胎盤絨毛膜羊膜炎產婦的孕產不良結局分析

Adverse peripartum outcomes of the histologic chorioamnionitis patients

目的通過分析組織學絨毛膜羊膜炎(HCA)產婦的孕產不良結局,尋找HCA相關高危因素及其預防方式。方法收集2019年11月~2020年11月期間,在澳門鏡湖醫院生產後,經評估胎盤送檢病理的患者。其中病理診斷為HCA產婦223例,無HCA產婦200例。對照分析兩組產婦孕產結局及其新生兒資料。結果HCA產婦的剖宮產比例顯著低於對照組。“剖宮產”患者中,破膜時間>12小時、產程期間發熱、產前CRP升高、胎膜早破、胎膜早破合併CRP升高、胎膜早破合併產程發熱、羊水糞染發生率均顯著高於對照組;但是,GBS感染率兩組無差異。HCA“陰道產”患者中,產程期間發熱、產前CRP升高、胎膜早破合併產程發熱和羊水糞染發生率顯著高於對照組;但是,破膜時間>12小時、胎膜早破、胎膜早破合併CRP升高、GBS感染率兩組無差異。所有HCA產婦的新生兒感染、新生兒濕肺、新生兒呼吸窘迫和早產兒的發生率、轉NICU比例兩組存在顯著差異;但是,新生兒肺炎、新生兒氣胸和轉入SBU的比例兩組無差異。HCA產婦的平均陰道檢查次數顯著高於對照組。結論建議將剖宮產病人中,破膜>12小時、產程期發熱、產前CRP升高、胎膜早破、胎膜早破合併CRP升高、胎膜早破合併產程發熱、羊水糞染患者;將陰道產病人中,產程期發熱、胎膜早破合併產程發熱、羊水糞染患者;以及所有陰檢次數多於6次的患者,均視為高危產婦。高危產婦實施產後胎盤病理檢查;對於有指征的高危產婦,在產程中預防性使用抗生素;對於胎膜早破或產前發熱患者,建議動態監測血清CRP水平。孕婦產程中,應盡量減少不必要的陰道檢查。

Objective To compare the peripartum and the newborns clinical data between the HCA positive and the control group in order to find out the prepartum high risk factors for HCA infection.Methods The pregnant women diagnosed with HCA(HCA group,223 cases)and no HCA(control group,200 cases)by placental pathological examinations in Kiang Wu Hospital from November 2019 to November 2020 were recruited in this study.A retrospective study was conducted on the peripartum and newborns clinical data between the two groups.Results The caesarean section rate(HCA group 43.5%vs control group 66.0%)was significantly lower in the HCA group than that in the control group.For those with caesarean section,the occurrence rate of>12 hour prolonged membrane rupture(HCA group 27.8%vs control group 9.1%),IF(HCA group 41.2%vs control group 7.6%),prepartum elevated CRP(HCA group 40.2%vs control group 13.6%),PROM(HCA group 47.4%vs control group 24.2%),PROM with CRP increase(HCA group 26.8%vs control group 8.3%),PROM with IF(HCA group 22.7%vs control group 3.8%),the meconium-stained amniotic fluid(HCA group 39.2%vs control group 19.7%)was significantly increased in the HCA patients,whereas the occurrence of GBS infection(HCA group 15.5%vs control group 16.7%)was not different between the two groups.For the vaginal delivery patients,the occurrence rate of IF(HCA group 39.7%vs control group 8.8%),the prepartum elevated CRP(HCA group 38.9%vs control group 20.6%),PROM with CRP(HCA group 23.0%vs control group 17.6%),PROM with IF(HCA group 22.2%vs control group 5.9%)and the meconium-stained amniotic fluid(MSAF)(HCA group 45.2%vs control group 26.5%)was significantly increased in the HCA patients;whereas the occurrence of>12 hour prolonged membrane rupture(HCA group 30.2%vs control group 32.4%),PROM(HCA group 44.4%vs control group 52.9%),and the GBS infection(HCA group 25.4%vs control group 27.9%)was not different between the two groups.Among the 295(from HCA group mothers)and the 240(from Control group mothers)newborns,the occurrence rate of newborn infection(HCA group 21.7%vs control group 12.5%),neonatal wet lung syndrome(NWLS)(HCA group 2.4%vs control group 11.7%),the infant respiratory distress syndrome(IRDS)(HCA group 6.1%vs control group 3.3%),the preterm delivery(HCA group 16.9%vs control group 8.3%)and NICU transfer rate(HCA group 4.7%vs control group 10.0%)were different between the two groups.The occurrence rate of newborns pneumonia(HCA group 14.9%vs control group 12.5%),the newborn pneumothorax(HCA group 1.4%vs control group 0.8%),and SBU transfer rate(HCA group 31.9%vs control group 40.8%)was not different between the two groups.The vaginal examination times(HCA group 6.13±3.68 vs control group 2.92±2.80)were significantly higher in the HCA group than that in control group.Conclusion We suggested to classify the caesarean delivery patients with>12 hour prolonged membrane rupture,IF,PROM,prepartum elevated CRP,PROM with elevated CRP,PROM with IF and MSAF;the vaginal delivery patients with IF,PROM with IF and MSAF;and all patients with≥6 vaginal examinations as high risk patients.For those high risk pregnant women,postpartum placental pathological examination were strongly recommended.Especially,for those PROM combined with IF patients,serum dynamic CRP should be monitored.Preventive antibiotics treatment could be applied if necessary.Vaginal examinations should be avoided whenever possible.