Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus, Denmark.
Danish Diabetes Academy, Odense University Hospital, Odense, Denmark.
Diabetologia. 2021 Feb;64(2):304-312. doi: 10.1007/s00125-020-05323-0. Epub 2020 Nov 6.
AIMS/HYPOTHESIS: Gestational diabetes mellitus (GDM) is generally defined based on glycaemia during an OGTT, but aetiologically includes women with defects in insulin secretion, insulin sensitivity or a combination of both. In this observational study, we aimed to determine if underlying pathophysiological defects evaluated as continuous variables predict the risk of important obstetric and neonatal outcomes better than the previously used dichotomised or categorical approaches.
Using data from blinded OGTTs at mean gestational week 28 from five Hyperglycemia and Adverse Pregnancy Outcome study centres, we estimated insulin secretion (Stumvoll first phase) and sensitivity (Matsuda index) and their product (oral disposition index [DI]) in 6337 untreated women (1090 [17.2%] with GDM as defined by the International Association of Diabetes and Pregnancy Study Groups). Rather than dichotomising these variables (i.e. GDM yes/no) or subtyping by insulin impairment, we related insulin secretion and sensitivity as continuous variables, along with other maternal characteristics, to obstetric and neonatal outcomes using multiple regression and receiver operating characteristic curve analysis.
Stratifying by GDM subtype offered superior prediction to GDM yes/no only for neonatal hyperinsulinaemia and pregnancy-related hypertension. Including the DI and the Matsuda score significantly increased the area under the receiver operating characteristic curve (AUROC) and improved prediction for multiple outcomes (large for gestational age [AUROC 0.632], neonatal adiposity [AUROC 0.630], pregnancy-related hypertension [AUROC 0.669] and neonatal hyperinsulinaemia [AUROC 0.688]). Neonatal hypoglycaemia was poorly predicted by all models. Combining the DI and the Matsuda score with maternal characteristics substantially improved the predictive power of the model for large for gestational age, neonatal adiposity and pregnancy-related hypertension.
CONCLUSION/INTERPRETATION: Continuous measurement of insulin secretion and insulin sensitivity combined with basic clinical variables appeared to be superior to GDM (yes/no) or subtyping by insulin secretion and/or sensitivity impairment in predicting obstetric and neonatal outcomes in a multi-ethnic cohort. Graphical abstract.
目的/假设：妊娠期糖尿病（GDM）通常基于口服葡萄糖耐量试验（OGTT）期间的血糖水平来定义，但从病因学角度来看，它包括胰岛素分泌缺陷、胰岛素敏感性缺陷或两者兼有的女性。在这项观察性研究中，我们旨在确定作为连续变量评估的潜在病理生理学缺陷是否比以前使用的二分类或分类方法更好地预测重要的产科和新生儿结局的风险。
使用来自五个 Hyperglycemia and Adverse Pregnancy Outcome 研究中心的平均妊娠 28 周时进行的盲 OGTT 的数据，我们在 6337 名未经治疗的女性（1090 名[17.2%]按国际糖尿病与妊娠研究组定义为 GDM）中估计了胰岛素分泌（Stumvoll 第一相）和敏感性（Matsuda 指数）及其乘积（口服处置指数[DI]）。我们没有将这些变量（即 GDM 是/否）二分类，也没有根据胰岛素功能障碍进行亚型分类，而是将胰岛素分泌和敏感性作为连续变量，并结合其他母体特征，使用多元回归和接受者操作特征曲线分析将其与产科和新生儿结局相关联。
按 GDM 亚型分层，仅对新生儿高胰岛素血症和妊娠相关高血压的预测优于 GDM 是/否。包括 DI 和 Matsuda 评分显著增加了接受者操作特征曲线下面积（AUROC），并改善了对多种结局的预测（巨大儿[AUROC 0.632]、新生儿肥胖[AUROC 0.630]、妊娠相关高血压[AUROC 0.669]和新生儿高胰岛素血症[AUROC 0.688]）。所有模型对新生儿低血糖的预测都很差。将 DI 和 Matsuda 评分与母体特征相结合，大大提高了模型对巨大儿、新生儿肥胖和妊娠相关高血压的预测能力。
结论/解释：连续测量胰岛素分泌和胰岛素敏感性并结合基本临床变量，在预测多民族队列的产科和新生儿结局方面似乎优于 GDM（是/否）或按胰岛素分泌和/或敏感性缺陷进行分类。
