懷孕期間環境職業因素對胎兒及母親健康之影響

Maternal and Fetal Health Effects of Prenatal Environmental and Occupational Factors

施屏(Ping Shih)

指導教授 ： 郭育良

共同指導教授 ： 陳保中(Pau-Chung Chen)

國立臺灣大學/公共衛生學院/環境與職業健康科學研究所/博士(2021年)

https://doi.org/10.6342/NTU202103077

摘要

空氣污染物暴露及環境職業因素可能有神經毒性或影響心理健康，而懷孕者及胎兒更是相關危害暴露的易感族群。父母對孩童健康，常主訴有生長發育障礙，而其中注意力不足過動症是全球最常見的孩童神經行為疾患；產後憂鬱症是產後母親普遍且嚴重的心理健康問題，易引發個人及家庭的負面影響。雖然近年來流行病學研究顯示，懷孕期間空氣污染物暴露及母親環境因素皆會增加上述疾病的罹病風險，但相關實驗設計及結果尚未能有一致性結論，且亦欠缺本土性流行病學資料。本研究期望能利用本土性世代研究資料，評估母親於早期的環境職業因子與空氣污染暴露是否會增加孩童過動症或產後憂鬱症之風險，具體目標為：
1.評估妊娠階段空氣污染物暴露濃度高低，對於出生後孩童罹患過動症（Hyperactivity disorder）的影響。
2.比較懷孕期間持續工作的母親於高工作壓力的環境，對於此胎未來發生過動症（Hyperactivity disorder）的關聯。
3.探討懷孕時期空氣污染物對於產後憂鬱症（Postpartum depression）的潛在效應。
本研究使用台灣出生世代研究（Taiwan Birth Cohort Study），評估母親及孩童相關疾病與危險因子狀況，並針對2004年至2005年的台灣環保署空氣品質監測網（Air Quality Monitoring Network）的空氣污染物數據，使用地理資訊系統（Geographic Information System）的空間分析方法，進行個人懷孕不同時期的空污暴露狀況配對，以探討懷孕時期的環境職業差異對於孩童與母親後續的健康效應之關聯強度。
第一部分研究結果發現，在納入最終分析的16376對母嬰中，有374名（2.3%）兒童在8歲之前曾被診斷出過動症。過動症的發生與妊娠時氮氧化物（NOx）暴露顯著相關，但與直徑小於或等於10微米的顆粒物（PM10）或二氧化硫無關。進一步以二氧化氮（NO2）以及一氧化氮（NO）分析，則只有NO與過動性成顯著相關（aOR per 3.14 ppb=1.26，95% CI= 1.09-1.46）。第二部分研究結果，在10,559名於懷孕期間繼續工作的母親中，與沒有工作壓力者相比，若在懷孕期間從事“非常有壓力的工作”者的孩童有1.91倍的機率將於8歲前被診斷過動症（95% CI: 1.21-3.04)，而具有“相當壓力的工作”者的孩童則有1.53倍的風險（95% CI: 1.04- 2.25）。而第三部分研究結果我們發現，在21,205名婦女間有3,654名（17.2％）在產後6個月內發生了產後憂鬱症。產後憂鬱症發生與懷孕期間暴露於一氧化碳（CO）和二氧化氮（NO2）顯著相關，但與直徑≤2.5μm的顆粒物(PM2.5)無關。經過反向逐步選擇探討不同時期空氣污染物暴露情況，懷孕早期的NO2暴露仍與產後憂鬱症呈現顯著相關（aOR per 10.7 ppb=1.081，95% CI= 1.003-1.165）。
綜上，我們發現懷孕時期若暴露到較高濃度的特定空氣汙染物或高壓力的工作，確實會影響出生後孩童的神經行為疾患以及母親產後心理狀態。因此，確切的治病機轉及其長期健康效應值得持續研究並進一步釐清。

關鍵字

Hyperactivity disorder ； Postpartum depression ； Air pollution ； Pregnancy ； Job stress ； Cohort study

並列摘要

Air pollutant exposure and environmental and occupational factors have neurotoxicity or affect mental health. For pregnant women and fetuses, they are susceptible to related hazards. Growth and development disorders are common complaints for children’s parents. Among them, attention deficit hyperactivity disorder is the most common neurobehavioral disorder in children around the world. Postpartum depression is a common and serious mental health problem for mothers after delivery, and easily causing negative impacts on individuals and families. Though recent epidemiological studies indicated air pollutions and environmental exposures during pregnancy may increase risks of the diseases, literature shows controversies, and most of previous researches were done in other countries with lacking of data in Taiwan. By using Taiwanese cohort studies, we aim to determine whether perinatal environmental risk factors, like air pollutants and maternal environmental factors, increase risk of childhood hyperactivity disorder and postpartum depression. The specific goals of the study include:
1.Evaluate the risk of gestational exposure to air pollution on offspring hyperactivity disorders.
2.Compare the strength of the relationship between work-related job stress during pregnancy and the future occurrence of children hyperactivity disorder.
3.Explore the potential roles of maternal air pollutants during pregnancy in postpartum depression.
The national database-Taiwan birth cohort study was used to assess mothers and children related diseases and risk factors. Based on the air pollutant data of the Environmental Protection Agency's Air Quality Monitoring Network from 2004 to 2005, the spatial analysis method of Geographic Information System was used to match the air pollution exposure condition of individuals in different periods of pregnancy. We then explored the correlation of environmental and occupational differences during pregnancy on the subsequent health effects of the child and the mother.
In the first part of the study, a total of 16,376 mother–infant pairs were included and 374 (2.3%) of the children had received a diagnosis of hyperactivity before 8 years of age. The occurrence of hyperactivity was significantly related to prenatal nitrogen oxide (NOx), but not to particulate matter 10 micrometers or less in diameter (PM10) or sulfur dioxide. Further analysis to separate effects by nitrogen dioxide (NO2) and/or nitrogen monoxide (NO) showed that only NO was significantly related to hyperactivity (aOR per 3.14 ppb=1.26，95% CI= 1.09-1.46). Secondly, 10,559 mothers who continued working during pregnancy were included in the final analysis. Compared with mothers without job stress, the adjusted odds ratio of child hyperactivity was 1.91 (95% CI: 1.21-3.04) for mothers with “very stressful” jobs during pregnancy and 1.53 (95% CI: 1.04- 2.25) for mothers with “rather stressful” jobs. Lastly, 3,654 (17.2%) developed Postpartum depression within 6 months postpartum among 21,205 participants. The occurrence of postpartum depression was significantly related to exposure to ambient concentrations of carbon monoxide (CO) and NO2 during pregnancy, but not to particulate matter ≤2.5µm in diameter (PM2.5). While relationship between postpartum depression and exposure during different periods was investigated using backward stepwise selection, NO2 exposure in the first trimester remained significantly related to postpartum depression (aOR per 10.7 ppb=1.081，95% CI= 1.003-1.165).
In conclusion, we have found that exposure to higher levels of specific air pollutants or higher job stress during pregnancy do affect the children neurobehavioral outcome and the mental health status of the mothers after childbirth. Future investigation is indicated to elucidate the possible underlying mechanisms and long-term health effects.

並列關鍵字

過動症 ； 產後憂鬱症 ； 空氣污染 ； 懷孕時期 ； 工作壓力 ； 世代追蹤研究

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