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产后抑郁症(postpartum depression, PPD)是在产褥期出现的抑郁,是以情绪低落、精神运动性激动或者迟钝、失眠或嗜睡、无价值感和过度内疚等一系列症状为特征的心理障碍。有资料[1-2]表明,PPD的发病率逐年增加,高达15%左右。若不加以重视,部分病人的PPD症状将持续1~2年或更久,严重者甚至产生自伤、自杀或伤婴等行为,且再次妊娠的复发率将达到20%~30%[3]。PPD的致病因素包括遗传、神经递质和分娩时的疼痛与焦虑、恐惧等。临床上有很多降低PPD发生率的措施,如产前宣教、围产期心理疏导和导乐陪伴分娩等,效果仍不理想。本研究使用针刺三阴交穴和合谷穴联合舒芬太尼复合罗哌卡因硬膜外分娩镇痛,探讨其对于PPD发生的影响。现作报道。
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3组产妇的年龄、孕周、BMI和新生儿体质量及性别差异均无统计学意义(P>0.05)(见表 1)。
分组 年龄/岁 孕周/周 BMI/(kg/m2) 新生儿体质量/kg 新生儿性别 男 女 SA组 27.77±2.52 39.12±1.21 26.03±1.33 3.35±0.30 31 29 S组 28.08±2.36 39.28±1.17 26.14±1.24 3.30±0.31 29 31 C组 28.02±2.43 39.25±1.23 26.35±1.29 3.31±0.30 28 32 F 0.28 0.30 0.98 0.46 0.31* P >0.05 >0.05 >0.05 >0.05 >0.05 MS组内 5.941 1.448 1.640 0.092 — *示χ2值 表 1 3组产妇一般情况比较(ni=60;x±s)
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3组T0时VAS评分差异无统计学意义(P>0.05)。与T0时比较,SA组、S组产妇在T1和T2时VAS评分均明显降低(P < 0.01),C组均明显增高(P < 0.01);且T1和T2时,SA组、S组VAS评分均明显低于C组(P < 0.01),SA组亦均明显低于S组(P < 0.01)(见表 2)。
分组 T0 T1 T2 F P MS组内 SA组 6.35±0.88 1.87±0.62**##△△ 2.13±0.62**##△△ 737.68 < 0.01 0.514 S组 6.33±0.91 2.35±0.63**△△ 2.73±0.63**△△▲▲ 535.39 < 0.01 0.541 C组 6.38±0.90 8.30±0.65△△ 9.12±0.56△△▲▲ 230.25 < 0.01 0.515 F 0.05 1 915.23 2 467.41 — — — P >0.05 < 0.01 < 0.01 — — — MS组内 0.809 0.402 0.366 — — — q检验:与C组比较**P < 0.01;与S组比较##P < 0.01;与T0比较△△P < 0.01;与T1比较▲▲P < 0.01 表 2 3组产妇VAS评分比较(ni=60;x±s; 分)
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3组产妇第一产程、第三产程和产后2 h出血量差异均无统计学意义(P>0.05);3组第二产程间差异有统计学意义(P < 0.01),其中SA组和C组第二产程均较S组明显缩短(P < 0.01),而SA组与C组差异无统计学意义(P>0.05)(见表 3)。
分组 产程/min 产后2 h出血量/mL 第一产程 第二产程 第三产程 SA组 550.28±165.14 49.55±15.94** 9.33±1.61 230.08±16.14 S组 546.55±168.34 78.15±21.07 9.35±1.54 234.25±17.07 C组 539.53±160.05 54.03±16.04** 9.13±1.14 231.18±16.20 F 0.07 44.58 0.42 1.03 P >0.05 < 0.01 >0.05 >0.05 MS组内 27 074.779 318.466 2.090 271.485 q检验:与S组比较**P < 0.01 表 3 3组产妇产程和产后2 h出血量比较(ni=60;x±s)
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SA组、S组产后EPDS评分和PPD发生率均低于C组(P < 0.05~P < 0.01),SA组EPDS评分和PPD发生率亦均低于S组(P < 0.01和P < 0.05)(见表 4)。
分组 EPDS评分/分 PPD发生 SA组 6.28±1.90△△▲▲ 2(3.33)*# S组 7.62±2.23△ 8(13.33)* C组 8.60±2.65 15(25.00) F 15.63 11.80□ P < 0.01 < 0.01 MS组内 5.191 — q检验:与C组比较△P < 0.05,△△P < 0.01;与S组比较▲▲P < 0.01。□示χ2值;与C组比较*P < 0.05,与S组比较#P < 0.05 表 4 3组产妇EPDS评分及PPD发生率比较(ni=60;x±s)
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镇痛前即刻,3组产妇血清Glu水平差异无统计学意义(P>0.05)。第三产程末和产后42 d,SA组、S组产妇Glu水平均较镇痛前即刻降低(P < 0.05~P < 0.01),且2组产妇血清Glu水平均低于C组(P < 0.05~P < 0.01),SA组亦均明显低于S组(P < 0.01)(见表 5)。
分组 镇痛前即刻 第三产程末 产后42 d SA组 3.54±1.02 2.87±0.62**##△△ 2.54±0.73**##△△ S组 3.62±1.03 3.24±0.73**△ 3.03±0.81*△△ C组 3.56±1.03 4.16±0.89 3.38±0.87 F 0.09 46.60 16.68 P >0.05 < 0.01 < 0.01 MS组内 1.054 0.568 0.652 q检验:与C组比较*P < 0.05,**P < 0.01;与S组比较##P < 0.01;与镇痛前即刻比较△P < 0.05,△△P < 0.01 表 5 3组产妇不同时点血清Glu水平比较(ni=60;x±s;mg/dL)
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3组产妇Bromage运动评分均为0级,无一例发生运动神经阻滞。SA组产妇无不良反应及追加镇痛;S组寒颤1例(1.7%)、瘙痒1例(1.7%),追加镇痛3例(5%)。3组产妇无一例出现呼吸抑制和尿潴留。
针刺穴位联合硬膜外分娩镇痛对产后抑郁症的影响
Effect of the acupuncture at acupoint combined with epidural labor analgesia on postpartum depression
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摘要:
目的 研究针刺穴位联合硬膜外分娩镇痛对产后抑郁症(PPD)的影响并探讨其机制。 方法 选取足月单胎初产妇180例,将无分娩镇痛要求的产妇设为对照组(C组),将有分娩镇痛要求产妇随机分为针刺穴位联合硬膜外分娩镇痛组(SA组)和硬膜外分娩镇痛组(S组),各60例。SA组行针刺三阴交穴、合谷穴联合0.5 μg/mL舒芬太尼复合0.08%罗哌卡因硬膜外分娩镇痛;S组行0.5 μg/mL舒芬太尼复合0.08%罗哌卡因硬膜外分娩镇痛;C组不实施分娩镇痛,按照自然分娩常规流程处理。记录3组产妇宫口开2 cm时(T0)、宫口全开时(T1)、胎儿娩出时(T2)的视觉疼痛模拟评分(VAS);用双抗体夹心ELISA法检测镇痛前即刻、第三产程末、产后42 d产妇血清中谷氨酸(Glu)水平,并于产后42 d进行爱丁堡产后抑郁量表(EPDS)评分,比较3组产妇PPD发生率。记录T0~T2时,按压镇痛泵及不良反应情况;记录产程、产后2 h出血量、分娩镇痛后Bromage运动评分。 结果 3组T0时VAS评分差异无统计学意义(P>0.05),T1和T2时,SA组、S组VAS评分均明显低于C组(P < 0.01),SA组亦均明显低于S组(P < 0.01)。3组产妇第一产程、第三产程和产后2 h出血量差异均无统计学意义(P>0.05);SA组和C组第二产程均较S组明显缩短(P < 0.01),而SA组与C组差异无统计学意义(P>0.05)。SA组、S组产后EPDS评分和PPD发生率均低于C组(P < 0.05~P < 0.01),SA组EPDS评分和PPD发生率亦均低于S组(P < 0.01和P < 0.05)。镇痛前即刻,3组产妇血清Glu水平差异无统计学意义(P>0.05);第三产程末和产后42 d,SA组、S组产妇Glu水平均较镇痛前即刻降低(P < 0.05~P < 0.01),且2组产妇血清Glu水平均低于C组(P < 0.05~P < 0.01),SA组亦均明显低于S组(P < 0.01)。3组产妇Bromage运动评分均为0级,无一例发生运动神经阻滞。 结论 针刺穴位联合硬膜外分娩镇痛可以降低PPD的发生率,其机制可能与血清Glu含量的降低及分娩疼痛减轻有关。 Abstract:Objective To explore the effects of the acupuncture at acupoint combined with epidural labor analgesia on the postpartum depression(PPD) and its mechanism. Methods One hundred and eighty full-term single primiparas were randomly divided into the acupuncture at acupoint combined with epidural labor analgesia group(group SA) and epidural labor analgesia group(group S), and the parturients without labor analgesia requirements were set as the control group(group C)(60 cases in each group).The group SA was treated with acupuncture at Sanyinjiao point and Hegu point combined with 0.5 μg/mL sufentanil and 0.08% ropivacaine for epidural labor analgesia.The group S was treated with 0.5 μg/mL sufentanil combined with 0.08% ropivacaine for epidural labor analgesia.The group C was not treated with labor analgesia, and the cases were treated with the routine process of natural labor.The visual pain analogue scores(VAS) in three groups were recorded when the uterine orifice was opened for 2 cm(T0), the uterine orifice was fully opened(T1), and the fetus was delivered(T2).The serum levels of glutamate(Glu) in three groups were measured by double-antibody sandwich ELISA method immediately before analgesia, at the end of the third stage of labor and postpartum 42 days, and the edinburgh postpartum depression scale(EPDS) scores were evaluated at postpartum 42 days.The incidence rates of PPD were compared among the three groups.The analgesic pump and adverse reactions in three groups were recorded at T0-T2.The labor course, postpartum 2 h blood loss and Bromage motion score after analgesia were recorded. Results There was no statistical significance in the VAS score among three groups at T0(P>0.05).At T1 and T2, the VAS scores in group SA and group S were significantly lower than that in group C(P < 0.01), and which in group SA was also significantly lower than that in group S(P < 0.01).There was no statistical significance in the blood loss among three groups in the first and second stage of labor and at postpartum 2 h(P>0.05).The second labor stage in group SA and group C was significantly shorter than that in group S(P < 0.01), but there was no statistical significance between group SA and group C(P>0.05).The EPDS score and PPD incidence in group SA and group S were lower than those in group C(P < 0.05 to P < 0.01), and the EPDS score and PPD incidence in group SA were lower than those in group S(P < 0.01 and P < 0.05).Immediately before analgesia, there was no statistical significance in the serum Glu levels among three groups(P>0.05).At the end of the third labor stage and postpartum 42 days, the maternal Glu levels in group SA and group S were lower than that immediately before analgesia(P < 0.01 and P < 0.05), which in the two groups were lower than that in group C(P < 0.01 and P < 0.05), and the maternal Glu level in group SA was significantly lower than that in group S(P < 0.01).The Bromage motion scores in three groups were 0, and the motor nerve block was not found in any of them. Conclusions The acupuncture at acupoint combined with epidural labor analgesia can reduce the incidence rate of PPD, and the mechanism may be related to the decrease of serum Glu levels and alleviating labor pain. -
Key words:
- postpartum depression /
- labor delivery /
- analgesia /
- acupuncture /
- acupoint /
- glutamate
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表 1 3组产妇一般情况比较(ni=60;x±s)
分组 年龄/岁 孕周/周 BMI/(kg/m2) 新生儿体质量/kg 新生儿性别 男 女 SA组 27.77±2.52 39.12±1.21 26.03±1.33 3.35±0.30 31 29 S组 28.08±2.36 39.28±1.17 26.14±1.24 3.30±0.31 29 31 C组 28.02±2.43 39.25±1.23 26.35±1.29 3.31±0.30 28 32 F 0.28 0.30 0.98 0.46 0.31* P >0.05 >0.05 >0.05 >0.05 >0.05 MS组内 5.941 1.448 1.640 0.092 — *示χ2值 表 2 3组产妇VAS评分比较(ni=60;x±s; 分)
分组 T0 T1 T2 F P MS组内 SA组 6.35±0.88 1.87±0.62**##△△ 2.13±0.62**##△△ 737.68 < 0.01 0.514 S组 6.33±0.91 2.35±0.63**△△ 2.73±0.63**△△▲▲ 535.39 < 0.01 0.541 C组 6.38±0.90 8.30±0.65△△ 9.12±0.56△△▲▲ 230.25 < 0.01 0.515 F 0.05 1 915.23 2 467.41 — — — P >0.05 < 0.01 < 0.01 — — — MS组内 0.809 0.402 0.366 — — — q检验:与C组比较**P < 0.01;与S组比较##P < 0.01;与T0比较△△P < 0.01;与T1比较▲▲P < 0.01 表 3 3组产妇产程和产后2 h出血量比较(ni=60;x±s)
分组 产程/min 产后2 h出血量/mL 第一产程 第二产程 第三产程 SA组 550.28±165.14 49.55±15.94** 9.33±1.61 230.08±16.14 S组 546.55±168.34 78.15±21.07 9.35±1.54 234.25±17.07 C组 539.53±160.05 54.03±16.04** 9.13±1.14 231.18±16.20 F 0.07 44.58 0.42 1.03 P >0.05 < 0.01 >0.05 >0.05 MS组内 27 074.779 318.466 2.090 271.485 q检验:与S组比较**P < 0.01 表 4 3组产妇EPDS评分及PPD发生率比较(ni=60;x±s)
分组 EPDS评分/分 PPD发生 SA组 6.28±1.90△△▲▲ 2(3.33)*# S组 7.62±2.23△ 8(13.33)* C组 8.60±2.65 15(25.00) F 15.63 11.80□ P < 0.01 < 0.01 MS组内 5.191 — q检验:与C组比较△P < 0.05,△△P < 0.01;与S组比较▲▲P < 0.01。□示χ2值;与C组比较*P < 0.05,与S组比较#P < 0.05 表 5 3组产妇不同时点血清Glu水平比较(ni=60;x±s;mg/dL)
分组 镇痛前即刻 第三产程末 产后42 d SA组 3.54±1.02 2.87±0.62**##△△ 2.54±0.73**##△△ S组 3.62±1.03 3.24±0.73**△ 3.03±0.81*△△ C组 3.56±1.03 4.16±0.89 3.38±0.87 F 0.09 46.60 16.68 P >0.05 < 0.01 < 0.01 MS组内 1.054 0.568 0.652 q检验:与C组比较*P < 0.05,**P < 0.01;与S组比较##P < 0.01;与镇痛前即刻比较△P < 0.05,△△P < 0.01 -
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