上海地区孕晚期血浆D-二聚体参考范围的建立及其预测产后出血的意义

Establishment of D-dimer reference intervals for pregnant women of 34 gestational weeks and its predictive value on postpartumhemorrhage

目的 ：建立上海地区健康孕妇孕晚期（34孕周）血浆D-二聚体参考范围,对影响D-二聚体的相关因素进行统计分析,评价其在预测孕妇产后出血中的临床意义。方法：选取2013年1月至2014年7月于本院产科门诊进行34孕周常规体检的6 398名健康孕妇,采用免疫比浊法检测其血浆D-二聚体值。另收集2 834例具有D-二聚体高危因素（如贫血、子宫异常、胎盘异常、羊水异常、高血压、糖尿病、不良孕史等）的孕妇及347例发生产后出血的孕产妇,分析其34孕周D-二聚体值的变化;同时选择40名非孕非经期健康妇女作为正常对照组。结果：6 398名34孕周健康孕妇的中位血浆D-二聚体值为1.25 mg/L（95%CI为1.22~1.28）,2 834例34孕周高危孕妇的中位血浆D-二聚体值为1.89 mg/L（95%CI为1.82~1.96）,两者间差异有统计学意义（P〈0.01）。30例健康孕妇发生产后出血者在34孕周时的中位血浆D-二聚体值为1.49 mg/L（95%CI为1.09~1.89）,而317例高危孕妇发生产后出血者在34孕周时的中位血浆D-二聚体值为1.91 mg/L（95%CI为1.70~2.11）,两者间差异无统计学意义（P〉0.05）。40名非孕非经期健康妇女的中位血浆D-二聚体值为0.30 mg/L（95%CI为0.22~0.38）。采用单因素Logistic回归分析显示,健康孕妇中34孕周血浆D-二聚体值对其发生产后出血的预测价值不明确（OR=1.49,95%CI为0.72~3.06）,而在高危孕妇中34孕周血浆D-二聚体值对其发生产后出血有预测价值（OR=2.01,95%CI为1.57~2.56）。结论：上海地区健康孕妇血浆34孕周D-二聚体的95%参考范围为〈3.05 mg/L,明显高于非孕非经期正常妇女;存在产科高危因素下,检测孕妇血浆D-二聚体值对预测产后出血有价值。

Objective： To establish reference intervals for D-dimer during the third trimester of pregnancy in Shanghai women, and to analyze the factors influencing the D-dimer level for evaluating its clinical significance in postpartum hemorrhage. Methods： 6398 cases of healthy pregnant women（healthy group） of 34 weeks gestation aged 19 to 49 years from maternity department in our hospital were enrolled, they had received routine medical examination from January 2013 to July 2014. Immune turbidimetric method was used to detect the plasma D-dimer level in pregnant woman at 34 weeks gestation. Changes in D-dimer level were analyzed in 2 834 cases with obstetric risk factors（uterus anomaly, abnormal placenta, anemia, amniotic fluid anomalies, history of high blood pressure, diabetes, adverse pregnancy）（observed group）and in 347 cases of postpartum hemorrhage. Forty healthy non-pregnant women when not menstruating were enrolled as control group. Results： The median level of plasma D-dimer was 1.25 mg/L（95%CI： 1.22-1.28） in 6 398 healthy pregnant women,and was 1.89 mg/L（95%CI： 1.82-1.96） in 2 834 cases with obstetric risk factors. There was significant difference between the two groups（P0.01）. Thirty pregnant women of healthy group had postpartum hemorrhage and D-dimer value was 1.49 mg/L（95%CI：1.09-1.89）, and the level of D-dimer was 1.91 mg/L（95%CI： 1.70-2.11） in 317 pregnant women with postpartum hemorrhage from observe group, there was no statistically significant difference between the two groups（P0.05）. D-dimer level was 0.30 mg/L（95%CI： 0.22-0.38）in control group. Plasma D-dimer level had predictive value for postpartum hemorrhage in pregnant women with obstetric risk factors（OR=2.01, 95%CI： 1.57-2.56）, while had no predictive value for postpartum hemorrhage in healthy pregnant women. Conclusions： The 95% reference range for D-dimer intervals in healthy pregnant women at 34 weeks gestation is 3.05 mg/L, which is much higher than that in healthy nonpregnant women when not menstruating. D-dimer has predictive value for postpartum hemorrhage in pregnant women with obstetric risk factors.