臺灣博碩士論文加值系統

背景：先天性心臟疾病的預防受限於危險因子的認知不足所以仍有阻礙。先前研究發現某些無法改變的危險因子，包括辨認出影響特定型態的先天性心臟病的基因異常與先天心臟病的發生有關，但比率至多只占15%；而對於可改變的危險因子，如環境暴露（如母親肥胖、罹患糖尿病等）影響等之認知與預防仍然有限。目前文獻顯示，母親肥胖、產前罹患糖尿病、癲癇、先天性心臟病會增加新生兒罹患先天性心臟病的機會。然而過去研究受限於樣本數不多，殘餘干擾因子影響等因素，研究證據有限，此外，母親吸菸、罹患高血壓、結締性組織疾病、甲狀腺疾患、是否與先天性心臟病有關，則是尚未有一致結論。
目的：本研究建置「台灣婦幼衛生主題健康資料庫」進行母親慢性疾病與新生兒先天性心臟病相關性之分析，包括分析新生兒先天性心臟病的盛行率，以及探討母親慢性疾病與新生兒先天性心臟病間之關聯性。
方法：本研究將採用回溯性世代追蹤研究，使用台灣2004-2011年的出生登記檔、出生通報檔，比對健保資料，分析新生兒先天性心臟病的盛行率，並以布阿松迴歸分析檢定先天性心臟病盛行率之年代趨勢。本研究利用廣義估計方程式利用邏吉斯迴歸納入母親、新生兒的人口學特性及母親慢性疾病後得出新生兒罹患全部先天性心臟病、複雜嚴重型先天性心臟病、簡單輕微型先天性心臟病調整後勝算比及95%信賴區間。最後再計算族群的可歸因危險性百分比，得知若消除先天性心臟病有關的危險因子後有多少比例的疾病發生率可預防。
結果： 2004-2010年研究樣本數共1,387,650名新生兒，共有27,240名新生兒在出生後1年內罹患先天性心臟病，盛行率為每19.63/1,000活產新生兒，排除〈37週的開放性動脈導管後，全部先天性心臟病盛行率為16.92/1,000活產新生兒，複雜嚴重型先天性心臟病盛行率為1.35/1,000活產新生兒，簡單輕微型先天性心臟病盛行率為16.57/1,000活產新生兒。使用廣義估計方程式做進一步的複迴歸分析發現母親罹患先天性心臟病（Adjusted odds ratio（AOR）=5.77）及第二型糖尿病（AOR=2.45）與新生兒罹患複雜嚴重型先天性心臟病有顯著相關。多種母親慢性疾病及吸菸行為與簡單輕微型先天性心臟病有關聯。其中關聯性最高且有統計顯著意義的為母親罹患先天性心臟病（AOR為2.68），次之為母親罹患第二型糖尿病（AOR=2.23），接下來依序為第一型糖尿病（AOR=1.83）、母親吸菸（AOR=1.68）、高血壓（AOR=1.29）、貧血（AOR=1.26）、結締性組織疾病（AOR=1.24）、情緒性障礙（AOR=1.23）。
結論：本研究發現影響簡單輕微型先天性心臟病的顯著危險因子較複雜嚴重型多，高齡（〉35歲）母親及罹患某些慢性疾病都會影響簡單輕微型先天性心臟病的發生，而受限於複雜嚴重型先天性心臟病的樣本數較少，因此影響先天性心臟病的危險因子還有待未來研究繼續探討。本研究所得出的母親慢性疾病與新生兒先天性心臟病的關聯性，期望研究結果的訊息，可以做為產前檢查等改善生產結果措施之參考。

Prevention of congenital heart defects (CHDs) has not been very successful due to limited knowledge of risk factors for CHDs. This study aimed to investigate the prevalence of childhood CHDs and to assess the risk of offspring CHDs in relation to maternal chronic disease. This was a retrospective cohort study with Birth Registration database 2004 to 2011, which was interlinked to Birth Certificate Application, and the National Health Insurance Research Database. We estimated, using logistic regression model with Generalized Estimating Equation (GEE) method, the crude and adjusted odds ratios (AOR) of offspring CHDs in relation to chronic conditions of mothers. Our study showed that the all-cause CHDs prevalence was estimated at 16.92 per 1,000 live births. Additionally, the prevalence of severe and simple form of CHDs was estimated at 1.35 and 16.57 per 1,000 live births, respectively. Significant risk factors for severe CHDs included congenital heart disease (AOR=5.77) and Type 2 diabetes mellitus (AOR=2.45). Several chronic maternal medical conditions conferred an increased risk of simple CHDs in the offspring. The highest AOR is noted for congenital heart diseases (AOR=2.68), followed by Type 2 diabetes mellitus (AOR=2.23), Type 1 diabetes mellitus (AOR=1.83), smoking (AOR=1.68), hypertension (AOR=1.29), anemia (AOR=1.26), systemic connective tissue disorders (AOR=1.24), and mood disorder (AOR=1.23). Findings from our study suggested that a number of chronic conditions in mothers may lead to increased risk of CHDs in offspring, which warrants attention of both pregnant women and clinicians.

第壹章、前言................................................1
第一節 研究背景與重要性....................................1
第二節 研究目的...........................................4
第三節 研究假設...........................................4
第貳章、文獻探討............................................5
第一節 先天性心臟病的分類.................................5
第二節 先天性心臟病盛行率.................................11
第三節 先天性心臟病的危險因子.............................12
第四節 先天性心臟病的預後..................................7
第參章、研究材料與方法......................................18
第一節 婦幼主題式資料庫之建置..............................18
一、資料來源..........................................18
二、資料比對所遭遇的困難...............................19
三、資料處理過程......................................20
四、婦幼主題式資料庫的建立.............................22
第二節 母親慢性疾病與新生兒先天性心臟病關聯性探討...........22
一、資料來源 ..........................................22
二、研究世代擷取......................................22
三、暴露變項定義......................................23
四、結果變項定義......................................23
五、潛在干擾因子定義..................................24
六、統計方法 .........................................24
第肆章、研究結果...........................................27
第一節 婦幼主題式資料庫之建置.............................27
一、補正出生登記資料中母親之唯一身分證字號..............27
二、將新生兒出後2個月內依附在他人名下就醫之紀錄補正回來..29
第二節 母親慢性疾病與新生兒先天性心臟病關聯性探討...........30
一、先天性心臟病盛行率之研究結果.......................30
二、父母親特性、新生兒特性與先天性心臟病關聯性探討.......30
三、母親行為因素、罹患慢性疾病與先天性心臟病關聯性探討...32
四、先天性心臟病可歸因危險比...........................35
第伍章、討論..............................................37
第一節 研究主要發現......................................37
第二節 本研究結果的重要性.................................38
第三節 與過去研究結果比較.................................38
第四節 研究的優勢與限制...................................42
第陸章、結論與建議.........................................46
第柒章、參考資料..........................................92

表目錄
表1、2004-2010年新生兒罹患特定型態先天性心臟病的人數、每100,000活產盛行率...............................................47
表2、父母親、新生兒特性的全部先天性心臟病盛行率及勝算比......49
表3、父母親、新生兒特性的複雜嚴重型先天性心臟病盛行率及勝算比.53
表4、父母親、新生兒特性的簡單輕微型先天性心臟病盛行率及勝算比.57
表5、母親行為及慢性疾病的全部先天性心臟病盛行率及勝算比......61
表6、母親行為及慢性疾病的複雜嚴重型先天性心臟病盛行率及勝算比.63
表7、母親行為及慢性疾病的簡單輕微型先天性心臟病盛行率及勝算比.65
表8、母親慢性疾病與各類複雜嚴重型先天性心臟病盛行率之勝算比...67
表9、母親行為及慢性疾病與各類簡單輕微型先天性心臟病盛行率之勝算比 ........................................................69

 
圖目錄
圖1、校正依附申報新生兒就醫紀錄中新生兒本身的身分證字號......71
圖2、2004-2010年出生的新生兒之資料擷取流程.................73
圖3、補正出生登記資料中母親之身分證字號的資料處理流程........75
圖4、先天性心臟病之年代別盛行率............................76
圖5、先天性心臟病之年代別盛行率............................76
圖6、簡單輕微型先天性心臟病之年代別盛行率...................77
圖7、母親行為因素及慢性疾病與全部先天性心臟病之調整後勝算比...78
圖8、母親行為因素及慢性疾病與複雜嚴重型先天性心臟病之調整後勝算比 .........................................................78
圖9、母親慢性疾病與法洛氏四合群症之調整後勝算比..............79
圖10、母親慢性疾病與大動脈轉位之調整後勝算比................79
圖11、母親慢性疾病與右心室雙出口之調整後勝算比..............80
圖12、母親慢性疾病與肺靜脈回流完全畸形之調整後勝算比.........80
圖13、母親慢性疾病與共同單一心室之調整後勝算比..............81
圖14、母親慢性疾病與左心發育不全症候群之調整後勝算比..........81
圖15、母親慢性疾病與共同動脈幹之調整後勝算比................82
圖16、母親慢性疾病與三尖瓣閉塞之調整後勝算比................82
圖17、母親慢性疾病與先天性矯正型大動脈轉位之調整後勝算比.....83
圖18、母親行為因素及慢性疾病與簡單輕微型先天性心臟病之調整後勝算比......................................................83
圖19、母親行為因素及慢性疾病與心房中膈缺損之調整後勝算比.....84
圖20、母親行為因素及慢性疾病與開放性動脈導管病之調整後勝算比..84
圖21、母親行為因素及慢性疾病與心室中膈缺損病之調整後勝算比....85
圖22、母親行為因素及慢性疾病與肺動脈瓣狹窄之調整後勝算比......85
圖23、母親行為因素及慢性疾病與主動脈狹窄之調整後勝算比.......86
圖24、母親行為因素及慢性疾病與心內墊膜缺損之調整後勝算比.....86
圖25、母親行為因素及慢性疾病與主動脈瓣狹窄之調整後勝算比.....87
圖26、母親行為因素及慢性疾病與葉伯斯丁氏畸形之調整後勝算比....87
圖27、母親行為因素及慢性疾病與部分肺靜脈回流異常之調整後勝算比.88
圖28、全部先天性心臟病的可歸因危險比........................89
圖29、全部先天性心臟病之母親吸菸與慢性疾病的可歸因危險比......89
圖30、複雜嚴重型先天性心臟病的可歸因危險比...................90
圖31、複雜嚴重型先天性心臟病之母親吸菸與慢性疾病的可歸因危險比.90
圖32、簡單輕微型先天性心臟病的可歸因危險比...................91
圖33、簡單輕微型先天性心臟病之母親吸菸與慢性疾病的可歸因危險比.91

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