個人化產前照護及早產防治技術之研發

Abstract

在妊娠產檢的過程中，胎兒窘迫和早產一直是婦產科醫師經常面對的問題和挑戰。產前診斷子宮內胎兒健康狀況的方法有很多種，除了超音波之外，胎心音及子宮收縮監測器是另一種最常用的儀器。胎心音及子宮收縮監測器是一種利用電子裝置來偵測和連續記錄胎心音及子宮收縮的儀器，並將胎心音及子宮收縮的紀錄用二條曲線表示。胎心音及子宮收縮監測器在臨床上使用主要的適應症是高危險妊娠（如︰妊娠高血壓、妊娠毒血症、妊娠糖尿病、早產、羊水過少、胎兒生長遲緩、過期妊娠等）或是已進入產程準備待產的孕婦。 胎心音及子宮收縮監測紀錄雖然只有二條曲線圖形，但其中蘊藏很多資訊可供醫護人員評估胎兒健康情形（如︰心率基準線、頻脈、緩脈、心率變異性、心跳加速或減速變化等）和子宮收縮情形（如︰頻率、持續時間、收縮壓力等），因此可以用來診斷是否有胎心音窘迫或早產等問題。 一般的胎心音及子宮收縮監測器必須在醫院裝置檢查，然後經由醫師判讀並做進一步的處置。然而對於有早產現象、子宮收縮、或是血壓高的孕婦，處理的原則之一是盡量臥床休息。如果要孕婦一旦有輕微症狀就到醫院檢查，容易在懷孕的過程必須常常掛急診到醫院，造成孕婦的困擾，對於住在距離產檢醫院較遠或偏遠地方的孕婦更是不便。 早產的發生率高達5~13%，其為造成70%新生兒死亡的主要因素，有50%新生兒神經發育上的異常也和早產有關。然而早產的症狀除了明顯的子宮收縮和破水，初期的症狀並無特異性(如:腰酸感、下墜感、或陰道分泌物增加)，容易和一般懷孕過程中常見的症狀混淆。目前在國內的診斷仍是以在醫院裝置子宮收縮監測器，利用陰道擴張器檢查子宮頸有無進行性的變化，和以陰道超音波量測子宮頸長度來判斷早產的可能性。 胎兒纖維結合素(fetal fibronectin)是一種醣蛋白，存在於子宮絨毛膜和蛻膜之間，當子宮收縮時，會造成胎兒纖維結合素釋放到子宮頸和陰道中。胎兒纖維結合素為目前文獻上認為偵測早產最具代表性的生物標記(biomarker)。 本論文主體架構主要分為兩個部份︰第一部分為個人化產前遠距照護︰利用一套新研發的胎心音及子宮收縮監測診斷系統讓孕婦在家中自我監測胎心音及子宮收縮的情形；第二部分為早產防治技術之研發︰在醫院中利用生物感測器偵測子宮頸陰道分泌物中之胎兒纖維結合素濃度以防治早產。 為了有效降低醫療成本和維護生命的安全，個人化遠距健康照護的概念正迅速發展並廣泛應用於日常生活，如︰血壓、血糖、血氧的偵測。吾人利用研發之LabVIEW軟體應用程式遠距監測和診斷胎心音及子宮收縮，並經由藍芽和WiFi無線網路上傳到醫院，實現個人化產前照護的構想。 生物感測器具有快速、精確、低成本之分析和檢驗的功能，其作用對象可以為蛋白質、酵素、核酸等，常應用於臨床檢驗、藥物試驗、生化分析、環境檢測等方面。表面電漿子共振(surface plasmon resonance, SPR)現象是一種應用於表面與介面特性量測的光學方法，為目前奈米光學中一個極熱門的研究課題。SPR感測器可展現即時與高靈敏度的生物分子相互作用量測，因而廣泛應用於生物化學等方面的研究；磁減量免疫(immunomagnetic reduction, IMR)檢測乃是利用磁性奈米粒子來與待測生物分子結合成磁性叢集後，再藉由量測這些磁性叢集的磁性改變量以檢測待測物的含量。表面電漿子共振和磁減量免疫檢測方式都有偵測其他生物標記成功的文獻報告(如︰結核菌、血紅素、C反應蛋白等)。 在國內，利用酵素連結免疫吸附法(enzyme-linked immunosorbent assay, ELISA)檢測胎兒纖維結合素的成本較高，患者的接受意願低。本論文研究中利用研發的表面電漿子共振及磁減量免疫檢測方式之生物感測器防治早產。我們建議遠距監測子宮收縮之早產高危險群患者到醫院中利用生物感測器再次評估其早產的可能性，給臨床醫護人員參考，期望能減少早產的發生，進而改善周產期的罹病率和死亡率。

Fetal compromise and preterm birth are two of the important problems in obstetrics. Cardiotocography (CTG), also known as electronic fetal monitoring, is a prevalent tool for recording fetal heart rates (FHRs) and uterine contractions (UCs) to evaluate fetal conditions and uterine activities during pregnancy. High risk pregnancies (such as gestational hypertension, preeclampsia, gestational diabetes mellitus, preterm labor, oligohydramnios, intrauterine growth restriction, and postdatism) are the indications of CTG. A complete interpretation of a cardiotocogram includes both qualitative and quantitative descriptions of FHR (baseline, baseline variability, acceleration, early deceleration, late deceleration, variable deceleration, prolonged deceleration, recurrent deceleration, and sinusoidal pattern) and UC (baseline uterine tone, contraction frequency, duration, and strength), which can diagnose non-reassuring fetal heart rate and predict preterm birth. In general, CTG was performed at hospitals and diagnosed by obstetricians. Before prenatal telemedicine, the CTG surveillance often required pregnant women to visit and stay in the hospital, and it was especially stressful for patients who reside far from hospitals. Preterm birth is the main cause of perinatal morbidity and mortality with an incidence of 5 to 13% in developed countries, and accounts for nearly 70% of neonatal deaths and 50% of neurologic disabilities. However, early detection of preterm birth is difficult because the initial signs and symptoms are often obscure and may be mimicked by normal pregnancies. Fetal fibronectin (fFN), which is a type of glycoprotein, is a major ingredient of the extracellular matrix originated in the interface between the maternal and fetal components of the choriodecidual junction. Preterm uterine contractions or cervical change is related to disruption of the choriodecidual junction, which leads fFN to release in the ectocervix or posterior vaginal fornix. fFN is the strongest biomarker to predict the risk of spontaneous preterm birth. This dissertation includes two main sections: The first section is prenatal telemedicine with a novel CTG analysis program; the second section is biosensors for fFN detection to predict the risk of preterm birth. Telemedicine with self-monitoring (such as blood pressure, blood sugar, and blood oxygen monitoring) is widely applied to provide clinical health care remotely. It can supply comparable health care, provide more convenience to patients, and may be cost-effective. In this dissertation we developed a prenatal telemedicine system with a novel objective and quantitative CTG analysis program based on the Laboratory Virtual Instrumentation Engineering Workbench (LabVIEW) graphical software to monitor FHRs and UCs at home. The results of CTG were then sent to the hospital via Bluetooth and WiFi networks. The development of biosensors provides an efficient, effective and accurate method of clinical examination, drug test, biochemical analysis, and environmental monitoring. Biosensors have been used to study a variety of biomolecules such as proteins, enzymes, and nucleic acids. Surface plasmon resonance (SPR) is an electromagnetic reaction of surface plasmons at the metal–dielectric interface of biosensors. In theory, when the analyte binds the ligand on the metal film, the interfacial architecture changes, and surface plasmons are excited by the light beam. We can measure the change of the resonant angle and determine the concentration of biomolecules of interest; Immunomagnetic reduction (IMR) is a technology developed to measure the reduction in the alternative-current (ac) magnetic susceptibility of magnetic reagents and detects the association between bio-functionalized magnetic nanoparticles and targeted bio-molecules. By way of the binding antibodies on the shell surface, magnetic nanoparticles connect the targeted bio-molecules and become either larger or clustered. The larger/clustered magnetic nanoparticles oscillate much less than that of initially individual magnetic nanoparticles, and we can analyze the targeted bio-molecules by measuring the diminution in ac magnetic susceptibility of the magnetic reagent. In Taiwan, the commercial fFN ELISA kit is not widely used because of its higher cost. In this dissertation, we developed the biosensors based on SPR and IMR to predict the risk of preterm birth. The biosensor is a promising method with quantitative detection, high sensitivity, high specificity, easy operation, and low cost. Pregnant women monitor FHRs and UCs at home and the high risk groups of fetal compromise or preterm birth are suggested to go to the hospital for further evaluation and management. In the hospital we use the biosensor to predict the risk of preterm birth in order to reduce the perinatal morbidity and mortality.