Study on clinical risk of maternal underlying medical conditions and onset of preeclampsia

目的 探讨母体合并内科疾病等子痫前期临床风险因素对子痫前期发病的影响,旨在提高和强化围孕期早期评估和识别高危人群的能力.方法 回顾性分析2008年11月至2011年1月间在北京大学第三医院住院的、合并内科疾病的子痫前期患者97例(M-PE组)及无内科疾病的单纯子痫前期患者203例(I-PE组)的临床资料,并分别与同期合并内科疾病未发生子痫前期孕妇183例及无内科疾病正常妊娠孕妇203例进行对比.结果 2008年11月至2011年1月本院子痫前期总体病例中,存在多胎及合并内科疾病等子痫前期临床风险因素者占43.1％ (159/369)；单胎妊娠中合并内科疾病者子痫前期发生率明显高于无内科合并症者,分别为15.0％ (97/646)、4.45％(210/4719),两者比较,差异有统计学意义(P＜0,05)；单胎妊娠子痫前期中合并内科疾病者占32.3％ (97/300).M-PE组孕妇比I-PE组的平均年龄[分别为(31.7±4.5)、(29.3±5.2)岁]、高龄孕妇比例[分别为29％( 28/97)、17.7％( 36/203)]、既往有子痫前期史孕妇比例[分别为11％ (11/97)、4.9％( 10/203)]、中晚孕期妊娠丢失史比例[分别为11％( 11/97)、3.0％ (6/203)]及早孕期体质指数(BMI)[分别为(26.0±5.6)、(23.3±3.7) kg/m2]、高BMI孕妇比例[分别为62％( 18/29)、33％ (18/55)]均明显增高,分别比较,差异均有统计学意义(P＜0.05).M-PE组比I-PE组诊断孕周中位数提前(分别为32.9、34.4周),发病孕周在32周之前者[分别为45％ (44/97)、34.0％( 69/203)]、在34周之前者[分别为54％ (52/97)、45.8％ (93/203)]及在孕32周前发生的重症病例所占比例[分别为45％ (44/97)、34.0％( 69/203)]均增加,分别比较,差异均有统计学意义(P＜0.05).以32孕周为界,I-PE组早发型患者平均早孕期BMI低于晚发型[分别为(20.9 ±2.0)、(23.4±3.8)kg/m2,P=0.269].以32孕周为早发型界定值,合并内科疾病是早发型子痫前期发病的独立影响因素(OR=1.718,95％ CI 为1.005 ～2.937,P=0.048)；无论以32孕周或34孕周界定早发型与晚发型,多因素回归分析显示,中晚孕期妊娠丢失史及不规律产前检查均是早发型子痫前期发病的独立影响因素(P均＜0.05).结论 存在内科疾病及多胎妊娠的子痫前期患者在同期子痫前期发生总人群中超过1/3;存在内科疾病的子痫前期患者其子痫前期发病孕周较早,是不容忽视的高危人群.单纯型子痫前期早发型患者早孕期BMI低于晚发型,早发型与晚发型子痫前期存在BMI方面的差异,提示两者可能存在母体异质性和不同的发病机制.中晚孕期妊娠丢失史及不规律产前检查均是早发型子痫前期发病的影响因素,应强化包括潜在内科疾病在内的临床风险因素的早期评估和产前检查.Objective To investigate the effect of clinical risk factors including maternal underlying medical conditions on the development of preeclampsia (PE) in order to improve and strengthen the early assessment of high clinical risk population of PE.Methods Clinical.observational data of patients with PE in Peking University Third Hospital from November 2008 to January 2011 were analyzed.Comparative analysis was made among medical conditions with PE (M-PE) sub-group and isolated PE (I-PE) sub-group and non-PE pregnancy with or without medical conditions (control group).Results Totally 159 cases,43.09％ (159/369) of total cases of PE had high clinical risk factors (multiple pregnancy and medical conditions) and 32.3％ (97/300) of singleton PE accompanied with medical conditions.The incidence of PE in singleton pregnancies with medical conditions was significantly higher than those without medical conditions [ 15.0％ (97/646) versus 4.45％ (210/4719),P ＜ 0.05 ].In M-PE sub-group,the average age [ ( 31.7 ± 4.5 ) versus ( 29.3 ± 5.2) year-old] and body mass index (BMI) in first trimester [ (26.0 ±5.6) versus (23.3 ± 3.7) kg/m2],the proportion with previous preeclampsia [ 11％ (11/97) versus 4.9％ (10/203) ] and pregnancy loss in third trimester [ 11％ ( 11/97 ) versus 3.0％ ( 6/203 ) ],were higher than those of I-PE sub-group ( all P ＜ 0.05 ).The onset of preeclampsia in M-PE sub-group was earlier than I-PE ( 32.9 versus 34.4 gestation weeks,P ＜ 0.05 ).The proportion serious cases of PE occurring before 32 gestational weeks were higher in M-PE than that of I-PE sub-group [ 45％ (44/97)versus 34.0％ (69/203),P ＜0.05].Multivariate regression analysis showed that previous history of late pregnancy loss and irregular prenatal care were clinical risk factors for early-onset PE whether early-onset was defined as ＜ 34 or ＜ 32 gestational weeks respectively (all P ＜ 0.05) ; medical conditions were risk factors for PE if early-onset was defined as ＜ 32 gestational weeks ( OR =1.718,95％ CI:1.005 - 2.937,P =0.048).Conclusions Multiple pregnancies and pregnancies with medical conditions exceed one-third of total subjects of PE.The onset of PE in subjects with maternal underlying medical conditions was earlier which is the subgroup should not be ignored.The difference of early pregnancy BMI may show the maternal heterogeneity in early onset and late onset of preeclampsia.Assessment of clinical risk factors including the underlying medical disorders for preeclampsia in early trimester should be strengthened.国家自然科学基金; 北京大学“985工程”资助项目PubMed中文核心期刊要目总览(PKU)中国科技核心期刊(ISTIC)中国科学引文数据库(CSCD)06405-4114