探讨多囊卵巢综合征(polycystic ovary syndrome, PCOS)患者妊娠期胰岛素抵抗(insulin resistance, IR)和血脂代谢变化特点。

选择2007年9月至2009年2月在本院妇产科确诊为多囊卵巢综合征，并成功妊娠的患者102例纳入PCOS组，年龄为(30.56±4.38)岁，按妊娠时间分为早孕组(n＝50，8～13孕周)，中孕组(n＝38，24～28孕周)和晚孕组(n＝14，32～36孕周)。选择同期在本院早孕咨询及产前检查门诊就诊的健康孕妇纳入对照组(n＝114)，同样按妊娠时间将其分为早孕组(n＝48)，中孕组(n＝50)和晚孕组(n＝16)(排除PCOS、糖尿病、严重内外科疾病等病史)，年龄为(30.67±3.55)岁(本研究遵循的程序符合本院人体试验委员会所制定的伦理学标准，得到该委员会批准，分组征得受试者本人的知情同意，并与之签署临床研究知情同意书)。对上述各组孕妇测定空腹血糖(fasting plasma glucose，FPG)、空腹胰岛素(fasting insulin, FINS)及血脂四项[总胆固醇(cholesterol，CHOL)、甘油三脂(cholesterol，TG)、高密度脂蛋白胆固醇(high density lipoprotein，HDL)、低密度脂蛋白胆固醇(low density lipoprotein cholesterol，LDL)]，并进行75 g葡萄糖耐量试验(oral glucose tolerance test，OGTT)，检测糖负荷后1 h，2 h和3 h血糖(P1G，P2G，P3G)和胰岛素水平(P1INS，P2INS，P3INS)。采取稳态模式评估法计算胰岛素抵抗指数( (homeostasis model assessment insulin resistance index，HOMA－IR)、胰岛β细胞分泌功能指数(HOMA－β)、胰岛素敏感指数(insulin sensitivity index, ISI)、血糖曲线下面积(area under curve of glucose，AUCglu)、胰岛素曲线下面积(area under curve of insulin，AUCins)，进行单因素分析比较。

①随着孕周增加，PCOS组孕妇血糖值比较：中孕组P2G高于早孕组(7.99±2.00 vs. 7.10±1.92，P<0.05)。PCOS组胰岛素水平比较：中孕组FINS，HOMA－IR和HOMA－β高于早孕组，而ISI低于早孕组(7.81±4.65 vs. 5.71±2.76；1.65±1.08 vs. 1.17±0.63；169.47±119.40 vs. 124.64±66.99；0.04±0.03 vs. 0.05±0.02)(P<0.05)。PCOS组孕妇脂代谢比较：中孕组CHOL，TG和HDL高于早孕组(5.85±1.27 vs. 4.67±1.14；3.21±1.40 vs. 1.75±1.05；1.82±0.27 vs.1.52±0.34)(P<0.05)；晚孕组CHOL，TG和HDL高于早孕组(6.02±1.74 vs. 4.67±1.14；4.10±2.00 vs. 1.75±1.05；1.75±0.32 vs. 1.52±0.34)(P<0.05)。② PCOS早孕组P1G，P2G和AUCglu高于早孕对照组(8.45±2.61 vs. 7.47±1.35；7.10±1.92 vs. 6.18±1.00；20.48±2.70 vs. 18.12±1.31)(P<0.05)；PCOS中孕组P1G，P2G和AUCglu高于中孕对照组(9.27±1.95 vs. 7.57±1.64；7.99±2.00 vs. 6.75±1.33；22.43±2.47 vs. 16.60±1.81)(P<0.05)。PCOS早孕组FINS，P2INS，AUCins，HOMA－IR和HOMA－β高于早孕对照组，ISI低于早孕对照组(5.71±2.76 vs. 4.51±1.79；86.67±62.54 vs. 61.59±28.90；190.67±60.47 vs. 146.61±28.17；1.17±0.63 vs. 0.91±0.40；124.64±66.99 vs. 93.21±66.12；0.05±0.02 vs. 0.06±0.02)(P<0.05)；PCOS中孕组P1INS，P2INS和AUCins高于中孕对照组(93.33±48.56 vs. 66.09±39.87；98.59±57.99 vs. 57.96±34.17；222.21±63.74 vs. 144.09±44.53)(P<0.05)；PCOS晚孕组FINS高于晚孕对照组(9.05±4.11 vs. 6.20±2.98；P<0.05)。血脂4项比较：PCOS早孕组TG，LDL高于早孕对照组(1.75±1.05 vs. 1.14±0.57；2.84±0.95 vs. 2.37±0.54)(P<0.05)；PCOS中孕组TG高于中孕对照组(3.21±1.40 vs. 2.25±0.70)(P<0.05)，HDL低于中孕对照组(1.82±0.27 vs. 2.02±0.46)(P<0.05)。

PCOS患者早孕期就存胰岛素敏感性下降，胰岛β细胞分泌增加，胰岛素抵抗较正常孕妇增加，其程度随孕期进展而增强，以中期妊娠增加明显。PCOS孕妇妊娠期血脂全面升高，TG升高最为明显。

To study insulin resistance and lipid metabolism in pregnant women with polycystic ovary syndrome (PCOS).

One hundred and two women with PCOS diagnosed pregnant from September 2007 to February 2009 in the Second Affiliated Hospital, Sun Yat-sen University were divided into early pregnancy group (n=50, 8th-13th pregnant week), second trimester pregnancy group (n=38, 24th-28th pregnant week), and third trimester group (n=14, 32nd-36th pregnant week). One hundred and fourteen pregnant women without PCOS were selected as control group; 48 in early pregnancy group, 50 in second trimester and 16 in third trimester respectively. People was excluded with PCOS, diabetes mellitus and serious medical disease and so on. The study protocol was approved by the Ethical Review Board of Investigation in Human Being of the Second Affiliated Hospital of SUN Yat-sen university. Informed consent was obtained from each patient. All groups were examined with fasting plasma glucose(FPG), fasting insulin(FINS) and lipid level including cholesterol (CHOL), triglyceride (TG), high density lipo-protein cholesterol (HDL) and low density lipoprotein cholesterol (LDL). Oral glucose tolerance test (75 g dextrose) was also performed to examine plasma glucose and insulin level on 1 h/2 h/3 h. HOMA-IR, HOMA-β and ISI were calculated. All subjects were followed up and pregnancy outcome were recorded.

①As gestational age of patients with PCOS developed, 2 h glucose of the second trimester increased than that of the first trimester (7.99±2.00 vs. 7.10 ± 1.92). About insulin level, plasma fasting insulin, indexes of HOMA-IR, HOMA-β increased, while ISI decreased (7.81±4.65 vs. 5.71±2.76; 1.65±1.08 vs. 1.17±0.63; 169.47±119.40 vs. 124.64±66.99; 0.04±0.03 vs. 0.05±0.02). And the levels of CHOL, TG, HDL in the second trimester group and third trimester group were higher than those in the first trimester group (5.85±1.27 vs. 4.67±1.14; 3.21±1.40 vs. 1.75±1.05; 1.82±0.27 vs.1.52±0.34 and 6.02±1.74 vs. 4.67±1.14; 4.10±2.00 vs. 1.75±1.05; 1.75±0.32 vs. 1.52±0.34). All of the differences above were significant(P<0.05). ②As to the level of glucose, plasma glucose on 1 h and 2 h after dextrose intake and AUCglu were higher in patients with PCOS during the first trimester than those in control group(8.45±2.61 vs. 7.47±1.35; 7.10±1.92 vs. 6.18±1.00; 20.48±2.70 vs. 18.12±1.31)(P<0.05); during the second trimester, plasma glucose on 1 h and 2 h after dextrose intake, AUCglu in PCOS group were higher than those in control group(9.27±1.95 vs. 7.57±1.64; 7.99±2.00 vs. 6.75±1.33; 22.43±2.47 vs. 16.60±1.81)(P<0.05). Besides, in the first trimester, plasma insulin levels including fasting stage, 2 h after dextrose intake and AUCins, HOMA-IR, HOMA-β of patients in PCOS group were higher than those in the control group, while the level of ISI were lower than that of control group(5.71±2.76 vs. 4.51 ± 1.79; 86.67 ± 62.54 vs. 61.59 ± 28.90; 190.67 ± 60.47 vs. 146.61 ± 28.17; 1.17±0.63 vs. 0.91±0.40; 124.64±66.99 vs. 93.21±66.12; 0.05±0.02 vs. 0.06±0.02)(P<0.05). In the second trimester, insulin level on 1 h and 2 h after dextrose intake and AUCins were higher than those in the control group (93.33 ± 48.56 vs. 66.09 ± 39.87; 98.59±57.99 vs. 57.96 ± 34.17; 222.21 ± 63.74 vs. 144.09 ± 44.53)(P<0.05). In the third trimester, fasting insulin level of PCOS group was higher than that in the control group(9.05±4.11 vs. 6.20±2.98; P<0.05). As to lipid metabolism, in patients with PCOS during the first trimester, plasma TG and LDL were higher than those in control group( 1.75±1.05 vs. 1.14±0.57; 2.84±0.95 vs. 2.37±0.54)(P<0.05). During the second trimester, plasma TG was higher while HDL was lower in patients with PCOS than control subjects(3.21±1.40 vs. 2.25±0.70; 2.84±0.95 vs. 2.37±0.54)(P<0.05).

As early as the first trimester of pregnancy, patients with PCOS developed insulin resistance. Insulin resistance aggravated while insulin sensitivity decreased as the gestational weeks increased, which was significant during the second trimester. Overall fasting plasma lipid level was elevated during pregnancy of patients with PCOS, which was more obvious for TG than other sorts of lipid.