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孕期增重与血压调节和糖脂代谢:现状及展望

2018-01-23 李玉明 中华医学信息导报

2016年的统计数据显示,全球18岁以上成年超重人口的数量已超过19亿,其中6.5亿人为肥胖,占世界人口总数的13%。超重和肥胖的流行与久坐不动的生活方式和城市化相关的高脂肪、高能量饮食摄入过量有关。这种趋势在育龄期年轻女性中尤其明显。超重和肥胖是高血压的重要危险因素。

2016年的统计数据显示,全球18岁以上成年超重人口的数量已超过19亿,其中6.5亿人为肥胖,占世界人口总数的13%。超重和肥胖的流行与久坐不动的生活方式和城市化相关的高脂肪、高能量饮食摄入过量有关。这种趋势在育龄期年轻女性中尤其明显。超重和肥胖是高血压的重要危险因素。据估计,女性中超过50%的新发高血压与超重和肥胖有关。近年来的研究显示,孕期增重过快,不仅与女性产后体质量滞留和超重有关,而且是妊娠期高血压疾病(HDP)发生发展的重要原因之一。此外,孕期增重过快引起的一系列代谢异常是妊娠期糖尿病(GDM)发生发展的重要诱因,可导致孕产妇和围产儿并发症发生风险的增加。因此,妊娠期体质量管理是孕期血压和糖脂代谢调节,以及产后体质量控制的关键切入点。

妊娠期肥胖与HDP

HDP是一组与妊娠期血压升高有关的综合征,包括慢性高血压(孕前高血压)、妊娠期高血压、子痫前期/子痫,以及慢性高血压合并的子痫前期/子痫,其发病率为5%~10%。每年全球约有5万例孕产妇和50万例围产儿死亡与HDP有关,是导致孕产妇及围产儿发病率和病死率增加的重要原因。HDP病因至今尚未阐明,但最近的证据表明,孕妇肥胖会增加HDP患病风险。孕前体质量指数(BMI)高和孕期体质量过度增长是HDP发生的危险因素,其机制涉及氧化应激、炎症和血管功能改变等。荷兰的一项前瞻性队列研究表明,孕期增重过度对HDP风险的增加独立于孕前BMI水平,且妊娠早期体质量增加对HDP的影响更为明显。近期,我们利用前瞻性队列发现,孕22~26周中体质量过度增加是引起舒张压在孕中晚期反弹性升高的原因,即使是在整个妊娠期血压处于正常水平(≤140/90 mmHg,1 mmHg=0.133 kPa)的孕妇,提示这一阶段是与孕期血压调节有关的关键增重时间窗(Hypertension. 2017;70∶804—812)。上述研究提示,通过对关键时间窗的孕妇提供管理,有可能降低妊娠中晚期血压升高水平,进而改善母子孕产结局。

HDP发生的另一项独立预测因素是阻塞性睡眠呼吸暂停综合征(OSAS)。OSAS定义为在睡眠时由完全性上呼吸道阻塞引起的反复阻塞性呼吸事件,临床表现为习惯性打鼾,夜晚间歇性上呼吸道阻塞和白天嗜睡。OSAS是继发性高血压的一个可能病因,与严重及顽固性高血压的发生相关。越来越多的证据表明,OSAS的典型症状——习惯性打鼾是妊娠期女性的常见表现,随着孕期的进展发生频率增加,在妊娠晚期影响高达1/3的孕妇。因此,对于血压升高并伴有妊娠期肥胖和增重过度的孕妇,应鉴别是否发生OSAS,以区分HDP的发生是否继发于孕期增重过度和肥胖,是否可以通过对体质量进行管理,而非使用降压药物来改善预后。OSAS高血压主要发生在夜间,呈非杓型特征(即与白天血压水平相比,夜间血压下降<10%)。进行孕妇24 h动态血压监测对鉴别HDP发生的原因发挥着至关重要的作用。

妊娠期肥胖与GDM

全球范围内,2型糖尿病患者数量已超过3.7亿人,且发病年龄呈现低龄化趋势;在育龄女性中,估计有2800万人患有2型糖尿病。GDM作为常见的妊娠并发症之一,在全球范围内影响着16.4%的孕妇。由于诊断标准的差异,GDM的患病率差异较大,有些国家的患病率高达25.1%。

妊娠本身即可引起生理性胰岛素抵抗和高胰岛素血症,其目的是确保胎儿发育所需的足够营养。胎盘对胎儿葡萄糖的转运则可进一步促进母体基础肝内葡萄糖产生量的增加(约30%)。上述生理性反应的失代偿可导致GDM的出现。GDM和2型糖尿病的病理生理学相似,可认为是2型糖尿病在妊娠期的早发性表现:有研究报道,30%~50%的GDM患者在产后可发展为2型糖尿病。GDM不仅对母亲的健康产生巨大的影响,而且对儿童的健康也会产生长期的影响。GDM发生的危险因素包括肥胖、高龄、多囊卵巢综合征、既往GDM和2型糖尿病家族史等,其中孕前肥胖和孕期增重过度是最重要的诱因。孕期增重过度导致的胰岛素抵抗增加可进一步恶化生理性胰岛素抵抗,进而增加GDM的风险。现有证据表明,妊娠早期的体质量增加是GDM的一个独立预测因素。一项病例-队列研究结果显示,在妊娠早期体质量增加每超过指南建议的1个标准差,孕妇患GDM的风险增加23%(95%CI0.2%~51%)。

妊娠期肥胖的干预研究

目前,改善妊娠期肥胖的方法主要有饮食干预、体育锻炼干预,以及饮食和体育锻炼相结合的干预措施。

(1)饮食干预

饮食干预包括通过健康饮食咨询、能量限制饮食等途径预防孕期增重过度。传统观点认为,应限制饮食中碳水化合物的摄入,使孕妇机体消耗脂肪代替碳水化合物,以此来减少餐后的血糖波动。但人们逐渐认识到,用脂肪替代膳食碳水化合物可能对母体的胰岛素抵抗不利,并可能导致胎儿脂肪过度堆积。近期陆续有研究证实,富含碳水化合物饮食(60%复合碳水化合物和25%脂肪)可使GDM患者24 h葡萄糖曲线下面积降低,且与常规低碳水化合物(40%碳水化合物)/高脂肪饮食(45%脂肪)相比,餐后游离脂肪酸明显降低。

(2)体育锻炼干预

缺乏体育锻炼会导致过度的脂肪蓄积,从而增加不良妊娠结局的风险。因此,体育锻炼被认为是改善妊娠结局的有效干预方法。有研究表明,体育锻炼对限制体质量增加是有益的,尽管受益程度有所不同。近期,针对随机临床试验的荟萃分析表明,通过中低等强度的有氧体育锻炼,孕妇的GDM发病风险降低28%~31%,孕期增重水平平均降低1.1 kg。此外,当这一锻炼方式在整个孕期进行实施时,GDM的患病风险降低更多(36%)。然而,任何体育锻炼干预研究的前提是识别和解决依从性问题。

(3)饮食和体育锻炼联合干预

饮食和体育锻炼联合干预可以防止孕期过度增重,降低HDP和GDM的发病风险。虽然不同的研究结果相差较大,但有荟萃分析结果显示,干预组和对照组间的结果差异很小;也有研究报告显示,与对照组相比,干预组体质量降低了2.2 kg,干预组发生孕期增重过度的风险降低约20%。与正常体质量的孕妇相比,接受饮食和体育锻炼联合干预的超重或肥胖孕妇子痫前期的发病率降低了22%。

小 结

肥胖,尤其是妊娠期肥胖在全世界范围的流行,是孕期和产后母子两代一系列健康问题的重要诱因。其中,HDP和GDM等与孕期增重过度有关的孕期并发症,不仅会导致不良的妊娠结局,还会增加母婴远期心血管、代谢性疾病患病风险和相关社会、公共卫生成本的支出。通过饮食和体育锻炼可干预、减轻妊娠期肥胖的影响,是降低HDP和GDM发病风险的有效途径。目前,仍需要得到进一步证实的、高效简便的干预方案,同时提高孕妇依从性,以减少HDP和GDM患病风险,缓解疾病负担。

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    2018-01-30 周周人

    学习...

    0

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    2018-01-25 huangdf
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    2018-01-24 明月清辉

    谢谢分享.学习了

    0

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    2018-01-24 swfzhanggui

    加强孕期检测.保障母婴安全

    0

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    2018-01-23 清风拂面

    谢谢.学习受益匪浅

    0

  7. [GetPortalCommentsPageByObjectIdResponse(id=283628, encodeId=7680283628da, content=学习..., beContent=null, objectType=article, channel=null, level=null, likeNumber=141, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/ajNVdqHZLLDcVAydhtcpjiaxLrZD7Eb5YnKPgf7ypGpfyl7FflFyAenvQLbib6T0LPXIhXo9SPNPXYYFFJbEgykztwJ0HQ61I3F9GxIVKWsgQ/0, createdBy=f38d2052407, createdName=周周人, createdTime=Tue Jan 30 22:10:59 CST 2018, time=2018-01-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1254861, encodeId=2327125486186, content=<a href='/topic/show?id=78b3e6858b7' target=_blank style='color:#2F92EE;'>#糖脂代谢#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=76858, encryptionId=78b3e6858b7, topicName=糖脂代谢)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=19ad38, createdName=lq1767, createdTime=Thu Jan 25 13:30:00 CST 2018, time=2018-01-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1597070, encodeId=e1ca159e07027, content=<a href='/topic/show?id=e7f6842982d' target=_blank style='color:#2F92EE;'>#脂代谢#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=71, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84298, encryptionId=e7f6842982d, topicName=脂代谢)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=ce3218475330, createdName=huangdf, createdTime=Thu Jan 25 13:30:00 CST 2018, time=2018-01-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=281500, encodeId=473028150080, content=谢谢分享.学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=0, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6Nx0VGA4QMDzOP8oAgnV4h51EjSfehJ9QxyiaSmw8PB56BhY8KXFSxHCibXrzcy4abrzSibXQPxJ9kzrLcJyhhB8a/0, createdBy=1d3b1672603, createdName=明月清辉, createdTime=Wed Jan 24 08:33:30 CST 2018, time=2018-01-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=281421, encodeId=f3b7281421b9, content=加强孕期检测.保障母婴安全, beContent=null, objectType=article, channel=null, level=null, likeNumber=147, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/10/21/9461f3b3c9f14e1d844256cdd08f2cf3.jpg, createdBy=a30f1426910, createdName=swfzhanggui, createdTime=Wed Jan 24 01:36:34 CST 2018, time=2018-01-24, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=281389, encodeId=6731281389e3, content=谢谢.学习受益匪浅, beContent=null, objectType=article, channel=null, level=null, likeNumber=84, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/Q3auHgzwzM4o2XVpJ6449yqDsjibydI5HnJ8MibGxNn4HZiaZib0bdfibbwoz3KQrIyN9AGxq36ZlZRNicYlPfOOWMtwgsajY6mGNFiaPclFdowjD0/0, createdBy=97bd1338592, createdName=清风拂面, createdTime=Tue Jan 23 23:24:29 CST 2018, time=2018-01-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=281375, encodeId=33dd2813e554, content=孕早期就要严格控制吗, beContent=null, objectType=article, channel=null, level=null, likeNumber=130, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2018/12/31/60fc0213ae09a3dbbba19993663ef4db.jpg, createdBy=33c31971480, createdName=1e160a78m83(暂无匿称), createdTime=Tue Jan 23 22:59:57 CST 2018, time=2018-01-23, status=1, ipAttribution=)]
    2018-01-23 1e160a78m83(暂无匿称)

    孕早期就要严格控制吗

    0

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