-
自然分娩产后出血(postpartum hemorrhage,PPH)是指产妇在分娩后24 h内阴道失血量≥500 mL,属产科危重并发症[1]。随我国生育政策放宽,高龄追生现象及妊娠期各种并发症明显增多,使得PPH高危因素较以往有明显变化,导致以往一些PPH预测评分表内容不能适应目前生育人群结构的变化。PPH的突发性不仅会引起感染、贫血,失血过多还可引起弥散性血管内凝血、失血性休克等并发症,甚至增加产妇死亡风险[2]。然而,目前关于PPH危险因素的研究都是基于一些分娩过程中的指标进行[3-4],缺乏结合孕妇临产前指标。本研究结合孕妇临产前指标并整合近年孕妇分娩后发生PPH的各危险因素,构建有效的预测模型,为临床早期评估可能发生PPH的高风险孕妇提供参考。现作报道。
-
PPH组与非PPH组的年龄、多胎、妊高症、临产前D-二聚体、临产前Fib、第三产程时间、胎盘粘连、胎儿体质量指标的比较差异均有统计学意义(P < 0.01)(见表 1)。
分组 n 年龄/岁 孕次 产次 孕周/周 多胎 剖宫产史 妊高症 妊娠期糖尿病 临产前Hb/(g/L) 临产前D-二聚体/(mg/L) PPH组 229 29.38±3.50 1.39±0.38 1.12±0.31 39.42±1.76 13 39 34 16 124.75±16.43 0.45±0.12 非PPH组 2 838 27.22±3.11 1.36±0.41 1.10±0.28 39.34±1.83 67 396 158 131 126.39±17.34 0.43±0.09 t — 10.01 1.07 1.03 0.64 6.53* 1.65* 31.10* 2.61* 1.38 3.14 P — < 0.01 >0.05 >0.05 >0.05 < 0.01 >0.05 < 0.01 >0.05 >0.05 < 0.01 分组 n 临产前PT/s 临产前APTT/s 临产前TT/s 临产前Fib/(g/L) 第一产程/min 第二产程/min 第三产程/min 胎盘粘连 胎儿体质量/kg PPH组 229 10.89±0.92 31.78±2.95 12.71±1.27 4.03±0.58 6 003.57±190.54 80.21±25.16 10.22±3.32 27 3.33±0.73 非PPH组 2 838 11.01±1.05 32.07±2.86 12.86±1.75 4.59±0.62 5 989.75±192.95 77.98±24.37 7.83±2.15 156 3.15±0.58 t — 1.68 1.47 1.27 13.21 1.04 1.33 15.41 14.96* 4.42 P — >0.05 >0.05 >0.05 < 0.01 >0.05 >0.05 < 0.01 < 0.01 < 0.01 *示χ2值 表 1 2组的临床资料比较(x±s)
-
以孕妇自然分娩后是否(0=否;1=是)发生PPH为因变量,将表 1分析有统计学意义(P < 0.05)的因素作为自变量,对分类资料进行赋值[多胎(0=否;1=是)、妊高症(0=无;1=有)、胎盘粘连(0=无;1=有)],计量资料(年龄、临产前D-二聚体、临产前Fib、第三产程时间、胎儿体质量)以实际值录入。多因素logistic回归分析显示,年龄高、多胎、有妊高症、临产前D-二聚体升高、第三产程时间长、有胎盘粘连、胎儿体质量大均是孕妇自然分娩发生PPH的危险因素(P < 0.01),临产前Fib升高为孕妇自然分娩发生PPH的保护因素(P < 0.01)(见表 2)。
变量 B SE Waldχ2 P OR(95%CI) 年龄 0.39 0.032 153.04 < 0.01 1.481(1.391~1.576) 多胎 1.76 0.414 18.12 < 0.01 5.825(2.588~13.114) 妊高症 1.07 0.251 18.26 < 0.01 2.927(1.788~4.790) 临产前D-二聚体 2.59 0.873 8.80 < 0.01 13.305(2.405~73.599) 临产前Fib -2.62 0.180 213.22 < 0.01 0.073(0.051~0.103) 第三产程时间 0.05 0.014 13.07 < 0.01 1.054(1.04~1.084) 胎盘粘连 0.77 0.271 8.06 < 0.01 2.155(1.268~3.662) 胎儿体质量 0.72 0.133 29.15 < 0.01 2.048(1.579~2.657) 表 2 多因素logistic分析结果
-
列线图模型依据表 2所筛选出的8个影响因素进行构建(见图 1)。内部验证发现,列线图模型预测孕妇自然分娩PPH的AUC为0.824,灵敏度为0.819,特异度为0.715,提示列线图模型的区分能力较好(见图 2)。拟合优度(Hosmer-Lemeshow)偏差性检验模型预测值与实际值之间的偏差性不具备统计学意义(χ2=5.07,P < 0.05),表明预测模型不存在过拟合现象。经Bootstrap法自1 000次抽样对列线图模型的验证发现校准曲线的MAE为0.004,说明校正曲线与理想曲线贴合良好,模型预测值与实际发生值具有良好的一致性(见图 3)。
孕妇自然分娩产后出血的风险列线图预测模型构建与验证
Construction and validation of a risk nomogram prediction model for postpartum hemorrhage in pregnant women during spontaneous delivery
-
摘要:
目的探讨孕妇自然分娩产后出血(PPH)的危险因素,并建立风险列线图预测模型。 方法收集在产科进行产检并最终阴道分娩的3 067例产妇的临床信息。以产妇分娩后24 h内是否发生PPH分为PPH组(n=229)和非PPH组(n=2 838)。对2组的临床信息进行比较,使用logistic回归分析筛选孕妇自然分娩PPH的危险因素并构建预测模型。用ROC曲线下面积(AUC)、灵敏度、特异度评价模型效能,用Bootstrap自抽样法对模型进行内部验证。 结果PPH组与非PPH组的年龄、多胎、妊娠期高血压疾病、临产前D-二聚体、临产前Fib、第三产程时间、胎盘粘连、胎儿体质量指标的比较差异均有统计学意义(P < 0.01)。多因素logistic回归分析显示,年龄高、多胎、有妊娠期高血压疾病、临产前D-二聚体升高、第三产程时间长、有胎盘粘连、胎儿体质量大均是孕妇自然分娩发生PPH的危险因素(P < 0.01),临产前Fib升高为孕妇自然分娩发生PPH的保护因素(P < 0.01)。利用上述8个指标构建列线图预测模型并验证,发现模型预测孕妇自然分娩PPH的AUC为0.824、灵敏度为0.819、特异度为0.715。经Bootstrap法自1 000次抽样对模型验证发现校准曲线的MAE为0.004,表明模型在预测孕妇自然分娩PPH发生风险与实际发生具有良好的一致性。 结论临床整合孕妇的年龄、胎数、妊娠期高血压疾病、临产前D-二聚体、临产前Fib、第三产程时间、胎盘粘连、胎儿体质量指标构建预测模型,可提高评估孕妇自然分娩PPH的准确性。 Abstract:ObjectiveTo explore the risk factors for postpartum hemorrhage (PPH) in pregnant women during spontaneous delivery, and to establish a risk nomogram prediction model. MethodsThe clinical information of 3 067 parturients who underwent an obstetric examination and eventually delivered vaginally in the department of obstetrics was collected.According to the occurence of PPH within 24 hours after delivery, the parturients were divided into PPH group (n=229) and non-PPH group (n=2 838).The clinical information of the two groups was compared, and logistic regression analysis was used to screen the risk factors for PPH in spontaneous delivery and a prediction model was established.The area under the ROC curve, sensitivity and specificity were used to evaluate the performance of the model, and Bootstrap self-sampling method was used to verify the model internally. ResultsThere were significant differences between PPH group and non-PPH group in age, multiple pregnancy, pregnancy induced hypertension, prenatal D-dimer, prenatal Fib, the third stage of labor, placental adhesion, and fetal body mass (P < 0.01).Multivariate logistic regression analysis showed that high age, multiple births, pregnancy induced hypertension, pre-partum D-dimer elevation, long third stage of labor, placenta adhesion, and large fetal body mass were all risk factors for PPH in spontaneous delivery of pregnant women (P < 0.01), and pre-partum Fib elevation was a protective factor for PPH in spontaneousl delivery of pregnant women (P < 0.01).By using the above 8 indicators to construct and verify the nomogram prediction model, it was found that the AUC of the model was 0.824, the sensitivity was 0.819, and the specificity was 0.715 for predicting PPH in spontaneous delivery of pregnant women.After 1 000 samples of Bootstrap method, the MAE of the calibration curve was 0.004, which showed that the model had a good consistency in predicting the risk of spontaneous delivery PPH in pregnant women and the actual occurrence. ConclusionsThe clinical integration of pregnant women's age, number of fetuses, pregnancy-induced hypertension, pre-partum D-dimer, pre-partum Fib, the third stage of labor, placental adhesions, and fetal weight indicators are used to construct a prediction model that can improve the accuracy of evaluating pregnant women's spontaneous delivery PPH. -
Key words:
- spontaneous childbirth /
- postpartum hemorrhage /
- risk factors /
- nomogram
-
表 1 2组的临床资料比较(x±s)
分组 n 年龄/岁 孕次 产次 孕周/周 多胎 剖宫产史 妊高症 妊娠期糖尿病 临产前Hb/(g/L) 临产前D-二聚体/(mg/L) PPH组 229 29.38±3.50 1.39±0.38 1.12±0.31 39.42±1.76 13 39 34 16 124.75±16.43 0.45±0.12 非PPH组 2 838 27.22±3.11 1.36±0.41 1.10±0.28 39.34±1.83 67 396 158 131 126.39±17.34 0.43±0.09 t — 10.01 1.07 1.03 0.64 6.53* 1.65* 31.10* 2.61* 1.38 3.14 P — < 0.01 >0.05 >0.05 >0.05 < 0.01 >0.05 < 0.01 >0.05 >0.05 < 0.01 分组 n 临产前PT/s 临产前APTT/s 临产前TT/s 临产前Fib/(g/L) 第一产程/min 第二产程/min 第三产程/min 胎盘粘连 胎儿体质量/kg PPH组 229 10.89±0.92 31.78±2.95 12.71±1.27 4.03±0.58 6 003.57±190.54 80.21±25.16 10.22±3.32 27 3.33±0.73 非PPH组 2 838 11.01±1.05 32.07±2.86 12.86±1.75 4.59±0.62 5 989.75±192.95 77.98±24.37 7.83±2.15 156 3.15±0.58 t — 1.68 1.47 1.27 13.21 1.04 1.33 15.41 14.96* 4.42 P — >0.05 >0.05 >0.05 < 0.01 >0.05 >0.05 < 0.01 < 0.01 < 0.01 *示χ2值 表 2 多因素logistic分析结果
变量 B SE Waldχ2 P OR(95%CI) 年龄 0.39 0.032 153.04 < 0.01 1.481(1.391~1.576) 多胎 1.76 0.414 18.12 < 0.01 5.825(2.588~13.114) 妊高症 1.07 0.251 18.26 < 0.01 2.927(1.788~4.790) 临产前D-二聚体 2.59 0.873 8.80 < 0.01 13.305(2.405~73.599) 临产前Fib -2.62 0.180 213.22 < 0.01 0.073(0.051~0.103) 第三产程时间 0.05 0.014 13.07 < 0.01 1.054(1.04~1.084) 胎盘粘连 0.77 0.271 8.06 < 0.01 2.155(1.268~3.662) 胎儿体质量 0.72 0.133 29.15 < 0.01 2.048(1.579~2.657) -
[1] 刘兴会, 陈锰. 基于大数据的产后出血临床处理[J]. 中国实用妇科与产科杂志, 2018, 34(1): 33. [2] Prevention and management of postpartum haemorrhage: Green-top Guideline No.52[J]. BJOG, 2017, 124(5): e106. [3] 赵悦淑, 张龙梅, 王蕊, 等. 2005-2014年河南省孕产妇产科出血死亡原因及相关因素分析[J]. 中国妇幼保健, 2017, 32(7): 1357. [4] LEE HJ, LEE YJ, AHN EH, et al. Risk factors for massive postpartum bleeding in pregnancies in which incomplete placenta previa are located on the posterior uterine wall[J]. Obstet Gynecol Sci, 2017, 60(6): 520. doi: 10.5468/ogs.2017.60.6.520 [5] 谢幸, 苟文丽. 妇产科学[M]. 8版. 北京: 人民卫生出版社, 2013: 211. [6] EVENSEN A, ANDERSON JM, FONTAINE P. Postpartum hemorrhage: prevention and treatment[J]. Am Fam Physician, 2017, 95(7): 442. [7] VALDES V, ADONGO PB, NWAMEME AU, et al. Risk factors for self-reported postpartum hemorrhage in Ga East, Ghana[J]. Int J Gynaecol Obstet, 2018, 142(2): 201. doi: 10.1002/ijgo.12523 [8] 金洪运, 刘贵. 高龄孕妇剖宫产产后出血的影响因素分析[J]. 中国煤炭工业医学杂志, 2020, 23(3): 252. [9] BERNSTEIN PS, MARTIN JN, BARTON JR, et al. National partnership for maternal safety: consensus bundle on severe hypertension during pregnancy and the postpartum period[J]. Obstet Gynecol, 2017, 130(2): 347. doi: 10.1097/AOG.0000000000002115 [10] 张颖, 郝培培, 何佩. 高龄产妇产前血清FIB、D-二聚体、血红蛋白及血小板与产后出血的关系[J]. 中国妇幼保健, 2021, 36(5): 1021. [11] 李昀晖, 徐畅, 张文, 等. 妊娠晚期孕妇D-二聚体水平异常升高的因素分析[J]. 国际检验医学杂志, 2021, 42(1): 21. [12] 蒋一逍, 李力, 刘宿, 等. 纤维蛋白原在产后出血中的临床应用研究进展[J]. 解放军医学杂志, 2021, 46(5): 498. [13] KAVLE JA, STOLTZFUS RJ, WITTER F, et al. Association between anaemia during pregnancy and blood loss at and after delivery among women with vaginal births in Pemba Island, Zanzibar, Tanzania[J]. J Health Popul Nutr, 2008, 26(2): 232. [14] 韩宁玉, 王欣. 产程时限与产后出血相关性的临床研究[J]. 中华妇产科杂志, 2020, 55(10): 673. [15] MOLEIRO ML, GURDES-MARTINS L, MENDES A, et al. Modified pereira suture as an effective option to treat postpartum hemorrhage due to uterine atony[J]. Rev Bras Ginecol Obstet, 2018, 40(2): 92. [16] 倪胜莲, 曹琳琳, 郭志超, 等. 低风险初产妇产后出血风险预测[J]. 中国生育健康杂志, 2021, 32(2): 117. [17] 沈婕, 任青, 林元, 等. 二胎孕妇产后出血的危险因素及预测模型的建立[J]. 中国妇产科临床杂志, 2019, 20(5): 458. [18] 杨炜博, 唐仕芳, 马娟, 等. 美国妇产科医师协会"巨大儿指南(2020)"解读[J]. 中国计划生育和妇产科, 2020, 12(8): 15.