕期体质指数改变、孕周、糖尿病家族史、自然流产史、孕次、产次、空腹血糖、空