妊娠期及产后脓毒症68例临床分析

Clinical analysis of 68 cases of sepsis during pregnancy and the postpartum period

目的探讨妊娠期及产后脓毒症的临床特征、病因、治疗和预后。方法收集1997年1月至2019年12月中国医学科学院北京协和医院收治的68例妊娠期及产后脓毒症孕产妇的临床资料,根据感染来源分为产科感染组(30例)及非产科感染组(38例),分析其临床表现、感染源及微生物学特点、治疗和预后。结果(1)一般情况及临床特征:脓毒症发生于产前39例(57%,39/68),产后29例(43%,29/68)。非产科感染组孕产妇呼吸、肾、肝、凝血功能障碍发生率比产科感染组高,多器官功能障碍、心脏骤停、血乳酸水平≥4 mmol/L更常见,序贯器官衰竭评分高于产科感染组,各项指标两组分别比较,差异均有统计学意义(P均<0.05)。(2)感染源及微生物学特点:脓毒症最常见的病因是生殖道感染(37%,25/68);其中,产科感染组以绒毛膜羊膜炎(40%,12/30)最常见,非产科感染组以腹腔感染(34%,13/38)居多。诊断为血流感染(BSI)的孕产妇37例(54%,37/68),其中以革兰阴性杆菌菌血症多见(70%,26/37),最常见的致病菌是大肠埃希菌;继发性BSI最常继发于生殖道感染(65%,17/26)。(3)治疗:非产科感染组患者ICU入住率、机械通气和血管活性药物使用率均高于产科感染组,两组分别比较,差异均有统计学意义(P均<0.05)。32例(47%,32/68)脓毒症孕产妇行外科手术清除感染源,其中子宫切除术5例。(4)预后:孕产妇脓毒症的病死率为19%(13/68),非产科感染组(29%,11/38)高于产科感染组(7%,2/30),两组比较,差异有统计学意义(P=0.020)。产前诊断脓毒症至终止妊娠的时间为(5.5±8.6)d;其中,产科感染组(1.9±2.2)d,非产科感染组(7.7±10.3)d,两组相比,差异有统计学意义(P=0.029)。不良妊娠结局发生于早、中孕期者(72%,18/25)高于晚孕期者(3/14),两者比较,差异有统计学意义(P=0.002)。结论妊娠期及产后脓毒症是一种潜在的危及生命的疾病,非产科感染比产科感染孕产妇并发症更多、病情更危重、预后更差,及时发现危险因素、早期识别和积极治疗有助于改善母儿预后。

Objective To investigate the clinical features,etiology,and prognosis of sepsis during pregnancy and the postpartum period.Methods Sixty-eight pregnant women with maternal sepsis treated in Peking Union Medical College Hospital from January 1997 to December 2019 were collected,and divided into obstetric infection group(30 cases)and non-obstetric infection group(38 cases)according to different infection sources.Clinical manifestations,types of infection sources,microbiological characteristics,treatment and outcomes were studied and analyzed.Results(1)General conditions and clinical features:sepsis occurrence rate was 57%(39/68)and 43%(29/68)in prenatal and postpartum period,repectively.Statistical analysis showed that incidence of respiratory,renal,liver and coagulation dysfunction in non-obstetric infection group were significantly higher than those in obstetric infection group,and multiple organ dysfunction,cardiac arrest and blood lactate≥4 mmol/L were more common(all P<0.05).Sequential organ failure score in non-obstetric infection group was also significantly higher than that in obstetric infection group(P<0.05).(2)Types of infection sources and microbiological characteristics:the most common maternal sepsis was genital tract sepsis(37%,25/68).Chorioamnionitis was the most common cause in obstetric sepsis(40%,12/30),while intra-abdominal infection was the most common cause in non-obstetric sepsis(34%,13/38).Thirty-seven patients(54%,37/68)were diagnosed as bloodstream infection(BSI).Gram-negative bacteremia accounted for 70%(26/37),the most common pathogen of which was Escherichia coli.BSI was most commonly secondary to a genital tract infection(65%,17/26).(3)Treatment:the ICU hospitalization rates and the utilization rate of mechanical ventilation and vasoactive agents in non-obstetric group were higher than those in obstetric group with significant differences(all P<0.05).Thirty-two patients(47%,32/68)underwent surgery to remove the infection sources,including 5 cases of hysterectomy.(4)Prognosis:the case fatality rate of maternal sepsis was 19%(13/68),which was significantly higher in the non-obstetric infection group(29%,11/38)compared with the obstetric infection group(7%,2/30;P=0.020).The time from diagnosis of sepsis to termination of pregnancy was(5.5±8.6)days in prenatal women,and time in obstetric infection group[(1.9±2.2)days]was significantly less than that of non-obstetric infection group[(7.7±10.3)days,P=0.029].Adverse pregnancy outcomes were higher in the first and second trimester(72%,18/25)than in the third trimester(21%,3/14),and the difference was statistically significant(P=0.002).Conclusions Sepsis during pregnancy and the postpartum period is a potentially life-threatening disease.Pregnant women with non-obstetric sepsis have more complications,more serious condition and worse prognosis than those with obstetric infection.Timely detection of risk factors,early identification and active treatment are helpful to improve maternal and fetal prognosis.