早产高危因素及早产儿预后的临床分析
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摘要
【目的】:1) 探究早产的高危因素及影响早产儿预后的因素;2)建立早产高危因素评分表,为临床进行早产预测或早产高危人群的筛查提供依据。
【方法】:
1.第一部分回顾性分析:查阅暨南大学第一附属医院早产病历723份;按病因分为自然早产组(541例,A组)和医源性早产组(182例,B组)。对自然早产组进行1:1配对,查取在分娩年段上有可比性的足月分娩病历(541例,C组)为对照组,进行logistic回归分析,筛选早产的高危因素。并分析早产的妊娠结局和影响早产儿预后的相关因素。
2.第二部分前瞻性研究:1) 选取单胎妊娠孕妇400例,使用多胺法检测BV;跟踪妊娠结局。2) 另外选取单胎妊娠孕妇332例,于孕20～34周之间经会阴测量宫颈管长度,跟踪妊娠结局。数据分析采用x~2检验或Fisher's确切检验。
3.第三部分早产预测:建立早产高危因素评分表,对2004年6月～2005年3月的133例孕妇进行早产预测的前瞻性研究。
【结果】:
第一部分回顾性分析:
1.对自然早产的相关因素分析显示:胎膜早破、不明原因的早产和臀位分别占38.4%、30.1%、9.4%,居前三位;医源性早产的病因之中,妊娠高血压疾病、产前出血性疾病和胎儿宫内窘迫分别占38.4%、25.8%、22.8%,居前三位。
2.前次早产史、胎膜早破、妊娠期中重度贫血、多双胎妊娠、宫颈机能不全、孕妇外周血淋巴细胞记数升高是早产的高危因素;O型血、系统产检是早产的保护因素。
3.在30周前,胎龄与早产儿死亡率呈负相关;胎龄在30～32~(+6)周,死亡率较30周前明显降低,但在30～32~(+6)内死亡率无明显降低;妊娠33周后死亡率降低到9%以下,33周后各胎龄组死亡率之间的差异无统计学意义;与30-32~(+6)周相比有显著差异(P=0.035),
4.在30周前,早产儿窒息率随胎龄增加而降低;30～33~(+6)周窒息率降低为33.3%～39.6%,与30周前相比差异有统计学意义;34周后窒息率降至21.1%以下,与30～32~(+6)周相比差异有统计学意义,34周以后各胎龄组窒息率的差异无统计学意义。
Objective:1. To identify the risk factors of premature delivery. 2. To establish a scoring system for predicting premature delivery, in order to predict premature delivery or to screening high-risk group of pregnant women.Methods:part 1: A retrospective study was designed and a total of 723 pregnant women with premature delivery were included in our study, these women were divided into group A and B. The former including 541 cases was spontaneous premature delivery, while the later including 182 cases was iatrogenic premature delivery. Another 541 cases who delivered at term served as a control group ( group C). Part 2: 1 To study the relationship between bacterial vaginosis (BV) and premature delivery, a prospective study was conducted in 400 pregnant women, the BV was checked during the second trimester and their pregnant outcome was followed. 2 Another prospective study was designed for researching the relationship between cervical length and premature delivery, 332 pregnant women were included in this study, using tranperineum ultrasonograph measured the cervical length at 20~34 weeks gestational age , and their pregnant outcome were followed. Part 3: A scoring system of risk factor was established in order to predict premature delivery. Result:Parti:1 Among the 541 cases of spontaneous premature deliveries, 38.4% were premature rupture of membranes (PROM), 30.1% were idiopathic premature delivered and 9.4% were breech presentations; among iatrogenic premature deliveries, 30.75% were hypertensive disorder complicating pregnancy, 25.8% were placenta praevia or placenta abruption, 22.8% were induced labor because of fetal distress.2 PROM, previous historical premature delivery, severe anaemia, twin or multiple pregnancy, cervical incompetence, maternal lymphocyte member elevated abnormally were risk factors for spontaneous premature delivery, systemic antenatal care and blood group " O " were protective factors.3 Mortality rate and incidence of RDS of premature infant were inverse correlated with gestational age. Both of them were higher in gestational age <33 weeks than that ≥ 33 weeks, statistically there was a significant difference between two groups (P<0.05)4 There was a significant difference in the incidence of asphyxia of premature infant between gestational age< 34 weeks and gestational age≥ 34 weeks (P=0.044).5 Incidence of asphyxia and mortality rate in premature infant was significantly different between infant with birth weight <2Kg group and weight ≥ 2Kg group.
6 RDS, pulmonary hemorrhage and septicemia were mainly causes of death for premature infant.7 Antepartum use of dexamethasone (DXM) decreased the incidence of RDS and mortality rate of premature infant before 33 weeks gestational age, there was a significantly different between treatment group and un-treatment group in the incidence of RDS and mortality rate, but no significant difference in DXM effect between two groups after 33 weeks gestational age.Part 2:1 BV affected 20% of pregnancies, there was no significant difference in the incidence of premature delivery between BV positive group and negative group (p= 1 >0.05). BV was not risk a factor for premature delivery.2 The incidence of premature delivery increased when cervical length was less than 3.5 cm (checked during 20~34 weeks gestational age)(p=0.01).Part 3:In our scoring system, when predictive value was 1, then the sensitivity was 92.86%, specificity was 83.52%, and missed diagnosis rate was 7.14%. when predictive value was 3, then the sensitivity was 52.38%, specificity was 96.70%, and misdiagnosis rate was 3.3%. Conclusion:1 PROM, previous historical premature delivery, severe anemia, twin or multiple pregnancy, cervical incompetence, maternal lymphocyte member elevates abnormally are risk factors for premature delivery, systemic antenatal care and blood group "O" were are protective factors.2 Less than 33 weeks gestational age, incidence of RDS and mortality rate of premature infant are higher than that of infant older than 33 weeks; less then 34 weeks gestational age, incidence of asphyxia in premature infant is higher than that of older than 34 weeks.3 Incidence of asphyxia and mortality rate of premature infant are higher in birth weight less than 2 Kg group than that of more than 2 Kg.4 There is non-significant difference in incidence of premature delivery between BV positive group and negative group, BV is not a risk factor for premature delivery.5 The incidence of premature delivery increases when pregnant women's cervical length is less than 3.5 cm (checked during 20-34 weeks gestational age).6 The scoring system for high-risk factor can be used for screening the high-risk group of premature delivery and for decided the interfere objects.
【方法】:
1.第一部分回顾性分析:查阅暨南大学第一附属医院早产病历723份;按病因分为自然早产组(541例,A组)和医源性早产组(182例,B组)。对自然早产组进行1:1配对,查取在分娩年段上有可比性的足月分娩病历(541例,C组)为对照组,进行logistic回归分析,筛选早产的高危因素。并分析早产的妊娠结局和影响早产儿预后的相关因素。
2.第二部分前瞻性研究:1) 选取单胎妊娠孕妇400例,使用多胺法检测BV;跟踪妊娠结局。2) 另外选取单胎妊娠孕妇332例,于孕20～34周之间经会阴测量宫颈管长度,跟踪妊娠结局。数据分析采用x~2检验或Fisher's确切检验。
3.第三部分早产预测:建立早产高危因素评分表,对2004年6月～2005年3月的133例孕妇进行早产预测的前瞻性研究。
【结果】:
第一部分回顾性分析:
1.对自然早产的相关因素分析显示:胎膜早破、不明原因的早产和臀位分别占38.4%、30.1%、9.4%,居前三位;医源性早产的病因之中,妊娠高血压疾病、产前出血性疾病和胎儿宫内窘迫分别占38.4%、25.8%、22.8%,居前三位。
2.前次早产史、胎膜早破、妊娠期中重度贫血、多双胎妊娠、宫颈机能不全、孕妇外周血淋巴细胞记数升高是早产的高危因素;O型血、系统产检是早产的保护因素。
3.在30周前,胎龄与早产儿死亡率呈负相关;胎龄在30～32~(+6)周,死亡率较30周前明显降低,但在30～32~(+6)内死亡率无明显降低;妊娠33周后死亡率降低到9%以下,33周后各胎龄组死亡率之间的差异无统计学意义;与30-32~(+6)周相比有显著差异(P=0.035),
4.在30周前,早产儿窒息率随胎龄增加而降低;30～33~(+6)周窒息率降低为33.3%～39.6%,与30周前相比差异有统计学意义;34周后窒息率降至21.1%以下,与30～32~(+6)周相比差异有统计学意义,34周以后各胎龄组窒息率的差异无统计学意义。
Objective:1. To identify the risk factors of premature delivery. 2. To establish a scoring system for predicting premature delivery, in order to predict premature delivery or to screening high-risk group of pregnant women.Methods:part 1: A retrospective study was designed and a total of 723 pregnant women with premature delivery were included in our study, these women were divided into group A and B. The former including 541 cases was spontaneous premature delivery, while the later including 182 cases was iatrogenic premature delivery. Another 541 cases who delivered at term served as a control group ( group C). Part 2: 1 To study the relationship between bacterial vaginosis (BV) and premature delivery, a prospective study was conducted in 400 pregnant women, the BV was checked during the second trimester and their pregnant outcome was followed. 2 Another prospective study was designed for researching the relationship between cervical length and premature delivery, 332 pregnant women were included in this study, using tranperineum ultrasonograph measured the cervical length at 20~34 weeks gestational age , and their pregnant outcome were followed. Part 3: A scoring system of risk factor was established in order to predict premature delivery. Result:Parti:1 Among the 541 cases of spontaneous premature deliveries, 38.4% were premature rupture of membranes (PROM), 30.1% were idiopathic premature delivered and 9.4% were breech presentations; among iatrogenic premature deliveries, 30.75% were hypertensive disorder complicating pregnancy, 25.8% were placenta praevia or placenta abruption, 22.8% were induced labor because of fetal distress.2 PROM, previous historical premature delivery, severe anaemia, twin or multiple pregnancy, cervical incompetence, maternal lymphocyte member elevated abnormally were risk factors for spontaneous premature delivery, systemic antenatal care and blood group " O " were protective factors.3 Mortality rate and incidence of RDS of premature infant were inverse correlated with gestational age. Both of them were higher in gestational age <33 weeks than that ≥ 33 weeks, statistically there was a significant difference between two groups (P<0.05)4 There was a significant difference in the incidence of asphyxia of premature infant between gestational age< 34 weeks and gestational age≥ 34 weeks (P=0.044).5 Incidence of asphyxia and mortality rate in premature infant was significantly different between infant with birth weight <2Kg group and weight ≥ 2Kg group.
6 RDS, pulmonary hemorrhage and septicemia were mainly causes of death for premature infant.7 Antepartum use of dexamethasone (DXM) decreased the incidence of RDS and mortality rate of premature infant before 33 weeks gestational age, there was a significantly different between treatment group and un-treatment group in the incidence of RDS and mortality rate, but no significant difference in DXM effect between two groups after 33 weeks gestational age.Part 2:1 BV affected 20% of pregnancies, there was no significant difference in the incidence of premature delivery between BV positive group and negative group (p= 1 >0.05). BV was not risk a factor for premature delivery.2 The incidence of premature delivery increased when cervical length was less than 3.5 cm (checked during 20~34 weeks gestational age)(p=0.01).Part 3:In our scoring system, when predictive value was 1, then the sensitivity was 92.86%, specificity was 83.52%, and missed diagnosis rate was 7.14%. when predictive value was 3, then the sensitivity was 52.38%, specificity was 96.70%, and misdiagnosis rate was 3.3%. Conclusion:1 PROM, previous historical premature delivery, severe anemia, twin or multiple pregnancy, cervical incompetence, maternal lymphocyte member elevates abnormally are risk factors for premature delivery, systemic antenatal care and blood group "O" were are protective factors.2 Less than 33 weeks gestational age, incidence of RDS and mortality rate of premature infant are higher than that of infant older than 33 weeks; less then 34 weeks gestational age, incidence of asphyxia in premature infant is higher than that of older than 34 weeks.3 Incidence of asphyxia and mortality rate of premature infant are higher in birth weight less than 2 Kg group than that of more than 2 Kg.4 There is non-significant difference in incidence of premature delivery between BV positive group and negative group, BV is not a risk factor for premature delivery.5 The incidence of premature delivery increases when pregnant women's cervical length is less than 3.5 cm (checked during 20-34 weeks gestational age).6 The scoring system for high-risk factor can be used for screening the high-risk group of premature delivery and for decided the interfere objects.
引文
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