【作者】 黄小玲；

【导师】 邱丽倩；

【作者基本信息】 浙江大学 ， 妇产科学， 2018， 硕士

【摘要】 目的:1.本研究基于浙江省孕产妇梅毒监测数据,探讨孕产妇不同时期确诊梅毒感染的影响因素,为优化干预策略提供科学依据。2.探讨妊娠梅毒治疗与不良围产结局的关系,为有效改善母婴预后提供科学依据。方法:1.回顾性分析2013～2016年浙江省孕产妇梅毒监测系统报告病例,针对孕产妇本次怀孕首次确诊梅毒感染时期进行分组,分为孕期确诊和产时确诊。采用非条件logistic回归分析孕产妇不同时期确诊梅毒的影响因素,p<0.05为差异有统计学意义。2.回顾性分析2013～2016年浙江省监测数据库上报的梅毒感染孕产妇资料,采用非条件logistic回归进行不良妊娠结局影响因素分析。结果1.孕产妇梅毒感染确诊时期影响因素分析(1)单因素分析显示,不同时期确诊梅毒感染孕产妇的民族、户籍、文化程度、职业、产次、子女数、梅毒分期、性伴侣感染和报告年份分布差异均有统计学意义(p均<0.01)。(2)多因素分析显示,与未生育相比,产1次(OR3.05,95%CI2.25-4.15)和产2次(OR 4.46,95%CI 2.94-6.79)产时确诊风险增加。多子女数(OR 1.79,95%CI 1.18-2.72)、一期梅毒(OR 1.54,95%CI 1.16-2.05)和性伴感染(OR 1.76,95%CI 1.60-1.94)也是产时确诊高危因素。2.妊娠梅毒治疗与围产结局的关系(1)一般情况妊娠梅毒感染者共9038人,年龄范围15～45岁,主要分布在20～34岁年龄段,共计7298例(80.75%);外地人口居多4901例占54.23%;低文化水平较多,小学以下1378例(15.25%),初、高中有6808例(75.33%),大学以上770例(8.52%);初婚者较多,共7560例(83.65%);无业者占绝大数,有3885例(42.99%)。(2)生育情况随着孕次增加,妊娠梅毒感染诊断率增加,孕次≥3者4688例(51.87%);初产妇共4034例(44.63%),产次为1者3788例(41.91%),现无子女4346例(48.09%),子女数为1共3703例(40.97%)。(3)梅毒感染相关情况梅毒分期中隐性梅毒为主共7472例(82.76%);感染途径以性传播为主,共4100例(45.36%),母婴传播34例(0.38%);而性伴侣检测状态中不详者5962例(65.97%),RPR 检测 5456 例,<1:4 共 3904 例(71.56%),1:4-1:8 共 1169例(21.42%),>1:8 共 383 例(7.02%);TRUST 检测 3582 例,<1:4 共 2600 例(72.59%),1:4-1:8 共 751 例(20.97%),>1:8 共 231 例(6.44%)。(4)梅毒治疗与不良妊娠结局①整体情况总不良妊娠结局2837例(31.39%),其中自然流产712例,死胎死产163例,早产853例,出生缺陷36例,低出生体重529例,其它不良妊娠结局544例。②疗程数治疗一个疗程比治疗两个以上疗程增加了不良妊娠结局风险,主要在低出生体重儿风险增加(OR 3.63,95%CI2,23-5.90)。③是否治疗的比较未治疗的比治疗的增加了不良妊娠结局风险(OR6.42,95%CI 3.32-12.44);其中自然流产(OR 1.25,95%CI 0.52-3.02)、出生缺陷(OR 2.140,95%CI 0.09-52.18)、低出生体重(OR33.50,95%CI 13.09-85.76)。④治疗时期孕晚期抗梅毒治疗对比孕早中期治疗增加了不良妊娠结局风险主要在早产和低出生体重儿风险增加,风险值分别为:(OR 1.52,95%CI 1.13-2.06)、(OR 1.45,95%CI 1.23-1.719)。(5)婴儿情况①一般情况婴儿共9169例,出生体重平均3216±70.51g,平均孕周均为38±0.45周。早产儿853例(9.44%),低出生体重儿527例(5.85%),先天梅毒儿89例(0.97%)。男婴儿 4741 例(51.71%),女婴 4282 例(46.70%)。②先天梅毒情况本文研究确诊先天梅毒患婴共89例,平均孕周35±0.45周,平均出生体重2362±61.25g,男婴 43 例(48.86%),女婴 45 例(51.14%),早产儿:43 例(48.86%),低出生体重儿:48例(54.55%),先天梅毒确诊通过血清学滴度检测79例,暗视野螺旋体检测0例,梅毒螺旋体IgM检测阳性9例。先天梅毒患婴接受RPR检测51例:<1:4共9例(17.6%),1:4-1:8共7例(13.73%),>1:8 共 35 例(68.63%);接受 TRUST 检测 28 例:<1:4 共 1 例(3.57%),1:4-1:8 共 7 例(25.00%),>1:8 共 20 例(71.43%);其母亲 RPR 检测 55 例:<1:4共 9 例(16.40%),1:4-1:8 共 19 例(34.50%),>1:8 共 27 例(49.10%),TRUST检测 33 例:<1:4 共 8 例(24.20%),1:4-1:8 共 11 例(33.3%),>1:8 共 14 例(42.40%);先天梅毒患婴及其母亲不同血清学检测不同滴度水平所占比例分布有统计学意义(p<0.05)。结论:1.不同时期确诊梅毒感染孕产妇人口学特征差异明显,产时确诊的孕产妇少数民族、省外户籍、低文化程度、无固定职业、多产次、多子女数、高期别梅毒、性伴侣感染比例更高。2.产时确诊的高危因素包括:多产次、多子女数、一期梅毒和性伴侣感染。3.梅毒感染孕产妇高危人群有:流动人口、低文化程度、无固定职业、多次妊娠史患者。4.妊娠梅毒多为隐性梅毒,且以性传播感染为主,但是性伴侣检测比例较低。5.未治疗、未充分治疗和孕晚期治疗的妊娠梅毒,增加了流产、死胎死产、早产、低出生体重等不良妊娠结局发生风险。6.先天梅毒患儿具有较高比例的早产和低出生体重儿,血清滴度水平高者占较高比例,且母亲血滴度水平均较高。更多还原

【Abstract】 Objective:1.Based on the monitoring data of maternal syphilis in Zhejiang province,this study explored the factors influencing the diagnosis of maternal syphilis in different periods,providing scientific basis for optimizing intervention strategies.2.To explore the relationship between treatment of pregnancy syphilis and adverse perinatal outcomes,and provide a scientific basis for effectively improving maternal and infant outcomes.Methods:1.Data were based on maternal syphilis monitoring system of Zhejiang province.Pregnant women with syphilis during 2013-2016 were collected.We used the unconditional Logistic regression model to analyze the influencing factors of maternal syphilis diagnosed occasion,p<0.05 was considered statistically significant.2.Data were based on maternal syphilis monitoring system of Zhejiang province.Pregnant women with syphilis during 2013-2016 were collected.Unconditional logistic regression was used to analyze the influencing factors of adverse pregnancy outcomes.Results:1.Analysis of factors influencing the diagnosis of parturient syphilis infection(1)Univariate analysis showed significant differences in distribution of maternal ethnicity,status of residence,education,employment,parity,number of children,syphilis stage,infection status of sexual partner,and reporting year,between women diagnosed at delivery and during pregnancy(for all,p<0.01).(2)Multivariate analysis indicated that Han nationality,Women with higher parity(OR=3.05;95%CI:2.25～4.15 for parity=1 and OR=4.46;95%CI:2.94～6.7 for parity≥ 2),with more children(OR=1.79;95%CI:1.18～2.72),with primary syphilis(OR=1.54;95%CI:1.16～2.05)and partner infection(OR=1.76;95%CI:1.60～1.94)increased risk of diagnose at delivery.2.Relationship between treatment of pregnancy syphilis and perinatal outcome(1)general conditionTotal of 9038 pregnant women were collected.Age range from 15-45 years,mostly range from 20-34 years,about 7298 cases(80.75%),54.23%of them were non local resident,most of them reported had low level education,primary or low about 1378 cases,junior and senior high school about 6808 cases,college or above about 770 cases;83.65%of them were first marriage,42.99%of them were unemployed.(2)fertility circumstanceAs the gravidity increasing,the one who diagnosed syphilis infection was increasing,but as the parity increasing,littler pregnant women diagnosed syphilis infection,[4688 cases(51.87%)for gravidity≥3,4034 cases(44.63%)for parity=0,3788 cases(41.91%)for parity=0 44.63%].Currently,there were 4346 cases(48.09%)without children,and there were 3703 cases(40.97%)with one children.(3)Syphilis infectionThere were 7472 cases(82.76%)of latent syphilis;sexual transmission were 4100 cases(45.36%)and mother-to-child transmission were 34 cases(0.38%);in the study showed that 5962 women whose sexual partner knew nothing of whether infected syphilis,5456 cases tested RPR positive:3904 cases in<1:4;1169 cases in 1:4-1:8,383 cases in>1:8;3582 cases tested TRUST positive:2600 cases in<1:4;751 cases in 1:4-1:8,231 cases in>1:8.(4)Treatment of syphilis and adverse pregnancy outcomes① Overall situation In total,about 2837 women suffered serious adverse pregnancy outcomes,including 712 cases of natural abortion,163 cases of stillbirth or neonatal death,853 cases of premature birth,36 cases of birth defects,529 cases of low birth weight,and 544 cases of other adverse pregnancy outcomes.② Number of course The risk of adverse pregnancy outcome was increased by one course of treatment over two courses of treatment,mostly about low birth weight(OR 3.63,95%CI 2.23-5.90).③ Treatment versus untreatment The untreated increased risk of adverse pregnancy outcomes(OR 6.42,95%CI 3.32-12.44).Among them,low birth weight was infected mostly.(OR 33.50,95%CI 13.09-85.76).④Treatment period The risk of adverse pregnancy outcome was increased by anti-syphilis treatment in the third trimester,mostly premature birth(OR 1.52,95%CI 1.13-2.06),and low birth weight(OR 1.45,95%CI 1.23-1.719).(5)infant statement①general conditionA total of 9169 infants were born with an average birth weight of 3216±70.5 1g and an average gestational age of 38±0.45 weeks.There were 853 premature infants(9.44%),527 infants with low birth weight(5.85%)and 88 infants with congenital syphilis(0.96%).There were 4,741 male infants(51.71%)and 4,282 female infants(46.70%).②congenital syphilisIn this study,89 infants were diagnosed with congenital syphilis,with an average gestational age of 35±0.45 weeks,an average birth weight of 2362±61.25g,43 cases were male infants(48.86%),45 cases were female infants(51.14%),43 cases were premature infants(48.86%),48 cases were infants of low birth weight(54.55%),79 cases diagnosed with congenital syphilis were tested positive through serological titer,and 0 cases were detected by dark field spirulina,9 cases were detected positive by IgM of treponema pallidum.There were 51 cases of infants tested RPR positive:9 cases in<1:4;7 cases in 1:4-1:8,35 cases in>1:8;28 cases of infants tested TRUST positive:1 cases in<1:4;7 cases in 1:4-1:8,20 cases in>1:8;55 cases whose mother tested RPR positive:9 cases in<1:4;19 cases in 1:4-1:8,27 cases in>1:8;33 cases whose mother tested TRUST positive:8 cases in<1:4;11 cases in 1:4-1:8,14 cases in>1:8,the proportion of infants with congenital syphilis and their mothers at different titers was statistically significant(P<0.05).Conclusion:1.There were significant differences in the demographic characteristics of pregnant and parturient women diagnosed with syphilis at different stages.The proportion of pregnant and parturient women who were diagnosed with syphilis at childbirth was higher than that of ethnic minorities,non-registration,low educational level,no fixed occupation,multiple parity,multiple children,high stage syphilis and sexual partner infection.2.The risk factors identified at birth included:multiple parity,multiple children,primary syphilis and sexual partner infections.3.The pregnant and parturient women infected by syphilis have a high proportion of non-residents,low education level,no fixed occupation,and mostly with multiple pregnancies.4.Pregnancy syphilis is mostly latent syphilis and sexually transmitted,but the rate of sexual partner detection is low.5.Untreated and inadequate treatment pregnancy syphilis,increases the risk of miscarriage,stillbirth,premature birth,low birth weight and other adverse pregnancy outcomes,while late pregnancy treatment also increases the risk of adverse pregnancy outcomes.6.Children with congenital syphilis have high rates of premature delivery and low birth weight infants.The serum titer level was higher,and the mother’s blood titer level was higher.更多还原