妊娠期高血压疾病相关重症监护病房住院病例的临床内审

Clinical audit of intensive care unit admission relating to hypertensive disorders of pregnancy

目的评价妊娠期高血压疾病（hypertensivedisordersofpregnancy，HDP）的管理质量，提出改进措施。方法根据中华医学会HDP指南建立临床内审核查表，对2014年1月1日至2016年12月31日66例进入本院重症监护病房（intensivecareunit，ICU）救治的HDP患者从院前、院内和患者因素等3个方面进行评价。采集的数据还包括患者的一般资料、HDP的并发症、急性病理生理Ⅱ评分以及住院日。计量资料采用t或Mann-WhitneyU检验；计数资料采用矿检验。结果（1）2014年至2016年，本院分娩总量为18573例，其中HDP为1561例，占8．4％。66例入住ICU的HDP患者中，44例（66．7％）为子痫前期，16例（24．2％）为慢性高血压并发子痫前期，6例（9．1％）为子痫，未发生孕产妇死亡。（2）HDP严重并发症的发生率由高到低依次为心功能不全（17例，25.8％），溶血、肝酶升高、血小板减少综合征（15例，22．7％），需要输血治疗的贫血／血小板减少（12例，18．2％），肾功能不全（7例，10．6％），子痫（6例，9．1％），肺水肿／急性呼吸窘迫综合征（5例，7．6％），胎盘早剥（4例，6．1％），颅内静脉窦血栓形成（2例，3．0％），脑出血和肝破裂（各1例，1．5％）。66例的急性生理与慢性健康评分Ⅱ评分为（9．0±3．9）分；ICU住院时间为2（1-30）d，总住院时间为8（4-32）d。（3）与建档孕妇相比，未建档孕妇的年龄更大[（33．0±6．0）与（29．1±5．4）岁，t=2．616】，初产妇较少[23．8％（5／21）与71．1％（32／45）例，X^2。=13．006]，产前检查次数更少[2（0-4）次与5（2-10）次，Z=110．000】，入院血压更高[收缩压：（177．0±24．1）与（155．5±24．6）mmHg，t=-3．322；舒张压：（116．4±14．6）与（108．0±18．7）mmHg，t=-3．013（1mmHg=0．133kPa）】（P值均〈0．05）。（4）66例中，7例（10．6％）有子痫前期病史，但孕期均未使用阿司匹林预防；21例（31．8％）孕期没有做到每次产前检查测量血压；24例（36．4％）在首次发现高血压时没有进行必要的辅助检查。（5）排除20例首次发现高血压即收住人院的孕妇外，其余46例接受了门诊管理。这46例中，18例（39．1％）未监测血压，26例（56．5％）未监测血、尿常规及脏器功能。（6）29例（43．9％）未及时转诊或收住院。（7）所有孕妇接受了硫酸镁解痉治疗。33例出现严重高血压（收缩压≥160mmHg或舒张压≥110mmHg）者均接受了降压治疗，血压控制达标。36例妊娠26～34周“且胎儿存活者，在分娩前均接受了地塞米松促胎儿成熟治疗。3例人院后未及时终止妊娠。结论通过临床内审发现，HDP管理的不足包括患者教育、高危人群筛查、早期诊断以及孕期管理等方面。对HDP管理的改进措施包括加强患者教育，培训基层医生，规范执行产前检查流程，以及建立产科危重症转诊网络等。

Objective To assess the current practice in managing hypertensive disorders of pregnancy （HDP） and provide possible interventions to improve the quality of care. Methods A checklist was developed based on Chinese Medical Association＇s guideline on HDP. A criteria-based audit was conducted on 66 HDP patients who were admitted to the Intensive Care Unit （ICU） of Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School between January 1, 2014 and December 31, 2016. The quality of care during antepartum and hospitalized period were evaluated, and patient factors were also considered. We also collected data on patients＇ demographics, complications of HDP, acute physiology and chronic health evaluation （APACHE） 1I score and duration of hospital stay. T or Mann-Whitney U test or Chi-square test was performed. Results （1） From 2014 to 2016, the number of deliveries in Nanjing Drum Tower Hospital was 18 573, with 1 561 cases （8.4%） of HDP. Among the 66 cases being audited, 44 （66.7%） were preeclampsia; 16 （24.2%） were preeelampsia complicated by chronic hypertension; six （9.1%） were eclampsia; no maternal death was reported. （2） Complications of HDP in this study included heart failure （17 cases, 25.8%）, hemolysis, elevated liver enzyme levels, low platelet count （HELLP） syndrome （15 cases, 22.7%）, anemia and/or thrombopenia requiring transfusion （12 cases, 18.2%）, renal dysfunction （seven cases, 10.6%）, eclampsia （six cases, 9.1%）, pulmonary edema/acute respiratory distress syndrome （five cases, 7.6%）, placenta abruption （four cases, 6.1%）, cerebral venous and sinus thrombosis （two cases, 3.0%）, cerebral hemorrhage （one case, 1.5%） and hepatic rupture （one case, 1.5%）. Their APACHE II score was 9.04±3.9. The duration oflCU and hospital stay was 2 （1-30） d and 8 （4 -32） d, respectively. （3） Compared with the gravidas who registered during antenatal care, those without registrations were older [（33.0±6.0） vs （29.1±5.4） years old, t=-2.616], having less antenatal visits [2 （0-4） vs 5 （2-10） times, Z=ll0.000] and higher blood pressure on admission [（177.04±24.1） vs （155.54±24.6） mmHg of systolic blood pressure （t=-3.322）, and （116.44± 14.6） vs （108.04±18.7） mmHg of diastolic blood pressure （t=-3.013, 1 mmHg=0.133 kPa）], and only a few of them were nulliparas [23.8%（5/21） vs 71.1%（32/45）, X^2=13.006] （all P〈0.05）. （4） Among the 66 cases, seven （10.6%） had preeclampsia history, but none of them received aspirin for HDP prevention; 21 （31.8%） did not have regular testing of blood pressure during antenatal check; 24 （36.4%） did not receive proper antenatal evaluation when hypertension was identified. （5） After excluding 20 cases directly admitted upon the first diagnosis of HDP, the rest 46 were managed in the outpatient department. Eighteen of them （39.1%） did not have blood pressure monitoring and 26 of them （56.5%） did not have a regular test of hemoglobin, platelet, urine protein, liver or renal function. （6） Twenty-nine gravidas （43.9%） suffered a delay in referral or admission. （7） All gravidas received magnesium sulphate administration. Thirty-three cases with severe hypertension （systolic blood pressure ≥160 mmHg or diastolic blood pressure ≥110 mmHg） were given antihypertensive drugs with satisfactory blood pressure control. Thirty-six cases with living fetus （26-34^＋6 gestational weeks） received antenatal dexamethasone. Termination of pregnancy was delayed in three cases after admission. Conclusions The management of HDP is not good enough in patients＇ education, screening for high- risk population, early diagnosis and antenatal care. Quality improvement efforts should be focused on strengthening patient education, training of doctors in primary and secondary hospitals, implementing protocols on antepartum care of preeclampsia and establishing a referral system for patients with severe obstetric complications.