单一三级医疗转诊中心的重度子痫前期临床特点分析

Clinical characteristics of severe pre-eclampsia in a single tertiary referral center

目的分析单一三级医疗转诊中心终止妊娠的重度子痫前期(SPE)孕妇的临床特点,探讨在三级转诊系统内防控和延缓SPE及其严重并发症发生的可行性及提升的关键点。方法回顾性分析2020年1月至12月在北京大学第三医院(为北京市三级医疗转诊中心之一)住院治疗并终止妊娠的217例SPE孕妇的临床资料,分析比较基层医疗机构转诊(外院转诊组)与三级医疗转诊中心规律产前检查(本院组)的SPE孕妇的临床特点、发病风险因素和严重并发症的发生情况,以及转诊时机对临床特点和围产结局的影响。结果(1)临床特点:217例SPE孕妇中,外院转诊组84例,本院组133例。外院转诊组SPE孕妇与本院组比较,中位临床诊断孕周[分别为31.5周(28.1~34.6周)、35.6周(33.3~37.2周);Z=-6.547,P<0.01]、终止妊娠孕周[分别为32.3周(29.5~35.1周)和36.3周(34.4~37.5周);Z=-6.554,P<0.01]、严重并发症出现孕周[分别为30.6周(26.4~32.7周)和34.9周(32.7~36.5周);Z=-4.040,P<0.01]均显著提早,孕产妇ICU入住率[分别为10.7%(9/84)、3.8%(5/133);χ^(2)=4.126,P=0.042]、新生儿ICU入住率[分别为72.9%(51/70)、54.7%(70/128);χ^(2)=6.286,P=0.012]均显著升高,活产率显著低于本院组[分别为83.3%(70/84)、96.2%(128/133);χ^(2)=10.736,P=0.001]。(2)风险因素分析:外院转诊组中肥胖、高龄或子痫前期史者SPE临床诊断孕周和终止妊娠孕周均明显早于本院组(P均<0.05);存在慢性高血压者,外院转诊组孕妇严重并发症出现孕周明显早于本院组(P<0.05);无明确发病风险因素者,外院转诊组SPE的临床诊断孕周、终止妊娠孕周、严重并发症出现孕周均显著早于本院组(P<0.05)。(3)严重并发症发生情况:外院转诊组和本院组严重并发症的前3位均为高血压脑病或脑血管意外[分别为20.2%(17/84)、7.5%(10/133)]、HELLP综合征[分别为7.1%(6/84)、8.3%(11/133)]、胎盘早剥[分别8.3%(7/84)、7.5%(10/133)],外院转诊组高血压脑病或脑血管意外的发生率明显高于本院组(χ^(2)=7.645,P=0.006)。(4)转诊时机:转诊时机分为严重并发症出现后转诊(8.3%,7/84)、临床发病后转诊(67.9%,57/84)、出现预警信息后转诊(14.3%,12/84)和发现发病风险因素后转诊(9.5%,8/84)。转诊时机越早,从临床诊断至严重并发症出现的间隔时间、转诊至终止妊娠的间隔时间、转诊至严重并发症出现的间隔时间越长(P均<0.05),新生儿ICU入住率越低,活产率越高;出现严重并发症后转诊的孕产妇ICU入住率明显高于其他转诊时机者(P<0.05)。结论SPE可以发生在各级医院;三级医疗转诊中心虽可延缓SPE的发病时间及严重并发症的发生时间,但仍有必要进一步提高防控意识;基层医疗机构应早期识别SPE的发生风险并及时转诊,此是改善母儿结局及充分发挥转诊系统作用的重要环节。

Objective To explore the feasibility and key point of improvement in preventing and postponing the onset of severe pre-eclampsia(SPE)and its severe complications in the tertiary referral system by analyzing the clinical characteristics of SPE in a single tertiary referral center.Methods The clinical data of 217 patients with SPE who were hospitalized and terminated pregnancy in Peking University Third Hospital from January 2020 to December 2020 were retrospectively analyzed.The risk factors,clinical characteristics and severe complications of SPE between the patients referred from primary hospitals(referral group)and the patients received regular prenatal care in the tertiary referral center(central group)were compared,as well as the influence of the referral timing on the characteristics and perinatal outcome.Results(1)Clinical characteristics:among the 217 cases of SPE,84 cases were in the referral group and 133 cases were in the central group.The gestational ages at SPE clinical diagnosis[31.5 weeks(28.1-34.6 weeks)vs 35.6 weeks(33.3-37.2 weeks);Z=-6.547,P<0.01],termination of pregnancy[32.3 weeks(29.5-35.1 weeks)vs 36.3 weeks(34.4-37.5 weeks);Z=-6.554,P<0.01]and onset of SPE severe complications[30.6 weeks(26.4-32.7 weeks)vs 34.9 weeks(32.7-36.5 weeks);Z=-4.040,P<0.01]in the referral group were significantly earlier than those in the central group,the rates of ICU[10.7%(9/84)vs 3.8%(5/133);χ^(2)=4.126,P=0.042]and neonatal ICU hospitalization[72.9%(51/70)vs 54.7%(70/128);χ^(2)=6.286,P=0.012]were higher than those in the central group,while the live birth rate[83.3%(70/84)vs 96.2%(128/133);χ^(2)=10.736,P=0.001]was lower than that of the central group.(2)Analysis of risk factors:for the patient whose risk factors were obesity,advanced age or pre-eclampsia history,the gestational ages at SPE clinical diagnosis and termination of pregnancy in the referral group were significantly earlier than those in the central group(P<0.05).For those with chronic hypertension,the gestational ages at severe complications onset in the referral group were significantly later than those in the central group(P<0.05).For those without obvious risk factors,the gestational ages at SPE clinical diagnosis,termination of pregnancy and onset of SPE severe complications in the referral group were earlier than those in the central group(P<0.05).(3)Analysis of severe complications:the top three severe complications in the referral group and the central group were hypertensive encephalopathy/cerebrovascular accident[20.2%(17/84)vs 7.5%(10/133)],HELLP syndrome[7.1%(6/84)vs 8.3%(11/133)]and placental abruption[8.3%(7/84)vs 7.5%(10/133)].The rate of hypertensive encephalopathy/cerebrovascular accident in the referral group was significantly higher than that in the central group(χ^(2)=7.645,P=0.006).(4)Analysis of referral timings:the timings included referral after onset of SPE severe complications(8.3%,7/84),referral after onset of SPE(67.9%,57/84),referral after detection of SPE early warning signs(14.3%,12/84)and referral after detection of SPE risk factors in the 2nd and 3rd trimester(9.5%,8/84).The earlier the referral,the longer the interval from clinical diagnosis to onset of severe complications,from referral to termination of pregnancy,and from referral to severe complications onset(P<0.05).The earlier the referral,the lower the NICU hospitalization rates,the higher the live birth rates.The ICU hospitalization rate of referrals after severe complications onset was significantly higher than those of the other three referral timing groups(P<0.05).Conclusions SPE occurs in hospitals of different levels.Although tertiary referral center may postpone the onset of SPE and its severe complications,reduce the severity of SPE and prolong the gestational age,its awareness of prevention and control still needs to be further improved.Early identification of the risk of SPE and timely referral are important parts of improving SPE adverse outcomes in primary medical institutions.The significance and value of referral system need to be brought into full play.