妊娠期脂质耐量试验在妊娠期糖尿病风险预测中的价值

doi:10.3969/j.issn.1674-8115.2021.02.013

上海交通大学学报(医学版) ›› 2021, Vol. 41 ›› Issue (2): 210-216.doi: 10.3969/j.issn.1674-8115.2021.02.013

妊娠期脂质耐量试验在妊娠期糖尿病风险预测中的价值

刘庆¹(), 蔡雯², 张瑞晴², 卢聪², 张佳荣²^,³(), 徐先明²

^1.同济大学附属第一妇婴保健院妇产科，上海 201204
^2.上海交通大学附属第一人民医院妇产科，上海 201600
^3.复旦大学附属中山医院妇产科，上海 200032

收稿日期:2020-05-18 出版日期:2021-02-28 发布日期:2021-02-28
通讯作者: 张佳荣 E-mail:18101917515@163.com;maggie1974@126.com
作者简介:刘庆（1993—），女，住院医师，硕士；电子信箱：18101917515@163.com。
基金资助:
上海市教育委员会高峰高原学科建设计划(20172020)

Value of pregnancy lipid tolerance test in predicting risk of gestational diabetes mellitus

Qing LIU¹(), Wen CAI², Rui-qing ZHANG², Cong LU², Jia-rong ZHANG²^,³(), Xian-ming XU²

^1.Department of Obstetrics and Gynecology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai 201204, China
^2.Department of Obstetrics and Gynecology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai 201600, China
^3.Department of Obstetrics and Gynecology, Zhongshan Hospital, Fudan University, Shanghai 200032, China

Received:2020-05-18 Online:2021-02-28 Published:2021-02-28
Contact: Jia-rong ZHANG E-mail:18101917515@163.com;maggie1974@126.com
Supported by:
Shanghai Municipal Education Commission—Gaofeng Clinical Medicine Grant Support(20172020)

摘要/Abstract

摘要：

目的·探讨妊娠期口服脂质耐量试验（oral lipid tolerance test，OLTT）在妊娠期糖尿病（gestational diabetes mellitus，GDM）风险预测中的价值。方法·2019年5月—2019年12月在上海交通大学附属第一人民医院南院招募孕妇71例，于孕14~20周行OLTT，即于空腹和脂餐后（2、4 h）抽取静脉血，分别检测三酰甘油（triacylglycerol，TAG）、游离脂肪酸（free fat acid，FFA）、小而密低密度脂蛋白（small dense low density lipoprotein，sd-LDL）。根据口服葡萄糖耐量试验（oral glucose tolerance test ，OGTT）结果分为GDM组（n=22）和对照组（n=49），组间比较年龄等一般指标，以及空腹和脂餐后（2、4 h）的TAG、FFA、sd-LDL水平。根据OLTT中空腹和脂餐后（2、4 h）的TAG、FFA、sd-LDL中位数分别分组，比较各组间OGTT血糖（包括空腹血糖、1 h血糖、2 h血糖）、稳态模型胰岛素抵抗指数（homeostatic model assessment for insulin resistance，HOMA-IR）的差异，比较各组GDM发生率。绘制受试者工作特征曲线（receiver operator characteristic curve，ROC曲线），比较各指标对GDM的曲线下面积（area under curve，AUC）。结果·GDM组与对照组的年龄等一般指标比较，差异无统计学意义（P>0.05）。GDM组的空腹和脂餐后（2、4 h）TAG、sd-LDL以及脂餐后4 h FFA均显著高于对照组，差异有统计学意义（均P<0.05）；而空腹和脂餐后2 h FFA的组间差异无统计学意义（均P>0.05）。空腹高TAG组空腹血糖水平显著高于空腹低TAG组，差异有统计学意义（P<0.05）；而1、2 h血糖值的差异无统计学意义（均P>0.05）。脂餐后2 h高TAG组空腹、1 h血糖值显著高于脂餐后2 h低TAG组，差异有统计学意义（均P<0.05）。脂餐后4 h高TAG组的OGTT空腹、1 h血糖值显著高于脂餐后4 h低TAG组，差异有统计学意义（均P<0.05）。空腹和脂餐后（2、4 h）高TAG组、高sd-LDL组的HOMA-IR均显著高于对应的低TAG组、低sd-LDL组（均P<0.05）。空腹高TAG组与空腹低TAG组的GDM发生率比较，差异无统计学意义（P>0.05）。脂餐后（2、4 h）高TAG组孕妇的GDM发生率均高于对应的低TAG组（均P<0.05）。ROC曲线分析结果显示，脂餐后4 h FFA对GDM的AUC最大（P<0.05）。结论·妊娠期妇女糖脂代谢密切相关。GDM孕妇在孕中期行OGTT检查之前即表现为脂代谢异常，14~20周进行OLTT作为空腹血脂检查的补充，对GDM风险预测具有重要价值，可以提前发现GDM高危人群。

关键词: 妊娠期糖尿病, 口服脂质耐量试验, 三酰甘油

Abstract:

Objective·To explore the value of gestational oral lipid tolerance test (OLTT) in predicting the risk of gestational diabetes mellitus (GDM).

Methods·From May 2019 to December 2019, 71 pregnant women were recruited in Shanghai General Hospital. OLTT was performed during 14－20 gestational weeks. Triacylglycerol (TAG), free fat acid (FFA) , and small dense low density lipoprotein (sd-LDL) were tested on an empty stomach in the morning and 2 and 4 h after eating a high-fat meal. According to the oral glucose tolerance test (OGTT), the pregnant women were divided into GDM group (n=22) and control group (n=49). General indicators such as age; and the levels of TAG, FFA and sd-LDL on an empty stomach and after a fat meal (2 and 4 h) were compared between the two groups. According to the median of fasting and postprandial (2 and 4 h) TAG, FFA, and sd-LDL in OLTT, the pregnant women were divided into different groups. OGTT blood glucose (including fasting blood glucose, 1 h blood glucose, and 2 h blood glucose) , homeostatic model assessment for insulin resistance (HOMA-IR) and the incidence of GDM were compared between the groups. The area under curve (AUC) of each indicator against GDM was compared by receiver operator characteristic (ROC) curve.

Results·There was no statistical difference in general indicators such as age between the GDM group and the control group (P>0.05). The fasting and postprandial (2 and 4 h) TAG, sd-LDL and postprandial 4 h FFA in the GDM group were significantly higher than those in the control group, and the differences were statistically significant (all P<0.05). There was no significant difference between the two groups in fasting and 2 h FFA after meal (both P>0.05). The fasting blood glucose level of the fasting high TAG group was significantly higher than that of the fasting low TAG group, and the difference was statistically significant (P<0.05). However, there was no statistically significant difference in blood glucose at 1 h and 2 h between the two groups (both P>0.05). The fasting blood glucose and 1 h blood glucose of the 2 h high TAG group were significantly higher than those of the corresponding low TAG group, and the differences were statistically significant (both P<0.05). The OGTT fasting and 1 h blood glucose levels of the 4 h high TAG group were significantly higher than those of the corresponding low TAG group, and the difference was statistically significant (both P<0.05). The HOMA-IR of all high TAG groups was significantly higher than that of the corresponding groups (all P<0.05). The HOMA-IR of all high sd-LDL groups was significantly higher than that of the corresponding group (all P<0.05). There was no significant difference in the incidence of GDM between the fasting high TAG group and the fasting low TAG group (P>0.05). After meals (2 and 4 h), the incidence of GDM in pregnant women in the high TAG group was higher than that in the corresponding low TAG group (P<0.05). ROC curve analysis showed that the AUC of 4 h FFA versus GDM was the largest and was statistically significant (P<0.05).

Conclusion·Glycolipid metabolism in pregnant women is closely related. Pregnant women with GDM already show abnormal lipid metabolism during the second trimester (before OGTT examination). OLTT during 14－20 weeks of gestation can be used as a supplement to fasting blood lipid testing, and has important value in GDM risk prediction, and can identify high-risk of GDM in advance.

Key words: gestational diabetes mellitus (GDM), oral lipid tolerance test (OLTT), triacylglycerol

中图分类号:

R714.25

刘庆, 蔡雯, 张瑞晴, 卢聪, 张佳荣, 徐先明. 妊娠期脂质耐量试验在妊娠期糖尿病风险预测中的价值[J]. 上海交通大学学报(医学版), 2021, 41(2): 210-216.

Qing LIU, Wen CAI, Rui-qing ZHANG, Cong LU, Jia-rong ZHANG, Xian-ming XU. Value of pregnancy lipid tolerance test in predicting risk of gestational diabetes mellitus[J]. JOURNAL OF SHANGHAI JIAOTONG UNIVERSITY (MEDICAL SCIENCE), 2021, 41(2): 210-216.

图/表 10

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Item	Control group (n=49)	GDM group (n=22)	P value
Age/year	30.6±3.9	31.5±4.9	0.113
Gravidity/n	2.1±0.5	1.2±1.2	0.311
Parity/n	0.5±0.5	0.6±0.7	0.576
Birth interval/year	2.7±3.6	2.4±4.2	0.717
Prepregnancy BMI/(kg·m^－2)	21.3 (19.7?24.3)	21.4 (20.8?24.5)	0.094
Systolic blood pressure/mmHg	114.1±8.9	113.4±8.8	0.333
Diastolic blood pressure/mmHg	68.1±9.6	70.1±8.0	0.158
GPT/(U·L^－1)	16.4 (12.3?20.4)	14.8 (11.6?19.4)	0.907
GOT/(U·L^－1)	16.4 (13.6?18.2)	15.2 (12.5?24.0)	0.928

Item	Control group (n=49)	GDM group (n=22)	P value
Age/year	30.6±3.9	31.5±4.9	0.113
Gravidity/n	2.1±0.5	1.2±1.2	0.311
Parity/n	0.5±0.5	0.6±0.7	0.576
Birth interval/year	2.7±3.6	2.4±4.2	0.717
Prepregnancy BMI/(kg·m^－2)	21.3 (19.7?24.3)	21.4 (20.8?24.5)	0.094
Systolic blood pressure/mmHg	114.1±8.9	113.4±8.8	0.333
Diastolic blood pressure/mmHg	68.1±9.6	70.1±8.0	0.158
GPT/(U·L^－1)	16.4 (12.3?20.4)	14.8 (11.6?19.4)	0.907
GOT/(U·L^－1)	16.4 (13.6?18.2)	15.2 (12.5?24.0)	0.928

Variable	Fasting PG/(mmol·L^-1)		1 h PG/(mmol·L^-1)		2 h PG/(mmol·L^-1)		HOMA-IR
Variable	M(P₂₅?P₇₅)	P value	M(P₂₅?P₇₅)	P value	M(P₂₅?P₇₅)	P value	M(P₂₅?P₇₅)	P value
Fasting TAG		0.005		0.087		0.112		0.003
Low binary	4.2 (4.2?4.8)		7.7±1.6		7.0 (6.1?7.7)		1.2 (0.8?1.4)
High binary	4.8 (4.4?5.0)		8.5±1.8		7.2 (6.4?8.1)		1.7 (1.1?2.2)
2 h TAG		0.000		0.004		0.058		0.009
Low binary	4.4 (4.2?7.6)		7.6±1.4		7.0 (6.1?7.6)		1.2 (0.8?1.6)
High binary	4.9 (4.6?5.1)		8.7±1.9		7.3 (6.4?7.9)		1.5 (1.1?2.2)
4 h TAG		0.000		0.016		0.078		0.020
Low binary	4.4 (4.2?4.7)		7.7±1.4		7.0 (6.1?7.7)		1.2 (0.9?1.6)
High binary	4.9 (4.5?5.1)		8.6±1.9		7.3 (6.3?8.0)		1.5 (1.2?2.2)
Fasting FFA		0.311		0.401		0.067		0.306
Low binary	4.7 (4.3?5.1)		8.3±1.7		7.4 (6.6?7.9)		1.4 (1.0?2.1)
High binary	4.6 (4.3?4.8)		8.0±1.8		7.0 (6.1?7.6)		1.2 (0.9?1.7)
2 h FFA		0.382		0.818		0.840		0.739
Low binary	4.7 (4.3?5.1)		8.1±2.0		7.1 (6.3?7.7)		1.3 (0.9?2.0)
High binary	4.6 (4.4?4.8)		8.1±1.5		7.1 (6.3?7.8)		1.3 (1.0?1.8)
4 h FFA		0.047		0.613		0.629		0.441
Low binary	4.5 (4.3?4.9)		8.0±1.4		7.4 (6.6?7.7)		1.2 (0.9?1.7)
High binary	4.7 (4.5?5.0)		8.3±2.0		6.9 (6.3?2.1)		1.4 (1.0?2.1)
Fasting sd-LDL		0.003		0.218		0.505		0.015
Low binary	4.4 (4.2?4.7)		7.9±1.7		7.1 (6.0?7.8)		1.2 (0.8?1.6)
High binary	4.8 (4.4?5.0)		8.4±1.7		7.2 (6.4?7.9)		1.5 (1.1?2.2)
2 h sd-LDL		0.002		0.178		0.490		0.011
Low binary	4.4 (4.2?4.7)		7.8±1.7		7.1 (6.0?7.7)		1.2 (0.8?1.5)
High binary	4.9 (4.5?5.0)		8.4±1.8		7.1 (6.3?7.9)		1.6 (1.1?2.2)
4 h sd-LDL		0.001		0.284		0.936		0.008
Low binary	4.4 (4.2?4.7)		7.9±1.7		7.1 (6.1?7.8)		1.1 (0.8?1.4)
High binary	4.8 (4.5?5.0)		8.4±1.7		7.2 (6.3?7.8)		1.6 (1.2?2.1)

Variable	Fasting PG/(mmol·L^-1)		1 h PG/(mmol·L^-1)		2 h PG/(mmol·L^-1)		HOMA-IR
Variable	M(P₂₅?P₇₅)	P value	M(P₂₅?P₇₅)	P value	M(P₂₅?P₇₅)	P value	M(P₂₅?P₇₅)	P value
Fasting TAG		0.005		0.087		0.112		0.003
Low binary	4.2 (4.2?4.8)		7.7±1.6		7.0 (6.1?7.7)		1.2 (0.8?1.4)
High binary	4.8 (4.4?5.0)		8.5±1.8		7.2 (6.4?8.1)		1.7 (1.1?2.2)
2 h TAG		0.000		0.004		0.058		0.009
Low binary	4.4 (4.2?7.6)		7.6±1.4		7.0 (6.1?7.6)		1.2 (0.8?1.6)
High binary	4.9 (4.6?5.1)		8.7±1.9		7.3 (6.4?7.9)		1.5 (1.1?2.2)
4 h TAG		0.000		0.016		0.078		0.020
Low binary	4.4 (4.2?4.7)		7.7±1.4		7.0 (6.1?7.7)		1.2 (0.9?1.6)
High binary	4.9 (4.5?5.1)		8.6±1.9		7.3 (6.3?8.0)		1.5 (1.2?2.2)
Fasting FFA		0.311		0.401		0.067		0.306
Low binary	4.7 (4.3?5.1)		8.3±1.7		7.4 (6.6?7.9)		1.4 (1.0?2.1)
High binary	4.6 (4.3?4.8)		8.0±1.8		7.0 (6.1?7.6)		1.2 (0.9?1.7)
2 h FFA		0.382		0.818		0.840		0.739
Low binary	4.7 (4.3?5.1)		8.1±2.0		7.1 (6.3?7.7)		1.3 (0.9?2.0)
High binary	4.6 (4.4?4.8)		8.1±1.5		7.1 (6.3?7.8)		1.3 (1.0?1.8)
4 h FFA		0.047		0.613		0.629		0.441
Low binary	4.5 (4.3?4.9)		8.0±1.4		7.4 (6.6?7.7)		1.2 (0.9?1.7)
High binary	4.7 (4.5?5.0)		8.3±2.0		6.9 (6.3?2.1)		1.4 (1.0?2.1)
Fasting sd-LDL		0.003		0.218		0.505		0.015
Low binary	4.4 (4.2?4.7)		7.9±1.7		7.1 (6.0?7.8)		1.2 (0.8?1.6)
High binary	4.8 (4.4?5.0)		8.4±1.7		7.2 (6.4?7.9)		1.5 (1.1?2.2)
2 h sd-LDL		0.002		0.178		0.490		0.011
Low binary	4.4 (4.2?4.7)		7.8±1.7		7.1 (6.0?7.7)		1.2 (0.8?1.5)
High binary	4.9 (4.5?5.0)		8.4±1.8		7.1 (6.3?7.9)		1.6 (1.1?2.2)
4 h sd-LDL		0.001		0.284		0.936		0.008
Low binary	4.4 (4.2?4.7)		7.9±1.7		7.1 (6.1?7.8)		1.1 (0.8?1.4)
High binary	4.8 (4.5?5.0)		8.4±1.7		7.2 (6.3?7.8)		1.6 (1.2?2.1)

Variable	GDM /n (%)	P value
Fasting TAG		0.144
Low binary	8 (22.9)
High binary	14 (38.9)
2 h TAG		0.003
Low binary	5 (14.2)
High binary	17 (47.2)
4 h TAG		0.008
Low binary	6 (16.7)
High binary	16 (45.7)
Fasting FFA		0.311
Low binary	13 (37.1)
High binary	9 (25.0)
2 h FFA		0.382
Low binary	12 (34.3)
High binary	10 (27.7)
4 h FFA		0.047
Low binary	8 (22.8)
High binary	14 (38.8)
Fasting sd-LDL		0.003
Low binary	6 (17.1)
High binary	16 (44.4)
2 h sd-LDL		0.002
Low binary	6 (16.7）
High binary	16 (45.7）
4 h sd-LDL		0.001
Low binary	8 (22.8）
High binary	14 (38.9)

妊娠期脂质耐量试验在妊娠期糖尿病风险预测中的价值

Value of pregnancy lipid tolerance test in predicting risk of gestational diabetes mellitus

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Metrics

OLTT	AUC	Standard error	P value	Best diagnostic value	Sensitivity/%	Specificity/%	95%CI(AUC)
Fasting TAG	0.701	0.065	0.007	1.690	86.0	44.9	0.573?0.829
2 h TAG	0.681	0.068	0.015	2.795	77.3	61.2	0.548?0.814
4 h TAG	0.662	0.069	0.030	2.250	86.4	49.0	0.527?0.798
Fasting FFA	0.494	0.077	0.941	-	-	-	0.343?0.645
2 h FFA	0.487	0.070	0.857	-	-	-	0.350?0.623
4 h FFA	0.670	0.068	0.023	0.915	54.5	79.6	0.537?0.802
Fasting sd-LDL	0.701	0.069	0.007	28.555	86.4	49.0	0.565?0.837
2 h sd-LDL	0.713	0.068	0.004	34.580	72.7	63.3	0.579?0.847
4 h sd-LDL	0.702	0.069	0.007	44.730	50.0	85.7	0.567?0.838

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