| Abstract | Gestacijski dijabetes melitus najčešći je metabolički poremećaj u trudnoći. Trudnoće komplicirane gestacijskim dijabetesom imaju lošije ishode u odnosu na trudnoće s normalnom tolerancijom glukoze. Žene koje su bolovale od GDM-a i njihova djeca imaju kasnije u životu povišeni rizik razvoja dijabetesa melitusa, arterijske hipertenzije, dislipidemije, pretilosti i metaboličkog sindroma. Ciljevi studije bili su odrediti pojavnost GDM-a prema IADPSG kriterijima, usporediti ishode trudnoća opterećenih s GDM-om s obzirom na WHO (1999.) i IADPSG dijagnostičke kriterije te odrediti stupanj inzulinske rezistencije u skupini trudnica s GDM-om prema IADPSG kriterijima i njihovoj novorođenčadi.
ISPITANICE I METODE: Istraživanje je podijeljeno u retrospektivni i prospektivni dio te je provedeno u Klinici za ženske bolesti i porode KBC-a Zagreb. U retrospektivnom dijelu obuhvaćeno je 2 405 trudnica koje su rodile u razdoblju od 2009. do 2010. godine. Na temelju rezultata oGTT-a trudnice su podijeljene u 4 skupine: prva skupina trudnica s GDM-om po WHO kriterijima; druga skupina trudnica s normalnom tolerancijom glukoze prema WHO kriterijima, a koje su prema IADPSG kriterijima imale GDM; treća skupina trudnica s GDM-om po WHO i IADPSG kriterijima (preklapajuća skupina) i četvrta skupina trudnica s normalnom tolerancijom glukoze prema oba kriterija. Prospektivni dio istraživanja proveden je tijekom 2011. godine na uzorku od 120 trudnica. Prva skupina od 60 trudnica s koncentracijom glukoze natašte 5,1 - 6,9 mmol/L (GDM) i druga skupina od 60 trudnica s normalnom tolerancijom glukoze. Analizirani su opći podaci trudnica i novorođenčadi te primarni ishodi trudnoća (fetalna makrosomija i hipertrofija, trudnoće dovršene carskim rezom) i sekundarni ishodi trudnoća (hipertenzivni poremećaji u trudnoći, fetalna hipotrofija i prijevremeni porod). U prospektivnom dijelu analizirane su koncentracije glukoze i C-peptida iz krvi majke i umbilikalne krvi te je određena inzulinska rezistencija. REZULTATI: Utvrdili smo statistički značajno veću pojavnost GDM-a prema IADPSG kriterijima u odnosu na WHO kriterije (6,2% vs. 21,7%; Χ² = 361; p < 0,001). Trudnice s hiperglikemijskim poremećajem u trudnoći imale su lošije ishode trudnoća u odnosu na trudnice s normalnom tolerancijom glukoze. Zabilježene su statistički značajne razlike u demografskim podacima trudnica po ispitivanim skupinama. Ukupni udio prekomjerno teških i pretilih trudnica bio je najviši u skupini trudnica koje su imale GDM po IADPSG kriterijima (44%) (skupina 2). Navedene trudnice imale su statistički značajno višu stopu fetalne makrosomije (23,2%), hipertrofične djece (25,1%), rađale su u prosjeku najtežu djecu, najvišeg ponderalnog indeksa. Stopa carskih rezova je u navedenoj skupini trudnica bila statistički značajno viša u odnosu na trudnice s normalnom tolerancijom glukoze (20,0% vs. 13,8%, p < 0,001). Trudnice s GDM-om iz prospektivnog dijela istraživanja, a koje su liječene dijabetičkom dijetom, češće su rađale makrosomnu i hipertrofičnu djecu, trudnoće su češće dovršavane carskim rezom. Razlike su u odnosu na skupinu trudnica s normalnom tolerancijom glukoze bile statistički značajne (p = 0,043). Inzulinska rezistencija novorođenčadi majki s gestacijskim dijabetesom značajno je bila viša u odnosu na novorođenčad majki s normalnom tolerancijom glukoze (p < 0,001). Porastom indeksa tjelesne mase raste stopa nepovoljnih ishoda trudnoća. Udio kronične hipertenzije (3%), gestacijske hipertenzije (18,8%), carskog reza (31%), fetalne makrosomije (24,4%) i fetalne hipertrofije (28%) bio je najviši u pretilih trudnica u odnosu na trudnice normalne tjelesne težine (p < 0,001). Udio hipotrofične djece (10,9%) i prijevremenog poroda (6,5%) bio je najviši u pothranjenih trudnica. Nađena je statistički značajna pozitivna korelacija između tjelesne težine trudnica na početku trudnoće i novorođenačke težine.
ZAKLJUČAK: Zbog snižene granične vrijednosti koncentracije glukoze natašte, IADPSG kriterijima otkrivamo veći broj trudnica s hiperglikemijskim poremećajem u trudnoći. U trudnica koje po WHO kriterijima imaju normalnu toleranciju glukoze, a po IADPSG kriterijima imaju GDM, zabilježeni su lošiji ishodi trudnoća. Niže vrijednosti glikemije, od one definirane za dijabetes u trudnoći, povezane su s nepovoljnim ishodima trudnoća. Hiperglikemijski poremećaji u trudnoći usko su vezani uz problem pretilosti. Pretile žene bi trebalo educirati i liječiti znatno prije trudnoće i na taj način umanjiti rizik nepovoljnih ishoda trudnoća. Važan naglasak trebao bi biti na mjerama prevencije pretilosti. |
| Abstract (english) | Gestational diabetes mellitus is the most common metabolic disorder in pregnancy. Pregnancies with gestational diabetes have worse outcomes compared to pregnancies with normal glucose tolerance. The objectives of the study were to determine the incidence of GDM according to the IADPSG criteria, to compare the outcomes of pregnancies with GDM based on the WHO (1999) and IADPSG diagnostic criteria and to determine the degree of insulin resistance in a group of pregnant women with GDM according to the IADPSG criteria and their newborns.
PATIENTS AND METHODS: The study is divided into retrospective and prospective part. A retrospective part included 2 405 pregnant women who delivered in the Department of Obstetrics and Gynecology Clinical Hospital Centre Zagreb in the period from 2009 to 2010.
Based on the results of the oGTT pregnant women were divided into four groups: the first group of pregnant women with gestational diabetes according to the WHO criteria; the second group of pregnant women with normal glucose tolerance according to the WHO criteria, but according to the IADPSG criteria with gestational diabetes; the third group of pregnant women with overlapping results and the fourth group of pregnant women with normal glucose tolerance according to the both criteria. A prospective part of the study analyzed 120 pregnant women divided according to the results of oGTT in the two groups. The first group included 60 pregnant women with GDM according to the IADPSG criteria (fasting plasma glucose 5,1 - 6,9 mmol/L) and the second group included 60 pregnant women with normal glucose tolerance. We analyzed demographic data of pregnant women and their newborns, primary outcomes (LGA, macrosomia, cesarean section) and secondary outcomes (hypertensive disordes, preterm delivery, SGA). Prospectively we analyzed concentration of plasma glucose and C-peptide in maternal and umbilical blood samples. RESULTS: We found significantly higher prevalence of GDM according to the IADPSG criteria compared to the WHO criteria (6.2% vs. 21.7%; Χ² = 361; p < 0.001). Pregnant women with hyperglycemic disorders in pregnancy had worse pregnancy outcomes compared to pregnant women with normal glucose tolerance. The overall proportion of overweight and obese pregnant women was the highest in the group of untreated pregnant women with GDM according to the IADPSG criteria (44%) (group 2). In this group we found significantly higer rate of fetal macrosomia (23,2%) and LGA (25,1%). The rate of caesarean section was significantly higher in comparison to healthy controls (20.0% vs. 13.8%, p < 0,001). Prospectively, in a group of pregnant women with GDM according to the IADPSG criteria, who were treated, we found higher rate of macrosomia, LGA and cesarean section. The differencies were statistically significant (p = 0,043). The newborns of diabetic pregnant women had higher insulin resistance compared to the newborns of pregnant women with normal glucose tolerance (p < 0,001). Increased body mass index is associated with adverse pregnancy outcomes. The rate of chronic hypertension (3%), gestational hypertension (18,8%), cesarean section (31%), fetal macrosomia (24,4%) and LGA (28%) was significantly higher in obese pregnant women compared tonpregnant women with normal body weight (p < 0,001). The rate of preterm delivery (6,5%) and SGA (10,9%) was higher in underweight pregnant women.
CONCLUSION: IADPSG diagnostic criteria for GDM reveals more women with hyperglycemic disorders in pregnancy. A group of pregnant women who were normoglycemic according to the WHO criteria, but according to the IADPSG were diagnosed GDM, had adverse pregnancy outcomes. Lower values of glycemia, than those defined for diabetes in pregnancy, are associated with adverse pregnancy outcomes. Hyperglycemic disorders in pregnancy are closely related to obesity. Obese women should be educated and treated well before the pregnancy to reduce the risk of adverse pregnancy outcomes. The important focus should be on the prevention of obesity. |
