妊娠合并慢性肾病围产期多学科团队管理价值研究

Value of multidisciplinary team management in perinatal period for pregnant women with chronic kidney disease

目的探讨妊娠合并慢性肾病(CKD)孕妇围产期采取多学科团队(MDT)管理模式临床疗效。方法选择2018年1月至2022年12月于陆军军医大学第一附属医院妇产科分娩,并且于孕前或孕龄<25孕周时明确诊断为CKD的70例孕妇为研究对象。根据CKD孕妇围产期管理模式,将其分别纳入研究组(n=40,围产期采取MDT管理模式干预)与对照组(n=30,围产期采取产科单一科室医护联合管理模式干预)。采用回顾性研究方法,收集2组孕妇的一般临床资料,围产期干预前、后,即早、晚孕期肌酐浓度、24 h尿蛋白定量等肾功能指标,妊娠期并发症、妊娠结局等,并对这些指标采用成组t检验、Mann-Whitney U检验、χ^(2)检验或连续性校正χ^(2)检验或Fisher确切概率法进行比较。本研究获得陆军军医大学第一附属医院医学伦理委员会批准[审批号:(B)KY2023085]。结果①2组CKD孕妇年龄、身高、孕前3个月体重和人体质量指数(BMI)等一般临床资料分别比较,差异均无统计学意义(P>0.05)。②干预前,2组CKD孕妇早孕期24 h尿蛋白定量、肌酐浓度等肾功能指标分别比较,差异均无统计学意义(P>0.05)。干预后,研究组CKD孕妇晚孕期24 h尿蛋白定量显著低于对照组,并且差异有统计学意义(Z=-3.09、P=0.002)。③研究组CKD孕妇妊娠期并发症总发生率为50.0%(20/40),显著低于对照组的86.7%(26/30),并且差异有统计学意义(χ^(2)=10.23、P=0.001)。研究组CKD孕妇甲状腺功能异常率为5.0%(2/40),显著低于对照组的30.0%(9/30),并且差异有统计学意义(χ^(2)=6.31、P=0.012)。④研究组孕妇早产、引产、自然流产等不良妊娠结局总发生率为12.5%(5/40),显著低于对照组的43.3%(13/30),并且差异有统计学意义(χ^(2)=8.53、P=0.008)。⑤研究组CKD孕妇新生儿出生体重、胎龄及生后1、5、10 min Apgar评分,均显著高于对照组,并且差异均有统计学意义(t=-2.90、P=0.007,t=-2.33、P=0.027,t=-2.37、P=0.027,t=-2.13、P=0.042,t=-2.07、P=0.048)。结论对CKD孕妇围产期采用MDT管理模式干预,可有效降低围产期并发症发生率,减轻肾脏负担,降低不良妊娠结局、早产等发生率。

Objective To explore the clinical effect of multidisciplinary team(MDT)management model in pregnant women with chronic kidney disease(CKD)during perinatal period.Methods Seventy pregnant women who gave birth at Department of Obstetrics and Gynecology,the First Affiliated Hospital of Army Medical University from January 2018 to December 2022 and were diagnosed with CKD before pregnancy or at gestational age<25 weeks were selected as the research subjects.According to the perinatal management model of CKD pregnant women,they were included into study group(n=40,receiving MDT management intervention measures during perinatal period)and control group(n=30,receiving an obstetric single-department joint management intervention measures by medical and nursing staff during perinatal period).General clinical data,renal function indicators such as creatinine concentration and 24 h urine protein quantification before and after perinatal intervention(the first and third trimester pregnancy),pregnancy complications,and pregnancy outcomes of two groups were collected by retrospective study method,and were compared by independent-samples t test,Mann-Whitney U test,and chi-square test or continuity correction chi-square test or Fisher′s exact probability method.This study has been approved by the Medical Ethics Committee of the First Affiliated Hospital of Army Medical University[Approval No.(B)KY2023085].Results①There were no statistical differences in general clinical data such as age,height,weight and body mass index(BMI)three months before pregnancy between two groups(P>0.05).②Before intervention,there were no statistical differences between two groups in renal function indicators such as 24 h urine protein quantification and creatinine concentration in the first trimester pregnancy(P>0.05).After intervention,the 24 h urinary protein quantification of CKD pregnant women in the third trimester pregnancy of study group was significantly lower than that of control group,and the difference was statistically significant(Z=-3.09,P=0.002).③The total incidence of pregnancy complications of study group was 50.0%(20/40),which was significantly lower than that of control group 86.7%(26/30),and the difference was statistically significant(χ^(2)=10.23,P=0.001).The incidence of thyroid dysfunction in study group was 5.0%(2/40),which was significantly lower than that of control group 30.0%(9/30),and the difference was statistically significant(χ^(2)=6.31,P=0.012).④The total incidence of adverse pregnancy outcomes such as premature birth,induced abortion,and spontaneous abortion in study group was 12.5%(5/40),which was significantly lower than that of control group 43.3%(13/30),and the difference was statistically significant(χ^(2)=8.53,P=0.008).⑤The birth weight,gestational age at birth,and Apgar scores at 1,5,and 10 min after birth of newborns delivered by CKD pregnant women in the study group all were significantly higher than those in the control group,and the differences were statistically significant(t=-2.90,P=0.007;t=-2.33,P=0.027;t=-2.37,P=0.027;t=-2.13,P=0.042;t=-2.07,P=0.048).Conclusions Adopting intervention measures of MDT management model during perinatal period for CKD pregnant women can effectively reduce the incidence of perinatal complications,alleviate renal burden,reduce incidence of adverse pregnancy outcomes and premature birth.