【作者】 李雪松；

【导师】 赵艳晖；

【作者基本信息】 吉林大学 ， 临床医学硕士（专业学位）， 2023， 硕士

【摘要】 研究目的:收集早发型重度子痫前期患者的病例资料,并选用适当的方法对数据处理后,进行回顾性分析,通过联合应用脑胎盘比和无应激胎心监护结果,分析其在不同终止妊娠时机对母婴围生期结局的影响,探讨其最适宜的分娩时机,将结果应用到临床上,以改善母婴妊娠结局。研究内容:收集患者详细的病例资料。关于患者本人的资料包括姓名、住院号、年龄、孕次及产次、终止妊娠时孕周、肝肾功是否异常、是否胎盘早剥、是否发生HELLP综合征、是否出现子痫、是否出现胎盘粘连;新生儿的资料包括:出生后Apgar1min评分、新生儿是否死亡、是否出现胎儿窘迫、是否发生胎儿生长受限、是否出现新生儿窒息。研究方法:收集2017-01-01至2022-12-01间于吉林大学第二医院门诊或住院行母胎血流监测并住院分娩的早发型重度先兆子痫的孕妇资料,在排除其中双胎妊娠、胎死宫内、引产、合并严重其它产科并发症的孕妇后,共纳入研究156例。纳入的所有患者均经剖宫产终止妊娠,且终止妊娠之前均已使用激素进行促胎肺成熟治疗。根据患者母胎血流监测中脑胎盘比值及无应激胎心监护的结果进行分组,具体的分组为:脑胎盘比值与胎心监护均异常组(n=22),其中又分为终止妊娠时孕周<34周(n=10)、终止妊娠时孕周≥34周(n=12);脑胎盘比值正常,胎心监护结果异常组(n=33),其中终止妊娠时孕周<34周组(n=16)、终止妊娠时孕周≥34周组(n=17);脑胎盘比值异常,胎心监护正常组(n=38),其中终止妊娠时孕周小于32周组(n=9)、32-34周组(n=14)、大于等于34周组(n=15);脑胎盘比值及胎心监护均正常组(n=61),其中终止妊娠时孕周小于32周(n=15)、32周-34周组(n=21)、大于等于34周组(n=25)。结果:1.脑胎盘比及无应激胎心监护均正常组妊娠结局比较:小于32周组(n=15)、32周-34周组(n=21)、大于34周组(n=25)三组患者的年龄、孕次、产次,以P小于0.05为统计学差异,计算结果表示三组数据组间均无统计学差异;比较三组患者的胎盘早剥率、子痫发生率、肝肾功异常发生率、胎盘粘连发生率、三组新生儿死亡率、HELLP综合征发生率,结果提示均无统计学差异(P>0.05)。三组新生儿出生后1min Apgar评分、胎儿窘迫发生率、胎儿生长受限发生率及新生儿窒息发生率均存在明显的统计学差异(P<0.01)。对具有差异的组间校正后再进行两两检验,出生后1min Apgar评分三组间均存在差异(P<0.0167);小于32周组及32周-34周组,其胎儿窘迫发生率、胎儿生长受限发生率及新生儿窒息发生率均高于大于34周组,存在统计学差异(P’<0.0167);小于32周组胎儿窘迫发生率、胎儿生长受限发生率与32周-34周组相比,差异不具有统计学意义(P’>0.0167);小于32周组新生儿窒息发生率高于32周-34周组,差异具有统计学意义(P<0.0167)。出生后1min Apgar评分组间校正比较:小于32周组和32周-34周组P=0.000;32周-34周组和大于34周组比较:P=0.000;小于32周组和大于34周组比较:P=0.000;胎儿窘迫组间校正比较:小于32周组和32周-34周组P=0.500;32周-34周组和大于34周组比较:P=0.013;小于32周组和大于34周组比较:P=0.001;胎儿生长受限组间校正比较:小于32周组和32周-34周组P=0.090;32周-34周组和大于34周组比较:P=0.016;小于32周组和大于34周组比较:P=0.000新生儿窒息组间校正比较:小于32周组和32周-34周组P=0.016;32周-34周组和大于34周组比较:P=0.016;小于32周组和大于34周组比较:P=0.0002.脑胎盘比值异常和无应激胎心监护正常组妊娠结局比较:小于32周组(n=9)、32周-34周组(n=14)、大于34周组(n=15)三组患者的年龄、孕次、产次,以P小于0.05为统计学差异,计算结果表示三组数据组间均无统计学差异;三组患者的胎盘早剥率、HELLP综合征发生率、子痫发生率、肝肾功异常发生率、胎盘粘连发生率,结果提示均无统计学差异(P>0.05);三组新生儿死亡率及胎儿窘迫发生率无统计学差异(P>0.05),三组新生儿出生后1min Apgar评分、胎儿生长受限发生率及新生儿窒息发生率均存在明显统计学差异(P<0.01)。对具有差异的组间校正后再进行两两检验,小于32周组胎儿生长受限发生率及新生儿窒息发生率高于32周-34周组及大于34周组,存在统计学差异(P’<0.0167),小于32周组1min Apgar评分明显低于32周-34周组及大于34周组;大于34周组出生后1min Apgar评分、胎儿窘迫发生率、胎儿生长受限发生率、新生儿窒息发生率与32周-34周组相比,差异不具有统计学意义(P>0.0167)。出生1min Apgar评分两组间校正比较:小于32周组和32周-34周组P=0.000;32周-34周组和大于34周组比较:P=0.697;小于32周组和大于34周组比较:P=0.000;胎儿生长受限组间校正比较:小于32周组和32周-34周组P=0.013;32周-34周组和大于34周组比较:P=0.651;小于32周组和大于34周组比较:P=0.003;新生儿窒息组间校正比较:小于32周组和32周-34周组P=0.001;32周-34周组和大于34周组比较:P=0.598;小于32周组和大于34周组比较:P=0.0003.脑胎盘比值正常,无应激胎心监护异常组妊娠结局比较:小于等于34周组(n=16)、大于34周组(n=17)两组患者的年龄、孕次、产次,以P小于0.05为统计学差异,计算结果表示两组数据组间均无统计学差异;两组患者的胎盘早剥率、HELLP综合征发生率、子痫发生率、肝肾功异常发生率、胎盘粘连发生率,结果提示均无统计学差异(P>0.05).;两组患者的新生儿出生后1min Apgar评分、新生儿死亡率、胎儿窘迫率、胎儿生长受限率、胎儿窒息率,结果提示均无统计学差异(P>0.05)4.脑胎盘比值和无应激胎心监护均异常组:小于等于34周组(n=10)、大于34周组(n=12)。两组患者的年龄、孕次、产次,以P小于0.05为统计学差异,计算结果表示两组数据组间均无统计学差异,两组患者的胎盘早剥率、HELLP综合征发生率、子痫发生率、肝肾功异常发生率、胎盘粘连发生率,结果提示均无统计学差异(P>0.05);两组患者的新生儿出生后1min Apgar评分、新生儿死亡率、胎儿窘迫率、胎儿生长受限率、胎儿窒息率,结果提示均无统计学差异(P>0.05)。结论:1.临床上选择早发型重度子痫前期终止妊娠的时机,应对胎儿脑胎盘比和无应激胎心监护的结果产生足够的重视,根据具体的情况选择合适的时间终止妊娠,充分做好术前的准备,以减少不良母婴围产结局。2.对于脑胎盘比和无应激胎心监护均正常的患者,在妊娠34周以后终止妊娠,围生期结局会较好;3.早发型重度先兆子痫患者中脑胎盘比异常而胎心监测正常的,应在妊娠32周之后终止妊娠,且继续妊娠无法使母婴妊娠结局得到改善。在本研究中,因入组病例数量较少(n=38),可能缺乏对样本总体的代表性,需行大样本分析进一步验证。4.本样本中脑胎盘比正常而无应激胎心监护异常的早发型重度先兆子痫患者,在充分给予胎心纠正措施后,胎心监测结果仍未能得到明显改善的,在给予促胎肺成熟治疗后应该尽快终止妊娠。5.脑胎盘比和无应激胎心监护均异常的早发型重度先兆子痫患者,给予侧卧位、吸氧等措施后胎心监测结果仍提示异常的,应立即终止妊娠。更多还原

【Abstract】 Objective:The case data of patients with early-onset severe preeclampsia were collected,and the appropriate methods were selected for data processing,and retrospectively analyzed,and the effects of cerebral placental ratio and non-stressed fetal heart rate monitoring results on maternal and infant perinatal outcomes at different termination times were analyzed,and the most suitable timing of delivery was discussed,and the results were applied clinically to improve maternal and infant pregnancy outcomes.Research content:Collect detailed case data of patients.The patient’s personal information includes name,hospital number,age,pregnancy and birth times,gestational weeks at the time of termination of pregnancy,whether liver and kidney function are abnormal,whether placental abruption occurs,whether HELLP syndrome occurs,whether eclampsia occurs,and whether placental adhesion is found;The data of newborns include: Apgar1 min score after birth,whether the newborn died,whether there was fetal distress,whether there was fetal growth restriction,and whether there was neonatal asphyxia.Research methods:The data of patients who suffered from early-onset severe pre-eclampsia who were delivered in the outpatient department of the Second Hospital of Jilin University from January 1,2017 to December 1,2022 were collected.There were 156 samples taken into the study after excluding the pregnant women with twin pregnancy,intrauterine fetal death,induced labor,and severe other obstetric complications.All the patients included in the study were terminated by cesarean section,and had been treated with hormone to promote fetal lung maturation before termination of pregnancy.The patients were divided into two groups according to the results of brain-planta ratio and non-stress fetal heart rate monitoring in the monitoring of maternal and fetal blood flow.The specific groups were: abnormal brain-planta ratio and fetal heart rate monitoring group(n=22),which were divided into three groups: gestational week<34 weeks at the time of termination of pregnancy(n=10),gestational week ≥ 34 weeks at the time of termination of pregnancy(n=12);The group with normal ratio of brain to placenta and abnormal results of fetal heart monitoring(n=33),including the group with gestational week<34 weeks at the time of termination of pregnancy(n=16)and the group with gestational week ≥ 34 weeks at the time of termination of pregnancy(n=17);The abnormal ratio of brain to placenta and normal fetal heart rate monitoring group(n=38),in which the gestational weeks were less than 32 weeks(n=9),32-34 weeks(n=14),and34 weeks or more(n=15)at the time of termination of pregnancy;Brain placental ratio and fetal heart rate monitoring were normal in the group(n=61),of which the gestational weeks were less than 32 weeks(n=15),32 weeks to 34 weeks(n=21),and34 weeks or more(n=25)at the time of termination of pregnancy.Result:1.1.Comparison of pregnancy outcomes in the normal group of cerebral placental ratio and non-stressed fetal heart rate monitoring: the age,pregnancy and birth of patients in the three groups of patients less than 32 weeks(n=15),32-34 weeks(n=21),and more than 34 weeks(n=25),with P less than 0.05 as a statistical difference,the calculation results showed that there was no statistical difference between the three groups of data;the placental abruption rate,eclampsia incidence,liver and kidney function abnormalities,placental adhesion rate,neonatal mortality rate of the three groups,The incidence of HELLP syndrome showed no statistically significant difference(P>0.05).There were significant differences in the incidence of Apgar score,fetal distress,fetal growth restriction and neonatal asphyxia at 1 min after birth between the three groups(P<0.01).After adjusting for differences between groups,there were differences between the three groups(P<0.0167),and the incidence of fetal distress,fetal growth restriction and neonatal asphyxia were higher in the group less than 32 weeks and 32 weeks to 34 weeks,and there were statistical differences(P’<0.0167).Compared with the 32-week group,the incidence of fetal distress and fetal growth restriction were not statistically significant(P’>0.0167).The incidence of neonatal asphyxia was higher in the group less than 32 weeks and was statistically significant(P<0.0167).Adjusted comparison between groups with Apgar score at 1 min postnatal period: P=0.000 in the group less than 32 weeks and 32 weeks to 34 weeks;P=0.000 between the group at 32 weeks to 34 weeks and group greater than 34 weeks;P=0.000 between groups with less than 32 weeks and groups greater than 34 weeks;P=0.500 in the group with fetal distress;P=0.500 in the group with less than 32 weeks to 34 weeks;P=34 weeks in the group from 32 weeks to 34 weeks 0.013;P=0.001 between groups less than 32 weeks and groups greater than 34 weeks;adjusted comparison between groups with fetal growth restriction: P=0.090 in groups less than 32 weeks and 32 weeks to 34 weeks;P=0.016 between groups at 32 weeks to 34 weeks and groups greater than34 weeks;P=0.000 Corrected comparison between groups with neonatal asphyxia:P=0.000 between groups with neonatal asphyxia: P= 0.016;P=0.016 between the 32-34 week group and the group greater than 34 weeks;P=0.000 between the group less than 32 weeks and the group greater than 34 weeks;Corrected comparison between groups of fetal growth restriction: P=0.090 in the group of less than 32 weeks and the group of 32-34 weeks;Comparison between the 32-34 week group and the group over34 weeks: P=0.016;Comparison between the less than 32 weeks group and the more than 34 weeks group: P=0.000 correction comparison between the neonatal asphyxia groups: P=0.016 between the less than 32 weeks group and the 32-34 weeks group;Comparison between the 32-34 week group and the group over 34 weeks: P=0.016;Comparison between groups less than 32 weeks and more than 34 weeks: P=0.0002.Comparison of pregnancy outcomes in the group with abnormal cerebral placental ratio and normal non-stressed fetal heart rate monitoring: the age,pregnancy and birth time of patients in the three groups of patients with abnormal cerebral placental ratio and non-stressed fetal heart rate monitoring: the age,pregnancy and birth time of patients in the three groups of patients less than 32 weeks(n=9),32 weeks to34 weeks(n=14),and P less than 0.05 as the statistical difference,the calculation results showed that there was no statistical difference between the three groups of data groups;the rate of placental abruption,the incidence of HELLP syndrome,the incidence of eclampsia,the incidence of abnormal liver and kidney function,and the incidence of placental adhesions in the three groups,The results showed that there were no significant differences(P>0.05),there were no significant differences in neonatal mortality and fetal distress between the three groups(P>0.05),and there were significant differences in Apgar score,fetal growth restriction and neonatal asphyxia at1 min after birth(P<0.01).The incidence of fetal growth restriction and neonatal asphyxia in the group less than 32 weeks was higher than that in the 32-34 weeks group and greater than 34 weeks(P’<0.0167),and the 1min Apgar score in the group less than32 weeks was significantly lower than that in the 32-34 weeks group and greater than34 weeks.Compared with the 32-week to 34-week group,there were no significant differences in the 1 min Apgar score,fetal distress,fetal growth restriction,and neonatal asphyxia in the group greater than 34 weeks(P’>0.0167).Adjusted comparison between the two groups with Apgar score at 1 min of birth: P=0.000 in the group less than 32 weeks and 32 weeks to 34 weeks;P=0.697 between the group at 32 weeks to 34 weeks;P=0.000 between groups with less than 32 weeks and groups greater than 34 weeks;P=0.013 between groups with fetal growth restriction: P=0.013 in the group less than32 weeks and 32 weeks to 34 weeks;P= 0.651;P=0.003 between groups less than 32 weeks and groups greater than 34 weeks;comparison between groups with neonatal asphyxia: P=0.001 in group less than 32 weeks and 32 weeks to 34 weeks;P=0.598 in groups with groups less than 32 weeks and groups greater than 34 weeks;P=0.000 in groups less than 32 weeks and groups greater than 34 weeks3.Comparison of pregnancy outcomes in the group with normal cerebral placenta ratio and non-stressful fetal heart rate monitoring: age,pregnancy and birth time of patients in the group less than or equal to 34 weeks(n=16)and the group greater than34 weeks(n=17),with P less than 0.05 as the statistical difference,the calculation results indicate that there is no statistical difference between the two groups of data;the rate of placental abruption,the incidence of HELLP syndrome,the incidence of eclampsia,the incidence of liver and kidney function abnormalities,and the incidence of placental adhesions in the two groups,The results showed no significant difference(P>0.05),and there were no significant differences in neonatal Apgar score,neonatal mortality,fetal distress rate,fetal growth restriction rate and fetal asphyxia rate at 1 min after birth between the two groups(P>0.05)4.The cerebral placental ratio and non-stressed fetal heart rate monitoring were abnormal: less than or equal to 34 weeks group(n=10),greater than 34 weeks group(n=12).The age,pregnancy and parity of the two groups were statistically different with P less than 0.05,and the calculation results showed that there was no statistical difference between the two groups,and there was no significant difference in placental abruption,HELLP syndrome,eclampsia,liver and kidney dysfunction,and placental adhesion rate between the two groups(P>0.05).The results showed no significant difference(P>0.05)Conclusion:1.Clinically,the timing of termination of pregnancy in early onset severe preeclampsia should be selected,and sufficient attention should be paid to the results of fetal brain placental ratio and non-stress fetal heart rate monitoring.The appropriate time should be selected to terminate pregnancy according to the specific situation,and the preoperative preparation should be fully made to reduce the perinatal outcome of poor mothers and infants.2.For patients with normal brain placental ratio and non-stress fetal heart rate monitoring,termination of pregnancy after 34 weeks of pregnancy will lead to better perinatal outcomes for the pregnant women and newborns;3.Patients with early-onset severe pre-eclampsia with an abnormal cerebral placental ratio and normal fetal heart rate monitoring should terminate the pregnancy after 32 weeks’ gestation,and prolonging the continuation of pregnancy does not improve maternal and infant pregnancy outcomes.In this study,due to the small number of enrolled cases(n=38),there may be a lack of representativeness of the sample population,and large sample analysis is required for further verification.4.For patients with early-onset severe preeclampsia with normal brain placenta and abnormal fetal heart monitoring without stress,if the fetal heart monitoring results have not been significantly improved after adequate fetal heart correction measures have been given,pregnancy should be terminated as soon as possible after the treatment of promoting fetal lung maturity.5.For patients with early-onset severe preeclampsia who have abnormal brain placental ratio and non-stress fetal heart monitoring,if the fetal heart monitoring results still indicate abnormalities after taking measures such as lateral lying position and oxygen inhalation,the pregnancy should be terminated immediately.更多还原