• Langue : Français, Anglais
• Discipline : Médecine. Endocrinologie et métabolismes
• Identifiant : 2022ULILM282
• Type de thèse : Doctorat de médecine
• Date de soutenance : 27/09/2022

Résumé en langue originale

Contexte : Malgré l’optimisation de la prise en charge au cours de la grossesse, les diabétiques de type 2 présentent un sur-risque de complications materno-foetales. L’objectif était d’évaluer l’impact de l’HbA1C des 1er et 3e trimestres, sur les complications maternelles et foetales au cours des grossesses de patientes DT2. Matériel et Méthode: Étude observationnelle, monocentrique, rétrospective, conduite au CHU de Lille entre 1997 et 2021. Nous avons recueilli les données métaboliques, les complications materno-foetales au cours des grossesses de DT2. Après description de la pré-éclampsie, LGA, prématurité, malformations congénitales, transferts en réanimation néonatale (NICU), nous avons étudié leur association avec l’HbA1C du 1er et 3ème trimestre. Nous avons réalisé une analyse en sous-groupes afin d’étudier l'association entre la cinétique d’HbA1c au cours de la grossesse et les complications materno-foetales. Résultats: 583 patientes incluses. Age moyen de 33.9 ± 5.4 ans, IMC prégestationnel de 34.9 ± 7.10 kg/m2. On décrivait 49.4% de césariennes, 15.6% de prématurité, 12.2% de transferts en NICU, de 5.3% de malformations congénitales et 29.2% de LGA. L’HbA1C du 1er trimestre est associée au LGA (OR 1.33 ; 95%IC 1.09 -1.62 ; p=0.004), à la prématurité (OR 1.39 ; 95%IC 1.11 -1.75 ; p=0.004), à la césarienne (OR 1,66 ; 95%IC 1.11 -2.48 ; p=0.014) et aux admissions en NICU (OR 1.33 ; 95%IC 1.75 -2.29 ; p<0.001). L’HbA1C du 3e trimestre est associé au LGA (OR 2.67 ; 95%IC 1.75 -4.07 ; p<0.001), la césarienne (OR 1.30 ; 95%IC 1.02 - 1.66 ; p=0.031), aux admissions en NICU (OR 1.43 ; 95%IC 1.02 -2.01 ; p=0.038). L’analyse en sous-groupe retrouve qu’en cas de déséquilibre tardif, pour chaque augmentation de 0,1 % de l'HbA1c au 1er trimestre, les risques de prématurité (OR 1.39 ; 95%IC 1.11 -1.75 ; p=0.004) et d’admission NICU (OR 1.75 ; 95%IC 1.33 - 2.29 ; p<0.001) augmentent. En cas de déséquilibre au 3ème trimestre, le risque de LGA est majoré (OR 2.67 ; 95%IC 1.75 -4.07 ; p<0.001). Conclusion: L’HbA1C est associée aux complications materno-foetales. En cas de déséquilibre glycémique précoce, l’élévation de l’HbA1C du 1er trimestre est associée à un sur-risque de transfert NICU et de prématurité, même en cas de correction de l’équilibre glycémique ultérieur. En cas de déséquilibre tardif, le niveau d’HbA1c est un marqueur du risque de LGA.

Résumé traduit

Background and objective : Despite the optimization of management during pregnancy, type 2 diabetics (T2DM) still have a higher risk of maternal and fetal complications. The objective was to evaluate the impact of glycemic control, as assessed by HbA1C in the first and third trimesters, on maternal and fetal complications in pregnancies of patients with T2DM. Research design : Observational, monocentric, retrospective study conducted at the Jeanne de Flandres maternity hospital (Lille University Hospital) between 1997 and 2021. We collected metabolic data, obstetric, fetal and neonatal complications during T2DM pregnancies. After describing the adverse pregnancy events (pre-eclampsia, LGA, SGA, prematurity, congenital malformations, transfers to neonatal intensive care), we studied their association with glycemic control (HbA1C 1st and 3rd trimester). Finally, we performed a subgroup analysis of metabolic control to study the association between HbA1C kinetics during pregnancy and maternal-fetal complications. Results were expressed as odds ratios (OR) and their 95% confidence intervals (CI). Results : 583 T2DM patients gave birth to a live, singleton child during the study period. The mean age was 33.9 ± 5.4 years, the pregestational BMI was 34.9 ± 7.10 kg/m2 with a mean total weight gain during pregnancy of 8.0kg (3.0-12.0). The mean HbA1C in the first trimester was 6.33 ± 0.99% and in the third trimester 5.93 ± 0.75%. The median duration of diabetes was 2.0 years (0.0-5.0). 82.7% of women were multiparous. Pregnancies were marked by the occurrence of 12.0% of severe hypertension, 7.9% of pre-eclampsia, 11.0% of proteinuria. Caesarean sections represented 49.4% of deliveries with a median term of 38 weeks of amenorrhea (37.6-38.9). The mean weight of the newborns was 3329 ± 688 grams. The prematurity rate was 15.6%, the neonatal intensive care unit transfer rate was 12.2% and the congenital malformation rate was 5.3%. 29.2% of newborns were LGA and 7.9% SGA. 1.4% of births were marked by shoulder dystocia. First trimester HbA1C was associated with LGA (OR 1.33; 95%IC 1.09 -1.62; p=0.004), prematurity (OR 1.39; 95%IC 1.11 -1.75; p=0.004), caesarean section (OR 1.66; 95%IC 1.11 -2.48; p=0.014) and transfer to neonatal intensive care unit (OR 1.33; 95%IC 1.75 -2.29; p<0.001) Third-trimester HbA1C was associated with LGA (OR 2.67; 95%IC 1.75 -4.07; p<0.001), cesarean section (OR 1.30; 95%IC 1.02 -1.66; p=0.031), and neonatal intensive care unit transfer (OR 1.43; 95%IC 1.02 -2.01; p=0.038). Metabolic balance subgroup analysis found that in case of early imbalance, for each 0.1% increase in HbA1c in the 1st trimester, the risks of prematurity (OR 1.39; 95%IC 1.11 -1.75; p=0.004) and neonatal intensive care admission (OR 1.75; 95%IC 1.33 -2.29; p<0.001) increased. In case of late imbalance, for each 0.1% increase in HbA1c in the third trimester, the risk of LGA was increased (OR 2.67; 95%IC 1.75 -4.07; p<0.001). Conclusions: 1st but also 3rd trimester HbA1C is associated with maternal-fetal complications in T2DM pregnancies. In case of early glycemic imbalance, the elevation of HbA1C in the first trimester is associated with a higher risk of transfer to the neonatal intensive care unit and prematurity, even if glycemic control is corrected before the third trimester. In case of late imbalance, the HbA1c level is a marker of the risk of LGA. These results confirm the need to obtain a strict glycemic balance during the whole pregnancy but also the importance of pre-conceptional preparation.