子痫前期并发胎儿生长受限的影响因素及其Nomogram预测模型建立

Influencing factors of fetal growth restriction in patients with preeclampsia and the establishment of a Nomogram prediction model

目的探讨子痫前期(preeclampsia,PE)并发胎儿生长受限(fetal growth restriction,FGR)的影响因素,并构建Nomogram预测模型。方法选取湖州市妇幼保健院于2021年8月至2023年5月收治的273例PE患者为研究对象,分为建模组(n=191)及验证组(n=82)。多因素Logistic回归分析确定PE并发FGR的影响因素;R4.3.1构建预测PE并发FGR的Nomogram模型;受试者工作特征(ROC)曲线及霍斯默-莱梅肖(H-L)拟合优度检验评估Nomogram模型预测PE并发FGR的区分度和一致性。结果建模组和验证组发病孕周、血压、血红蛋白、尿蛋白(urine protein,UP)、尿酸、脐动脉收缩压/舒张压(systolic pressure/diastolic pressure,S/D)、D-二聚体(D-dimer,D-D)和产次等比较,差异无统计学意义(P>0.05)。与未并发FGR组比较,并发FGR组发病孕周较早,UP、S/D和D-D水平及羊水过少占比明显升高,血小板计数(platelet count,PLT)明显降低(t/χ^(2)=2.588、1.437、6.262、5.464、9.881、3.326,P<0.05)。多因素Logistic回归分析表明UP、S/D、D-D、羊水过少为PE并发FGR的危险因素(OR=1.004、3.807、1.006、4.348,P<0.05),PLT为其保护因素(OR=0.980,P<0.05)。Nomogram模型显示,PE患者上述5个影响因素总得分为149时,并发FGR的概率为60%;总得分为167时,并发FGR的概率为90%,超过167分概率为90%以上。建模组H-L检验χ^(2)=6.736,P=0.565,验证组χ^(2)=5.812,P=0.668。建模组和验证组ROC曲线下面积(AUC)分别为0.924(95%CI:0.883~0.965)和,0.932(95%CI:0.880~0.984)敏感度分别为83.93%和90.48%,特异度分别为89.63%和81.97%。临床决策曲线(DCA)评估Nomogram模型预测PE患者并发FGR临床应用价值。结论基于UP、S/D、D-D、PLT、羊水过少这5个指标构建的预测PE并发FGR发生风险的Nomogram模型具有较高的区分度和一致性。

Objective To explore the influencing factors of fetal growth restriction(FGR)in patients with preeclampsia(PE)and construct a Nomogram prediction model.Methods From Aug.2021 to May.2023,273 PE patients admitted to our hospital were regarded as the study subjects,and grouped into a modeling group(n=191)and a validation group(n=82).Multivariate logistic regression analysis was applied to determine the influencing factors of FGR in PE patients.R4.3.1 was applied to construct a Nomogram model for predicting FGR in PE patients.Receiver operating characteristic(ROC)curve and the Hosmer Lemeshoe(H-L)goodness of fit test were applied to evaluate the discrimination and consistency of the Nomogram model in predicting FGR in PE patients.Results There was no statistically obvious difference in gestational age,blood pressure,hemoglobin,urinary protein(UP),uric acid,umbilical artery systolic/diastolic blood pressure(S/D),D-dimer(D-D),or birth frequency between the modeling group and the validation group(P>0.05).Compared with no concurrent FGR group,the onset of pregnancy in the concurrent FGR group was earlier,the levels of UP,S/D,and D-D,and the proportion of oligohydramnios were obviously higher,and the platelet count(PLT)was obviously lower(t/χ^(2)=2.588,1.437,6.262,5.464,9.881,3.326,P<0.05).Multivariate Logistic regression analysis showed that UP,S/D,D-D,and oligohydramnios were risk factors for FGR in PE patients(OR=1.004,3.807,1.006,4.348,P<0.05),while PLT was a protective factor(OR=0.980,P<0.05).Nomogram model showed that when the total score of the above 5 influencing factors in PE patients was 149,the probability of concurrent FGR was 60%;when the total score was 167,the probability of concurrent FGR was 90%,and the probability of exceeding 167 was over 90%.Modeling group H-L testχ^(2)=6.736,P=0.565,validation groupχ^(2)=5.812,P=0.668.The area under the ROC curve(AUC)of the modeling group and the validation group was 0.924(95%CI:0.883-0.965)and 0.932(95%CI:0.880-0.984),respectively.The sensitivity was 83.93%and 90.48%,and the specificity was 89.63%and 81.97%,respectively.Decision curve analysis(DCA)was applied to evaluate the clinical application value of the Nomogram model in predicting FGR in PE patients.Conclusion The Nomogram model constructed based on the five indicators of UP,S/D,D-D,PLT,and oligohydramnios for predicting the risk of FGR in PE patients has high discrimination and consistency.