孕中期子宫动脉多普勒超声血流参数联合血清学指标预测不良妊娠结局的价值

Value of Doppler ultrasound blood flow parameters of uterine artery combined with screen of serological indexes in the second trimester for predicting the adverse pregnancy outcomes

目的探讨孕中期子宫动脉多普勒超声血流参数联合母体血清学指标产前筛查预测不良妊娠结局的价值。方法纳入2018年12月至2020年5月在广元市妇幼保健院产检并分娩的782例孕妇为研究对象。均于孕15~20+6周,采用多普勒超声测量子宫动脉血流参数[搏动指数(pulsatility index,PI)、血流阻力指数(resistance index,RI)],检测母体血清β-人绒毛膜促性腺激素(β-human chorionic gonadotropin,β-hCG)、游离雌三醇(unconjugated estriol,uE3)、甲胎蛋白(alpha-fetoprotein,AFP)水平,并计算中位数倍数(multiple of median,MoM)值。随访至产后42 d,根据妊娠结局分为不良组和正常组。统计学方法采用χ^(2)检验、t检验、非参数检验、多因素Logistic回归分析、受试者操作特性(receiver operating characteristic,ROC)曲线。结果782例孕妇中,718例(91.8%)孕妇正常妊娠(正常组),64例(8.2%)发生不良妊娠结局(不良组)。不良组与正常组孕妇的PI评分[2(1,4)与1(0,1)分]、RI值[0.64(0.48,0.83)与0.43(0.34,0.54)]、血清β-hCG MoM值[1.34(0.80,2.12)与0.69(0.26,1.23)IU/L]、血清AFP MoM值[0.98(0.56,2.27)与0.63(0.32,1.44)μg/L]比较,不良组均高于正常组;不良组的血清uE3 MoM值低于正常组[0.63(0.28,0.96)与0.80(0.31,1.55)nmol/L];差异均有统计学意义(P值均<0.05)。多因素Logistic回归分析显示,PI评分升高(OR=3.917,95%CI:2.675~5.736)、RI值升高(OR=143.247,95%CI:28.726~714.313)、β-hCG升高(OR=3.050,95%CI:2.002~4.647)、AFP升高(OR=1.844,95%CI:1.292~2.631)、uE3降低(OR=0.556,95%CI:0.316~0.977)可能是不良妊娠结局的危险因素(P值均<0.05)。ROC曲线分析显示,PI评分预测不良妊娠结局的曲线下面积(AUC)为0.796,截断值为1.50分;RI值的AUC为0.791,截断值为0.62;β-hCG的AUC为0.742,截断值为0.85 IU/L;uE3的AUC为0.575,截断值为0.96 nmol/L;AFP的AUC为0.675,截断值为1.97μg/L;5项联合检测的AUC为0.929,均高于单项检测指标。结论孕中期子宫动脉多普勒超声血流参数和血清学指标异常与不良妊娠结局有关,PI评分、RI值及血清β-hCG、AFP升高、uE3降低可能是不良妊娠结局的危险因素,联合检测有助于提高不良妊娠结局的预测效果。

Objective To investigate the value of Doppler ultrasound blood flow parameters of uterine artery combined with prenatal screen of serological indexes in the second trimester for predicting the adverse pregnancy outcomes.Method From December 2018 to May 2020,782 pregnant women who underwent prenatal examination and gave birth in Guangyuan Maternal and Child Health Hospital were included as the research objects.At 15~20+6 weeks,the uterine artery blood flow parameters[pulsatility index(PI)and blood flow resistance index(RI)]were measured by Doppler ultrasound.The serumβ-human chorionic gonadotropin(β-hCG),unconjugated estriol(uE3)and alpha-fetoprotein(AFP)were detected,while the multiple of median(MoM)values were calculated.Followed up to 42 days postpartum,they were divided into adverse group and normal group according to the pregnancy outcome.Chi-square test,t test,nonparameter test,multivariate Logistic regression analysis,receiver operating characteristic(ROC)curve were used for statistical analysis.Result Of the 782 pregnant women,718 pregnant women(91.8%)had normal pregnancy(normal group);64 cases(8.2%)of pregnant women had adverse pregnancy outcomes(adverse group).PI score[2(1,4)vs 1(0,1)],RI value[0.64(0.48,0.83)vs 0.43(0.34,0.54)],the MoM value ofβ-hCG[1.34(0.80,2.12)vs 0.69(0.26,1.23)IU/L]and the MoM value of AFP[0.98(0.56,2.27)vs 0.63(0.32,1.44)μg/L]in the adverse group were higher than those in the normal group(P<0.05).The MoM value of uE3 in the adverse group was lower than that of normal group[0.63(0.28,0.96)vs 0.80(0.31,1.55)nmol/L,P<0.05].Multivariate Logistic regression analysis showed that PI score increased(OR=3.917,95%CI:2.675-5.736),RI value increased(OR=143.247,95%CI:28.726-714.313),β-hCG increased(OR=3.050,95%CI:2.002-4.647),AFP increased(OR=1.844,95%CI:1.292-2.631)and uE3 decreased(OR=0.556,95%CI:0.316~0.977)might be risk factors for adverse pregnancy outcomes(all P<0.05).ROC curve analysis showed that the AUC of PI scores in predicting the adverse pregnancy outcomes was 0.796 while the cut-off was 1.50.The AUC of RI was 0.791,while the cut-off was 0.62.The AUC ofβ-hCG was 0.742,while the cut-off was 0.85 IU/L.The AUC of uE3 was 0.575,while the cut-off was 0.96 nmol/L.The AUC of AFP was 0.675,while the cut-off was 1.97μg/L.The AUC of the five indexes combined was 0.929,which was higher than that of single index.Conclusion Abnormal ultrasonic blood flow parameters and serological indexes of uterine artery in the second trimester of pregnancy are related to adverse pregnancy outcomes.The increase of PI score,RI value,β-hCG and AFP,and the decrease of uE3 may be the risk factors of adverse pregnancy outcomes.Combined detection is helpful to improve the prediction effect of adverse pregnancy outcomes.