“二孩政策”对产科重症患者转入ICU的影响

Clinical analysis of obstetric patients admitted to ICU in the past decade

目的:探索“二孩政策”全面实施前后对产科重症患者转入重症医学科(ICU)的影响。方法:对2007年1月1日至2019年6月30日转入昆明医科大学第一附属医院ICU的产科重症患者进行回顾分析。研究对象包括本院转入ICU和外院直接转入ICU的产科患者。将其分为两组,第1组:2007年1月1日至2016年5月31日转入ICU的产科重症患者;第2组:2016年6月1日至2019年6月30日转入ICU的产科重症患者。收集患者的一般资料、转入ICU主要原因、疾病严重程度、ICU内主要干预等数据,比较两组患者转入ICU的主要原因(ICU第一诊断),一般资料、临床特征,主要妊娠并发症/合并症及母亲结局。按照世界卫生组织2012年孕产妇死亡疾病分类-10(ICD-10)将产妇死亡原因分为:直接产科死亡和间接产科死亡。结果:(1)研究期间,本院共计分娩63703人次。两组共计转入ICU患者540例,其中第1组376例(本院340例,外院36例),第2组164例(本院159例,外院5例)。本院孕产妇ICU转入率0.78%(499/63703)。(2)转入ICU主要原因中以产科因素为主,前五位原因依次是产后出血、妊娠期高血压疾病、心脏病、脓毒症和急性胰腺炎。其中,第2组患者产后出血(P=0.02)和妊娠合并急性胰腺炎(P<0.01)的比例更高,但脓毒症患者的比例下降(P=0.04)。(3)一般资料和临床特征,第2组患者年龄更大,孕次、产次、流产次数更多,失血量更多,ICU住院天数和总住院天数均更长(P均<0.05),通过介入栓塞动脉止血的比例更高,ICU内机械通气的比例也更高(P均<0.05)。(4)主要妊娠并发症/合并症,第2组产后出血的比例较高,其中以胎盘因素导致产后出血的比例升高,宫缩乏力的因素下降(P均<0.05)。妊娠期糖尿病、妊娠合并急性胰腺炎、妊娠合并肝内胆汁淤积症及甲状腺问题的比例均增加,但HELLP综合征、先心病的比例下降(P均<0.05)。(5)研究期间,孕产妇死亡共13例(本院8例,外院5例);10例间接产科死亡,3例直接产科死亡。本院孕产妇死亡率为12.6/10万(8/63703),濒临死亡率为536.9/10万(342/63703)。结论:研究期内,重症孕产妇转入ICU的主要原因仍以产科因素为主,分别为产后出血、妊娠期高血压疾病、心脏病和脓毒症。“二孩政策”之后,短期内年分娩数量达到顶峰,转入ICU的重症孕产妇数量随之上升。产后出血的发生率增加,其中胎盘因素导致的产后出血比例增加而宫缩乏力所占的比例下降,失血量增加,住院时间延长,ICU内机械通气的比例增加;死亡原因主要以妊娠期的合并症/并发症为主。

Objective:To review the impact of the“Two-child policy”on the ICU admission of critically ill obstetric patients.Methods:All critically ill obstetric patients transferred to ICU were examined from Jan.1,2007 to June 30,2009.These critically ill obstetric patients were defined as two groups.Group 1,patient who was transferred to the ICU during the period from Jan.1,2007 to May 31,2016.Group 2,patient who was transferred to the ICU during the period from June 1,2016 to June 30,2019.Data was collected from medical records,including demographic characteristics and clinical characteristics,indications in ICU admission,severity of illness(APACHE II score),interventions in ICU,complications/comorbidities during pregnancy,and maternal outcomes.The indexes of these critically ill obstetric patients were analysed and compared between the two groups.The causes of maternal mortality were divided into direct obstetric deaths and indirect obstetric deaths according to the World Health Organization(WHO)2012 Maternal Mortality Disease Code-10(ICD-10).Results:During the review period,there were 63703 deliveries in our hospital.A total of 540 cases were transferred to ICU in the two groups,including 376 cases in Group 1(340 cases of our institution,36 cases from other hospitals)and 164 cases in Group 2(159 cases of our institution,5 cases from other hospitals).The ICU admission rate of mother in our hospital was 0.78%(499/63703).Obstetrical factors were the principal reasons for ICU admission.The top five factors were postpartum hemorrhage,hypertensive disorder complicating pregnancy,heart disease,sepsis and acute pancreatitis respectively.Among them,the proportion of patients with postpartum hemorrhage(P=0.02)and acute pancreatitis in pregnancy(P<0.01)was significantly higher in Group 2,but the proportion of patients with sepsis decreased(P=0.04).Compared with Group 1 on the demographic characteristics and clinical characteristics,women were older,had more gravidity,parity,abortions,blood loss,longer ICU stay and total hospital stay(all P<0.05)in Group 2,Also,more interventional arterial embolization and mechanical ventilation was seen in Group 2(all P<0.05).On the causes of postpartum hemorrhage,placental factors leading to postpartum hemorrhage increased and factors of uterine inertia decreased(P<0.05)in Group 2 than that in Group 1.The proportion of gestational diabetes,acute pancreatitis,intrahepatic cholestasis during pregnancy and thyroid problems all increased,but the proportion of HELLP syndrome and congenital heart disease decreased(all P<0.05).During the audit period,there was a total of 13 cases of maternal death,10 cases died of direct obstetric death and 3 cases died of indirect obstetric death.The maternal mortality rate in our hospital was12.6/100,000 and the maternal near miss rate was 536.9/100,000.Conclusions:During the audit period,reason for ICU admission of critically ill obstetric patients were still mainly obstetric factors,including postpartum hemorrhage,hypertensive disorder,heart disease and sepsis.The main causes of maternal death were complications during pregnancy.