血糖水平对妊娠期糖尿病孕妇及胎儿心功能影响的研究

发布时间：2018-05-06 16:56

本文选题：妊娠期糖尿病 + 血糖　；参考：《新乡医学院》2017年硕士论文

【摘要】：背景心脏功能储备是指机体在大手术、创伤、劳累等严重应激状态下,心脏额外做功的能力。心脏功能储备高低与心功能关系密切。心脏功能储备越好,心脏功能衰竭的可能性越低。对于孕产妇来说,整个妊娠过程中母体各个系统及器官均发生了一系列生理变化。随着孕期延长,以循环系统变化最为显著,心脏负荷加重,孕中、末期产妇心脏储备功能明显下降。任何导致孕产妇心脏功能的损伤都可进一步导致心脏功能储备减少。妊娠期间,母体心脏处于高容量负荷状态,做功负荷显著增加,在此过程中,任一原因导致的患者母体心脏组织细胞损伤,心肌收缩乏力,均显著减少泵功能射血能力,导致全身有效氧供减少,组织缺氧,影响胎儿血液氧与营养物质供应以及组织细胞代谢,部分严重患者,母婴安全风险骤然上升。妊娠期糖尿病(gestational diabetes mellitus,GDM)是指既往无糖尿病病史或者未诊断为糖尿病人群,在妊娠期间,发生与妊娠相关的糖耐量异常。既往资料显示妊娠期,母体出现高血糖状态可能对孕妇及胎儿造成不良影响,导致临床相关围生期并发症发生率升高,严重影响孕妇生命安全和新生儿预后。既往有研究显示长期的高糖刺激可导致患者体内处于慢性微炎症反应状态。患者血管内皮细胞功能受损,心肌肥大,心肌细胞变性,导致临床心脑血管疾病发生率升高。孕中、晚期正常妊娠者,随着妊娠时间延长,体内雌孕激素及相关生长因子水平变化,刺激全身毛细血管扩张,导致孕产妇体内有效循环血流量显著增加,外周机体组织细胞氧耗加快,同时也由于孕后期胎儿正常生长发育代谢加快,对于母体血液氧供增加,孕中后期母婴生理变化使母体心脏泵功能显著上升,心脏负荷快速增加,此时,心脏功能储备量对于维持机体正常代谢极为重要。妊娠期,母体血糖的波动变化,对于心肌细胞正常代谢是否产生一定影响,目前尚缺乏研究。GDM患者母体长期高血糖可通过胎盘转移到胎儿体内,形成胎儿高血糖状态,刺激胎儿胰岛素释放增加,形成巨大儿,影响胎儿肺脏发育,导致胎儿急性呼吸窘迫综合征发生率增加。孕中晚期,胎儿心脏处于快速成长及功能变化期。那么,胎儿高血糖状态对于心脏发育及功能变化是否存在影响,尚缺乏研究。课题研究目的试探讨在不同血糖水平状态下,血糖升高对于妊娠期糖尿病患者与胎儿心脏功能的影响,以期为妊娠期糖尿病患者的心脏管理提供科学依据。目的探讨不同血糖水平对于孕中期、孕晚期妊娠期糖尿病患者孕产妇及胎儿心脏功能影响。方法1、研究对象:选择2013年09月至2016年12月诊断为妊娠期糖尿病孕产妇210例,年龄25~40岁,平均年龄(33.69±8.17)岁,孕23~25周,平均孕周(23.18±1.74)周,均为单胎妊娠,初次超声检查排除胎儿先天性结构畸形。2、研究分组:入组对象分为三组。娠期糖尿病患者依据孕期血糖控制水平分为血糖控制良好组(优控组)135例与血糖控制不良组(差控组)72例,同期选择健康孕产妇80例作为对照组研究对象。3、研究方法:入组对象分别与孕中期(孕26~27周末)、孕晚期(≥28孕周)采用超声心动图检测三组孕产妇及胎儿心腔结构及功能参数变化。采用乳胶增强免疫比浊定量检测孕产妇血清超敏C反应蛋白水平(hs-CRP,mg/L),采用免疫荧光法检测血浆钠尿肽(BNP,pg/mL)。4、超声指标:⑴孕产妇心脏检查指标:左室射血分数(LVEF,%)、左心室舒张末期内径(LVEDd,mm);左心室收缩末期内径(LVEDs,mm);左心房内径(LAD);室间隔厚度(IVST,mm);左室后壁厚度(LVPWT,mm);二尖瓣舒张早期充盈的速度/二尖瓣舒张晚期充盈的速度(E/A);二尖瓣舒张早期充盈的速度/心肌舒张早期二尖瓣环根部运动速度的峰值比(E/Ea)。⑵胎儿心脏结构参数:舒张期左心室后壁厚度(LVPWd,mm)、舒张期室间隔厚度(IVSd,mm)、右心室前壁厚度(RVAW,mm、主动脉内径(AO,mm)、肺动脉内径(PA,mm)。⑶胎儿心脏功能参数:左、右心室射血分数(%)、三尖瓣E/A比值(E/ATV)、二尖瓣E/A比值(E/AMV)、二尖瓣E/Em比值(E/Em MV)、三尖瓣E/A比值(E/ATV)、二尖瓣环位移(MAD,mm)、三尖瓣环位移(TAD,mm)。结果1.孕中期,差控组、优控组与对照组孕产妇左室射血分数、LVEDd、LVEDs、LAD、IVST、LVPWT参数差异无统计学意义(P0.05)。E/A、E/Ea、血浆钠尿肽、血清C反应蛋白水平差异有统计学意义(P0.05)。其中,差控组与优控组、差控组与对照组比较,E/A、E/Ea、hs-CRP、BNP差异均有统计学意义(P0.05)。优控组与对照组比较,各指标差异无统计学意义(P0.05)。2.孕晚期,差控组、优控组与对照组孕产妇左室射血分数、左心室收缩末期内径差异无统计学意义(P0.05)。左心室舒张末期内径、左心房内径、室间隔厚度、左室后壁厚度、E/A、E/Ea、血浆钠尿肽、血清C反应蛋白水平差异有统计学意义(P0.05)。其中,差控组与优控组、差控组与对照组比较,LVEDd、LVEDs、LAD、IVST、LVPWT、E/A、E/Ea、hs-CRP、BNP差异均有统计学意义(P0.05)。优控组与对照组比较,E/A、E/Ea、hs-CRP、BNP差异有统计学意义(P0.05)。3.孕中期,差控组、优控组与对照组胎儿舒张期左心室后壁厚度、舒张期室间隔厚度、舒张期右心室前壁厚度、主动脉内径、肺动脉内径差异无统计学意义(P0.05)。4.孕晚期,差控组、优控组与对照组胎儿舒张期左心室后壁厚度、主动脉内径差异无统计学意义(P0.05)。舒张期室间隔厚度、舒张期右心室前壁厚度、肺动脉内径差异有统计学意义(P0.05)。5.孕中期,差控组、优控组与对照组胎儿左、右心室射血分数、二尖瓣E/A比值(E/AMV)、二尖瓣E/Em比值差异无统计学意义(P0.05)。三尖瓣E/A比值、三尖瓣E/Em比值、二尖瓣环位移、三尖瓣环位移差异有统计学意义(P0.05)。6.孕晚期,差控组、优控组与对照组胎儿左、右心室射血分数、二尖瓣E/A比值、二尖瓣E/Em比值、三尖瓣E/A比值、三尖瓣E/Em比值、二尖瓣环位移、三尖瓣环位移差异有统计学意义(P0.05)。其中,优控组与对照组比较,差异无统计学意义(P0.05)。7.孕产妇血浆BNP水平与胎儿E/EmMV、E/EmTV、MAD、TAD呈中度相关,相关系数分别为(r=0.482;0.578;0.420;0.519;P0.05)。结论1.高血糖水平可以使妊娠期糖尿病孕产妇及胎儿心脏结构及功能受损。2.血浆钠尿肽水平与孕产妇、胎儿心脏舒张功能指标呈正相关。
[Abstract]:Background cardiac function reserve refers to the ability of the body to do extra work under severe stress, such as major operation, trauma, and fatigue. The heart function reserve is closely related to heart function. The better the heart function reserve is, the lower the possibility of heart failure. For pregnant and lying in and lying in the pregnant and lying in pregnant women, the system and organs of the mother body are all in the whole pregnancy. A series of physiological changes occurred. With the prolonged pregnancy, the most significant changes in the circulation system, the aggravation of the heart load, the decrease of the cardiac reserve function in the pregnant and late pregnant women. Any damage to the cardiac function of the pregnant and parturient can further reduce the cardiac function reserve. During pregnancy, the maternal heart is in a high capacity load state. A significant increase in work load, in the process, caused by any cause of the patient's maternal cardiac tissue damage, and the fatigue of the myocardium, significantly reduced the pump function, reduced the total effective oxygen supply, tissue hypoxia, the supply of oxygen and nutrients in the fetus and the metabolism of tissue cells, some serious patients, and the maternal and infant safety. Gestational diabetes mellitus (GDM) refers to abnormal glucose tolerance associated with pregnancy during pregnancy without a history of diabetes or not diagnosed as diabetes. Previous data show that maternal hyperglycemia may have adverse effects on pregnant women and fetus during pregnancy, leading to clinical trials. The incidence of perinatal complications increases, which seriously affects the life safety of pregnant women and the prognosis of the newborn. Previous studies have shown that long-term high glucose stimulation can lead to chronic microinflammatory reaction in the patient. The function of vascular endothelial cells, cardiac hypertrophy, and myocardial cell degeneration may lead to the incidence of cardiovascular and cerebrovascular diseases. In gestation, in pregnant women with late pregnancy, with the prolonged pregnancy time, the changes of estrogen and progesterone and related growth factor levels in the body stimulate the telangiectasia in the whole body, which leads to a significant increase in the effective circulation blood flow in the pregnant and lying in and in the pregnant and lying in the body, the oxygen consumption in the tissue cells in the peripheral body is accelerated, and the normal growth and development metabolism of the fetus in the late pregnancy is accelerated. When the maternal blood oxygen supply is increased, the maternal and infant physiological changes in the middle and late pregnancy make the maternal cardiac pump function rise and the heart load increase rapidly. At this time, the cardiac function reserve is very important to maintain the normal metabolism of the body. The long-term hyperglycemia of.GDM patients can be transferred to the fetus through placenta, forming fetal hyperglycemia, stimulating fetal insulin release and forming giant infants, affecting fetal lung development and increasing the incidence of fetal acute respiratory distress syndrome. In the middle and late pregnancy, the fetal heart is in rapid growth and functional changes. What is the effect of fetal hyperglycemia on cardiac development and functional changes? The purpose of this study is to explore the effects of elevated blood glucose on gestational diabetes and fetal heart function at different levels of blood glucose in order to provide a scientific basis for the heart management of patients with gestational glycuria. The effect of different blood sugar levels on the maternal and fetal cardiac function in the middle pregnancy and the late trimester of pregnancy. Method 1. The object of study was to select 210 pregnant women with gestational diabetes from 09 months to December 2016 2013, age 25~40 years, average age (33.69 + 8.17) years, pregnant 23~25 weeks, and average gestational weeks (23.18 + 1.74) weeks, all Single fetal pregnancy, first ultrasound examination excluded congenital structural malformation.2, study group: the group was divided into three groups. According to the level of blood glucose control during pregnancy, 135 cases of blood glucose control group (excellent control group) and 72 cases of poor control group (difference control group), 80 cases of healthy pregnant and lying in the control group were selected as the control group at the same time. Like.3, study methods: the group of pregnant women and the three groups of pregnant and parturients and fetal heart cavity structure and function parameters were detected by echocardiography in the middle stage of pregnancy (pregnant 26~27 weekend) and in the third trimester of pregnancy (> 28 gestational weeks). The serum hypersensitivity C reverse protein level (hs-CRP, mg/L) was measured by latex enhanced immunoturbidimetry (hs-CRP, mg/L), and the immunofluorescence method was used to detect the blood. Plasma natriuretic peptide (BNP, pg/mL).4, ultrasound index: (1) maternal cardiac index: left ventricular ejection fraction (LVEF,%), left ventricular end diastolic diameter (LVEDd, mm); left ventricular end systolic diameter (LVEDs, mm); left atrium diameter (LAD); ventricular septum thickness (IVST, mm); left ventricular posterior wall thickness (LVPWT,); mitral valve filling velocity / mitral valve The velocity of late filling (E/A); the velocity of early diastolic filling of mitral valve / early diastolic mitral annulus velocity peak ratio (E/Ea). (2) fetal cardiac structural parameters: diastolic left ventricular posterior wall thickness (LVPWd, mm), diastolic interventricular septum thickness (IVSd, mm), right ventricular anterior wall thickness (RVAW, mm, aorta diameter (AO, mm), pulmonary artery, and pulmonary artery) PA (mm). (3) fetal cardiac function parameters: left, right ventricular ejection fraction (%), three apical valve E/A ratio (E/ATV), mitral valve E/A ratio (E/AMV), mitral valve E/Em ratio (E/Em MV), three apex E/A ratio (E/ATV), mitral annular displacement (MAD), three apex annular displacement. Results the left ventricular ejection of pregnant women in the middle of 1. pregnancy, differential control group and control group The difference of blood fraction, LVEDd, LVEDs, LAD, IVST, LVPWT was not statistically significant (P0.05).E/A, E/Ea, plasma natriuretic peptide and serum C reactive protein level difference was statistically significant (P0.05). The difference between the difference control group and the optimal control group, the difference control group and the control group, were statistically significant. The superior control group was compared with the control group. There was no statistical significance (P0.05) in the late pregnancy (.2.). There was no significant difference in left ventricular ejection fraction and left ventricular end systolic diameter (P0.05). Left ventricular end diastolic diameter, left atrium diameter, interventricular septum thickness, left ventricular posterior wall thickness, E/A, E/Ea, plasma natriuretic peptide and serum C reactive protein level. The difference was statistically significant (P0.05). The differences in LVEDd, LVEDs, LAD, IVST, LVPWT, E/A, E/Ea, hs-CRP, BNP were statistically significant (P0.05) in the difference control group and the control group, and the difference in E/A, E/Ea, hs-CRP and BNP was statistically significant (P0.05). Diastolic left ventricular posterior wall thickness, diastolic interventricular septum thickness, diastolic right ventricular anterior wall thickness, aortic diameter, pulmonary artery diameter difference was not statistically significant (P0.05).4. late pregnancy, differential control group, optimal control group and control group fetal diastolic left ventricular posterior wall thickness, active pulse internal diameter difference was not statistically significant (P0.05). Diastolic interventricular septum thickness Degree, diastolic right ventricle anterior wall thickness, pulmonary artery diameter difference was statistically significant (P0.05).5. mid pregnancy, differential control group, excellent control group and control group fetal left, right ventricular ejection fraction, mitral valve E/A ratio (E/AMV), mitral valve E/Em ratio difference was not statistically significant (P0.05). Three apical valve E/A ratio, three tip E/Em ratio, mitral valve ring displacement, three tips There was significant difference in the displacements of the valvular ring (P0.05).6. in the late pregnancy, in the difference control group, the left, right ventricular ejection fraction, the mitral valve E/A ratio, the mitral valve E/Em ratio, the three apical valve E/A ratio, the three apical valve E/A ratio, the mitral valve E/Em ratio, the mitral valve ring displacement, and the three apical annulus displacement were statistically significant (P0.05). The superior control group was compared with the control group. The difference was not statistically significant (P0.05) the level of plasma BNP in.7. pregnant and parturient was moderately related to fetal E/EmMV, E/EmTV, MAD, TAD, and the correlation coefficient was (r=0.482; 0.578; 0.420; 0.519; P0.05). Conclusion the level of 1. hyperglycemia in gestational diabetes pregnant and parturient women and fetal heart structure and function impaired.2. plasma natriuretic peptide level and pregnant and parturient women, fetus The index of cardiac diastolic function was positively correlated.

【学位授予单位】：新乡医学院
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R714.256

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