臍血皮質(zhì)醇的表達差異與雙胎生長不一致的關(guān)系

倪麗，吳兆勇

臍血皮質(zhì)醇的表達差異與雙胎生長不一致的關(guān)系

倪麗，吳兆勇

嘉興市婦幼保健院藥劑科，浙江嘉興 314000

研究胎兒臍血皮質(zhì)醇的表達差異與雙胎生長不一致的關(guān)系。選取2021年1月至2022年12月于嘉興市婦幼保健院診斷為雙絨毛膜雙胎的52對胎兒為研究對象，根據(jù)雙胎出生體質(zhì)量差是否≥15%將其分為DT組（胎兒生長不一致，25對）和CT組（胎兒生長一致，27對）。收集兩組孕婦及胎兒的相關(guān)臨床資料，比較兩組孕婦、雙胎胎兒間基本情況和兩組胎兒臍血的皮質(zhì)醇水平。兩組孕婦的年齡、分娩孕周、產(chǎn)次、孕前體質(zhì)量指數(shù)、受孕方式、分娩時間、雙胎是否同性比較，差異均無統(tǒng)計學(xué)意義（>0.05）；DT組和CT組胎兒的羊水深度、臍動脈SD值、臍帶繞頸情況、胎盤形狀、雙胎性別比較，差異均無統(tǒng)計學(xué)意義（>0.05）。DT組低體質(zhì)量胎兒的皮質(zhì)醇水平顯著高于高體質(zhì)量胎兒（<0.05），而CT組兩胎兒的皮質(zhì)醇水平比較差異無統(tǒng)計學(xué)意義（>0.05）。雙胎胎兒臍血中皮質(zhì)醇水平的差異可能與雙絨毛膜雙胎胎兒生長不一致有關(guān)。

雙胎生長不一致；皮質(zhì)醇；雙絨毛膜雙胎

雙胎生長不一致的定義是雙胎出生體質(zhì)量差異明顯，其診斷標(biāo)準(zhǔn)目前尚存爭議[1]。雙胎生長不一致的發(fā)生率隨著我國輔助生殖技術(shù)的日益成熟而不斷上升，是造成圍生期胎兒死亡的原因之一[2]。胎兒的宮內(nèi)發(fā)育受母體、環(huán)境、胎兒等因素的共同調(diào)節(jié)，研究顯示胎兒的出生體質(zhì)量可能與孕期暴露的各種激素水平有關(guān)，但導(dǎo)致雙胎生長不一致的原因尚不明確[3-4]。皮質(zhì)醇作為一種糖皮質(zhì)激素，其對胎兒體質(zhì)量的影響已有報道，研究顯示胎兒過多地暴露于糖皮質(zhì)激素會導(dǎo)致胎兒出生體質(zhì)量偏低[5]，但皮質(zhì)醇水平對雙胎生長不一致的作用卻未見報道。本研究以雙絨毛膜雙胎生長不一致胎兒為研究對象，通過化學(xué)發(fā)光法測定胎兒臍血中皮質(zhì)醇的含量來研究胎兒臍血皮質(zhì)醇的表達差異與雙胎生長不一致的關(guān)系，以期為臨床提供預(yù)防、治療依據(jù)。

1 資料與方法

1.1 研究對象

選取2021年1月至2022年12月于嘉興市婦幼保健院診斷為雙絨毛膜雙胎的52對胎兒為研究對象。納入標(biāo)準(zhǔn)：①雙絨毛膜雙胎妊娠、胎兒無畸形；②剖宮產(chǎn)胎兒娩出后收集胎兒臍靜脈血，進行化學(xué)發(fā)光法檢測；③孕婦及胎兒病歷資料完整。排除標(biāo)準(zhǔn)：①胎兒先天畸形；②孕婦產(chǎn)前接受過激素治療，接受過糖、脂代謝等藥物治療；③孕婦合并妊娠糖尿病、妊娠高血壓、甲狀腺功能亢進、甲狀腺功能減退、多囊卵巢綜合征等。根據(jù)雙胎出生體質(zhì)量差是否≥15%將其分為DT組（胎兒生長不一致，25對）和CT組（胎兒生長一致，27對）。本研究符合《世界醫(yī)學(xué)協(xié)會赫爾辛基宣言》相關(guān)要求，并經(jīng)嘉興市婦幼保健院倫理委員會審議通過[倫理審批號：2020（醫(yī)倫）–1]。所有參與研究的孕婦均簽署知情同意書。

1.2 方法

根據(jù)病歷記載的信息，收集兩組孕婦及新生兒的基本信息，包括年齡、孕周、孕次、產(chǎn)次、受孕方式、分娩時間、雙胎性別、孕期羊水深度、臍動脈SD值、臍帶繞頸情況、胎盤形狀、出生體質(zhì)量等。相關(guān)診斷標(biāo)準(zhǔn)參考第9版《婦產(chǎn)科學(xué)》。剖宮產(chǎn)當(dāng)天胎兒娩出后，新生兒稱重、采集臍靜脈血2ml，3500轉(zhuǎn)/min離心5min，取血清，化學(xué)發(fā)光法測定臍血中皮質(zhì)醇含量。

1.3 統(tǒng)計學(xué)方法

2 結(jié)果

2.1 兩組孕婦、胎兒的基本情況比較

兩組孕婦的年齡、分娩孕周、產(chǎn)次、孕前體質(zhì)量指數(shù)（body mass index，BMI）、受孕方式、分娩時間、雙胎是否同性別比較，差異均無統(tǒng)計學(xué)意義（>0.05），見表1。DT組每對雙胎中體質(zhì)量較大的為大孩、較小的為小孩，CT組因每對雙胎體質(zhì)量接近，隨機分為A孩、B孩。DT組和CT組胎兒的羊水深度、臍動脈SD值、臍帶繞頸情況、胎盤形狀、雙胎性別比較，差異均無統(tǒng)計學(xué)意義（>0.05），見表2。

表1 兩組孕婦的基本情況比較[n（%）]

表2 兩組胎兒的基本情況比較[n（%）]

2.2 兩組胎兒的臍血皮質(zhì)醇水平比較

DT組小孩的皮質(zhì)醇水平顯著高于大孩（<0.05），而CT組A孩與B孩的皮質(zhì)醇水平比較差異無統(tǒng)計學(xué)意義（>0.05），見表3。

表3 兩組胎兒的臍血皮質(zhì)醇水平比較（）

3 討論

導(dǎo)致雙胎生長不一致的相關(guān)風(fēng)險因素較多，包括高齡產(chǎn)婦、輔助生殖技術(shù)的應(yīng)用、妊娠高血壓及雙胎性別不一致等[6]。近年的研究重點聚焦于胎盤功能對雙胎發(fā)育的影響，認(rèn)為妊娠過程中胎盤絨毛發(fā)育不良、胎盤之一質(zhì)量小或胎盤面積分配不均等均可導(dǎo)致雙胎生長不一致[7-8]。本研究將上述已知的相關(guān)風(fēng)險因素進行統(tǒng)計分析后，發(fā)現(xiàn)兩組研究對象的相關(guān)風(fēng)險因素差異并無統(tǒng)計學(xué)意義。

研究顯示胎兒臍血中的皮質(zhì)醇含量與胎兒出生體質(zhì)量密切相關(guān)[9]。皮質(zhì)醇作為一種糖皮質(zhì)激素，是下丘腦–垂體–腎上腺分泌的產(chǎn)物，在應(yīng)激反應(yīng)中被釋放以調(diào)節(jié)多種重要功能，從而維持體內(nèi)代謝平衡。皮質(zhì)醇對胎兒的生長發(fā)育發(fā)揮重要作用[10]。本研究發(fā)現(xiàn)，在兩組孕婦基本情況無差異的前提下，DT組胎兒體質(zhì)量較輕者，其臍血的皮質(zhì)醇含量較高，原因之一就是胎盤糖皮質(zhì)激素障礙，胎兒過度接觸糖皮質(zhì)激素所致[11-12]。而雙絨毛膜雙胎生長受限模式可遵循單胎生長受限的模式[13-14]，故考慮DT組雙胎生長不一致的發(fā)生可能與過多的糖皮質(zhì)激素通過胎盤屏障進入胎兒有關(guān)。

糖皮質(zhì)激素在妊娠早期有助于實現(xiàn)胚胎的植入，在妊娠第7～14周可促進胎兒腎上腺發(fā)育，在妊娠的最后3個月可抑制脫氫表雄酮合成并促進女性生殖器發(fā)育。出生前，胎兒血清糖皮質(zhì)激素水平會顯著增加，以確保胎兒肺部和其他幾個器官的正常發(fā)育[15]。若妊娠期糖皮質(zhì)激素從母體到胎兒傳導(dǎo)不足，則胎兒肺功能受損而導(dǎo)致新生兒死亡率增加，傳導(dǎo)過量則會抑制胎兒的生長發(fā)育并使胎兒成年后患上心血管疾病及代謝性疾病，如高血壓、葡萄糖耐受不良、糖尿病、腦卒中等[16-18]。

綜上所述，在排除相關(guān)風(fēng)險因素的影響下，雙絨毛膜雙胎的體質(zhì)量較輕者其臍血皮質(zhì)醇的含量顯著升高，可能與雙胎生長不一致的發(fā)生有關(guān)。

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The relationship between fetal cord blood cortisol expression difference and twins growth inconsistency

Department of Clinical Pharmacy, Jiaxing Maternity and Child Health Care Hospital, Jiaxing 314000, Zhejiang, China

To study the difference of cortisol expression in cord blood of twins with inconsistent growth.Fifty-two pairs of dichorionic twins diagnosed in Jiaxing Maternity and Child Health Care Hospital from January 2021 to December 2022 were selected as study objects. The twins were divided into DT group (discordant fetal growth, 25 pairs) and CT group (concordant fetal growth, 27 pairs) according to whether the birth weight difference was ≥15%. The clinical data of pregnant women and fetuses in two groups were collected, and the basic situation between pregnant women and twins and the levels of cortisol in fetal cord blood between twins of two groups were compared.There were no statistically significant differences between the two groups in age, gestational week, delivery time, pre-pregnancy body mass index, conception method, delivery time and sex of twins (>0.05). There were no significant differences between DT group and CT group in amniotic fluid depth, umbilical artery SD value, umbilical cord around neck, placenta shape and twin sex (>0.05). The low weight fetus in DT group had significantly higher cortisol levels than the high weight fetus (<0.05), and there was no significant difference in cortisol levels between the two fetuses in CT group (>0.05).The differences in cortisol levels in the umbilical blood of twins may be related to the inconsistent growth of the fetus in dichorionic twins.

Twins growth inconsistency; Cortisol; Dichorionic twins

R714

A

10.3969/j.issn.1673-9701.2023.28.004

浙江省醫(yī)藥衛(wèi)生科技計劃項目（2021KY1121）；浙江省公益技術(shù)研究計劃/實驗動物項目（LGD20H300001）；嘉興市科技計劃項目（2021AD30130）

吳兆勇，電子信箱：472413857@qq.com

（2023–03–10）

（2023–09–15）