葉文 方曉紅 熊文棟 王連云 王劍平 童夏 王繁
[關(guān)鍵詞] 妊娠期高血壓;子癇前期;正念干預(yù);高危孕婦
[中圖分類號(hào)] R714.24? ? ? ? ? [文獻(xiàn)標(biāo)識(shí)碼] B? ? ? ? ? [文章編號(hào)] 1673-9701(2021)17-0060-05
Effect of mindfulness intervention on blood pressure of high-risk pregnant women during pregnancy and prevention of preeclampsia
YE Wen? ?FANG Xiaohong? ?XIONG Wendong? ?WANG Lianyun? ?WANG Jianping? ?TONG Xia? ?WANG Fan
Department of Obstetrics, the Second Affiliated Hospital of Wenzhou Medical University, Wenzhou? ?325000, China
[Abstract] Objective To study the effect of mindfulness intervention (mindfulness body scanning) on blood pressure of high-risk pregnant women during pregnancy, and to explore its feasibility in preventing preeclampsia. Methods Eligible pregnant women with high risk of gestational hypertension in the Department of Obstetrics of the Second Affiliated Hospital of Wenzhou Medical University from June 2018 to June 2019 were included as the research objects. They were randomly divided into two groups. The experimental group(n=27) underwent mindful body scanning at the specified time, while the control group (n=39) received no intervention measures. Both groups underwent normal prenatal examination. Finally,the maternal and infant outcomes of the two groups of high-risk pregnant women were analyzed. Results After adjusting SBP,DBP before intervention in both groups, after intervention,the SBP,DBP decreased in the experimental group effectively(95%CI: 6.797-12.276 mg, P<0.05; 95%CI: 3.070-6.963 mmHg, P<0.05). The incidence of hypertensive disorder complicating pregnancy in the experimental group was 11.1%, which was slightly higher than that of(10.3%) in the control group, but without significant difference(P>0.05). The incidence of preeclampsia was 0.0% in the experimental group, which was significantly lower than that of(20.5%) in the control group, with statistically significant difference(P<0.05). The gestational weeks were (38.8±1.10)weeks in the experimental group, which was longer than that of (37.8±2.17) weeks in the control group, with statistically significant difference(P<0.05). Conclusion Systematic mindful body scanning can reduce the pregnancy blood pressure of high-risk pregnant women and have a certain preventive effect on the occurrence of preeclampsia. Mindful body scanning has no economic pressure, with high safety and effectiveness,which can be used as one of the effective measures to prevent preeclampsia.
[Key words] Hypertensive disorder complicating pregnancy; Preeclampsia; Mindfulness intervention; High-risk pregnant women
妊娠期高血壓疾病是一種妊娠期特有的疾病,包括妊娠合并慢性高血壓、妊娠期高血壓、子癇前期等,我國發(fā)病率為9.4%,嚴(yán)重影響母嬰健康,是孕產(chǎn)婦和圍生兒發(fā)病和死亡的主要原因之一。目前除終止妊娠外,該病尚無有效的治療方式,因此如何預(yù)防成為了是目前研究的熱點(diǎn)。學(xué)者們對(duì)阿司匹林預(yù)防子癇前期進(jìn)行大量研究[1-2],認(rèn)為阿司匹林可以預(yù)防早發(fā)型子癇前期,但對(duì)晚發(fā)型子癇前期無明顯影響。但是,有研究證實(shí)[3]阿司匹林可能會(huì)輕微增加超過500 mL的產(chǎn)后出血的風(fēng)險(xiǎn),這一結(jié)果的證據(jù)質(zhì)量被降級(jí)為中等。國際上補(bǔ)充與替代療法正逐漸成為一種流行趨勢,常常用于治療各種健康問題,如心血管疾病、癌腫瘤等慢性疾病[4-6],其中身心療法在不同醫(yī)學(xué)領(lǐng)域不斷被證實(shí)有效[7]。正念覺知干預(yù)[8]作為一種安全和無介入的非藥物治療方式,也是在減輕壓力、改善抑郁[9]、降低血壓[10]等多個(gè)方面的評(píng)估中表現(xiàn)出臨床上有顯著意義的效果??v觀國內(nèi)外的相關(guān)研究,有關(guān)正念練習(xí)與妊娠期高血壓疾病的臨床研究非常少,因此,通過病例對(duì)照研究,探討正念練習(xí)的核心之一正念身體掃描對(duì)妊娠血壓的影響及預(yù)防子癇前期的可行性,現(xiàn)報(bào)道如下。
1對(duì)象與方法
1.1研究對(duì)象
本研究于2018年6月至2019年6月在溫州醫(yī)科大學(xué)附屬第二醫(yī)院產(chǎn)科門診孕婦中篩選具有妊娠高血壓疾病高危因素的孕婦開展正念干預(yù)的隨機(jī)分組試驗(yàn)。納入標(biāo)準(zhǔn):根據(jù)美國預(yù)防服務(wù)工作組對(duì)妊娠期高血壓疾病制定的中高危因素標(biāo)準(zhǔn)[11],符合下列1個(gè)高危因素或兩個(gè)及其以上的中危因素即可入選。高危因素:有慢性高血壓或Ⅰ/Ⅱ型糖尿病;含有以下兩個(gè)或以上的中危因素視為高危:①年齡>35歲;②肥胖孕婦,身體質(zhì)量指數(shù)(Body mass index,BMI)>30 kg/m2;③母親或姐妹有子癇前期的家族史;④初產(chǎn)婦;⑤個(gè)體因素:如既往有小于胎齡兒生育史、不良孕產(chǎn)史、與上一次妊娠間隔10年以上;⑥低收入人群。排除標(biāo)準(zhǔn)[12]:根據(jù)國內(nèi)2020年妊娠期高血壓疾病指南,排除明確推薦使用阿司匹林藥物的高危因素[13]:①子癇前期病史、胎兒宮內(nèi)生長受限(Intraterine growth restriction,IUGR)、胎盤早剝病史、腎臟病史及高凝情況者;②首次產(chǎn)檢時(shí)間超16周或首次查尿常規(guī)尿蛋白陽性者;③多胎妊娠、宮頸機(jī)能不全者;④合并智力障礙、伴有精神疾病者;⑤有行走障礙的孕婦,如嚴(yán)重的恥骨聯(lián)合分離、下肢殘疾、骨折恢復(fù)期等;⑥不同意參與本研究者。
符合上述條件的孕婦總共82例,采用隨機(jī)數(shù)字表法分為試驗(yàn)組和對(duì)照組,每組各41例。最終獲得有效數(shù)據(jù)試驗(yàn)組27例,對(duì)照組39例。兩組一般資料比較,差異無統(tǒng)計(jì)學(xué)意義(P>0.05),具有可比性。該研究由醫(yī)院醫(yī)學(xué)倫理委員會(huì)審核批準(zhǔn),所有臨床研究對(duì)象遵循自愿原則并簽署知情同意書。
1.2 方法
1.2.1 干預(yù)措施? 試驗(yàn)組需在孕20~36周接受專業(yè)正念訓(xùn)練師指導(dǎo)下的正念身體掃描現(xiàn)場培訓(xùn)每周1次,另外在家中根據(jù)提示正念訓(xùn)練師的指導(dǎo)音頻進(jìn)行練習(xí)并且維持1周至少5次,每次20~30 min,并通過微信直播、微信打卡、階段性培訓(xùn)、產(chǎn)檢面對(duì)面隨訪等追蹤練習(xí)情況。正念身體掃描練習(xí)簡易內(nèi)容[14]:①首先將注意力轉(zhuǎn)移到身體中;②如果您覺得舒服,可以閉上眼睛;③您會(huì)發(fā)現(xiàn)自己的身體就座在任何地方,感覺到身體在椅子上、地板上的重量;④深吸一口氣;⑤深呼吸時(shí),會(huì)吸收更多的氧氣,使身體充滿活力,呼氣時(shí),要有更深的放松感;⑥您會(huì)注意到腳在地板上,注意到腳在地板上的感覺,包括重量和壓力、振動(dòng)、熱量;⑦您會(huì)注意到雙腿緊貼椅子,受壓,搏動(dòng),沉重,輕盈;⑧注意背部靠在椅子上;⑨將注意力轉(zhuǎn)移到胃部,如果您的胃緊張或緊繃,請使其軟化,喘口氣;⑩注意您的手是緊張還是緊繃,看看是否可以使其軟化;?輥?輯?訛注意您的手臂,感覺在您的懷里,讓您的肩膀柔軟;?輥?輰?訛注意您的脖子和喉嚨,使其柔軟,放松;?輥?輱?訛松開您的下巴,讓您的臉部和面部肌肉柔軟;?輥?輲?訛然后注意您的整個(gè)身體,再吸一口氣;?輥?輳?訛盡可能地注意自己的整個(gè)身體,喘口氣,然后,當(dāng)您準(zhǔn)備就緒時(shí),就可以睜開眼睛。對(duì)照組無干預(yù)措施,兩組均按照孕期保健指南方案[13]進(jìn)行產(chǎn)檢。
1.2.2 產(chǎn)檢血壓的管理? 試驗(yàn)組和對(duì)照組孕婦來院產(chǎn)檢,到達(dá)產(chǎn)科門診后在平靜狀態(tài)下通過歐姆龍電子血壓計(jì)(HEM-7317),由護(hù)士進(jìn)行右臂動(dòng)脈規(guī)范測量血壓并記錄,隨后試驗(yàn)組坐姿下通過指導(dǎo)音頻進(jìn)行正念身體掃描練習(xí)20 min,對(duì)照組孕婦坐姿休息20 min,兩組孕婦均再一次進(jìn)行血壓測量并記錄。
1.3觀察指標(biāo)及評(píng)價(jià)標(biāo)準(zhǔn)
包括兩組一般資料、干預(yù)后血壓、母嬰結(jié)局(妊娠期高血壓、子癇前期發(fā)生率)、分娩孕齡、早產(chǎn)、IUGR、新生兒體重等。妊娠期高血壓及子癇前期診斷標(biāo)準(zhǔn)參考妊娠期高血壓疾病指南[12]。
1.4統(tǒng)計(jì)學(xué)方法
采用SPSS 22.0統(tǒng)計(jì)學(xué)軟件進(jìn)行數(shù)據(jù)分析。符合正態(tài)分布的計(jì)量資料以均數(shù)±標(biāo)準(zhǔn)差(x±s)表示,組間比較采用t檢驗(yàn),不符合正態(tài)采用非參數(shù)秩和檢驗(yàn),干預(yù)前后的血壓對(duì)比采用協(xié)方差比較。計(jì)數(shù)資料以[n(%)]表示,組間比較采用χ2檢驗(yàn),P<0.05為差異有統(tǒng)計(jì)學(xué)意義。
2 結(jié)果
2.1兩組孕婦一般資料比較
試驗(yàn)組和對(duì)照組孕婦的一般情況比較,如年齡、孕前BMI、高危因素分布情況,職業(yè)婦女分布情況、受教育水平、入組前首次測量的收縮壓(Systolic blood pressure,SBP)、舒張壓(Diastolic blood pressure,DBP)比較,差異均無統(tǒng)計(jì)學(xué)意義(P>0.05),具有可比性。見表1。
2.2兩組孕婦干預(yù)前后血壓變化比較
兩組孕婦分別調(diào)整干預(yù)前基礎(chǔ)SBP、DBP,對(duì)干預(yù)后的SBP、DBP變化進(jìn)行比較,差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。分別調(diào)整兩組孕婦干預(yù)前的SBP、DBP,試驗(yàn)組孕婦干預(yù)后較對(duì)照組更有效的降低SBP、DBP(95%CI:6.797~12.276 mmHg;95%CI:3.070~6.963 mmHg)。見表2。
2.3兩組的母嬰結(jié)局比較
兩組孕婦均未發(fā)生胎盤早剝、子癇、HELLP綜合癥。試驗(yàn)組孕婦妊娠期高血壓發(fā)生率略高于對(duì)照組,但差異無統(tǒng)計(jì)學(xué)意義(P>0.05),試驗(yàn)組子癇前期發(fā)生率較對(duì)照組顯著降低,差異有統(tǒng)計(jì)學(xué)意義(P=0.031),試驗(yàn)組的分娩孕齡較對(duì)照組長,差異有統(tǒng)計(jì)學(xué)意義(P=0.017),兩組孕婦早產(chǎn)、胎兒宮內(nèi)生長受限(Intraterine growth restriction,IUGR)發(fā)生率比較,差異無統(tǒng)計(jì)學(xué)意義(P>0.05)。兩組孕婦新生兒均未出現(xiàn)新生兒窒息情況,兩組新生兒出生體重比較,差異無統(tǒng)計(jì)學(xué)意義(P>0.05)。見表3。
3 討論
妊娠期高血壓疾病主要是由滋養(yǎng)細(xì)胞異常侵襲、免疫調(diào)節(jié)異常、血管內(nèi)皮損傷等引起,是導(dǎo)致早產(chǎn)、低出生體重兒等不良出生結(jié)局的原因,也是導(dǎo)致圍產(chǎn)兒死亡的重要原因之一,嚴(yán)重威脅母嬰生命安全[14-15]。為此積極探索妊娠期高血壓疾病的預(yù)防及治療手段極為重要。
補(bǔ)充與替代治療中的身心療法逐漸應(yīng)用于慢性高血壓患者的降壓治療[12],特別是正念干預(yù)在降壓臨床治療中越來越流行。有研究顯示,子癇前期婦女比健康孕婦感覺到更多的壓力和更少的社會(huì)支持[16],而高社會(huì)心理壓力又與慢性高血壓共同作用,又使子癇前期的風(fēng)險(xiǎn)增加20倍,強(qiáng)調(diào)了減輕心理壓力的重要性[17]。小劑量的阿司匹林通過影響血栓素-前列腺素平衡,抑制血小板聚集,有利于血管舒張,成為預(yù)防子癇前期的孕早期推薦用藥,但國內(nèi)外對(duì)使用阿司匹林的高危因素尚無統(tǒng)一標(biāo)準(zhǔn)??紤]到孕婦本身早孕期對(duì)服用藥物的擔(dān)憂,且國內(nèi)外有關(guān)正念干預(yù)與妊娠期高血壓疾病的研究較少,因此在溫州醫(yī)科大學(xué)附屬第二醫(yī)院進(jìn)行前瞻性隨機(jī)臨床試驗(yàn)。
臨床試驗(yàn)證明,在慢性疾病的患者中正念冥想能有效降低試驗(yàn)組的血壓[18]。印度一項(xiàng)隨機(jī)對(duì)照研究通過調(diào)查和評(píng)價(jià)孕婦干預(yù)前后完成的自主神經(jīng)功能測試的問卷證實(shí),與對(duì)照組相比,研究組感覺應(yīng)激評(píng)分和呼吸頻率明顯下降,冷壓試驗(yàn)中的孕婦血壓、心算試驗(yàn)中的孕婦收縮壓明顯下降[19]。該研究反映了正念冥想能使副交感神經(jīng)張力增加,降低交感神經(jīng)張力,調(diào)節(jié)交感神經(jīng)系統(tǒng),減少孕婦日常感知的壓力,從而對(duì)妊娠期高血壓起到保護(hù)作用。本研究結(jié)果顯示,試驗(yàn)組孕婦的正念身體掃描干預(yù)更有助于降低收縮壓、舒張壓,與高危孕婦會(huì)不自覺的出現(xiàn)緊張、焦慮情緒有關(guān),而正念身體掃描能調(diào)節(jié)交感神經(jīng)系統(tǒng),緩解孕婦的緊張情緒,從而更有效的降低其收縮壓和舒張壓。
國外研究證實(shí),瑜伽可以減少妊娠期高血壓、子癇前期、妊娠期糖尿病和宮內(nèi)生長受限的發(fā)生,甚至對(duì)胎兒結(jié)局也有積極影響[20]。瑜伽和正念有所不同,瑜伽包含的冥想并不如正念的純粹,且正念身體掃描與其他心理放松方式生理反應(yīng)相似而又不同,對(duì)自主神經(jīng)功能和心臟功能影響更為顯著[20]。但目前未見到高危孕婦與正念身體掃描干預(yù)的病例研究。本研究結(jié)果顯示,試驗(yàn)組孕婦的分娩孕齡較對(duì)照組延長,可能與子癇前期的發(fā)生具有相關(guān)性,子癇前期會(huì)增加早產(chǎn)風(fēng)險(xiǎn)。試驗(yàn)組孕婦的子癇前期的發(fā)生率顯著低于對(duì)照組,這其中很重要的點(diǎn)可能在于能堅(jiān)持正念身體掃描的孕婦,本身依從性很高,且對(duì)正念身體掃描的認(rèn)可度高,在練習(xí)后獲得良好的體驗(yàn),從而更加認(rèn)真的練習(xí),形成一個(gè)較好的良性循環(huán)。正念訓(xùn)練具有足夠的力量將注意力重新分配給予任務(wù)相關(guān)的思想,下調(diào)感知的激活并增強(qiáng)情感反應(yīng),與右額葉皮質(zhì)和左顳頂葉區(qū)域之間的高頻波半球間連通性增強(qiáng)有關(guān),而盲目的冥想可能會(huì)誘發(fā)更消極的情感狀態(tài),并在更大程度上上調(diào)感知的激活。正念身體掃面可以改善消極情緒,本研究對(duì)象本身存在相關(guān)高危因素,在妊娠這個(gè)特殊時(shí)期,更容易出現(xiàn)焦慮情況,而正念身體掃描恰好可幫助孕婦緩解孕期焦慮情緒,減輕壓力,促進(jìn)身心健康,從而改善母嬰結(jié)局。
綜上所述,高危孕婦孕期進(jìn)行系統(tǒng)的正念身體掃描可以有效降低血壓和子癇前期的發(fā)生率。該方法安全有效,無經(jīng)濟(jì)壓力,可以作為預(yù)防妊娠期高血壓疾病的有效措施之一。
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(收稿日期:2020-06-25)