唾液皮质醇表达与分娩生理、心理应激反应：前瞻性研究
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Physiological and psychological stress responses to labor and delivery as expressed by salivary cortisol: a prospective study
背景与目的
分娩被认为是一个应激性事件，但尚无研究报道通过分娩时及产后的皮质醇表达水平来监测分娩应激过程。本研究旨在阐明分娩过程中通过唾液皮质醇浓度和压力调查问卷进行测量的生理和心理应激模式，以及它们与产科和新生儿结局的关系。
方 法
本项前瞻性观察性研究共收集了来自同一所高等学术中心的167名低风险、单胎、足月妊娠的孕妇。分别于分娩潜伏期、活跃期、宫颈完全扩张期以及分娩后2min、2h、24h，采用唾液皮质醇测量值和情绪压力问卷(压力量表0~10)对生理应激进行评估。测定脐带血皮质醇和pH值。评估分娩方式、阵痛与分娩期间并发症和新生儿早期结局。
结 果
唾液皮质醇浓度由潜伏期至活跃期逐渐升高。分娩后2min内观察到了上升的最大值（从平均值1.06 μg/dl上升至1.67 μg/dl：升高了57%）。分娩后2h内,皮质醇浓度逐渐下降，并在分娩24h后达到非妊娠水平(0.16 μg/dl)。分娩期间和产后2h内皮质醇浓度高于非妊娠妇女平均浓度（0.5 μg/dl）。与非硬膜外麻醉的产妇相比，硬膜外麻醉的产妇在宫颈开全时(p=0.026)和产后2h(p=0.016)的皮质醇浓度较低。心理应激在潜伏期和宫颈完全扩张期达到峰值(平均值分别为4.56、4.29)，产后即刻出现最大降幅（从4.29下降至2.04，下降了52%）。胎头吸引术分娩组脐带血皮质醇水平高于自然阴道分娩组(17±2 vs. 11±3.8,p=0.03)。
结 论
本项研究揭示了低风险孕妇分娩时皮质醇浓度的变化过程，其中最大上升出现在产后数分钟内。主观应激水平在分娩过程中逐渐下降。唾液皮质醇浓度变化反映了分娩过程中的应激状况，可作为参考以评估复杂妊娠和皮质醇在分娩过程中的作用。
原始文献摘要
Miller N, Asali AA, Agassi-Zaitler M, et al. Physiological and psychological stress responses to labor and delivery as expressed by salivary cortisol: a prospective study.[J]. Am J Obstet Gynecol 2019. DOI：10.1016/j.ajog.2019.06.045
Background: Labor is considered a stressful event, yet no study has described the course of stress measured by cortisol during labor and postpartum .
Objective: To describe the patterns of physiological and psychological stress during labor as measured by salivary cortisol concentrations and stress questionnaires and their correlation to obstetric and neonatal outcomes.
Study Design: This prospective, observational study included 167 women with low-risk, singleton, term deliveries at a tertiary academic center. Physiological stress was evaluated by salivary cortisol measurements and emotional stress by questionnaire (Stress scale ranging from 0-10) during the latent phase, active phase and full dilation stages of labor, as well as 2 minutes, 2 hours and 24 hours after delivery. Cord blood cortisol and pH were also obtained. Modes of delivery, complications during labor and delivery, and early neonatal outcomes were evaluated.
Results: Salivary cortisol concentrations increased gradually from latent phase to active phase. The maximum increase was observed within 2 minutes of the delivery (from an average of 1.06 μg/dl to 1.67 μg/dl: 57% increase). Within 2 hours after delivery, cortisol decreased and reached a non-gravid concentration after 24 hours (0.16 μg/dl). Cortisol concentrations during labor and up to 2 hours postpartum were above the average concentration of non-gravid women (0.5 μg/dl). Women with epidural anesthesia had lower cortisol concentrations at complete dilation (p=0.026) and 2 hours postpartum (p=0.016) compared to women without epidural. Psychological stress peaked during latent and full dilation phases (mean 4.56, 4.29, respectively). Maximum decrease from 4.29 to 2.04 (52%) occurred immediately postpartum. Cord cortisol was higher among women delivered by vacuum extraction compared to spontaneous vaginal delivery (17 ± 2 vs. 11 ± 3.8, p=0.03).
Conclusions: This study reveals the course of cortisol concentrations during labor for low-risk pregnancies, with maximum increase immediately postpartum. Subjective stress levels decreased over the course of labor. Salivary cortisol portrays stress during labor and may be used as a reference to evaluate complicated pregnancies and to evaluate the role of cortisol during these deliveries.
麻醉学文献进展分享
贵州医科大学高鸿教授课题组
翻译：冯玉蓉 编辑：何幼芹 审校：王贵龙