本文選題：妊娠期糖尿病 + 血糖�。� 參考：《新鄉(xiāng)醫(yī)學(xué)院》2017年碩士論文

【摘要】：背景心臟功能儲備是指機體在大手術(shù)、創(chuàng)傷、勞累等嚴(yán)重應(yīng)激狀態(tài)下,心臟額外做功的能力。心臟功能儲備高低與心功能關(guān)系密切。心臟功能儲備越好,心臟功能衰竭的可能性越低。對于孕產(chǎn)婦來說,整個妊娠過程中母體各個系統(tǒng)及器官均發(fā)生了一系列生理變化。隨著孕期延長,以循環(huán)系統(tǒng)變化最為顯著,心臟負(fù)荷加重,孕中、末期產(chǎn)婦心臟儲備功能明顯下降。任何導(dǎo)致孕產(chǎn)婦心臟功能的損傷都可進一步導(dǎo)致心臟功能儲備減少。妊娠期間,母體心臟處于高容量負(fù)荷狀態(tài),做功負(fù)荷顯著增加,在此過程中,任一原因?qū)е碌幕颊吣阁w心臟組織細(xì)胞損傷,心肌收縮乏力,均顯著減少泵功能射血能力,導(dǎo)致全身有效氧供減少,組織缺氧,影響胎兒血液氧與營養(yǎng)物質(zhì)供應(yīng)以及組織細(xì)胞代謝,部分嚴(yán)重患者,母嬰安全風(fēng)險驟然上升。妊娠期糖尿病(gestational diabetes mellitus,GDM)是指既往無糖尿病病史或者未診斷為糖尿病人群,在妊娠期間,發(fā)生與妊娠相關(guān)的糖耐量異常。既往資料顯示妊娠期,母體出現(xiàn)高血糖狀態(tài)可能對孕婦及胎兒造成不良影響,導(dǎo)致臨床相關(guān)圍生期并發(fā)癥發(fā)生率升高,嚴(yán)重影響孕婦生命安全和新生兒預(yù)后。既往有研究顯示長期的高糖刺激可導(dǎo)致患者體內(nèi)處于慢性微炎癥反應(yīng)狀態(tài)。患者血管內(nèi)皮細(xì)胞功能受損,心肌肥大,心肌細(xì)胞變性,導(dǎo)致臨床心腦血管疾病發(fā)生率升高。孕中、晚期正常妊娠者,隨著妊娠時間延長,體內(nèi)雌孕激素及相關(guān)生長因子水平變化,刺激全身毛細(xì)血管擴張,導(dǎo)致孕產(chǎn)婦體內(nèi)有效循環(huán)血流量顯著增加,外周機體組織細(xì)胞氧耗加快,同時也由于孕后期胎兒正常生長發(fā)育代謝加快,對于母體血液氧供增加,孕中后期母嬰生理變化使母體心臟泵功能顯著上升,心臟負(fù)荷快速增加,此時,心臟功能儲備量對于維持機體正常代謝極為重要。妊娠期,母體血糖的波動變化,對于心肌細(xì)胞正常代謝是否產(chǎn)生一定影響,目前尚缺乏研究。GDM患者母體長期高血糖可通過胎盤轉(zhuǎn)移到胎兒體內(nèi),形成胎兒高血糖狀態(tài),刺激胎兒胰島素釋放增加,形成巨大兒,影響胎兒肺臟發(fā)育,導(dǎo)致胎兒急性呼吸窘迫綜合征發(fā)生率增加。孕中晚期,胎兒心臟處于快速成長及功能變化期。那么,胎兒高血糖狀態(tài)對于心臟發(fā)育及功能變化是否存在影響,尚缺乏研究。課題研究目的試探討在不同血糖水平狀態(tài)下,血糖升高對于妊娠期糖尿病患者與胎兒心臟功能的影響,以期為妊娠期糖尿病患者的心臟管理提供科學(xué)依據(jù)。目的探討不同血糖水平對于孕中期、孕晚期妊娠期糖尿病患者孕產(chǎn)婦及胎兒心臟功能影響。方法1、研究對象:選擇2013年09月至2016年12月診斷為妊娠期糖尿病孕產(chǎn)婦210例,年齡25~40歲,平均年齡(33.69±8.17)歲,孕23~25周,平均孕周(23.18±1.74)周,均為單胎妊娠,初次超聲檢查排除胎兒先天性結(jié)構(gòu)畸形。2、研究分組:入組對象分為三組。娠期糖尿病患者依據(jù)孕期血糖控制水平分為血糖控制良好組(優(yōu)控組)135例與血糖控制不良組(差控組)72例,同期選擇健康孕產(chǎn)婦80例作為對照組研究對象。3、研究方法:入組對象分別與孕中期(孕26~27周末)、孕晚期(≥28孕周)采用超聲心動圖檢測三組孕產(chǎn)婦及胎兒心腔結(jié)構(gòu)及功能參數(shù)變化。采用乳膠增強免疫比濁定量檢測孕產(chǎn)婦血清超敏C反應(yīng)蛋白水平(hs-CRP,mg/L),采用免疫熒光法檢測血漿鈉尿肽(BNP,pg/mL)。4、超聲指標(biāo):⑴孕產(chǎn)婦心臟檢查指標(biāo):左室射血分?jǐn)?shù)(LVEF,%)、左心室舒張末期內(nèi)徑(LVEDd,mm);左心室收縮末期內(nèi)徑(LVEDs,mm);左心房內(nèi)徑(LAD);室間隔厚度(IVST,mm);左室后壁厚度(LVPWT,mm);二尖瓣舒張早期充盈的速度/二尖瓣舒張晚期充盈的速度(E/A);二尖瓣舒張早期充盈的速度/心肌舒張早期二尖瓣環(huán)根部運動速度的峰值比(E/Ea)。⑵胎兒心臟結(jié)構(gòu)參數(shù):舒張期左心室后壁厚度(LVPWd,mm)、舒張期室間隔厚度(IVSd,mm)、右心室前壁厚度(RVAW,mm、主動脈內(nèi)徑(AO,mm)、肺動脈內(nèi)徑(PA,mm)。⑶胎兒心臟功能參數(shù):左、右心室射血分?jǐn)?shù)(%)、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)、二尖瓣環(huán)位移(MAD,mm)、三尖瓣環(huán)位移(TAD,mm)。結(jié)果1.孕中期,差控組、優(yōu)控組與對照組孕產(chǎn)婦左室射血分?jǐn)?shù)、LVEDd、LVEDs、LAD、IVST、LVPWT參數(shù)差異無統(tǒng)計學(xué)意義(P0.05)。E/A、E/Ea、血漿鈉尿肽、血清C反應(yīng)蛋白水平差異有統(tǒng)計學(xué)意義(P0.05)。其中,差控組與優(yōu)控組、差控組與對照組比較,E/A、E/Ea、hs-CRP、BNP差異均有統(tǒng)計學(xué)意義(P0.05)。優(yōu)控組與對照組比較,各指標(biāo)差異無統(tǒng)計學(xué)意義(P0.05)。2.孕晚期,差控組、優(yōu)控組與對照組孕產(chǎn)婦左室射血分?jǐn)?shù)、左心室收縮末期內(nèi)徑差異無統(tǒng)計學(xué)意義(P0.05)。左心室舒張末期內(nèi)徑、左心房內(nèi)徑、室間隔厚度、左室后壁厚度、E/A、E/Ea、血漿鈉尿肽、血清C反應(yīng)蛋白水平差異有統(tǒng)計學(xué)意義(P0.05)。其中,差控組與優(yōu)控組、差控組與對照組比較,LVEDd、LVEDs、LAD、IVST、LVPWT、E/A、E/Ea、hs-CRP、BNP差異均有統(tǒng)計學(xué)意義(P0.05)。優(yōu)控組與對照組比較,E/A、E/Ea、hs-CRP、BNP差異有統(tǒng)計學(xué)意義(P0.05)。3.孕中期,差控組、優(yōu)控組與對照組胎兒舒張期左心室后壁厚度、舒張期室間隔厚度、舒張期右心室前壁厚度、主動脈內(nèi)徑、肺動脈內(nèi)徑差異無統(tǒng)計學(xué)意義(P0.05)。4.孕晚期,差控組、優(yōu)控組與對照組胎兒舒張期左心室后壁厚度、主動脈內(nèi)徑差異無統(tǒng)計學(xué)意義(P0.05)。舒張期室間隔厚度、舒張期右心室前壁厚度、肺動脈內(nèi)徑差異有統(tǒng)計學(xué)意義(P0.05)。5.孕中期,差控組、優(yōu)控組與對照組胎兒左、右心室射血分?jǐn)?shù)、二尖瓣E/A比值(E/AMV)、二尖瓣E/Em比值差異無統(tǒng)計學(xué)意義(P0.05)。三尖瓣E/A比值、三尖瓣E/Em比值、二尖瓣環(huán)位移、三尖瓣環(huán)位移差異有統(tǒng)計學(xué)意義(P0.05)。6.孕晚期,差控組、優(yōu)控組與對照組胎兒左、右心室射血分?jǐn)?shù)、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、二尖瓣環(huán)位移、三尖瓣環(huán)位移差異有統(tǒng)計學(xué)意義(P0.05)。其中,優(yōu)控組與對照組比較,差異無統(tǒng)計學(xué)意義(P0.05)。7.孕產(chǎn)婦血漿BNP水平與胎兒E/EmMV、E/EmTV、MAD、TAD呈中度相關(guān),相關(guān)系數(shù)分別為(r=0.482;0.578;0.420;0.519;P0.05)。結(jié)論1.高血糖水平可以使妊娠期糖尿病孕產(chǎn)婦及胎兒心臟結(jié)構(gòu)及功能受損。2.血漿鈉尿肽水平與孕產(chǎn)婦、胎兒心臟舒張功能指標(biāo)呈正相關(guān)。
[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.

【學(xué)位授予單位】：新鄉(xiāng)醫(yī)學(xué)院
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R714.256

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