Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic., Australia.
Diabetes and Vascular Medicine Unit, Monash Health, Melbourne, Vic., Australia.
Diabet Med. 2019 Feb;36(2):177-183. doi: 10.1111/dme.13799. Epub 2018 Sep 3.
With no current randomized trials, we explored the impact of tight compared with standard treatment targets on pregnancy outcomes in gestational diabetes mellitus (GDM).
This cohort study of singleton births ≥ 28 weeks' gestation was conducted at two major Australian maternity services (2009-2013). Standardized maternal, neonatal and birth outcomes were examined using routine healthcare data and compared for women with GDM at Service One (n = 2885) and Service Two (n = 1887). Services applied different treatment targets: Service One (standard targets, reference group) fasting < 5.5 mmol/l, 2-h postprandial < 7.0 mmol/l; Service Two (tight targets) fasting < 5.0 mmol/l, 2-h postprandial < 6.7 mmol/l. Multivariable regression with propensity score adjustment was used to examine associations between targets and outcomes.
GDM prevalence and insulin use were 7.9% and 31% at Service One, and 5.7% and 46% at Service Two. There were no differences in primary outcomes: birthweight > 90th centile [adjusted odds ratio (OR) 1.06, 95% confidence interval (CI) 0.87-1.30] and < 10th centile (OR 0.84, 95% CI 0.70-1.01), or secondary outcomes gestational hypertension, pre-eclampsia, shoulder dystocia or a perinatal composite. Service Two with tight targets had increased induction of labour (OR 3.63, 95% CI 3.17-4.16), elective Caesarean section (OR 1.75, 95% CI 1.37-2.23) and Apgar scores < 7 at 5 min (OR 1.54, 95% CI 1.05-2.25), decreased hypoglycaemia (OR 0.76, 95% CI 0.61-0.94]), jaundice (OR 0.47, 95% CI 0.35-0.63) and respiratory distress (OR 0.68, 95% CI 0.47-0.98).
Tight GDM treatment targets were associated with greater insulin use and no difference in primary birthweight outcomes. The service with tight targets had higher obstetric intervention, lower rates of reported hypoglycaemia, jaundice, respiratory distress and lower Apgar scores. High-quality interventional data are required before tight treatment targets can be implemented.
由于目前尚无随机试验，我们探讨了与标准治疗目标相比，严格的治疗目标对妊娠期糖尿病（GDM）妊娠结局的影响。
这项单胎妊娠≥28 周的队列研究在澳大利亚的两家主要产科服务机构进行（2009-2013 年）。使用常规医疗数据检查标准化的产妇、新生儿和分娩结局，并将服务一（n=2885）和服务二（n=1887）中患有 GDM 的女性的结果进行比较。服务机构采用不同的治疗目标：服务一（标准目标，参考组）空腹<5.5mmol/L，餐后 2 小时<7.0mmol/L；服务二（严格目标）空腹<5.0mmol/L，餐后 2 小时<6.7mmol/L。采用多变量回归和倾向评分调整，研究目标与结局之间的关系。
服务一的 GDM 患病率和胰岛素使用率分别为 7.9%和 31%，服务二的分别为 5.7%和 46%。主要结局出生体重>第 90 百分位数[调整后的优势比（OR）1.06，95%置信区间（CI）0.87-1.30]和<第 10 百分位数（OR 0.84，95%CI 0.70-1.01]和次要结局妊娠高血压、子痫前期、肩难产或围生期复合结局均无差异。采用严格目标的服务二增加了引产（OR 3.63，95%CI 3.17-4.16）、选择性剖宫产（OR 1.75，95%CI 1.37-2.23）和 5 分钟时 Apgar 评分<7（OR 1.54，95%CI 1.05-2.25）的发生率，降低了低血糖（OR 0.76，95%CI 0.61-0.94）、黄疸（OR 0.47，95%CI 0.35-0.63）和呼吸窘迫（OR 0.68，95%CI 0.47-0.98）的发生率。
严格的 GDM 治疗目标与更多的胰岛素使用相关，但对主要出生体重结局没有影响。采用严格目标的服务机构产科干预更多，报告的低血糖、黄疸、呼吸窘迫和 Apgar 评分较低。在实施严格的治疗目标之前，需要有高质量的干预数据。
