【作者】 齐昊；

【导师】 杨静；

【作者基本信息】 山西医科大学 ， 内分泌学， 2009， 硕士

【摘要】 背景与目的甲状腺功能减退症和亚临床甲状腺功能减退症是常见的内分泌疾病,而育龄妇女是这种疾病的高发人群。孕妇合并甲减和亚临床甲减可增加妊娠不良结局和并发症的发生,是妊娠的高危因素。由于甲减和亚临床甲减起病隐匿,临床表现缺乏特异性,容易忽略,故对高危妇女进行早期筛查、诊断并及时给予足量甲状腺素补充治疗,可有效降低不良妊娠结局的发生,所以应提高对妊娠女性中甲减和亚临床甲减的认识和关注。本研究旨在动态观察妊娠期间甲状腺功能对孕妇妊娠结局和产科并发症发生情况的影响,为评估孕妇甲减和甲减对妊娠及其结局的影响提供理论依据。研究方法通过前瞻性的分析2008年3月-2008年12月间,在山西医科大学第一医院妇产科筛查、治疗和随访妊娠女性共149例。初诊时进行甲状腺功能筛查,应用化学发光法(CIA)法测定血清游离三碘甲状腺原氨酸(FT3)、游离甲状腺素(FT4)、促甲状腺激素(TSH)水平、抗甲状腺过氧化物酶抗体(TPOAb)。依据甲状腺功能筛查结果,按甲状腺功能分组:甲状腺功能减退症组、亚临床甲状腺功能减退组、正常对照组。首先关注在整个研究人群中甲状腺功能减退症和亚临床甲状腺功能减退症的总体患病率。其次在甲状腺功能减退症组、亚临床甲状腺功能减退组和正常对照组,根据妊娠的不同时期、孕妇年龄、既往有无甲状腺病史和危险因素进一步分组研究,对于亚临床甲减患者还根据严格定义的各种组成成分以及TSH不同水平分组,对于以上各个亚组研究其筛查时的甲状腺功能水平。达到甲状腺功能减退症和亚临床甲状腺功能减退诊断标准者,参照美国甲状腺学会推荐的方案给予及时干预治疗和随访。分析、观察各组孕妇出现流产、早产、死胎以及各种产科并发症(如胎儿窘迫、胎儿宫内发育迟缓、妊高症和妊娠糖代谢异常等)的比率,评估甲状腺疾病对妊娠结局的影响及干预治疗的效果。研究结果①本研究中,妊娠女性甲减的患病率为2.68%(4/149),和国内外的文献数据比较接近,而亚临床甲减的发病率为23.49%(35/149),远远高于以往文献的结果。②亚临床甲状腺功能减退组患者包含四种组成,其中单纯TSH升高和单纯FT4降低患者比例较高。③甲状腺功能减退症和亚临床甲状腺功能减退组在筛查时TSH的水平出现明显的升高,与正常对照组相比均有统计学差异(P＜0.01)。但FT3、FT4降低程度不明显,与正常对照组相比,无统计学差异(P＞0.05)。经过药物干预,甲状腺功能减退症组和亚临床甲状腺功能减退组患者甲状腺功能指标基本控制在参考范围内,与正常对照组相比差异无统计学意义(P＞0.05)。④既往有甲状腺病史组的TPOAb阳性率明显高于既往甲状腺病史阴性组,差异有统计学意义(P＜0.01)。⑤甲状腺功能减退症和亚临床甲状腺功能减退症组与正常对照组相比,妊娠不良结局发生率明显升高,差异有统计学意义(P＜0.01)。既往甲状腺病史阳性组与阴性组相比较,前者不良结局和并发症发生率均明显增高,差异有统计学意义(P＜0.01)。⑥按不同的TSH水平分组,TSH＞10 uIU/ml组的不良结局及并发症发生率最高,与TSH 2.5—4.2 uIU/ml组和TSH 4.2-10 uIU/ml组相比,差异有统计学意义(P＜0.01):TSH4.2-10 uIU/ml组的不良结局及并发症的发生率,较TSH2.5-4.2 uIU/ml组升高,差异有统计学意义(P＜0.01)。⑦妊娠晚期甲减和亚临床甲减的发生率明显升高。⑧在不同年龄组妊娠女性中,21-25岁组亚临床甲减的发生率明显升高。结论:甲状腺功能减退症和亚临床甲状腺功能减退症对妊娠有不良的影响,增加妊娠的风险。但是,通过及时、适当的治疗,保证甲状腺功能水平维持在正常范围,可将并发症等风险降低,达到满意的妊娠结果。所以,对高危人群进行筛查,妊娠期严密的监测甲状腺功能水平,及时诊断和治疗对于保护孕妇健康具有十分重要的意义。更多还原

【Abstract】 Background and objective:Subclinical hypothyroidism is common in the population and especially in reproductive women.It is noticed that maternal thyroid dysfunction during pregnancy such as hypothyroidism can lead to both obstetrical complications and adverse reproductive outcomes. Not only overt,but also subclinical thyroid disorders are high risk for pregnancy. Hypothroidism is a chronic but progressive disease,without overt clinical characteristics,so thyroid function screening in high-risk women is necessary and treatment should be caught out in time.Subclinical hypothyroidism is moving with a result of overt hypothyroidism, which is related to the increased level of TSH,as well as the positive thyroid peroxidase antibody(TPOAb).Hyperthyroidism can lead to severe complications on both mother and offspring,which is only next to gestational diabetes.However the adverse effect is minor if mothers get treatment during pregnancy.The aim of this study was to monitor the change of thyroid function and antibody during the course of pregnancy in those who suffer from various thyroid disorders and normal control.We evaluate the consequences of pregnancy outcomes and determine management and therapeutic intervention in relation to pregnancy outcomes,providing to clinical obstetrician as a theoretically proof.Method:A descriptive analysis involving 149 pregnant women who visited and delivered in the first hospital of Shanxi Province from March 2008 to December 2008.Firstly,with high-sensitive chemical irradiance assay(CIA) technique,we analyzed the concentrations of thyroid stimulating hormone(TSH),free triiodo-thyroxine(FT3),free thyroxine(FT4) and TPOAb in pregnant women during their antenatal visit.According to the results of thyroid function tests assessed by standard laboratory reference ranges,we classified them into four different groups:overt hypothyroidism,subclinical hypothyroidism, normal and other thyroid dysfunction.The last group is excluded in this study.We pay attention to the prevalence of overt hypothyroidism & subclinical hypothyroidism as a whole.Then according to the stages of pregnancy,age of pregnant women,history of thyroid disease and other risk factors,we divide the groups above into several subgroups.We divided the pregnant women into groups according to different components of subclinical hypothyroidism and different levels of TSH.Then we can analyze the thyroid function without therapy.We intervene the patients with hypothyroidism and subclinical hypothyroidism.After several months of observation & follow-up,we got the final data of pregnant women with miscarriage,abortion and other complications to evaluate the effect of hypothyroidism and subclinical hypothyroidism on pregnancy.Results:①In this study,the prevalence of hypothyroidism is 2.68%(4/149),similar to the data of published articles,while the prevalence of subclinical hypothyroidism is 23.49%(35/149), much higher than the results having been reported.②There are four components of subclinical hypothyroidism,and in them groups of patients with simple TSH elevation & simple FT4 decreasing have higher ratios.③The levels of TSH in groups of patients with hypothyroidism & subclinical hypothyroidism are higher than those of the normal groups during the screening(P＜0.01) while decreasing of FT3 & FT4 is not obvious(P＞0.05).Thyroid function in controlled hypothyroidism group is in the reference range,and no significant difference is showed compared to the normal group(P＞0.05).④The ratio of positive TPOAb in a high-risk group was significantly higher than those without a past history of thyroid disease(P＜0.01).⑤We observed that significantly higher incidences of adverse obstetrical outcomes and complications in uncontrolled hypothyroidism group and subclinical hypothyroidism group compared with normal group(P＜0.01).The incidences of adverse outcomes is obviously increased in women who have a high risk than those without a past history of thyroid disease(P＜0.01).⑥According to the TSH level,we divide the study women into four groups,as TSH＞10 uIU/ml,TSH4.2-10 uIU/ml,TSH2.5-4.2 uIU/ml and TSH＜2.5 uIU/ml group.Following the raising of TSH level,the incidences of adverse outcomes and complications were increased.⑦The prevalence of hypothyroidism & subclinical hypothyroidism is much higher in the 3rd trimester.⑧The prevalence of subclinical hypothyroidism is much higher in the group of 21-25 years old pregnant women.Conclusion:Presence of clinical & subclinical thyroid disorders can negatively affect the pregnancy. However,if mothers with thyroid disease get adequate treatment in time and remain thyroid function normal,the adverse influence maybe reduced to the least.So serial monitoring and therapeutic intervention maybe necessary for the prevention of undesirable obstetric outcomes.更多还原