摘要
目的描述孕期贫血的患病率及其分布特征,探讨孕期贫血及其他危险因素如孕期合并症、并发症、孕晚期心理因素等对新生儿出生体重的影响,为进一步进行孕期贫血、低出生体重儿的预防干预研究,更好地开展孕期保健服务提供基础依据。
方法研究对象来自2006年9月至2007年5月间到安徽省蚌埠市蚌埠医学院附属医院产科门诊进行产前检查的孕妇。按观察队列的纳入与排除标准,收集到完整资料的研究对象共计461例。进入队列时,收集孕妇及其丈夫社会人口学基本资料以及孕早期健康体检资料。定期随访并收集孕妇孕20周以后直至分娩的体重、感染性疾病、孕期合并症和并发症,以及孕晚期的血液学常规检查和血生化检查指标,并于孕晚期采用焦虑自评量表(SAS)、抑郁自评量表(SDS)和生活事件量表(LES)对孕妇的心理因素进行评定。运用SPSS 11.0软件包进行资料的统计分析。
结果孕期贫血总患病率为49.7%。孕晚期血红蛋白水平较孕早期下降,贫血患病率孕早期为25.8%,孕晚期为43.8%。贫血患病率随着孕妇或其丈夫文化程度的增高而降低,初中以下、高中、大专以上文化程度者贫血患病率逐渐降低;孕妇或其丈夫职业为农民者贫血患病率最高,职业为文教卫生和公务员者最低。孕晚期血红蛋白和孕晚期血浆白蛋白均与出生体重呈显著正相关。孕期感染性疾病组、其他合并症组低出生体重检出率分别高于无孕期感染性疾病组和无其他合并症组。产科并发症组低出生体重检出率高于无产科并发症组。但贫血组新生儿出生体重和非贫血组之间差异无显著性。单因素Logistic回归分析结果显示孕晚期血红蛋白、孕晚期白蛋白、孕期感染性疾病、孕期其他合并症、胎儿宫内窘迫、胎膜早破、孕期体重增重7个变量有统计学意义。多因素Logistic回归分析显示,孕晚期白蛋白、孕期体重增重与低出生体重呈负相关,RR分别为0.871和0.835,95%CI分别为0.783-0.970和0.766-0.911;孕期感染性疾病、孕期其他合并症、胎儿宫内窘迫、胎膜早破使低出生体重风险增高,RR分别为3.061、7.219、5.080和4.873,95%CI分别为1.062-8.821、2.874-18.137、1.862-13.863和2.087-11.382。
结论孕妇孕期贫血患病率达49.7%,贫血随孕周增加而加重。孕期贫血与孕妇及其家庭社会经济等因素有关。孕晚期血红蛋白、血浆白蛋白水平和新生儿出生体重呈正相关。孕期感染性疾病以及孕期其他合并症、胎膜早破和胎儿宫内窘迫是低出生体重的危险因素。没有发现孕妇孕晚期焦虑、抑郁症状与新生儿出生体重之间有统计学关联。
Objective This study was performed to reveal the prevalence and characteristics of anemia in pregnancy, explore the influences of pregnancy anemia and other risk factors on newborns’birth weight, such as complications during pregnancy and psychological factors during terminal pregnancy, and to suggest ways to make the further prevention programs on anemia during pregnancy and low birth weight and develop better health care for pregnant women.
Methods All subjects were recruited from pregnant women who accepted health care in the obstetrical clinic of Attached Hospital of Bengbu Medical College in Bengbu City, North of Anhui Province, during the period from Sep. 2006 to May. 2007. Completed data of 461 subjects were collected according to the inclusion and exclusion criteria for the cohort of subjects. Health examination records of the subjects during early pregnancy were collected in the beginning they entered the cohort, as well as basic information as social economic characteristics of the pregnant women and their husbands. Weight, infection disease, accompany disease and obstetric complication of the pregnant women were gathered in the following period, and hematology and biochemical index were detected during terminal pregnancy, together with psychological factors determined by LES, SAS, and SDS. Statistical analyses were performed using SPSS 11.0.
Results The total prevalence of anemia during pregnancy was 49.7%. Hemoglobin decreased in terminal pregnancy compared to early pregnancy, and led to an increase of anemia prevalence from 25.8% to 43.8%.The prevalence of anemia during pregnancy negatively related to education level of pregnant women and that of their husbands, e.g. from groups of less than junior middle school, senior middle school, to higher than junior college it gradually decreased. Also, the prevalence of anemia during pregnancy was higher in farmers than in those who were civil servants or worked in culture, education and public health enterprises.Hemoglobin and serum albumin during terminal pregnancy were positively related to newborn’s birth weight. The prevalence of low birth weight was significantly lower in newborns of those women who with infection disease or other accompany disease or obstetric complications during pregnancy than those without these diseases. However, no significant difference was found between newborns of anemia and non-anemia groups. Uni-variable logistic regression analyses of risk factors for low birth weight indicated that hemoglobin during terminal pregnancy, infection disease and other accompany diseases during pregnancy, fetal asphyxia, premature rupture of membranes, and weight gain during pregnancy were significantly associated with low birth weight. Multivariate Logistic regression analysis showed that serum albumin during terminal pregnancy and weight gain during pregnancy were negatively related to low birth weight, with RR equal to 0.871 and 0.835, with 95%C.I between 0.783-0.970 and 0.766-0.911; While infectious disease and other accompany diseases during pregnancy, fetal asphyxia, and premature rupture of membranes increased risk of low birth weight, with RR equal to 3.061, 5.080, 7.219, 4.873, respectively, and with 95%C.I in 1.062-8.821, 2.874-18.137, 1.862-13.863, and 2.087-11.382, respectively.
Conclusion The total prevalence of anemia during pregnancy is 49.7%. Anemia during pregnancy aggravates with pregnancy progress, and there exist significant associations between anemia in pregnancy and social economic status of pregnancy women and their families. Women with anemia during pregnancy incline to develop infection disease and other pregnancy accompany diseases and obstetric complications.Hemoglobin and serum albumin during terminal pregnancy positively relate to the newborns’birth weight. Infectious diseases and other accompany diseases during pregnancy, premature rupture of membranes, and fetal distress are risk factors for low birth weight. No significant association is found between anxiety, depression of women during terminal pregnancy and newborns’birth weight.
引文
1.马润玫,劳子僖,陈芳.妊娠期缺铁性贫血与补铁.实用妇产科杂志, 2006; 22(5): 270-272.
2.乐杰,主编.妇产科学.北京:人民卫生出版社, 2005.
3. World Health Organization. Nutrition for Health and Development, Sustainable Development and Healthy Environments. Nutrition for Health and Development, 2000; 16.
4. Levy A, Fraser D, Katz M, et al.Maternal anemia during pregnancy is an independent risk factor for low birthweight and preterm delivery. Eur J Obstet Gynecol Reprod Biol, 2005; 122(2): 182-186.
5. Scholl TO. Iron status during pregnancy: setting the stage for mother and infant. Am J Clin Nutr, 2005; 81(5): 1218-1222.
6.郭志荣,蒋国雄,周永兰,等.妊娠期贫血与出生结果.中华流行病学杂志, 2002; 23(9): 128-131.
7.程露平,洪慧莉,涂知明.孕妇贫血对妊娠并发症及新生儿的影响调查.中国优生与遗传杂志, 2007; 15(8): 64-65.
8.唐咏梅,陈晓钟,李桂荣,等.缺铁性贫血对孕妇免疫功能及感染性疾病的影响,卫生研究, 2006; 35(1): 79-81.
9.崔芹,王占晖.妊娠期精神因素对胎儿体重影响的临床观察.中国煤炭工业医学杂志, 2003; 6(5): 425.
10.张明园,主编.精神科评定量表手册.长沙:湖南科技出版社, 1993.
11.首都儿科研究所, 11省妇幼保健院(所). 1998年中国育龄妇女贫血贫血调查.中国生育健康杂志, 2002; 13(3): 102-107.
12.陶芳标,主编.妇幼保健学.合肥:安徽大学出版社, 2003; 314.
13.陈华,陈新,陈海兰,等.江苏、浙江2省18县(市)新生儿出生体重描述性分析.中华围产医学杂志, 2003; 6(4): 229-232.
14.胡少瑾,顾仁骏,徐贵红. 76例初产妇分娩前后焦虑、抑郁状况调查.健康心理学杂志, 2001; 9(6): 464-465.
15. WHO. The prevalence of anemia in women . Geneva: World Health Organization, 1992: 1-20.
16.潘迎,武明辉,谢争,等.北京市孕产妇贫血患病率分析.中国妇幼保健, 2007; 22(10): 1364-1366.
17.芮东升,靳蕾,叶荣伟.中国南方10个县级市妇女妊娠合并贫血患病状况.中国生育健康杂志, 2006; 16(3): 142-146.
18.孙利环,赵悦淑,徐冬梅. 1310例城市妇女妊娠期贫血发生状况及相关因素分析.中国妇幼保健, 2005; 20(22): 2998-2999.
19.张银川,李晓强,张霖,等.孕妇缺铁性贫血流行病学调查结果分析.中国妇幼保健, 2006; 21(1): 86-87.
20. Cogswell ME, Parvanta I, Ickes L, et al. Iron supplementation during pregnancy, anemia, and birth weight: a randomized controlled trial. Am J Clin Nutr, 2003; 78(4):773-781.
21.中国儿童、孕妇、育龄妇女铁缺乏症流行病学调查协作组.中国孕妇、育龄妇女铁缺乏症患病率调查.中华血液学杂志, 2004; 25(11): 653-657.
22. Geelhoed D, Agadzi F, Visser L, et al. Maternal and fetal outcome after severe anemia in pregnancy in rural Ghana. Acta Obstet Gynecol Scand, 2006; 85(1): 49-55.
23. Emamghorashi F, Heidari T. Iron status of babies born to iron-deficient anaemic mothers in an Iranian hospital. East Mediterr Health, 2004; 10(6): 808-814.
24.唐咏梅,周瑞华,宁鸿珍,等.缺铁性贫血对妊娠及其结局的影响.中国公共卫生, 2002; 18(2): 159-161.
25. Malhotra M, Sharma JB, Batra S, et al. Maternal and perinatal outcome in varying degrees of anemia. Int J Gynaecol Obstet, 2002; 79(2): 93-100.
26. Lee HS, Kim MS, Kim MH, et al. Iron status and its association with pregnancy out- come in Korean pregnant women. Eur J Clin Nutr, 2006; 60(9): 1130-1135.
27. Rizvi SA, Hatcher J, Jehan I, et al. Maternal risk factors associated with low birth weight in Karachi: a case-control study. East Mediterr health, 2007; 13(6): 1343- 1352.
28. Scholl TO, Reilly T. Anemia, iron and pregnancy outcome. J Nutr, 2000; 130: 443-447.
29. Tempelhoff GF, Heilmann L, Rudig L, et al. Mean maternal second-trimester hemo- globin concentration and outcome of pregnancy: a population-based study. Clin Appl Thromb Hemost, 2008; 14(1): 19-28.
30. Ratledge C. Iron metabolism and infection. Food Nutr Bull, 2007; 28: 515-523.
31. Bernard J Brabin, Mohammad Hakimi and David Pelletier. An analysis of anemia and pregnancy-related maternal mortality. J Nutr, 2001; 604-615.
32.苟文丽,宋青.妊娠与贫血的相互影响.实用妇产科杂志, 2003; 19 (3):129-130.
33. Ehrenberg HM,Dierker L, Milluzzi C, et al. Low maternal weight, failure to thrive in pregnancy,and adverse pregnancy outcomes. Am J Obestet Gynecol, 2003; 189: 1726-1730.
34. Osman NB, Challis K, Cotiro M, et al. Perinatal outcome in an obstetric cohort of Mozambican women. J Trop Pediatr, 2001, 47: 30-38.
35. Svare JA, Schmidt H, Hansen BB, et al. Bacterial vaginosis in a cohort of Danish pregnant women: prevalence and relationship with preterm delivery, low birthweight and perinatal infections. BJOG, 2006; 113(12): 1419-1425.
36. Purwar M, Ughade S, Bhagat B, et al. Bacterial vaginosis in early pregnancy and adverse pregnancy outcome. J Obstet Gynaecol Res, 2001; 27(4): 175-181.
37. Kayastha S, Tuladhar H. Study of low birth weight babies in Nepal Medical College. Nepal Med Coll, 2007; 9(4): 266-269.
38. Ganzevoort W, Rep A, De Vries JI, et al. Relationship between thrombophilic disor- ders and type of severe early-onset hypertensive disorder of pregnancy. Hypertens Pregnancy, 2007; 26(4): 433-445.
39. Buchbinder A, Sibai BM, Caritis S, et al. Adverse perinatal outcomes are Signifi- cantly higher in severe gestational hypertension than in mild preeclampsia. Am J Obstet Gynecol, 2002; 186(1): 66-71.
40. Sibai BM, Hauth J, Caritis S, et al. Hypertensive disorders in twin versus singleton gestations. Am J Obstet Gynecol, 2000; 182(4):938-942.
41. Zanardo V, Savio V, Sabrina G, et al. The effect of pre-eclampsia on the levels of coagulation and fibrinolysis factors in umbilical cord blood of newborns. Blood Coagul Fibrinolysis, 2005 ; 16(3): 177-181.
42.夏敏,徐爱群.妊娠合并心脏病161例临床分析.中国生育健康杂志, 2004; 15(5): 273-277.
43. Ness RB, Catov J. Invited commentary:Timing and types of cardiovascular risk factors in relation to offspring birth weight. Am J Epidemiol, 2007; 166(12): 1365- 1367.
44.金丽华.昆山市新生儿低出生体重危险因素分析.江苏卫生保健, 2002; 4(2):99.
45. Kondrackiene J, Beuers U, Zalinkevicius R, et al. Predictors of premature delivery in patients with intrahepatic cholestasis of pregnancy. World J Gastroenterol, 2007; 13(46):6226-6230.
46. Viinamaki H, Niskanen L, Pesonen P, et al. Evolution of postpartum mental health. J psychosom Obstet Gynaecol, 1997; 18(3): 213-219.
47.王素平,李真.孕妇焦虑抑郁情绪100例调查分析.河北北方学院学报, 2007; 24(5): 19-20.
48. Grjibovski A, Bygren LO, Svartbo B, et al. Housing conditions, perceived stress, smoking, and alcohol: determinants of fetal growth in Northwest Russia. Acta Obstet Gynecol Scand, 2004; 83(12):1159-1166.
1. World Health Organization. The prevalence of anaemia in women. Geneva: World Health Organization, 1992; 1-20.
2.首都儿科研究所. 1998年中国育龄妇女贫血情况调查.中国生育健康杂志, 2002; 13(3): 102-107.
3. Al-Saleh E, Nandakumaran M, Al-Shammari M, et al. Assessment of maternal-fetal status of some essential trace elements in pregnant women in late gestation: relationship with birth weight and placental weight. Matern Fetal Neonatal Med, 2004; 16(1): 9-14.
4. Starreveld JS, Kroos MJ, van Suijlen JD,et al. Ferritin in cultured human cyto- trophoblasts; synthesis and subunit distribution. Placenta, 1995;16: 383-395.
5. Centers for Disease Control and Prevention. Recommendations to prevent and control iron deficiency in the United States. Morb Mortal Wkly Rep, 1998; 47: 1-29.
6. Scholl TO. Iron status during pregnancy: setting the stage for mother and infant. Am J Clin Nutr, 2005; 81(5): 1218-1222.
7. Steer PJ. Maternal hemoglobin concentration and birth weight. Am J Clin Nutr, 2000; 71: 1285-1287.
8. Casanueva E, Viteri FE, Mares-Galindo M, et al. Weekly iron as a safe alternative to daily supplementation for nonanemic pregnant women. Arch Med Res, 2006; 37(5): 674-682.
9. Singla PN, Tyagi M, Kumar A, et al. Fetal growth in maternal anemia. Trop Pediatr, 1997; 43: 89-92.
10.许道琳,范明.妊娠中期贫血对新生儿体重的影响.中国妇幼保健, 2007; 22(26): 3759-3760
11. Dreyfuss M. Anemia and iron deficiency during pregnancy: etiologies and effects on birth outcomes in Nepal. Baltimore, 1998; 34: 258-264.
12. Goldenberg RL, Tamura T, DuBard M, et al. Plasma ferritin and pregnancy outcome. Am J Obstet Gynecol, 1996; 175: 1356-1359.
13. Singh K, Fong YF, Arulkumaran S. Anaemia in pregnancy—a crosssectional study in Singapore. Eur J Clin Nutr, 1998;52:65-70.
14.胡志坚,许容仙.孕妇贫血对妊娠的结局影响调查.中国公共卫生, 2002; 18(6): 660-661.
15.王春茶,施洁,陈兰芳,等.妊娠期母体血红蛋白浓度与妊娠结局的关系.中国妇幼保健, 2004; 19(6): 72-73.
16. Greenwood R, Golding J, McCaw-Binns A, et al. The epidemiology of perinatal death in Jamaica. Paediatr Perinat Epidemiol, 1994; 8: 143-157.
17. Madhavan Nair K, Bhaskaram P, Balakrishna N, et al. Response of hemoglobin, serum ferritin, and serum transferrin receptor during iron supplementation in pregnancy: a prospective study. Nutrition, 2004; 20(10): 896-899.
18. Simmons WK, Cook JD, Bingham KC, et al. Evaluation of a gastric delivery system for iron supplementation in pregnancy. Am J Clin Nutr, 1993; 58: 622-626.
19. Madhavan Nair K, Bhaskaram P, Balakrishna N, et al. Response of hemoglobin, serum ferritin, and serum transferrin receptor during iron supplementation in pregnancy: a prospective study. Nutrition, 2004; 20(10): 896-899.
20. Institute of Medicine, Food and Nutrition Board. Iron deficiency anemia: guidelines for prevention, detection and management among U.S. children and women of childbearing age. Washington, DC: National Academy Press, 1993.
21. Gaspar MJ, Ortega RM, Moreiras O. Relationship between iron status in pregnant women and their babies. Acta Obstet Gynecol Scand, 1993; 72: 534-537.
22. Paiva Ade A, RondóPH, Pagliusi RA, et al. Relationship between the iron status of pregnant women and their newborns. Rev Saude Publica, 2007; 41(3): 321-327.
23. Hokama T, Takenaka S, Hirayama K, et al. Iron status of newborns born to iron deficient anaemic mothers. J Trop Pediatr, 1996; 42: 75-77.
24. Milman N, Agger AO, Nielsen OJ. Iron status markers and serum erythropoietin in 120 mothers and newborn infants. Acta Obstet Gynecol Scand, 1994; 73: 200-204.
25. Tchernia G, Archambeaud MP, Yvart J, et al. Erythrocyte ferritin in human neonates: maternofetal iron kinetics revisited. Clin Lab Haematol, 1996; 18: 147- 153.
26. Rusia U, Flowers C, Madan N, et al. Serum transferrin receptor levels in the eva- luation of iron deficiency in the neonate. Acta Paediatr Jpn, 1996; 38: 455-459.
27. Tekinalp G, Oran O, Gurakan B, et al. Relationship between maternal and neonatal iron stores. Turk J Pediatr, 1996; 38: 439-445.
28. Harthoorn-Lasthuizen EJ, Lindemans J, Langenhuijsen MM. Does iron-deficient erythropoiesis in pregnancy influence fetal iron supply? Acta Obstet Gynecol Scand, 2001; 80(5): 392-396.