葉文 方曉紅 王連云 熊文棟 童夏 王繁
[摘要] 目的 研究正念行走對高危孕婦預(yù)防子癇前期的可行性,同時評價正念行走與阿司匹林對子癇前期預(yù)防的有效性。 方法 選取2018年1月至2019年12月在溫州醫(yī)科大學(xué)附屬第二醫(yī)院產(chǎn)科治療的妊娠期高血壓高危孕婦,隨機(jī)分為三組,均進(jìn)行正常產(chǎn)檢流程,試驗組(n=28)進(jìn)行正念行走鍛煉,給藥組(n=28)服用低劑量阿司匹林,對照組(n=31)無干預(yù)措施。分析三組高危孕婦的母胎結(jié)局。 結(jié)果 試驗組和給藥組孕婦妊娠期高血壓發(fā)生率(10.71%、10.71%)略高于對照組(6.50%),但子癇前期發(fā)生率(3.60%、0.00%)顯著低于對照組(22.60%),三組比較,差異有統(tǒng)計學(xué)意義(P<0.05)。對照組IUGR發(fā)生率(22.60%)高于試驗組(0.00%)和給藥組(10.71%),三組比較,差異有統(tǒng)計學(xué)意義(P<0.05)。試驗組新生兒出生體重為(3503.57±402.52)g大于給藥組的(3079.29±452.64)g和對照組的(3024.50±662.99)g,三組比較,差異有統(tǒng)計學(xué)意義(P<0.05)。 結(jié)論 高危孕婦孕期進(jìn)行系統(tǒng)的正念行走干預(yù)或小劑量阿司匹林給藥,均對子癇前期的發(fā)生具有一定預(yù)防作用,正念行走訓(xùn)練無經(jīng)濟(jì)壓力、安全有效,可以作為預(yù)防子癇前期的有效措施之一。
[關(guān)鍵詞] 妊娠期高血壓;子癇前期;正念行走;高危孕婦
[中圖分類號] R714.24? ? ? ? ? [文獻(xiàn)標(biāo)識碼] B? ? ? ? ? [文章編號] 1673-9701(2021)12-0067-05
Study on the prevention of preeclampsia by mindful walking for high-risk pregnant women
YE Wen? ?FANG Xiaohong? ?WANG Lianyun? ?XIONG Wendong? ?TONG Xia? ?WANG Fan
Department of Obstetrics, the Second Affiliated Hospital of Wenzhou Medical University, Wenzhou? ?325000, China
[Abstract] Objective To study the feasibility of mindful walking in the prevention of preeclampsia for high-risk pregnant women, and to evaluate the effectiveness of mindful walking and aspirin in the prevention of preeclampsia. Methods The eligible pregnant women with high risk of hypertension during pregnancy were enrolled in the department of obstetrics in the Second Affiliated Hospital of Wenzhou Medical University from January 2018 to December 2019 were selected and randomly divided into three groups. All three groups were given a normal antenatal inspection process, the test group(n=28) was given mindful walking exercise, the medication group (n=28) was given low-dose aspirin, the control group (n=31) was given no intervention measures. The maternal and fetal outcomes of the three groups of high-risk pregnant women were analyzed. Results The prevalence of hypertension during pregnancy in the pregnant women in the test group and medication group (10.71%, 10.71%) was slightly higher than that in the control group (6.5%). However, the incidence rate of preeclampsia (3.6%, 0.00%) was significantly lower than that in the control group (22.6%), the differences between the three groups were statistically significant(P<0.05). The incidence rate of fetal intrauterine growth restriction in the pregnant women in the control group (22.60%) was higher than that in the test group(0.00%) and medication group (10.71%), the differences between the three groups were statistically significant (P<0.05). The birth weight of newborns in the test group(3503.57±402.52) g was greater than that in the medication group(3079.29±452.64) g and the control group (3024.50±662.99) g, the differences between the three groups were statistically significant (P<0.05). Conclusion Systematic mindful walking intervention or low-dose aspirin administration during pregnancy for high-risk pregnant women have a certain preventive effect on the occurrence of preeclampsia. Mindful walking training has no economic pressure, it is safe and effective, can be used as one of the effective measures to prevent preeclampsia.
[Key words] Pregnancy-induced hypertension; Preeclampsia; Mindful walking; High-risk pregnant women
妊娠期高血壓是一種嚴(yán)重危害母嬰安全的孕產(chǎn)期常見并發(fā)癥,是導(dǎo)致孕產(chǎn)婦和圍生兒疾病及死亡的主要原因之一。妊娠期高血壓目前除終止妊娠外,尚無有效的治療方法,因此,如何預(yù)防是目前研究的熱點。近年來,補(bǔ)充與替代療法預(yù)防子癇前期成為一種流行趨勢,其中,中低強(qiáng)度運(yùn)動對子癇前期有一定的保護(hù)作用[1-2]。正念覺知干預(yù)[3]作為一種安全、無介入的非藥物治療方式,也是一種微量運(yùn)動方式,在減輕壓力、改善抑郁[4]、降低血壓[5]等方面具有顯著的臨床效果。作為正念覺知干預(yù)一個方面的正念行走干預(yù),以其結(jié)合輕微運(yùn)動和冥想干預(yù)為一體的優(yōu)點,表現(xiàn)出增進(jìn)精神健康的效應(yīng)[6-7]。目前,臨床有關(guān)正念行走與高危妊娠的研究較少,尚未見到正念行走與子癇前期預(yù)防的臨床研究。因此,本研究通過臨床病例對照試驗,研究正念行走預(yù)防高危孕婦子癇前期的可行性,現(xiàn)報道如下。
1 資料與方法
1.1一般資料
選取2018年1月至2019年12月在溫州醫(yī)科大學(xué)附屬第二醫(yī)院產(chǎn)科治療的妊娠期高血壓高危孕婦。納入標(biāo)準(zhǔn):根據(jù)美國預(yù)防服務(wù)工作組對妊娠期高血壓制訂的中高危因素標(biāo)準(zhǔn)[8],符合下列1個高危因素或2個及以上中危因素即可入選。高危因素:有慢性高血壓或Ⅰ/Ⅱ型糖尿病;具有下列2個或以上中危因素視為高危:①年齡大于35歲;②肥胖,體質(zhì)量指數(shù)(Body mass index,BMI)>30 kg/m2;③母親或姐妹有子癇前期病史;④初產(chǎn)婦;⑤個體因素:如既往有小于胎齡兒生育史、不良孕產(chǎn)史、與上一次妊娠間隔10年以上;⑥低收入人群。排除標(biāo)準(zhǔn):根據(jù)國內(nèi)2020年妊娠期高血壓指南[9],排除明確推薦使用阿司匹林的高危因素:子癇前期病史、胎兒宮內(nèi)生長受限(Intrauterine growth restriction,IUGR)、胎盤早剝病史、腎臟病史及高凝情況者;首次產(chǎn)檢時間超過16周或首次尿常規(guī)檢查尿蛋白呈陽性;多胎妊娠、宮頸機(jī)能不全;合并智力障礙、伴有精神疾病;合并行走障礙,如嚴(yán)重的恥骨聯(lián)合分離、下肢殘疾,骨折恢復(fù)期等;不同意參與本研究。符合上述條件的孕婦共104例,采用隨機(jī)數(shù)字表法分為三組,試驗組35例、給藥組34例、對照組35例,最終獲得有效數(shù)據(jù)試驗組28例、給藥組28例、對照組31例。本研究經(jīng)醫(yī)院醫(yī)學(xué)倫理委員會批準(zhǔn),所有患者簽署知情同意書。
1.2方法
三組均按照孕期保健指南[10]方案進(jìn)行產(chǎn)檢。試驗組在孕20~36周接受專業(yè)正念訓(xùn)練師指導(dǎo)下的正念行走培訓(xùn),并且維持至少20 min/次,4次/周,并通過微信打卡追蹤練習(xí)情況;給藥組在孕12~36周服用阿司匹林(BayerS.p.A,國藥準(zhǔn)字J20130078,批號:H20130192,規(guī)格:100 mg)100 mg,1次/d;對照組無其他干預(yù)措施。
正念行走訓(xùn)練主要內(nèi)容[11]如下:①尋找一處安靜不受打擾的路徑;②走路,數(shù)步伐,數(shù)10~15步暫停,停的時間長短隨意,回轉(zhuǎn)再走,如此周而復(fù)始;③走路時注意感知身體的每一個動作:舉步、行走中腳的移動、落步、感知身體重心的移動,如此周而復(fù)始;④保持自然速度,不刻意追求快走;⑤雙手可背在身后,亦可自然甩動;⑥感知呼吸的進(jìn)出和頭部的平衡,目光正視前方;⑦當(dāng)注意力不在身體感覺上、思想散漫到別處事物時,重新將注意力放回對身體的感知上;⑧當(dāng)正念行走逐漸熟練后,嘗試將其融合到日常生活中,養(yǎng)成“活在當(dāng)下”的習(xí)慣。
1.3觀察指標(biāo)及評價標(biāo)準(zhǔn)
主要觀察指標(biāo)包括人口學(xué)資料、高危因素、體格檢查、輔助檢查、有效性比較。主要有效性指標(biāo)包括妊娠期高血壓、子癇前期發(fā)生率;次要有效性指標(biāo)包括分娩孕齡及分娩方式、IUGR、早產(chǎn)、產(chǎn)后出血發(fā)生率及新生兒出生體重。妊娠期高血壓及子癇前期診斷標(biāo)準(zhǔn)參考妊娠期高血壓指南[11]。
1.4統(tǒng)計學(xué)方法
應(yīng)用SPSS 22.0統(tǒng)計學(xué)軟件進(jìn)行數(shù)據(jù)分析,符合正態(tài)分布且方差齊的計量資料用(x±s)表示,采用單因素方差分析;不符合正態(tài)分布或方差不齊的計量資料用[M(QL,QU)]表示,采用非參數(shù)秩和檢驗;計數(shù)資料用[n(%)]表示,采用χ2檢驗或Fisher精確概率法,P<0.05為差異有統(tǒng)計學(xué)意義。
2 結(jié)果
2.1 三組一般資料比較
三組一般資料比較,差異無統(tǒng)計學(xué)意義(P>0.05),具有可比性。
2.2三組孕中期子宮動脈血流動力學(xué)參數(shù)比較
三組孕22~24周B超監(jiān)測子宮動脈血流動力學(xué)參數(shù),搏動指數(shù)(Pulse index,PI)、阻力指數(shù)(Resistive index,RI)、收縮期峰值流速/舒張期流速(The ratio of the systolic peak value and the end-diastolic velocity of blood flow,S/D)、子宮動脈舒張期早期切跡比較,差異均無統(tǒng)計學(xué)意義(P>0.05)。但子宮動脈血流參數(shù)PI、RI、S/D高于同孕齡正常均值(0.89、0.55、2.23)。
2.3三組母胎結(jié)局比較
三組分娩前BMI、分娩孕齡比較,差異無統(tǒng)計學(xué)意義(P>0.05);試驗組和給藥組妊娠期高血壓發(fā)生率略高于對照組,但是子癇前期發(fā)生率顯著低于對照組,三組比較,差異有統(tǒng)計學(xué)意義(P<0.05);三組早產(chǎn)、產(chǎn)后出血比較,差異無統(tǒng)計學(xué)意義(P>0.05);對照組孕婦IUGR發(fā)生率高于試驗組和給藥組,三組比較,差異有統(tǒng)計學(xué)意義(P<0.05);三組均未發(fā)生新生兒窒息;試驗組新生兒體重大于對照組和給藥組,三組比較,差異有統(tǒng)計學(xué)意義(P<0.05),其中試驗組與對照組、試驗組與給藥組比較,差異均有統(tǒng)計學(xué)意義(P<0.05)。。
3 討論
妊娠期高血壓是孕婦特有的較常見的并發(fā)癥,發(fā)病率為5%~10%,嚴(yán)重威脅孕產(chǎn)婦生命安全,是導(dǎo)致早產(chǎn)、低出生體重兒等不良出生結(jié)局的原因,更是導(dǎo)致圍產(chǎn)兒死亡的重要原因之一,為此,積極探索妊娠期高血壓的預(yù)防及治療手段極為重要。
近年來,各種減壓治療方法被應(yīng)用于慢性高血壓患者的降壓治療[5],特別是正念干預(yù)在降壓臨床治療中越來越流行。同時,研究證實運(yùn)動能夠改善血管內(nèi)皮功能、降低動脈硬化、誘導(dǎo)血管生成,能夠改善妊娠期間的心血管功能[12]、降低妊娠期高血壓的風(fēng)險[13]。正念行走作為正念覺知干預(yù)的分支之一,其結(jié)合了微量運(yùn)動和冥想療法,可以在不同場合,以不同速度進(jìn)行練習(xí),對自身不加批判,適當(dāng)?shù)卣{(diào)節(jié)呼吸,將注意力集中到自身行走的肢體運(yùn)動部位上,以獲得活在當(dāng)下的感受,從而達(dá)到減壓的目的[14]。正念行走干預(yù)具有輕微有氧運(yùn)動特性,其在改善精神健康[15-16]、減輕壓力、降低血壓[17]方面已有文獻(xiàn)證據(jù),但國內(nèi)外均未見到正念行走與子癇前期預(yù)防的相關(guān)性研究,因此,在溫州醫(yī)科大附屬第二醫(yī)院進(jìn)行了前瞻性隨機(jī)對照試驗。
妊娠中晚期子宮動脈的高阻抗已證明與80%以上的早期子癇前期發(fā)生風(fēng)險有關(guān)[18]。早發(fā)型子癇前期患者的子宮動脈血流與正常孕婦比較,差異有統(tǒng)計學(xué)意義(P<0.05);子癇前期(>34周)患者與正常孕婦比較,差異無統(tǒng)計學(xué)意義(P>0.05)。試驗組孕婦在孕20周開始進(jìn)行正念行走干預(yù),正常孕婦子宮螺旋動脈重鑄從妊娠第6周開始至第22~24周完成,故入組孕婦在20周之前可能已經(jīng)出現(xiàn)不同程度的子宮螺旋動脈重鑄障礙,正念行走干預(yù)可能無法逆轉(zhuǎn)此變化。作為預(yù)測指標(biāo)之一,本研究結(jié)果顯示,各組子宮動脈血流參數(shù)比較,差異無統(tǒng)計學(xué)意義(P>0.05),驗證了正念行走與服用阿司匹林預(yù)防子癇前期發(fā)生的結(jié)論。
有研究結(jié)果顯示,參加中等強(qiáng)度至高強(qiáng)度職業(yè)體育活動的孕婦比參加低強(qiáng)度活動的婦女患IUGR的風(fēng)險要高得多。本研究結(jié)果顯示,試驗組的新生兒出生體重大于給藥組和對照組[19]。研究結(jié)果顯示,IUGR的子宮動脈血流同樣存在高阻抗,特別在子癇前期孕婦中[20],文中三組孕婦的子宮動脈血流提示高阻抗,但是在最終結(jié)局中,對照組的IUGR發(fā)生率更高,三組孕婦中,試驗組新生兒體重較其他兩組孕婦更重。正念行走干預(yù)可使孕婦身心放松、改善胎盤血流灌注、促進(jìn)胎盤生長,使得妊娠期胎兒宮內(nèi)發(fā)育情況較對照組有一定改善,這可能與新生兒出生體重的增加有關(guān)。子癇前期、重度子癇前期的孕婦更容易發(fā)生IUGR,這可能也是影響其妊娠結(jié)局的原因之一。
近年來,學(xué)者們針對阿司匹林預(yù)防子癇前期進(jìn)行了大量研究[21-22],認(rèn)為阿司匹林可以預(yù)防早發(fā)型子癇前期,但對晚發(fā)型子癇前期無明顯影響。目前認(rèn)為子癇前期的潛在發(fā)生機(jī)制是胎盤異常導(dǎo)致胎盤缺血,廣泛性內(nèi)皮功能障礙影響胎盤和全身循環(huán),血小板分泌的血栓A2(Thromboxane A2,TXA2)增加,前列環(huán)素(Prostaglandins I2,PGI2)減少,而阿司匹林可以中斷其轉(zhuǎn)化。有研究結(jié)果顯示,運(yùn)動訓(xùn)練促進(jìn)胎盤生長,改善母體血管生成平衡[23]。本研究結(jié)果顯示,試驗組和給藥組的子癇前期發(fā)生率顯著低于對照組,可能是由于能堅持正念行走運(yùn)動的孕婦身心放松,且對正念行走的認(rèn)可度高、依從性強(qiáng)、練習(xí)認(rèn)真,形成良性循環(huán),進(jìn)而可以減少導(dǎo)致內(nèi)皮功能障礙的因素,從而改善胎盤循環(huán)。有研究結(jié)果顯示,正念冥想能使副交感神經(jīng)張力增加、降低交感神經(jīng)張力、調(diào)節(jié)交感神經(jīng)系統(tǒng)、減少孕婦日常感知的壓力,從而對妊娠期高血壓起到保護(hù)作用[24]。正念冥想下進(jìn)行行走訓(xùn)練,具有足夠的力量將注意力重新分配給與任務(wù)相關(guān)的思想,下調(diào)感知激活并增強(qiáng)情感反應(yīng),與右額葉皮質(zhì)和左顳頂葉區(qū)域之間的高頻波半球間連通性增強(qiáng)有關(guān),而盲目的冥想下行走可能會誘發(fā)更消極的情感狀態(tài),并在更大程度上上調(diào)感知激活[25]。本試驗中,研究對象本身存在相關(guān)高危因素,在妊娠這個特殊時期,更容易出現(xiàn)焦慮情緒,而正念行走恰好可幫助孕婦緩解孕期焦慮情緒、減輕壓力、促進(jìn)身心健康,從而改善母胎結(jié)局。
綜上所述,高危孕婦孕期進(jìn)行系統(tǒng)的正念行走干預(yù)或小劑量阿司匹林,均對子癇前期的發(fā)生具有一定預(yù)防作用,正念行走訓(xùn)練無經(jīng)濟(jì)壓力、安全有效,可以作為預(yù)防子癇前期的有效措施之一。
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(收稿日期:2020-12-01)