妊娠并发症%红斑狼疮,系统性%狼疮肾炎%先兆子痫%妊娠结局
妊娠併髮癥%紅斑狼瘡,繫統性%狼瘡腎炎%先兆子癇%妊娠結跼
임신병발증%홍반랑창,계통성%랑창신염%선조자간%임신결국
Pregnancy complications%Lupus crythematosus,systemic%Lupus nephritis%Pre-eclampsia%Pregnancy outcome
目的 探讨系统性红斑狼疮(systemic lupus erythematosus,SLE)合并狼疮肾炎(lupus nephritis,LN)患者妊娠的母婴不良结局及危险因素.方法 对北京协和医院1 990年1月1日至2012年12月31日期间收治的93例LN患者共97例次妊娠进行回顾性分析.根据LN发病时间和病情程度分为3组:妊娠前疾病稳定组(52例次)、妊娠前疾病活动组(26例次)和妊娠期新确诊LN组(19例次).孕产妇不良结局包括妊娠期疾病加重、子痫前期、妊娠期或产后尿蛋白加重、妊娠期或产后肾功能损伤加重、孕产妇死亡、低血小板血症和低补体血症.胎儿或新生儿不良结局包括治疗性终止妊娠(因孕妇疾病加重需要终止妊娠)、胎儿丢失、新生儿死亡、早产、小于胎龄儿和新生儿窒息.组间率的比较采用x2检验和Fisher精确概率法,母婴不良结局的危险因素采用二项分类Logistic回归分析.结果 (1)孕产妇不良妊娠结局:妊娠前稳定组与活动组比较,在妊娠期疾病加重的比例差异无统计学意义[53.8％(28/52)与61.5％(16/26),x2=0.417,P＞0.05].除外妊娠20周前流产的病例(稳定组和活动组分别为5例次和4例次),2组子痫前期发生率差异也无统计学意义[36.2％(17/47)与59.1％(13/22),x2=3.204,P＞0.05].19例次妊娠期新确诊LN患者中,18例次妊娠≥20周,其中子痫前期发生率为6/18.(2)胎儿或新生儿不良结局:妊娠前疾病活动组治疗性终止妊娠的比例高于稳定组[42.3％ (10/26)与7.7％ (4/52),Fisher精确概率法,P＜0.01],差异有统计学意义.除外主动要求终止妊娠(稳定组3例次)和治疗性终止妊娠(稳定组4例次,活动组10例次)的病例,稳定组与活动组分别为45例次与16例次,活动组胎儿丢失和新生儿死亡的比例高于稳定组[5/16与6.7％(3/45),Fisher精确概率法,P＜0.05],差异有统计学意义.妊娠前活动组胎儿或新生儿不良结局发生率高于稳定组[92.3％ (24/26)与50.0％ (26/52),x2=13.483,P＜0.001],差异有统计学意义.19例次妊娠期新确诊LN组的患者中,治疗性终止妊娠5例次,胎儿丢失3例次,活产11例次,新生儿重度窒息并死亡2例次,早产9例次.(3)母婴不良结局危险因素Logistic回归分析:妊娠期疾病加重的独立危险因素为低补体血症(OR=0.300,95％CI:0.104～0.863)和低血小板血症(OR=0.054,95％CI:0.007～0.439)；LN孕妇发生子痫前期的独立危险因素为低血小板血症(OR=0.151,95％ CI∶0.046～0.499)和妊娠期LN复发或新发(OR=0.135,95 ％CI∶0.027～0.679);胎儿或新生儿不良结局的独立危险因素为孕妇发生子痫前期(OR=0.134,95％CI:0.028～0.637)和妊娠期疾病活动(OR=0.026,95 ％CI:0.005～～0.138).结论 LN患者妊娠前疾病活动增加胎儿或新生儿不良结局的风险.建议LN患者疾病稳定至少6个月以上再计划妊娠,妊娠期间应密切监测血压、肾功能、尿蛋白、血小板和补体水平等指标,及早发现疾病活动并及时治疗.
目的 探討繫統性紅斑狼瘡(systemic lupus erythematosus,SLE)閤併狼瘡腎炎(lupus nephritis,LN)患者妊娠的母嬰不良結跼及危險因素.方法 對北京協和醫院1 990年1月1日至2012年12月31日期間收治的93例LN患者共97例次妊娠進行迴顧性分析.根據LN髮病時間和病情程度分為3組:妊娠前疾病穩定組(52例次)、妊娠前疾病活動組(26例次)和妊娠期新確診LN組(19例次).孕產婦不良結跼包括妊娠期疾病加重、子癇前期、妊娠期或產後尿蛋白加重、妊娠期或產後腎功能損傷加重、孕產婦死亡、低血小闆血癥和低補體血癥.胎兒或新生兒不良結跼包括治療性終止妊娠(因孕婦疾病加重需要終止妊娠)、胎兒丟失、新生兒死亡、早產、小于胎齡兒和新生兒窒息.組間率的比較採用x2檢驗和Fisher精確概率法,母嬰不良結跼的危險因素採用二項分類Logistic迴歸分析.結果 (1)孕產婦不良妊娠結跼:妊娠前穩定組與活動組比較,在妊娠期疾病加重的比例差異無統計學意義[53.8％(28/52)與61.5％(16/26),x2=0.417,P＞0.05].除外妊娠20週前流產的病例(穩定組和活動組分彆為5例次和4例次),2組子癇前期髮生率差異也無統計學意義[36.2％(17/47)與59.1％(13/22),x2=3.204,P＞0.05].19例次妊娠期新確診LN患者中,18例次妊娠≥20週,其中子癇前期髮生率為6/18.(2)胎兒或新生兒不良結跼:妊娠前疾病活動組治療性終止妊娠的比例高于穩定組[42.3％ (10/26)與7.7％ (4/52),Fisher精確概率法,P＜0.01],差異有統計學意義.除外主動要求終止妊娠(穩定組3例次)和治療性終止妊娠(穩定組4例次,活動組10例次)的病例,穩定組與活動組分彆為45例次與16例次,活動組胎兒丟失和新生兒死亡的比例高于穩定組[5/16與6.7％(3/45),Fisher精確概率法,P＜0.05],差異有統計學意義.妊娠前活動組胎兒或新生兒不良結跼髮生率高于穩定組[92.3％ (24/26)與50.0％ (26/52),x2=13.483,P＜0.001],差異有統計學意義.19例次妊娠期新確診LN組的患者中,治療性終止妊娠5例次,胎兒丟失3例次,活產11例次,新生兒重度窒息併死亡2例次,早產9例次.(3)母嬰不良結跼危險因素Logistic迴歸分析:妊娠期疾病加重的獨立危險因素為低補體血癥(OR=0.300,95％CI:0.104～0.863)和低血小闆血癥(OR=0.054,95％CI:0.007～0.439)；LN孕婦髮生子癇前期的獨立危險因素為低血小闆血癥(OR=0.151,95％ CI∶0.046～0.499)和妊娠期LN複髮或新髮(OR=0.135,95 ％CI∶0.027～0.679);胎兒或新生兒不良結跼的獨立危險因素為孕婦髮生子癇前期(OR=0.134,95％CI:0.028～0.637)和妊娠期疾病活動(OR=0.026,95 ％CI:0.005～～0.138).結論 LN患者妊娠前疾病活動增加胎兒或新生兒不良結跼的風險.建議LN患者疾病穩定至少6箇月以上再計劃妊娠,妊娠期間應密切鑑測血壓、腎功能、尿蛋白、血小闆和補體水平等指標,及早髮現疾病活動併及時治療.
목적 탐토계통성홍반랑창(systemic lupus erythematosus,SLE)합병랑창신염(lupus nephritis,LN)환자임신적모영불량결국급위험인소.방법 대북경협화의원1 990년1월1일지2012년12월31일기간수치적93례LN환자공97례차임신진행회고성분석.근거LN발병시간화병정정도분위3조:임신전질병은정조(52례차)、임신전질병활동조(26례차)화임신기신학진LN조(19례차).잉산부불량결국포괄임신기질병가중、자간전기、임신기혹산후뇨단백가중、임신기혹산후신공능손상가중、잉산부사망、저혈소판혈증화저보체혈증.태인혹신생인불량결국포괄치료성종지임신(인잉부질병가중수요종지임신)、태인주실、신생인사망、조산、소우태령인화신생인질식.조간솔적비교채용x2검험화Fisher정학개솔법,모영불량결국적위험인소채용이항분류Logistic회귀분석.결과 (1)잉산부불량임신결국:임신전은정조여활동조비교,재임신기질병가중적비례차이무통계학의의[53.8％(28/52)여61.5％(16/26),x2=0.417,P＞0.05].제외임신20주전유산적병례(은정조화활동조분별위5례차화4례차),2조자간전기발생솔차이야무통계학의의[36.2％(17/47)여59.1％(13/22),x2=3.204,P＞0.05].19례차임신기신학진LN환자중,18례차임신≥20주,기중자간전기발생솔위6/18.(2)태인혹신생인불량결국:임신전질병활동조치료성종지임신적비례고우은정조[42.3％ (10/26)여7.7％ (4/52),Fisher정학개솔법,P＜0.01],차이유통계학의의.제외주동요구종지임신(은정조3례차)화치료성종지임신(은정조4례차,활동조10례차)적병례,은정조여활동조분별위45례차여16례차,활동조태인주실화신생인사망적비례고우은정조[5/16여6.7％(3/45),Fisher정학개솔법,P＜0.05],차이유통계학의의.임신전활동조태인혹신생인불량결국발생솔고우은정조[92.3％ (24/26)여50.0％ (26/52),x2=13.483,P＜0.001],차이유통계학의의.19례차임신기신학진LN조적환자중,치료성종지임신5례차,태인주실3례차,활산11례차,신생인중도질식병사망2례차,조산9례차.(3)모영불량결국위험인소Logistic회귀분석:임신기질병가중적독립위험인소위저보체혈증(OR=0.300,95％CI:0.104～0.863)화저혈소판혈증(OR=0.054,95％CI:0.007～0.439)；LN잉부발생자간전기적독립위험인소위저혈소판혈증(OR=0.151,95％ CI∶0.046～0.499)화임신기LN복발혹신발(OR=0.135,95 ％CI∶0.027～0.679);태인혹신생인불량결국적독립위험인소위잉부발생자간전기(OR=0.134,95％CI:0.028～0.637)화임신기질병활동(OR=0.026,95 ％CI:0.005～～0.138).결론 LN환자임신전질병활동증가태인혹신생인불량결국적풍험.건의LN환자질병은정지소6개월이상재계화임신,임신기간응밀절감측혈압、신공능、뇨단백、혈소판화보체수평등지표,급조발현질병활동병급시치료.
Objective To evaluate the maternal and fetal outcomes of pregnant women with lupus nephritis (LN) and the risk factors.Methods Ninety-three patients with 97 pregnancies from January 1st,1990 to December 31st,2012 in Peking Union Medical College Hospital were evaluated retrospectively.Objects of study were divided into three groups:stable lupus before pregnancy (stable group,52 cases),active lupus before pregnancy (active group,26 cases),and newly diagnosed LN during pregnancy (19 cases).Adverse maternal outcomes included exacerbated disease during pregnancy,preeclampsia,increased proteinuria and impaired renal function during pregnancy or postpartum,maternal death,thrombocytopenia and hypocomplementemia.Adverse fetal or neonatal outcomes included therapeutically termination of pregnancy,fetal loss,neonatal death,preterm labor,small gestational age and asphyxia.Statistical analysis was performed by Chi-square test or Fisher's exact test.A binary logistic regression model was used to evaluate the risk factors for adverse maternal and fetal outcomes.Results (1) Adverse maternal outcomes:There was no significant difference between exacerbated cases during pregnancies in stable group and that in active group [53.8 ％ (28/52) vs 61.5 ％ (16/26),x2 =0.417,P＞0.05].After deleting abortions before 20 weeks of gestation (5 cases in stable group and 4 cases in active group),there was no significant difference between preeclampsia incidence in stable group and that in active group [36.2％ (17/47) vs 59.1％ (13/22),x2 =3.204,P＞0.05].In nineteen newly diagnosed LN women,eighteen cases were over 20 weeks of gestation,during which preeclampsia incidence was 6/18.(2) Adverse fetal or neonatal outcomes:Therapeutically termination of pregnancy rate was higher in active group than that in stable group[42.3％(10/26) vs 7.7％(4/52),Fisher's exact test,P＜0.01].After deleting patients who required termination of pregnancy (three cases in stable group) and therapeutically termination of pregnancy (four cases in stable group and ten cases in active group),the rate of fetal loss and neonatal death was higher in active group than that in stable group [5/16 vs 6.7％(3/45),Fisher's exact test,P＜0.05].The rate of adverse fetal or neonatal outcomes was higher in active group than that in stable group [92.3％(24/26) vs50％(26/52),x2=13.483,P＜0.001].Among the nineteen newly diagnosed LN cases during pregnancy,the numbers of therapeutically termination of pregnancy and fetal loss were five and three cases respectively; among eleven live birth cases,two newborns died from severe asphyxia,and nine cases were preterm birth.(3) Binary logistic regression analysis showed that the independent risk factors for exacerbated lupus during pregnancy were hypocomplementemia (OR =0.300,95％ CI:0.104-0.863) and thrombocytopenia (OR =0.054,95％CI∶0.007-0.439).The independent risk factors for preeclampsia in LN pregnant women were thrombocytopenia (OR=0.151,95％CI:0.046-0.499) and LN recurrence or first diagnosed during pregnancy (OR=0.135,95％CI:0.027-0.679).The independent risk factors for adverse fetal or neonatal outcomes were preeclampsia (OR=0.134,95％CI:0.028-0.637) and lupus active during pregnancy (OR =0.026,95 ％ CI:0.005-0.138).Conclusions Active lupus before pregnancy is associated with poor maternal and fetal outcomes in lupus nephritis pregnancy.All pregnancies with LN should be planned,preferably after more than six months of quiescent disease.Blood pressure,renal function,proteinuria and level of platelet and serum complements should be closely monitored.
