妊娠期尿酮体水平与不同糖代谢孕妇围产期结局的研究分析

A study on urinary ketone levels during pregnancy and perinatal outcomes in pregnant women with different glucose metabolism status

摘要:

目的探究孕妇妊娠中、晚期尿酮体水平对孕妇及胎儿围产期并发症的影响。 方法回顾性分析2022年1月—2023年1月于同济大学附属同济医院妇产科分娩的771例孕妇的临床资料,根据口服葡萄糖耐量试验(oral glucose tolerance test, OGTT)结果将受试人群分为正常血糖孕妇和妊娠期糖尿病(gestational diabetes mellitus, GDM)孕妇。基于尿常规酮体结果将受试人群分为: 尿酮体阴性组(Ket-N组)、尿酮体阳性中度组(Ket-M组)、尿酮体阳性重度组(Ket-S组)。比较不同程度尿酮体水平正常血糖孕妇、GDM孕妇的一般资料、血液指标以及母儿临床结局的差异；用多因素Logistic分析母儿临床结局的影响因素以及有序多元Logistic分析不同尿酮体水平的影响因素。 结果正常血糖孕妇666例(86.38%)，GDM孕妇105例(13.62%)。在正常血糖组的孕妇中，Ket-N组、Ket-M组、Ket-S组占比为53.60%、36.04%、10.36%；在GDM孕妇中，各组占比为31.43%、33.33%、35.24%。正常血糖孕妇中，妊娠中期Ket-N组、Ket-M组、Ket-S组的占比为82.73%、13.21%、4.05%；妊娠晚期各组占比为61.71%、31.23%、7.06%。GDM孕妇中，妊娠中期Ket-N组、Ket-M组、Ket-S组占比为65.71%、22.86%、11.43%；妊娠晚期各组为37.14%、27.62%、35.24%。在正常血糖组的孕妇中，Ket-M组和Ket-S组先兆子痫、初产剖宫产的发生率高于Ket-N组(P<0.05)。Ket-S组新生儿窒息的发生率高于Ket-N组(P<0.05)。GDM组中，Ket-S组转入新生儿科病房的发生率高于Ket-N组和Ket-M组(P<0.05)。孕妇临床结局多因素Logistic回归分析结果显示，初次生产、丙氨酸氨基转移酶(aspartate aminotransferase, ALT)升高是孕妇出现不良临床结局危险性因素(OR值分别为11.912、1.025，P<0.05)。尿酮体水平有序多元Logistic回归分析结果显示，年龄、糖尿病家族史、GDM及孕期胰岛素治疗是孕妇出现高水平酮尿的危险因素(OR值分别为1.042、2.244、1.759、7.729，P<0.05)；年龄是正常血糖孕妇出现高水平酮尿的危险因素(OR=1.048，P<0.05)；孕前体质量指数(body mass index, BMI)、糖尿病家族史是GDM组孕妇出现高水平酮尿的危险因素(OR值分别为1.249、12.557，P<0.05)。 结论孕妇在妊娠中、晚期均易出现酮尿。正常血糖孕妇出现酮尿会增加先兆子痫以及初产剖宫产的风险，其子代发生新生儿窒息的风险升高；GDM孕妇妊娠中、晚期出现酮尿其新生儿转入新生儿科病房的风险升高。孕妇妊娠中、晚期出现不同水平的酮尿可能会增加孕妇及胎儿围产期不良妊娠结局的风险。

Abstract:

ObjectiveTo investigate the effects of urinary ketone level on perinatal complications in pregnant women and fetuses in mid-and late pregnancy. MethodsThe clinical data of a total of 771 pregnant women who delivered in the Obstetrics Department of Tongji Hospital from January 2022 to January 2023 were retrospectively analyzed. The pregnant women were divided into normoglycemic group and gestational diabetes mellitus(GDM) group according to oral glucose tolerance test results. The participants were further divided into three groups according to the urine ketone body test results: urine ketone-negative group: -/+-; moderate urinary ketones group: +/++; severe urinary ketones group: +++/++++. The differences in general characteristics, blood indices, and maternal-neonatal clinical outcomes were compared among normoglycemic pregnant women and GDM pregnant women with varying levels of urinary ketone bodies. Multivariate logistic was used to analyze the influencing factors of pregnancy outcomes of mothers and infants, and the influencing factors of urine ketone levels were analyzed by ordered multivariate logistic analysis. ResultsThere were 666(86.38%) pregnant women with normal blood glucose and 105(13.62%) with GDM in the study population. Among the normoglycemic pregnant women, the proportions of the urine ketone-negative(Ket-N) group, the moderate urinary ketones(Ket-M) group and the severe urinary ketones(Ket-S) group was 53.60%, 36.04% and 10.36% respectively; and it was 31.43%, 33.33% and 35.24% in the pregnant women with GDM, respectively. Among the normoglycemic pregnant women, the proportions of the Ket-S group, the Ket-M group and the Ket-S group was 82.73%、13.21% and 4.05%, respectively, in the second trimester of pregnancy; and it was 61.71%, 31.23% and 7.06%, respectively, in the third trimester. Among the pregnant women with GDM, the proportions of the Ket-N group, the Ket-M group and the Ket-S group was 65.71%, 22.86% and 11.43%, respectively, in the second trimester of pregnancy; and it was 37.14%, 27.62% and 35.24% respectively, in the third trimester. Among the normoglycemic pregnant women, the incidences of pre-eclampsia and primary caesarean section in the urine ketone positive group were both higher than those in the urine ketone negative group(both P<0.05). The incidence of neonatal asphyxia in the Ket-S group was higher than that in the Ket-N group(P<0.05). In the GDM group, the Ket-S group was transferred to the neonatal ward at a higher rate than the Ket-N group and the Ket-M group(P<0.05). The results of multivariate Logistic regression analysis of clinic outcomes in pregnant women showed that the initial birth and the elevating alanine aminotransferase(ALT) were risk factors for adverse clinic outcomes(OR=11.912，1.025, both P<0.05). The results of ordered multivariate Logistic regression analysis of urine ketone levels showed that age, family history of diabetes, GDM, and insulin therapy during pregnancy were risk factors for high levels of ketonuria in pregnant women(OR=1.042, 2.244, 1.759, 7.729, all P<0.05). Age was a risk factor for high levels of ketonuria in normoglycemic pregnant women(OR=1.048, P<0.05). Pre-pregnancy body mass index(BMI) and family history of diabetes were risk factors for high levels of ketonuria in pregnant women with GDM(OR=1.249, 12.557, both P<0.05). ConclusionPregnant women are prone to develop ketonuria in the second and third trimesters. The presence of ketonuria in normoglycemic pregnant women increases the risk of preeclampsia, primary cesarean delivery and neonatal asphyxia. GDM women with ketonuria in the second and third trimesters have an increased risk of neonates being admitted to the neonatal ward. In conclusion, the presence of different levels of ketonuria in the second and third trimesters of pregnancy may increase the risk of adverse perinatal pregnancy outcomes for both pregnant women and fetuses.