【作者】 侯海燕；

【导师】 陈亚琼；

【作者基本信息】 河北医科大学 ， 妇产科学， 2008， 硕士

【摘要】 目的:研究空气中多环芳烃(PAHs)与孕早期稽留流产之间的关系,从环境因素的角度探讨影响胚胎生长发育、导致稽留流产发生的可能危险因素。方法:流行病学调查结合实验研究。收集天津市市内六区15家综合医院和妇产科医院计划生育门诊近6年每个月人工流产手术例数以及当月稽留流产病例的详细信息。利用每月稽留流产的病例数占人工流产总数的百分比来比较月份之间、季节之间、采暖期与非采暖期之间稽留流产比例的差别。获取天津市环境监测中心2001年-2006年1月和7月市内六区国控测点苯并(a)芘(BaP)的月平均浓度监测值。从2007年4月-12月,收集天津市四家综合性医院计划生育门诊的稽留流产新发病例,同期按年龄、孕产次、妊娠周进行1:1配比选取对照,对照组为正常妊娠要求终止妊娠行人工流产术者。知情同意后由经过培训的调查员统一填写问卷调查表,收集研究对象孕期及孕前三个月接触环境危险因素的情况。人工流产手术后立刻用EDTA抗凝真空采血管抽取母亲外周血2ml,与问卷统一编号后,-20℃冰冻保存。每周批量提取母亲全血基因组DNA并做样品DNA浓度定量,高效液相色谱法(HPLC)检测母血中BaP内暴露生物学标志物BaP-DNA加合物的浓度,配对样本秩和检验分析病例组和对照组母血中BaP-DNA加合物水平有无差别。单因素分析与母血加合物水平、稽留流产可能有关的环境危险因素,用多元线性回归、logistic回归模型进行多因素分析,探讨与母血加合物有关的环境因素以及可能导致稽留流产的危险因素及其危险度的大小。结果:1天津地区近五年1月份苯并(a)芘的浓度显著高于7月份(P=0.0082),市内15家医院1月份因稽留流产病例数占门诊人工流产手术总数的百分比明显高于7月份(P=0.037)。稽留流产病例的比例有明显的季节性变化,从就诊时间来看,春季的稽留流产病例占总人工流产术的百分比最高(2.37%),其次为冬季(2.16%)、夏季(1.82%)、秋季(1.54%);冬春季病例比例显著高于夏秋季(P=0.001),从受孕时间来看,受孕时间处于冬季的妊娠妇女,稽留流产病例的比例最高(2.29%),其次为秋季(2.01%)、春季(1.92%)、夏季(1.72%)。且冬春季显著高于夏秋季(P=0.000)。提示采暖期稽留流产病例的比例要高于非采暖期。2提取收集到的112例母血基因组DNA并做浓度定量,两组DNA浓度之间无显著性差异(P=0.407)。高效液相色谱法检测BaP-DNA加合物的浓度,可测得最小值为1.81ng/ml,母血BaP-DNA加合物浓度均值为4.3±4.0加合物/108核苷酸,将有主动吸烟史以及有高危职业暴露的研究对象排除之后,104例样本被纳入本病例-对照研究。配对样本的秩和检验发现病例组母血BaP-DNA加合物浓度(6.3±4.7加合物/108核苷酸)显著高于对照组(2.4±1.4加合物/108核苷酸),两者之间差别有统计学意义(P=0.000)。控制孕妇学历、家庭人均月收入可能混杂因素后,发现母血BaP-DNA加合物是稽留流产的危险因素(OR=3.63, 95%CI 1.49-8.87),而孕妇学历为稽留流产的保护因素(OR=0.55,95%CI 0.32-0.94)。即母血BaP-DNA加合物浓度越高,发生稽留流产的危险性越大,孕妇受教育程度越高,其发生稽留流产的危险性越小。3对调查问卷进行分析。与母血BaP-DNA加合物有关的因素:单因素Spearman’s秩相关分析发现妊娠妇女家距马路的距离与母血BaP-DNA加合物含量之间存在负相关关系(r=-0.211,P=0.035),即家距马路的距离越近,母亲外周血BaP-DNA加合物的含量越高。将所有潜在的危险因素引入多元线性回归方程发现孕妇孕期经常做饭、居住地附近交通拥挤与母血BaP-DNA加合物水平存在正相关关系,而孕妇学历与母血BaP-DNA加合物水平有负相关关系,而家距马路的距离未选入方程。回归方程为Y=2.205+1.024X1-0.95X2+1.064X3。对母血BaP-DNA加合物水平影响由大到小依次为居住地附近马路交通状况(X3)、孕期孕妇做饭(X1)和孕妇学历(X2)。与稽留流产有关的因素:单因素分析发现孕妇低学历、低收入、孕妇和丈夫在孕前三个月内接触过有毒物质(农药、涂料、油漆)、孕期家庭装修史、孕期交通时间长、居住地距离马路较近、居住地附近交通拥挤、孕早期经常吃烧烤、孕期经常做饭、孕期烫发可能对胚胎的正常生长发育产生不良影响。将所有相关变量都选入条件Logistic回归模型后发现,孕期每日交通时间较长、孕期经常做饭、孕期家庭装修史、丈夫孕前三个月毒物接触史可能是稽留流产的危险因素。危险度从由大到小依次为孕期家庭装修史(OR=7.16, 95%CI 1.98-25.81)、丈夫孕前三个月毒物接触史(OR=5.87, 95%CI 1.15-29.82)、孕期每日交通时间(OR=2.67, 95%CI1.16-6.15)、孕期做饭(OR=1.46, 95%CI 1.05-2.03)。而孕妇受教育程度较高可能是稽留流产的保护因素(OR=0.45, 95%CI 0.28-0.73)。结论: 1母亲外周血较高水平的BaP-DNA加合物可能增加孕早期稽留流产发生的危险性。2孕期孕妇经常做饭和居住地附近交通拥挤可能与母血中BaP-DNA加合物浓度升高有关,而孕妇受教育程度越高,母体加合物水平可能越低。3孕期每日交通时间较长、孕期经常做饭、孕期家庭装修史、丈夫孕前三个月毒物接触史可能对胚胎的正常生长发育产生有不良影响,而受教育程度较高的孕妇,其发生稽留流产的危险性可能相对较小。更多还原

【Abstract】 Objective: To study the association between environmental PAHs and missed abortion in early pregnancy, explore the probable risk factors for embryo growth and development and missed abortion on environmental aspect.Methods: Epidemiology and experiment research. First obtain in the number of the abortion operations and the details of the missed abortion patients in each months of 6 recent years of 15 general hospitals and gynaeology and obstetrics hospitals in urban field of tianjin. Compare the differences of the percentage of missed abortion cases in all the abortion operations of each months between months, seasons and heating and nonheating period. Gain the monthly average levels of BaP in January and July from 2001 to 2006 in six national monitoring stations in urban field of tianjin from Environment monitoring centre. Collect the new cases of missed abortion in four general hospitals of tianjin from April to December 2007, and select the control by the rate of one to one according to ages, gravidity, parity and gestational weeks, subjects in control group are women that have the request for abortion operation in normal pregnancy. A questionnaire was administered by trained interviewers with the patients’agreement for information about environmental risk factors contact of wife and husband in and before pregnancy. Draw 2 ml maternal blood using EDTA anticoagulation tube after abortion operation, the sample and the questionnaire were encoded together and storaged in -20℃. Extract maternal blood genome DNA and examine its levels every week. Analyze the difference between BaP-DNA adducts levels of case and control group examined by high-performance liquid chromatography-fluorescence method (HPLC) by using signed-rank test. Analyze probable environmental risk factors for maternal blood adducts and missed abortion in separate models, explore probable influence factors for maternal adducts and missed abortion and its risk by multiple linear regression and logistic regression model respectly.Results: 1 BaP levels of January in recent five years in tianjin area are significantly higher than that of July (P=0.0082), the percentage of missed abortion cases in all the abortion operations of January in the 15 urban field hospitals is obviously higher than that of July. In addition, the case percentage has seasonal variation, Analyzing by the time of visit, we have found that the missed abortion case percentage in spring (2.37%)is the highest one, then comes winter (2.16%), summer (1.82%) and autumn (1.54%) in order. Winter and spring case percentage is significantly higher than summer and autumn (P=0.001).Women conceived during winter (2.29%), backwards to the visit, whose case percentage is the highest one, then comes autumn (2.01%), spring (1.92%) and summer (1.72%) in order, which indicates that the case percentage of heating period is higher than that of nonheating period.2 Significant difference is not found between the two groups by analyzing the extracted genome DNA of gained 112 maternal blood samples with DNA level examined (P=0.407). The lowest BaP-DNA adducts level detected by HPLC is 1.81ng/ml, the average of maternal adducts level is 4.3±4.0 adducts/108nucleotides. Women smoked and with occupational exposure are excluded. A total of 104 samples were included in this case-control study at last. we found that BaP-DNA adducts levels of the case group (6.3±4.7 adducts/108nucleotides) were significantly higher than that of the control group (2.4±1.4 adducts/108nucleotides)(P=0.000). Maternal adducts level was probably a significant risk factor for missed abortion (OR=3.52, 95%CI 1.44-8.62), while maternal education was a protective factor(OR=0.55, 95%CI 0.32-0.94)afer controlling potential confounders including maternal education, household monthly income.3 After analyzing the questionnaires, we found that maternal adducts level was negatively and significantly correlated with distance from residence to the nearest roadway by using spearman’s rank correlation method (r=-0.212,P=0.035), the nearer the distance from the residence to the roadway was, the higher maternal blood BaP-DNA adducts levels were. After selecting all potential effective factors, we found that cooking during pregnancy, traffic jam nearby the residence were positively and significantly correlated with maternal adducts, while the correlation between maternal adducts and maternal education was negative by multiple linear regression analysis. The regression equation is Y=2.205+1.024X1-0.95X2+1.064X3. The most effective factor for maternal adducts was traffic jam nearby the residence(X3), then came with cooking during pregnancyand (X1) and maternal education (X2) .In separate model, we found that lower education and income, toxic matter (pesticide, paint) contact of wife and husband during the three months before pregnancy, fitment history during pregnancy, more daily traffic hourstraffic jam nearby, roast food eating, cooking during pregnancy and perm in early pregnancy probably had adverse effects on embryo growth and development. We found that fitment history in early pregnancy(OR=7.16,95%CI 1.98-25.81), toxic matter (pesticide, paint) contact of husband during the three months before pregnancy(OR=5.87, 95%CI 1.15-29.82), more daily traffic hours(OR=2.67, 95%CI 1.16-6.15), cooking frequently during pregnancy(OR=1.46, 95%CI 1.05-2.03)were the probable risk factors for missed abortion by selecting all the correlated variables to the logistic regression model, while maternal education was a protective factor for missed abortion.Conclusion: 1 BaP-DNA adducts in maternal blood was a significant risk factor for missed abortion in early pregnancy. 2 Maternal education, cooking frequently during pregnancy and traffic jam nearby the residence may have effects on maternal BaP-DNA adducts by different degrees. 3 Daily traffic hours, cooking frequently during pregnancy, fitment history in early pregnancy and toxic matter (pesticide, paint) contact of husband during the three months before pregnancy may have adverse effects on embryo growth and development, while maternal education was a protective factor.更多还原