妊娠期甲型H1N1流行性感冒38例临床特点及重症/危重症的高危因素分析

Clinical features of 38 pregnant women with influenza A(H1N1)and risk factors for severe/critical cases

目的总结妊娠期甲型H1N1流行性感冒(简称流感)患者的临床特点以及重症/危重症的高危因素。方法回顾性纳入2017年10月至2019年3月郑州大学第一附属医院收治的38例妊娠期甲型H1N1流感患者,分为轻症组(29例)和重症/危重症组(9例)。采用两独立样本t检验、Mann-Whitney秩和检验和χ2检验分析2组间一般情况、治疗及母婴结局的差异,采用多因素logistic回归分析妊娠期重症/危重症流感的危险因素,采用受试者工作特性曲线评估相关指标对重症/危重症流感的预测价值。结果重症/危重症组患者年龄[(32±4)与(28±5)岁,t=2.155]、诊断流感孕周[33.3(27.3~37.1)与24.4(14.9~32.1)周,Z=-2.318]、妊娠期糖尿病的比例[4/9与7%(2/29),χ2=4.733]、热峰[(39.3±0.7)与(38.5±0.6)℃,t=3.556]、早产率[3/9与0%(0/29),χ2=6.412]、围产儿病死率[3/9与0%(0/29),χ2=6.412]及孕产妇病死率[2/9与0%(0/29),χ2=6.136]均升高(P值均<0.05)。多因素logistic回归分析显示,出现流感样症状至开始抗病毒治疗时间(OR=2.097,95%CI:1.103~3.989,P=0.024)和中性粒细胞/淋巴细胞比值(OR=1.361,95%CI:1.005~1.843,P=0.046)是妊娠期重症/危重症流感的独立危险因素。出现流感样症状至开始抗病毒治疗时间和中性粒细胞/淋巴细胞比值受试者工作特性曲线下面积分别为0.830(95%CI:0.635~1.000)和0.854(95%CI:0.697~1.000),对应的界值分别为4.500和9.655。即当发病>4.5 d开始抗病毒治疗预测重症/危重症流感的灵敏度为66.7%,特异度为93.1%;中性粒细胞/淋巴细胞比值>9.655时预测灵敏度为88.9%,特异度为72.4%。结论妊娠期甲型H1N1流感患者应及早抗病毒治疗,避免发生重症。重症/危重症患者病死率高,中性粒细胞/淋巴细胞比值或可作为临床快速评估病情严重程度的指标。

Objective To summarize the clinical characteristics of patients with influenza A(H1N1)during pregnancy,and analyze the risk factors for severe/critical cases.Methods A retrospective analysis was conducted on 38 cases diagnosed with influenza A(H1N1)during pregnancy and treated in the First Affiliated Hospital of Zhengzhou University from October 2017 to March 2019.The recruited cases were divided into mild(n=29)and severe/critical groups(n=9).Differences in general conditions,treatment and maternal and neonatal outcomes between the two groups were compared by two-sample t-test,Mann-Whitney rank sum test and Chi-square test.Multivariate logistic regression analysis was used to analyze the risk factors for severe/critical influenza.The receiver operating characteristic curve was used to evaluate the predictive value of relevant indicators for severe/critical influenza.Results The maternal age[(32±4)vs(28±5)years,t=2.155],average gestational weeks at diagnosis[33.3(27.3-37.1)vs 24.4(14.9-32.1)weeks,Z=-2.318],percentage of patients complicated by gestational diabetes mellitus[4/9 vs 7%(2/29),χ2=4.733],highest body temperature[(39.3±0.7)vs(38.5±0.6)℃,t=3.556],preterm birth rate[3/9 vs 0%(0/29),χ2=6.412],perinatal mortality[3/9 vs 0%(0/29),χ2=6.412]and maternal mortality rate[2/9 vs 0%(0/29),χ2=6.136]were all higher in the severe/critical group than in the mild group(all P<0.05).Multivariate logistic regression analysis showed that the interval from the onset of flu-like symptoms to the beginning of antiviral treatment(OR=2.097,95%CI:1.103-3.989,P=0.024)and the neutrophil-to-lymphocyte ratio(NLR)(OR=1.361,95%CI:1.005-1.843,P=0.046)were independent risk factors for severe/critical influenza in pregnant women with the area under the curve of 0.830(95%CI:0.635-1.000)and 0.854(95%CI:0.697-1.000)at the cut-off values of 4.500 and 9.655,respectively.The sensitivity and specificity for predicting severe/critical influenza were 66.7%and 93.1%when antiviral treatment was administered>4.5 d after the disease onset,and 88.9%and 72.4%when the NLR was above 9.655.Conclusions Early antiviral treatment should be started in patients with influenza A during pregnancy to avoid severe conditions.Patients with severe influenza A during pregnancy have higher maternal mortality rate.NLR may be used as a rapid clinical assessment marker for disease severity.