早发型重度子痫前期孕妇期待治疗中不良妊娠结局的危险因素分析

Risk factors of adverse pregnancy outcomes during expectant management of early onset severe pre-eclampsia

目的 探讨早发型重度子痫前期孕妇实施期待治疗过程中发生不良妊娠结局的危险因素.方法 选择2007年1月至2008年6月在首都医科大学附属北京妇产医院住院的早发型重度子痫前期并实施期待疗法的孕妇136例.按照妊娠结局分为良好结局组101例和不良结局组35例.采用回顾性分析方法,分析两组孕妇人院时的一般资料、妊娠结局、尿常规、血流动力学及血常规指标、肝肾功能,另分析不良妊娠结局的危险因素.结果 （1）一般资料：良好结局组与不良结局组孕妇入院时出现子痫前期症状的发生率（分别为35.6%及57.1%）比较,差异有统计学意义（P〈0.05）.两组孕妇年龄、孕次、孕前体质指数、入院时并发症发生率及规律产前检查率比较,差异均无统计学意义（P〉0.05）.（2）妊娠结局：良好结局组孕妇期待疗法平均天数为（6.5±8.2）d,不良结局组平均为（6.8±10.0）d,两组比较,差异无统计学意义（P〉0.05）.不良结局组孕妇主要并发症为胎盘早剥13例,心功能衰竭及肺水肿10例,溶血、肝酶升高和低血小板计数（HELLP）综合征5例,胎死宫内5例,无子痫发生.良好结局组孕妇均无以上并发症发生.（3）期待疗法中发病孕周及分娩孕周、血压及尿蛋白比较：良好结局组的发病孕周及分娩孕周[分别为（33.0±4.9）及（34.0±3.6）周]明显晚于不良结局组[分别为（31.3±3.4）及（32.1±3.0）周],收缩压及尿蛋白定量明显低于不良结局组.良好结局组中尿蛋白定性（＋＋＋）比例明显低于不良结局组.以上指标两组比较,差异均有统计学意义（P〈0.05）.（4）血流动力学及血常规：良好结局组孕妇血液黏度[（4.6±0.4）mPa·s]明显低于不良结局组,两组比较,差异有统计学意义（P〈0.05）.而心输出量、心脏指数、外周阻力及血管顺应性等指标在两组孕妇中比较,差异均无统计学意义（P〉O.05）.良好结局组孕妇血小板计数[（189±69）×10^9/L]明显高于不良结局组,而红细胞计数[（3.9±0.5）×10^12/L]和红细胞压积（0.34±0.05）却明显低于不良结局组.两组比较,差异均有统计学意义（P〈0.01）.（5）肝肾功能：良好结局组孕妇丙氨酸氨基转移酶[ALT,（18±12）U/L]、天冬氨酸氨基转移酶[AST,（24±9）U/L]、乳酸脱氢酶[LDH,（175±53）U/L]及尿素氮[BUN,（4.6±1.8）mmol/L,]水平明显低于不良结局组.两组比较,差异均有统计学意义（P〈0.05）.而血浆总蛋白（TP）、血浆白蛋白（Alb）、尿酸（UA）及血肌酐（cr）水平在两组中比较,差异均无统计学意义（P〉0.05）.（6）不良结局的危险因素分析：进入logistic回归方程的自变量分别为红细胞计数（OR值为3.68,P=0.000）,血小板计数（OR值为0.99,P=0.006）及分娩孕周（OR值为0.87,P=0.001）.显示红细胞计数越高,则在期待疗法中越有可能出现不良妊娠结局;血小板计数越低、分娩孕周越早,则提示期待疗法中愈易出现不良妊娠结局.结论 红细胞计数升高、血小板计数降低及分娩孕周过早,是早发型重度子痫前期孕妇实施期待疗法过程中发生不良妊娠结局的危险因素.

Objective To identify the risk factors of adverse pregnancy outcomes in expectant management of pregnant women with early onset severe pre-eclampsia （EOSP）. Methods Totally, 136 gravidas, who were diagnosed as ESOP and received expectant management from January 2007 to June 2008 in Beijing Obstetrics and Gynecology Hospital, were selected and divided into two groups; the favorable pregnancy outcome group （control, n=101）and the adverse pregnancy outcome group （n=35）.The general clinical information, pregnancy outcomes, routine urine test, hemodynamic data, routine blood test, liver and renal function test on admission were collected and the risk factors for adverse outcomes were retrospectively analyzed.Results （1）General clinical information; more women complained of preeclamptic symptoms on admission in the adverse outcome group than in the control group （35.6% vs.57.1 %,P〈 0.05）.No significant differences was found between the two groups in the maternal age, times of previous pregnancies, prevalence of concurrent complications, pre-pregnant body mass index （BMI）,proportion of women who had regular antenatal checks（P 〉 0.05）.（2） Pregnant outcomes; the average duration of expectant management in the control group were similar to the adverse outcomes group [（6.5 ± 8.2） days vs.（6.8 ±10.0） days, P 〉 0.05].The main complications in the adverse outcome group included placental abruption （n=13）, heart failure and pulmonary edema （n=10）,hemolysis, elevated liver enzymes and low platelet syndrome （HELIP syndrome, n=5）,and no eclampsia was reported.However, none of these complications was reported from the control group.（3）Blood pressure and proteinuria; the gestation ages at the onset of EOSP and at delivery in the control group were earlier than those of the adverse outcome group [（31.3 ± 3.4） weeks vs.（33.0 ± 4.9） weeks, （32.1 ± 3.0） weeks vs.（34.0 ± 3.6） weeks, P〈 0.05],the systolic blood pressure and urinary protein and the proportion of women with urinary protein of （＋ ＋ ＋）were also much higher in the adverse outcome group （all P〈0.05）.（4） Hemodynamics and routine blood tests; the blood viscosity in the control group was obviously lower than that of the adverse outcome group （P〈 0.05 ）.But there was no significant difference in the cardiac output, cardiac index, peripheral resistance and vascular compliance between the two groups （P 〉0.05）.The adverse outcome group showed lower platelet（PLT） level and higher red blood cell（RBC） count and hematocrit compared with those of the control（all P〈0.01）.（5）Liver and renal function; the alanine aminotransferase （ALT）, aspartate aminotransferase （AST）, lactate dehydrogenase （LDH）,blood urea nitrogen（BUN） in the adverse outcome group were significantly higher than those of the control group （all P〈0.05）, but the plasma level of total protein （TP）,albumin （Alb）, uric acid （UA） and creatinine （Cr） were similar between the two groups（P〉0.05）.（6） Risk factor analysis： RBC count （OR =3.68, 95% CI： 1.90-7.13 ）,PLT count （OR=0.99,95% CI：0.98-1.00） and the gestations at delivery （OR=0.87, 95% CI： 0.80-0.94） were the risk factors of adverse pregnancy outcomes during the expectant management of EOSP.Conclusion Elevated RBC count, reduced PLT count and earlier delivery weeks are the risk factors of adverse pregnancy outcomes during the expectant management of EOSP.