产后出血危险因素及高危评分系统临床价值研究

Clinical study of risk factors of postpartum hemorrahge and risk evaluation system

目的探讨发生产后出血的危险因素,以及建立产后出血高危评分系统和风险预测方程的临床应用价值。方法选择2008年12月至2009年12月在福建省妇幼保健院进行系统产前检查并住院分娩的212例产后出血患者作为病例组,采用1∶2病例对照研究方法选择同期住院分娩未发生产后出血的424例产妇作为对照组;采用单因素分析筛选产后出血高危因素。在全国产后出血防治协作组拟定"产后出血预测评分表"(简称"评分表")基础上,用筛选出的高危因素建立较全面的"产后出血高危评分系统"(简称"评分系统")。通过受试者工作特性(receiver–operating characteristics,ROC)曲线下面积(AUC)评价并比较评分表和评分系统工作效能。结果产后出血发生率为3.07%,其中严重产后出血发生率为15.56%。产后出血危险因素有孕妇年龄、产次、人工流产史、孕早期体重指数(BMI)、产前宫底高度、双胎或多胎妊娠、产前血小板计数(PLT)、前置胎盘、妊娠期高血压疾病、妊娠合并子宫肌瘤、胎儿腹围、羊水过多、分娩方式、子宫切口延裂、产道裂伤、第一产程异常、第三产程延长、胎盘粘连或植入、新生儿体重。用评分系统评分,若总评分≥6分或产前评分≥4分者发生产后出血危险性明显增加。评分表预测产后出血的ROC曲线AUC为0.657,评分系统评估产后出血的AUC为0.805。产后出血风险预测方程为:Z=1-1/[1+exp(-3.216+0.482×产前评分+0.452×产时产后评分)]或Z=1-1/[1+exp(-3.187+0.469×总评分)];严重产后出血风险预测方程为:Z=1-1/[1+exp(-3.715+0.146×总评分)]。结论产后出血发生与孕妇及胎儿因素、妊娠并发症及合并症、产程等均密切相关。评分系统总评分≥6分者或产前评分≥4分者应纳入产后出血重点监护范围。评分系统与评分表相比有较强预测产后出血的效能。

Objective To identify the risk factors of postpartum hemorrahge（PPH） and establish evaluation system and prediction equation for the risk of morbidity. Methods A case-control（1 ： 2） observational study was conducted.Totally 212 parturients with PPH, who presented to Fujian Maternity and Child Health Hospital for regular prenatal care and par- turition from December 2008 to December 2009, were selected as the study group.The control group consisted of 424 health parturients at the same period.Univariate analysis was used for risk factors screening.Then,based on ＂predict- scale of postpartum hemorrahge＂ set by national PPH prevention cooperation,establish perfect ＂risk evaluation system of PPH＂.Compare effectiveness between them by receiver-operating characteristics.Resaults Incidence of PPH was 3.07%, and 15.56% of them were severe PPH.The risk factors of PPH included age, parity,induced abortion,BMI in early pregnancy, uterine height,multiple pregnancy, PLT,placental previa,hypertensive disorders complicating pregnancy, hysteromyoma, fetal abdominal circumference, hydramnios, delivery way,uterine laceration of caesarean section,genital tract trauma, abnormal first stage,prolonged third stage, placental adherence or accrete and born weight.The risks of PPH increased significantly ,when total score ≥6 or antepartum score≥4.AUC of predict-scale used in this study was 0.657,and AUC of risk evaluation system was 0.805.Prediction equation for the risk of PPH was Z= 1-1/[ 1 ＋exp（-3.216＋0.482×antepartum score ＋ 0.452× intrapartum and postpartum score） ] ,or Z= 1-1 / [ 1 ＋ exp（- 3.187 ＋ 0.469× total score） ] .Conclusions The happening of PPH has a close association with the fundamental factors of pregnant woman, fetus, complications, labor and so on.Women with total score ≥6 or antepartum score≥4 required close monitoring.The risk evaluation system is more efficient than the predict-scale for detecting PPH.