本文關(guān)鍵詞： 回顧性研究 前瞻性研究 低甲狀腺素血癥 妊娠結(jié)局 甲狀腺自身抗體　出處：《第二軍醫(yī)大學》2017年碩士論文　論文類型：學位論文

【摘要】：目的:1.探討妊娠期低甲狀腺素血癥對妊娠結(jié)局及胎兒影響,明確激素治療的可行性及需要補充激素的孕婦特征。2.了解妊娠婦女甲狀腺功能狀況并建立本單位妊娠期婦女血清甲狀腺檢測指標特異參考范圍。3.探究低甲狀腺素血癥對妊娠期各檢測指標的影響并尋找影響游離甲狀腺素(freethyroxine,FT4)水平的因素。明確甲狀腺篩查的時機和隨訪重點,為妊娠期婦女分類指導提供依據(jù)。方法:回顧性分析2014年11月~2015年10月我院產(chǎn)科1633例住院孕婦資料,包括妊娠期間及分娩時各項檢查、末次超聲、新生兒足跟血促甲狀腺激素(TSH)值等資料,分組比較相關(guān)指標差異。前瞻性收集2016年2月~2017年1月我院產(chǎn)科門診1596例孕婦建卡資料,建卡時規(guī)范甲狀腺功能檢測,跟蹤其中期糖尿病篩查結(jié)果、最后一次超聲檢查結(jié)果和生產(chǎn)基本情況。采用2011年美國甲狀腺學會(American throid association,ATA)指南標準統(tǒng)計各甲狀腺疾病發(fā)病情況,并分組進行比較。探討妊娠期低甲狀腺素血癥對妊娠期的影響、妊娠結(jié)局的不同、胎兒基本情況的差異,分析與低甲狀腺素血癥相關(guān)的因素,明確甲狀腺篩查的時機和隨訪情況。結(jié)果:回顧性研究中,在資料完整的1141例孕婦中,既往有甲狀腺疾病史者200例,血游離甲狀腺素(FT4)低于正常值189例,正常對照組752例。依據(jù)血FT4水平低于正常值5%、5%~10%及10%以上,分為A(n=60)、B(n=40)、C(n=89)三組。與正常對照組比較,C組早產(chǎn)、妊娠期糖尿病、剖宮產(chǎn)率明顯增高(P0.05),B組孕前高血壓和血脂異常率也明顯升高(P0.05)。B組、C組剖宮產(chǎn)率明顯高于A組,且C組明顯高于正常對照組(P0.05)。分娩時C組孕婦年齡、體重、體質(zhì)指數(shù)、舒張壓及末次超聲胎兒頭圍均大于正常對照組孕婦(P0.01),但新生兒孕周(38.55±1.86周)小于正常對照組孕婦(39.14±1.57周,P0.01)。除去懷孕時發(fā)現(xiàn)甲狀腺功能異常及(或)既往有甲狀腺疾病史者200例,依據(jù)TPOAb水平是否陽性分組,TPOAb陽性組孕婦的糖化血紅蛋白水平(8.9±5.89%VS5.36±0.99%)和白蛋白/球蛋白比值(1.86±3.66VS1.43±0.20)明顯高于TPOAb陰性組(P0.01)(P0.05),而FT4水平明顯低于TPOAb陰性組(P0.05)。前瞻性研究中,得到本院妊娠婦女血清甲狀腺功能指標參考值范圍:早期妊娠:FT3 3.95-6.76 Pmol/L;FT4 12.38-22.47Pmol/L;TSH 0.01-5.17 m IU/L。中期妊娠:FT33.72-6.05Pmol/L;FT4 11.22-19.01Pmol/L;TSH 0.05-4.87 mIU/L。早期妊娠組建卡宮底高度、FT3、FT4、AST、TC、HbA1c、OGTT空腹血糖水平明顯高于中期妊娠組(p0.05)(p0.01)。低FT4組建卡孕周、年齡、體重、BMI、建卡時宮低高度大于正常對照組,TPOAb、WBC、中性粒細胞百分比、TC、TG、LDL-C水平、HbA1c值明顯高于正常對照組(p0.05)(p0.01);但身高、舒張壓、胎心、血色素、FT3、FT4、淋巴細胞百分率、HGB、紅細胞比積、白/球、血葡萄糖水平、肌酐水平明顯低于正常對照組(p0.05)(p0.01)。早期妊娠中,G組孕婦年齡明顯大于H組(32.71±2.81歲vs 29.51±3.87歲)(p0.05);中期妊娠中,I組建卡孕周明顯大于J組,TPOAb、肌酐、尿酸、HbA1c水平高于J組(p0.01)。低FT4組難產(chǎn)率(51.85%vs 41.31%)、胎盤粘連率(2.78%vs0.14%)、人工授精率(9.23%vs 4.90%)均明顯高于甲狀腺功能正常組(p0.05);但妊娠期糖尿病發(fā)生率低于該組(p0.05)。TPOAb(+)孕婦(106名)各甲狀腺功能異常情況發(fā)生率均高于全體孕前甲狀腺功能正常孕婦(1529名),但僅有亞臨床甲減有統(tǒng)計學差異(p0.05)。TPOAb(+)組TSH明顯高于TPOAb(-)組(p0.05);建卡孕周、ALT、AST水平均低于TPOAb(-)組(p0.05)。早期妊娠建卡孕婦,建卡時甲亢者復查率(100%)復查甲功正常率(60%)均最高;中期妊娠建卡孕婦,建卡時甲減者復查率(76.19%)最高,亞臨床甲減復查甲功正常率(15.78%)最高。結(jié)論:1、回顧性和前瞻性研究均提示妊娠期HT發(fā)病率日漸上升,且無論血TPOAb是否陽性,HT對妊娠結(jié)局及胎兒均會造成不同程度的影響。2、高齡及超重可能增加孕婦HT的發(fā)生風險,HT可能與孕婦糖調(diào)節(jié)異常間存在一定的相關(guān)性。3、TPOAb陽性可能對FT4、TSH水平及糖代謝異常有一定提示作用。4、建議應重視妊娠早期孕婦的甲功檢查,并依據(jù)病情制定相應診療計劃。
[Abstract]:Objective: 1. to investigate gestational hypothyroxinemia effect on the outcome of pregnancy and fetus, pregnant women.2. feasibility of hormone therapy and clear understanding of pregnant women need to supplement the hormone thyroid function status and establish the unit period of serum thyroid specific indexes of women reference range of.3. on pregnancy hypothyroxinemia indexes of pregnancy and to find effect effect of free thyroxine (freethyroxine, FT4) level factors. Clear time and follow-up focus on thyroid screening, provide the basis for the guidance of pregnant women. Methods: a retrospective analysis of the November 2014 ~2015 year in October in our hospital 1633 cases of hospitalized pregnant women during pregnancy and delivery, including the inspection, at the time of ultrasound, neonatal heel serum thyroid stimulating hormone (TSH) value data, comparing the differences of related index. Prospectively collected from February 2016 to January 2017 Gynecology clinic data of 1596 cases of pregnant women Jianka, Jianka standard thyroid function detection, tracking results of screening of diabetes during the last ultrasound examination results and the basic conditions of production. By 2011 the American Thyroid Association (American Throid, association, ATA) for each standard statistical incidence of thyroid disease, and pregnancy were compared. Hypothyroxinemia effect on pregnancy, pregnancy outcome, difference in the basic situation of the fetus, analysis of factors associated with hypothyroxinemia, clear thyroid screening time and follow-up. Results: in the retrospective study, the data of 1141 pregnant women in the complete history of 200 cases of thyroid disease history, blood free thyroxine (FT4) lower than normal in 189 cases, 752 cases of normal control group. On the basis of the blood FT4 level lower than the normal value of 5%, more than 5%~10% and 10%, divided into A (n=60), B (n= 40), C (n=89) three groups. Compared with normal control group, C group, preterm birth, gestational diabetes, the rate of cesarean section increased significantly (P0.05), B group, pre hypertension and dyslipidemia rate was significantly higher (P0.05).B group, C group, the cesarean section rate was significantly higher than A group, and C group was higher than the normal control group (P0.05). C group of childbirth maternal age, body weight, body mass index, diastolic blood pressure and the end time of ultrasonic fetal head circumference were higher than normal pregnant women in the control group (P0.01), but the neonatal gestational age (38.55 + 1.86 weeks) less than normal pregnant women in the control group (39.14 + 1.57 weeks, in addition to P0.01). To find the abnormal thyroid function during pregnancy and (or) 200 cases had a history of thyroid disease, according to the TPOAb level is positive group, HbA1c levels in TPOAb positive group (8.9 + 5.89%VS5.36 + 0.99%) and albumin / globulin ratio (1.86 + 3.66VS1.43 + 0.20) was significantly higher than TPOAb negative group (P0.01) (P0.05), while the level of FT4 TPOAb was significantly lower than the negative group (P0.05). The prospective study, the serum thyroid function of women of pregnancy index reference value range: early pregnancy: FT3 3.95-6.76 Pmol/L; FT4 12.38-22.47Pmol/L; TSH 0.01-5.17 m IU/L. FT4 11.22-19.01Pmol/L mid pregnancy: FT33.72-6.05Pmol/L; TSH; 0.05-4.87 mIU/L. early pregnancy form card fundal height, FT3, FT4. AST, TC, HbA1c, fasting blood glucose level of OGTT was significantly higher than that in mid pregnancy group (P0.05) (P0.01). The formation of low FT4 card gestational age, body weight, BMI, when the house of cards low height is greater than the normal control group, TPOAb, WBC, neutrophil percentage, TC, TG, LDL-C level, HbA1c value significantly higher than the normal control group (P0.05) (P0.01); but the height, diastolic blood pressure, fetal heart rate, hemoglobin, FT3, FT4, HGB, lymphocyte percentage, hematocrit, albumin / globulin, blood glucose level, serum creatinine levels were significantly lower than the normal control group (P0.05) (P0.01). 鏈熷濞犱腑,G緇勫瓡濡囧勾榫勬槑鏄懼ぇ浜嶩緇，

本文編號：1442031