原发免疫性血小板减少症患者围分娩期治疗对分娩结局的影响:前瞻性队列研究

Effects of peripartum treatment on delivery outcomes in women with primary immune thrombocytopenia:a prospective cohort study

目的原发免疫性血小板减少症(primary immune thrombocytopenia,ITP)患者围分娩期接受低剂量激素或静脉注射免疫球蛋白(intravenous immunoglobulin,IVIG)治疗对分娩结局的影响。方法本研究为前瞻性队列研究,研究对象为2017年1月至2021年12月在北京大学人民医院建档的妊娠合并ITP患者,将进入围分娩期(≥34周)血小板计数为(20~50)×109/L且无出血症状及孕34周前未接受药物者纳入本研究。根据患者意愿分为药物治疗组(口服泼尼松或IVIG)及单纯血小板输注组。采用t检验、Wilcoxon秩和检验和χ^(2)检验比较2组患者阴道分娩率、产后出血率及血小板输注量等差异,采用二分类logistic回归分析阴道分娩率、产后出血率的影响因素,采用多重线性回归分析血小板输注量的影响因素。结果研究期间,共纳入96例ITP患者,其中药物治疗组70例,单纯血小板输注组26例。药物治疗组阴道分娩率高于单纯血小板输注组[60.0%(42/70)与30.8%(8/26),χ^(2)=6.49,P=0.013]。校正经产妇比例、分娩孕周后,logistic回归分析显示,围分娩期药物治疗者阴道分娩率升高(OR=4.937,95%CI:1.511~16.136,P=0.008)。药物治疗组和单纯血小板输注组产后出血发生率分别为22.9%(16/70)和26.9%(7/26),差异无统计学意义(χ^(2)=0.17,P=0.789)。药物治疗组血小板输注量少于单纯血小板输注组[1 U(0~4 U)与1 U(1~3 U),Z=-2.18,P=0.029)],经校正入组时血小板计数、妊娠期并发症及贫血等因素后,药物治疗组血小板输注量仍较少(95%CI:0.053~0.911,P=0.028)。共分娩96例新生儿,无新生儿颅内出血发生。新生儿血小板减少的总体发生率为26.0%(25/96)。2组间新生儿出生体重、新生儿窒息及血小板减少的发生率比较差异均无统计学意义。结论ITP患者围分娩期药物治疗可提高阴道分娩率,减少血小板输注量,且未增加产后出血率。

Objective To investigate the effects of peripartum administration of low-dose corticosteroids or intravenous immunoglobulin(IVIG)on delivery outcomes in pregnant patients with primary immune thrombocytopenia(ITP).Methods This prospective cohort study involved pregnant women(≥34 gestational weeks)who were diagnosed with ITP in Peking University People's Hospital from January 2017 to December 2021.Their platelet counts were between 20×109/L to 50×109/L without bleeding and none of them had been treated with any medications.All patients were divided into medication group(prednisone or IVIG)and platelet transfusion group based on their preference.Differences in vaginal delivery rate,postpartum hemorrhage rate and platelet transfusion volume between the two groups were compared using t-test,Wilcoxon rank sum test and Chi-square test.Binary logistic regression was used to investigate the factors influencing the rates of vaginal delivery and postpartum hemorrhage.Multiple linear regression was used to analyze the factors influencing the platelet transfusion volume.Results A total of 96 patients with ITP were recruited with 70 in the medication group and 26 in the platelet transfusion group.The vaginal delivery rate in the medication group was higher than that in the platelet transfusion group[60.0%(42/70)vs 30.8%(8/26),χ^(2)=6.49,P=0.013].After adjusted by the proportion of multiparae and the gestational age at delivery,binary logistic regression showed that the increased vaginal delivery rate in patients undergoing the peripartum treatment(OR=4.937,95%CI:1.511-16.136,P=0.008).The incidence of postpartum hemorrhage in the two groups was 22.9%(16/70)and 26.9%(7/26),respectively,but no significant difference was shown(χ^(2)=0.17,P=0.789).The median platelet transfusion volume was lower in the medication group than in the platelet transfusion group[1 U(0-4 U)vs 1 U(1-3 U),Z=-2.18,P=0.029].After adjustment of related factors including the platelet count at enrollment,obstetrical complications and anemia,multiple linear regression showed that the platelet transfusion volume was also lower in the medication group(95%CI:0.053-0.911,P=0.028).Ninety-six newborns were delivered without intracranial hemorrhage.The overall incidence of neonatal thrombocytopenia was 26.0%(25/96).There was no significant difference in birth weight,and incidence of neonatal asphyxia or thrombocytopenia between the two groups.Conclusion Peripartum therapy in ITP patients may increase vaginal delivery rate and reduce platelet transfusion volume without causing more postpartum hemorrhage.