Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel.
Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel; The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel; Meuhedet Health Maintenance Organization, Haifa, Israel.
Am J Obstet Gynecol. 2024 Aug;231(2):259.e1-259.e10. doi: 10.1016/j.ajog.2023.11.1246. Epub 2024 Feb 15.
The relationship between gestational diabetes mellitus and adverse outcomes in multifetal pregnancies is complex and controversial. Moreover, limited research has focused on the risk of gestational diabetes mellitus progression to type 2 diabetes mellitus specifically in multifetal pregnancies, resulting in conflicting results from existing studies.
This study aimed to assess the risk of gestational diabetes mellitus progression to type 2 diabetes mellitus between singleton and multifetal pregnancies in a large cohort of parturients with a 5-year follow-up.
A retrospective study was conducted on a prospective cohort of pregnant individuals with pregnancies between January 1, 2017, and December 31, 2020, followed up to 5 years after delivery. Glucose levels during pregnancy were obtained from the Meuhedet Health Maintenance Organization laboratory system and cross-linked with the Israeli National Diabetes Registry. The cohort was divided into 4 groups: singleton pregnancy without gestational diabetes mellitus, singleton pregnancy with gestational diabetes mellitus, multifetal pregnancy without gestational diabetes mellitus, and multifetal pregnancy with gestational diabetes mellitus. Gestational diabetes mellitus was defined according to the American Diabetes Association criteria using the 2-step strategy. Univariate analyses, followed by survival analysis that included Kaplan-Meier hazard curves and Cox proportional-hazards models, were used to assess differences between groups and calculate the adjusted hazard ratios with 95% confidence intervals for progression to type 2 diabetes mellitus.
Among 88,611 parturients, 61,891 cases met the inclusion criteria. The prevalence of type 2 diabetes mellitus was 6.5% in the singleton pregnancy with gestational diabetes mellitus group and 9.4% in the multifetal pregnancy with gestational diabetes mellitus group. Parturients with gestational diabetes mellitus, regardless of plurality, were older and had higher fasting plasma glucose levels in the first trimester of pregnancy. The rates of increased body mass index, hypertension, and earlier gestational age at delivery were significantly higher in the gestational diabetes mellitus group among patients with singleton pregnancies but not among patients with multifetal pregnancies. Survival analysis demonstrated that gestational diabetes mellitus was associated with adjusted hazard ratios of type 2 diabetes mellitus of 4.62 (95% confidence interval, 3.69-5.78) in singleton pregnancies and 9.26 (95% confidence interval, 2.67-32.01) in multifetal pregnancies (P<.001 for both). Stratified analysis based on obesity status revealed that, in parturients without obesity, gestational diabetes mellitus in singleton pregnancies increased the risk of type 2 diabetes mellitus by 10.24 (95% confidence interval, 6.79-15.44; P<.001) compared with a nonsignificant risk in multifetal pregnancies (adjusted hazard ratio, 9.15; 95% confidence interval, 0.92-90.22; P=.059). Among parturients with obesity, gestational diabetes mellitus was associated with an increased risk of type 2 diabetes mellitus for both singleton and multifetal pregnancies (adjusted hazard ratio, 3.66; [95% confidence interval, 2.81-4.67; P<.001] and 9.31 [95% confidence interval, 2.12-40.76; P=.003], respectively).
Compared with gestational diabetes mellitus in singleton pregnancies, gestational diabetes mellitus in multifetal pregnancies doubles the risk of progression to type 2 diabetes mellitus. This effect is primarily observed in patients with obesity. Our findings underscore the importance of providing special attention and postpartum follow-up for patients with multifetal pregnancies and gestational diabetes mellitus, especially those with obesity, to enable early diagnosis and intervention for type 2 diabetes mellitus.
妊娠期糖尿病与多胎妊娠不良结局之间的关系复杂且存在争议。此外，专门针对多胎妊娠中妊娠期糖尿病进展为 2 型糖尿病的风险的研究有限，导致现有研究结果存在冲突。
本研究旨在评估在一项大型分娩队列中，经过 5 年随访，单胎和多胎妊娠中妊娠期糖尿病进展为 2 型糖尿病的风险。
对 2017 年 1 月 1 日至 2020 年 12 月 31 日期间妊娠的孕妇前瞻性队列进行回顾性研究，随访至分娩后 5 年。孕期血糖水平从 Meuhedet 健康维护组织实验室系统获得，并与以色列国家糖尿病登记处进行交叉链接。该队列分为 4 组：无妊娠期糖尿病的单胎妊娠、有妊娠期糖尿病的单胎妊娠、无妊娠期糖尿病的多胎妊娠和有妊娠期糖尿病的多胎妊娠。妊娠期糖尿病根据美国糖尿病协会标准，采用两步策略进行定义。使用单变量分析，然后是包括 Kaplan-Meier 风险曲线和 Cox 比例风险模型的生存分析，以评估组间差异，并计算调整后的危险比及其 95%置信区间，用于进展为 2 型糖尿病。
在 88611 名产妇中，有 61891 例符合纳入标准。有妊娠期糖尿病的单胎妊娠组和有多发性妊娠的妊娠期糖尿病组的 2 型糖尿病患病率分别为 6.5%和 9.4%。无论多胎与否，患有妊娠期糖尿病的产妇年龄更大，且在妊娠早期空腹血糖水平更高。在有妊娠期糖尿病的单胎妊娠患者中，体重指数增加、高血压和更早的分娩胎龄的发生率明显更高，但在有多发性妊娠的患者中则没有这种情况。生存分析表明，妊娠期糖尿病与单胎妊娠的 2 型糖尿病的调整后危险比为 4.62（95%置信区间，3.69-5.78），与多胎妊娠的 9.26（95%置信区间，2.67-32.01）相关（均<0.001）。基于肥胖状况的分层分析显示，在无肥胖的产妇中，与多胎妊娠相比，单胎妊娠中的妊娠期糖尿病使 2 型糖尿病的风险增加了 10.24（95%置信区间，6.79-15.44；<0.001），而多胎妊娠的风险没有显著增加（调整后的危险比为 9.15；95%置信区间，0.92-90.22；P=0.059）。在肥胖的产妇中，与单胎妊娠和多胎妊娠相比，妊娠期糖尿病都与 2 型糖尿病的风险增加相关（调整后的危险比分别为 3.66[95%置信区间，2.81-4.67；<0.001]和 9.31[95%置信区间，2.12-40.76；P=0.003]）。
与单胎妊娠中的妊娠期糖尿病相比，多胎妊娠中的妊娠期糖尿病使进展为 2 型糖尿病的风险增加一倍。这种影响主要在肥胖患者中观察到。我们的研究结果强调了为多胎妊娠和妊娠期糖尿病的患者提供特别关注和产后随访的重要性，特别是对肥胖患者，以便能够早期诊断和干预 2 型糖尿病。
