吳金兒,茅味蓉,朱宏濤,鄭錦麗
(余姚市人民醫(yī)院婦產(chǎn)科,浙江 余姚 315400)
子癇前期病史孕婦再次妊娠臨床特點(diǎn)及母嬰結(jié)局分析
吳金兒,茅味蓉,朱宏濤,鄭錦麗
(余姚市人民醫(yī)院婦產(chǎn)科,浙江 余姚 315400)
目的 探討早發(fā)型及晚發(fā)型子癇前期病史孕婦再次妊娠臨床特點(diǎn)及母嬰結(jié)局。方法 選取余姚市人民醫(yī)院婦產(chǎn)科2011年1月至2016年12月收治的98例子癇前期病史孕婦作為研究對(duì)象,分析子癇前期病史孕婦再次妊娠臨床特點(diǎn)并分析其母嬰結(jié)局。結(jié)果 前次妊娠為早發(fā)型子癇前期的患者本次妊娠臨床表現(xiàn)中頭痛、眼花、頭暈發(fā)生率均顯著高于晚發(fā)型子癇前期患者(χ2值分別為10.309、13.608、17.610,均P<0.05),且24h尿蛋白定量值顯著高于晚發(fā)型子癇前期患者(χ2=5.232,P<0.05)。前次妊娠為早發(fā)型子癇前期患者本次妊娠妊娠期高血壓疾病發(fā)病率高于晚發(fā)型子癇前期患者,但差異無統(tǒng)計(jì)學(xué)意義(χ2=1.768,P>0.05)而本次妊娠并發(fā)癥顯著高于晚發(fā)型子癇前期患者(χ2=25.247,P<0.01),主要為肝功能損害(27.50%)、腎功能損害(20.00%),兩組患者胎盤早剝、產(chǎn)后出血發(fā)生率無顯著性差異(χ2值分別為0.071、0.803,均P>0.05)。前次妊娠為早發(fā)型子癇前期患者新生兒窒息、低體重兒、新生兒低血糖、新生兒死亡發(fā)生率均顯著高于晚發(fā)型子癇前期患者(χ2值分別為5.009、10.648、7.701、4.487,均P<0.05),兩組胎兒生長(zhǎng)受限、新生兒濕肺、新生兒呼吸窘迫綜合征發(fā)生率均無顯著性差異(χ2值分別為0.803、0.001、1.465,均P>0.05)。結(jié)論 血壓增高、蛋白尿是子癇前期孕婦再次妊娠的主要臨床特點(diǎn),子癇前期孕婦孕周越短,出現(xiàn)并發(fā)癥越高,且圍產(chǎn)兒結(jié)局相對(duì)越差。
子癇前期;再次妊娠;母嬰結(jié)局;24h尿蛋白定量值
子癇前期又稱為先兆子癇,是一類發(fā)生于妊娠期間的特異性疾病?;颊咴谌焉锲陂g出現(xiàn)高血壓、尿蛋白陽性為主要的臨床表現(xiàn),隨著病情的發(fā)展,孕婦可能會(huì)出現(xiàn)多器官功能障礙,嚴(yán)重威脅到了孕產(chǎn)婦的生命健康[1]。隨著我國(guó)二胎政策的開放,部分子癇前期病史育齡期女性有再次生育要求,本文回顧性分析了曾有子癇前期病史再次妊娠患者的臨床資料,為子癇前期病史的女性再次妊娠風(fēng)險(xiǎn)提供參考。
1.1研究對(duì)象
選擇余姚市人民醫(yī)院婦產(chǎn)科2011年1月至2016年12月收治的有子癇前期病史孕婦98例為研究對(duì)象,年齡25~36歲,平均27.8 6±2.98歲,孕周26~40周,平均34.34±3.76周,詳細(xì)記錄患者一般資料,包括年齡、身高、體重、身體質(zhì)量指數(shù)(body mass index,BMI)。入選標(biāo)準(zhǔn):①患者前次妊娠經(jīng)臨床確診為子癇前期,診斷結(jié)果符合2013年美國(guó)婦產(chǎn)科醫(yī)師學(xué)會(huì)(The American college of obstetricians and gynecologists,ACOG)通過的子癇前期診斷標(biāo)準(zhǔn),分娩結(jié)束后血壓、腎功、尿常規(guī)等回復(fù)正常,前次分娩距本次妊娠≥2年;②兩次妊娠均在本院診治且有完成的病例資料。排除標(biāo)準(zhǔn):①存在心、腎等重要臟器疾病者(包括慢性腎炎、急性腎炎);②合并其他惡性腫瘤者。
1.2方法
根據(jù)前次妊娠患者子癇前期診斷時(shí)間分為早發(fā)型子癇前期(<34周發(fā)病)40例、晚發(fā)型子癇前期(≥34周發(fā)病)58例[2]。本次妊娠期間在本院產(chǎn)科門診詳細(xì)產(chǎn)檢,有并發(fā)癥者積極治療,如再次發(fā)生妊娠期高血壓疾病者根據(jù)孕婦個(gè)人情況進(jìn)行靜滴硫酸鎂、合理擴(kuò)容、鎮(zhèn)靜、穩(wěn)定血壓等治療,使用地塞米松至胎肺成熟,選擇合理時(shí)機(jī)終止妊娠。比較兩組患者的臨床表現(xiàn)、實(shí)驗(yàn)室各項(xiàng)檢測(cè)指標(biāo)(血常規(guī)、尿蛋白檢測(cè)、肝功能等)、圍產(chǎn)兒結(jié)局等資料。
1.3 統(tǒng)計(jì)學(xué)方法
2.1子癇前期病史孕婦再次妊娠臨床特點(diǎn)比較
前次妊娠為早發(fā)型子癇前期患者本次妊娠臨床表現(xiàn)中頭痛、眼花、頭暈發(fā)生率均顯著高于晚發(fā)型子癇前期患者(均P<0.05),且24h尿蛋白定量值顯著高于晚發(fā)型子癇前期患者(P<0.05),兩組患者年齡、孕前BMI、孕次、產(chǎn)次、舒張壓、收縮壓比較均無顯著性差異(均P>0.05),見表1。
項(xiàng)目早發(fā)型子癇前期(n=40)晚發(fā)型子癇前期(n=58)t/χ2P年齡(歲)27.16±2.7828.11±2.491.7690.079孕前BMI(kg/m2)22.31±3.1023.12±2.971.3190.190 孕次2.27±0.792.35±0.840.1380.327 產(chǎn)次0.82±0.230.71±0.200.2390.119臨床表現(xiàn) 頭痛18(45.00)9(15.51)10.3090.000 眼花21(52.50)10(17.24)13.6080.000 頭暈25(62.50)12(20.68)17.6100.00024h尿蛋白定量值(g)8.12±6.892.74±3.115.2320.024舒張壓(mmHg)121.12±16.34119.26±16.490.5510.189收縮壓(mmHg)176.59±31.98176.51±31.810.0120.435
2.2妊娠期并發(fā)癥及結(jié)局比較
前次妊娠為早發(fā)型子癇前期患者本次妊娠妊娠期高血壓疾病發(fā)病率高于晚發(fā)型子癇前期患者,但差異無統(tǒng)計(jì)學(xué)意義(P>0.05)。而前次妊娠為早發(fā)型子癇前期患者此次妊娠并發(fā)癥顯著高于晚發(fā)型子癇前期患者(P<0.01),患者主要并發(fā)癥為肝功能損害(27.50%)、腎功能損害(20.00%)。兩組患者胎盤早剝、產(chǎn)后出血發(fā)生率無顯著性差異(均P>0.05),見表2。
表2 子癇前期孕婦再次妊娠結(jié)局比較[n(%)]
Table 2 Comparison of subsequent pregnancy outcomes of pregnant women with preeclampsia history[n(%)]
2.3圍生兒結(jié)局比較
前次妊娠為早發(fā)型子癇前期患者新生兒窒息、低體重兒、新生兒低血糖、新生兒死亡發(fā)生率均顯著高于晚發(fā)型子癇前期患者(均P<0.05),兩組胎兒生長(zhǎng)受限、新生兒濕肺、新生兒呼吸窘迫綜合征發(fā)生率均無顯著性差異(均P>0.05),見表3。
表3 圍生兒結(jié)局比較[n(%)]
Table 3 Comparison of perinatal fetus outcomes[n(%)]
項(xiàng)目早發(fā)型子癇前期(n=40)晚發(fā)型子癇前期(n=58)χ2P新生兒窒息9(22.50)4(6.89)5.0090.025胎兒生長(zhǎng)受限3(7.50)2(3.44)0.8030.370新生兒濕肺2(5.00)3(5.17)0.0010.970低體重兒(<2500g)25(62.50)17(29.31)10.6480.000新生兒低血糖18(45.00)11(18.96)7.7010.006新生兒呼吸窘迫綜合征1(2.50)01.4650.226新生兒死亡3(7.50)04.4870.034
3.1妊娠期高血壓疾病研究背景
妊娠期高血壓是妊娠期中常見并發(fā)癥之一,其臨床表現(xiàn)主要以血壓升高、尿蛋白陽性、全身或局部水腫,對(duì)母嬰健康有嚴(yán)重影響,而且程度越重,對(duì)妊娠結(jié)局影響越大[3]。子癇前期是妊娠期高血壓疾病的五種病況之一,是導(dǎo)致孕婦及圍產(chǎn)兒患病率及死亡率高的重要因素之一,但目前臨床對(duì)于妊娠期高血壓疾病的具體發(fā)病機(jī)制尚未明確,治療子癇前期疾病仍然處于被動(dòng)狀態(tài),主要以預(yù)防及合理終止妊娠為主要手段。
3.2不同類型子癇前期病史再次妊娠并發(fā)癥分析
文獻(xiàn)報(bào)道,初產(chǎn)孕婦在子癇前期的發(fā)病較低,大約為2.3%~7.8%,而存在子癇前期病史再次妊娠者,其子癇前期發(fā)病率是初產(chǎn)孕婦7.2倍,主要以早發(fā)型子癇前期發(fā)病率為主。肥胖、多胎妊娠、有子癇前期史等都是妊娠期高血壓疾病的高危因素,其中有子癇前期病史的患者,再次妊娠時(shí)罹患妊娠期高血壓疾病的風(fēng)險(xiǎn)明顯增高,文獻(xiàn)報(bào)道子癇前期的再發(fā)風(fēng)險(xiǎn)高達(dá)13%~65%[4-5]。研究資料表明,首次子癇前期發(fā)病孕周與其再發(fā)風(fēng)險(xiǎn)存在負(fù)相關(guān)的關(guān)系,即發(fā)病孕周越早,再次妊娠時(shí)發(fā)生子癇前期的可能性越大[6]。
本研究結(jié)果發(fā)現(xiàn)前次妊娠為早發(fā)型子癇前期患者本妊娠期高血壓疾病發(fā)病率為10.00%,高于前次妊娠為晚發(fā)型子癇前期患者,但差異無統(tǒng)計(jì)學(xué)意義(P>0.05),可能與本次研究樣本量低有關(guān)。此外,本研究結(jié)果還發(fā)現(xiàn),前次妊娠為早發(fā)型子癇前期患者本次妊娠臨床表現(xiàn)中頭痛、眼花、頭暈發(fā)生率均顯著高于晚發(fā)型子癇前期患者(均P<0.05),且24h尿蛋白定量值顯著高于晚發(fā)型子癇前期患者(P<0.05),患者并發(fā)癥顯著高于晚發(fā)型子癇前期患者(P<0.01),主要為肝功能損害(27.50%)、腎功能損害(20.00%),提示早發(fā)型子癇前期女性再次妊娠更易出現(xiàn)并發(fā)癥,這與文獻(xiàn)報(bào)道的首次子癇前期發(fā)病孕周與其再發(fā)風(fēng)險(xiǎn)存在負(fù)相關(guān)的關(guān)系,即發(fā)病孕周越早,再次妊娠時(shí)發(fā)生子癇前期的可能性越大相似[6]。
3.3不同類型子癇前期病史再次妊娠圍產(chǎn)兒結(jié)局分析
文獻(xiàn)報(bào)道稱,存在子癇前期病史者孕婦再次妊娠時(shí),其并發(fā)癥發(fā)生率與前次妊娠孕周存在一定關(guān)聯(lián)[7],前次孕周>34周者再次妊娠并發(fā)癥發(fā)生率要低于<34周者,在一定程度中影響著母嬰結(jié)局[8]。Van Rijn等于2006年研究表明孕婦首次妊娠合并胎兒生長(zhǎng)受限,是再次妊娠發(fā)生子癇前期的獨(dú)立危險(xiǎn)因素,且子癇前期發(fā)病越早,發(fā)生胎兒生長(zhǎng)受限的風(fēng)險(xiǎn)也越高。本研究比較兩組患者母嬰結(jié)局后發(fā)現(xiàn),前次妊娠為早發(fā)型子癇前期患者新生兒窒息、低體重兒、新生兒低血糖、新生兒死亡發(fā)生率均顯著高于晚發(fā)型子癇前期患者(P<0.05),兩組胎兒生長(zhǎng)受限、新生兒濕肺、新生兒呼吸窘迫綜合征發(fā)生率均無顯著性差異(P>0.05)。
綜上所述,血壓增高、蛋白尿是子癇前期孕婦再次妊娠的主要臨床特點(diǎn),子癇前期孕婦孕周越短,其孕婦出現(xiàn)并發(fā)癥越高,且圍產(chǎn)兒結(jié)局相對(duì)越差,因此,對(duì)于有子癇前期史的女性應(yīng)重視產(chǎn)后管理,有生育要求者應(yīng)重視預(yù)防再次子癇前期,包括藥物預(yù)防、體重管理和生活習(xí)慣的改變。本文存在不足之處為研究病例數(shù)較少,結(jié)論仍需擴(kuò)大研究樣本量進(jìn)行進(jìn)一步研究論證。
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[專業(yè)責(zé)任編輯:李雪蘭]
Clinical characteristics and maternal and neonatal outcomes of subsequent pregnancy with preeclampsia history
WU Jin-er, MAO Wei-rong, ZHU Hong-tao,ZHENG Jin-li
(DepartmentofObstetricsandGynecology,People’sHospitalofYuyaoCity,ZhejiangYuyao315400,China)
Objective To explore the clinical characteristics and maternal and neonatal outcomes of subsequent pregnancy with early-onset or late-onset preeclampsia history. Methods Totally 98 pregnant women with preeclampsia history were selected during January 2011 to December 2016 in People’s Hospital of Yuyao City. The clinical characteristics and maternal and neonatal outcomes of subsequent pregnancy with preeclampsia history were analyzed. Results The incidences of headache, vertigo and dizziness in this pregnancy in patients with early-onset preeclampsia in previous pregnancy were significantly higher than those in patients with late-onset preeclampsia in previous pregnancy (χ2value was 10.309, 13.608 and 17.610, respectively, allP<0.05). The quantitative value of 24h urine protein of the patients with early-onset preeclampsia in previous pregnancy was significantly higher than that in patients with late-onset preeclampsia in previous pregnancy (χ2=5.232,P<0.05). The incidence of gestational hypertension in this pregnancy in patients with early-onset preeclampsia in previous pregnancy was higher than that in patients with late-onset preeclampsia in previous pregnancy, but there was no statistically significant difference (χ2=1.768,P>0.05). The incidence of pregnancy complications in this pregnancy in patients with early-onset preeclampsia in previous pregnancy was significantly higher than that in patients with late-onset preeclampsia in previous pregnancy (χ2=25.247,P<0.01). The main complications included liver function lesion (27.50%) and renal function impairment (20.00%). There was no significant difference in the incidence of placental abruption and postpartum hemorrhage between two groups (χ2value was 0.071 and 0.803, respectively, bothP>0.05). The incidence of neonatal asphyxia, low birth weight, neonatal hypoglycemia and neonatal death in patients with early-onset preeclampsia in previous pregnancy were significantly higher than that in patients with late-onset preeclampsia in previous pregnancy (χ2value was 5.009, 10.648, 7.701 and 5.009, respectively, allP<0.05). But there was no statistically significant difference in the incidence of fetal growth restriction, transient tachypnea of the newborn and neonatal respiratory distress syndrome between two groups (χ2value was 0.803, 0.001 and 1.465, respectively, allP>0.05). Conclusion High blood pressure and proteinuria are the main clinical characteristics of the subsequent pregnancy in pregnant women with preeclampsia history. The shorter the gestational age of subsequent pregnancy in pregnant women with preeclampsia history, the higher the incidence of complications, and the worse the perinatal fetus outcomes.
preeclampsia; subsequent pregnancy; maternal and neonatal outcomes; quantitative value of 24h urine protein
2017-02-12
吳金兒(1980-),女,主治醫(yī)師,主要從事產(chǎn)科臨床工作。
鄭錦麗,副主任醫(yī)師。
10.3969/j.issn.1673-5293.2017.04.017
R713
A
1673-5293(2017)04-0414-02