先于子痫前期的严重胎儿生长受限的临床特点及围产结局

Clinical characteristics and perinatal outcomes of severe fetal growth restriction preceding preeclampsia

目的探讨以严重胎儿生长受限(fetal growth restriction,FGR)为先发症状的子痫前期(preeclampsia,PE)的临床特点及围产结局。方法本研究为回顾性队列研究,研究对象为2012年1月至2022年12月在福建省妇幼保健院分娩的PE合并严重FGR的单胎活产病例。根据严重FGR和高血压发生的先后顺序将研究对象分为严重FGR先发组和高血压先发组。分析2组的一般资料、发病特征、妊娠并发症及新生儿结局。采用t检验、Mann-Whitney U检验和χ^(2)检验进行统计学分析。采用多因素线性回归或logistic回归分析校正混杂因素对围产结局的影响。结果(1)一般资料:共307例进入本研究,包括严重FGR先发组194例(63.2%)和高血压先发组113例(36.8%)。与高血压先发组比较,严重FGR先发组32周前严重FGR占比较高,PE诊断孕周较晚,早发型PE占比较低,终止妊娠孕周较大,诊断PE到终止妊娠间隔时间短[40.7%(46/113)与59.3%(115/194),χ^(2)=9.87;(32.8±5.1)周与(35.6±3.4)周,t=5.12;52.2%(59/113)与25.8%(50/194),χ^(2)=21.80;(34.7±3.1)周与(36.0±3.2)周,t=3.43;P值均<0.01]。2组诊断严重FGR与高血压的孕周间隔差异无统计学意义。(2)妊娠并发症:与高血压先发组比较,严重FGR先发组早产率更低,胎膜早破发生率更高[69.0%(78/113)与46.9%(91/194),χ^(2)=14.12;9.7%(11/113)与19.1%(37/194),χ^(2)=4.72;P值均<0.05]。采用多因素logistic回归分析校正终止妊娠孕周的差异后,2组妊娠并发症发生情况差异均无统计学意义。(3)新生儿结局:与高血压先发组比较,严重FGR先发组新生儿出生体重更重[(1757±605)g与(2067±684)g,t=4.12]、身长更长[(41.7±4.3)cm与(43.4±4.6)cm,t=3.10]、胎盘更重[(399±158)g与(486±147)g,t=2.36],剖宫产出生比例、重度SGA和低出生体重儿发生率更低[85.8%(97/113)与68.6%(133/194),χ^(2)=11.35;65.5%(74/113)与49.5%(96/194),χ^(2)=7.40;87.6%(99/113)与69.6%(135/194),χ^(2)=12.80;P值均<0.05],2组新生儿1 min Apgar评分及NICU入住率差异无统计学意义。多因素回归分析校正终止妊娠孕周的差异后发现,与高血压先发组相比,严重FGR先发组的新生儿体重较重,剖宫产风险较低[OR(95%CI)分别为80.18(0.95~159.42)和0.51(0.26~0.99),P值均<0.05]。结论严重FGR先发的PE孕妇较高血压先发孕妇PE发病晚,围产结局相对较好。需加强对严重FGR先发的PE孕妇的血压波动水平和高血压先发的PE孕妇的胎儿生长情况监测。

ObjectiveTo investigate the clinical characteristics and perinatal outcomes of preeclampsia(PE)with severe fetal growth restriction(FGR)as the initial symptom.MethodsThis retrospective cohort study included cases of singleton live births with PE and severe FGR delivered at Fujian Maternity and Child Health Hospital from January 2012 to December 2022.The cases were divided into two groups based on the sequence of severe FGR and hypertension onset:the severe FGR-first group and the hypertension-first group.General data,clinical characteristics,pregnancy complications,and neonatal outcomes were analyzed between the two groups.Statistical analyses were performed using t-tests,Mann-Whitney U tests,and Chi-square tests.Multivariate linear regression or logistic regression analyses were used to adjust for the effects of confounding factors on perinatal outcomes.Results(1)A total of 307 cases were included in the study,with 194 cases(63.2%)in the severe FGR-first group and 113 cases(36.8%)in the hypertension-first group.Compared to the hypertension-first group,the severe FGR-first group had a higher proportion of severe FGR before 32 weeks,later gestational age at PE diagnosis,lower proportion of early-onset PE,greater gestational age at pregnancy termination,and shorter interval from PE diagnosis to pregnancy termination[40.7%(46/113)vs.59.3%(115/194),χ^(2)=9.87;(32.8±5.1)weeks vs.(35.6±3.4)weeks,t=5.12;52.2%(59/113)vs.25.8%(50/194),χ^(2)=21.80;(34.7±3.1)weeks vs.(36.0±3.2)weeks,t=3.43;all P<0.01].There was no statistically significant difference in the interval between the diagnosis of severe FGR and hypertension between the two groups.(2)Compared to the hypertension-first group,the severe FGR-first group had a lower preterm birth rate and a higher incidence of premature rupture of membranes[69.0%(78/113)vs.46.9%(91/194),χ^(2)=14.12;9.7%(11/113)vs.19.1%(37/194),χ^(2)=4.72;both P<0.05].After adjusting for differences in gestational age at termination of pregnancy using multivariate logistic regression analysis,the results showed no statistically significant differences in the incidence of pregnancy complications between the two groups.(3)Compared with the hypertension-first group,the severe FGR-first group had higher neonatal birth weight[(1757±605)g vs.(2067±684)g,t=4.12],longer birth length[(41.7±4.3)cm vs.(43.4±4.6)cm,t=3.10],and heavier placentas[(399±158)g v s.(486±147)g,t=2.36].The rates of cesarean section,severe small for gestational age,and low birth weight were lower[85.8%(97/113)vs.68.6%(133/194),χ^(2)=11.35;65.5%(74/113)vs.49.5%(96/194),χ^(2)=7.40;87.6%(99/113)vs.69.6%(135/194),χ^(2)=12.80;all P<0.05].There were no statistically significant differences in the 1-minute Apgar scores and NICU admission rates between the two groups.After adjusting for differences in gestational age at termination of pregnancy using multivariate regression analysis,it was found that compared with the hypertension-first group,the severe FGR-first group had heavier neonates and a lower risk of cesarean section[OR(95%CI)were 80.18(0.95-159.42)and 0.51(0.26-0.99),both P<0.05].ConclusionsPregnant women with severe FGR preceding PE have a later onset of PE and relatively better perinatal outcomes compared to those with hypertension preceding PE.It is necessary to strengthen the monitoring of blood pressure fluctuations in pregnant women with severe FGR preceding PE and fetal growth in pregnant women with hypertension preceding PE.