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中华妇幼临床医学杂志(电子版) ›› 2019, Vol. 15 ›› Issue (05) : 512 -519. doi: 10.3877/cma.j.issn.1673-5250.2019.05.006

所属专题： 文献；

论著

分娩小于胎龄儿子痫前期孕妇24 h动态血压监测的价值
吕莉娟1, 周欣2, 何薇1, 尹爱华1,†()   
  1. 1. 广东省妇幼保健院医学遗传中心，广州　511460
    2. 天津医科大学总医院心内科　300052
  • 收稿日期:2019-04-09 修回日期:2019-09-01 出版日期:2019-10-01
  • 通信作者: 尹爱华

Clinical value of 24-h ambulatory blood pressure monitoring for delivery of small for gestational age infants in preeclampsia

Lijuan Lyu1, Xin Zhou2, Wei He1, Aihua Yin1,†()   

  1. 1. Medical Genetics Center, Guangdong Women and Children Hospital, Guangzhou 511460, Guangdong Province, China
    2. Department of Cardiology, Tianjin Medical University General Hospital, Tianjin300052, China
  • Received:2019-04-09 Revised:2019-09-01 Published:2019-10-01
  • Corresponding author: Aihua Yin
  • About author:
    Corresponding author: Yin Aihua, Email:
  • Supported by:
    Key Program for Prevention and Control of Eproductive Health and Major Birth Defects of National Key R&D Program of China(2016YFC1000703); Guangdong Medical Research Found(B2019013)
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引用本文：

吕莉娟, 周欣, 何薇, 尹爱华. 分娩小于胎龄儿子痫前期孕妇24 h动态血压监测的价值[J]. 中华妇幼临床医学杂志(电子版), 2019, 15(05): 512-519.

Lijuan Lyu, Xin Zhou, Wei He, Aihua Yin. Clinical value of 24-h ambulatory blood pressure monitoring for delivery of small for gestational age infants in preeclampsia[J]. Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition), 2019, 15(05): 512-519.

目的

探讨24 h动态血压监测(ABPM)，对于预测子痫前期(PE)孕妇分娩小于胎龄(SGA)儿的价值。

方法

选取2015年6月至2017年6月在广东省妇幼保健院产科分娩的733例PE孕妇为研究对象。根据PE孕妇分娩SGA儿与适于胎龄(AGA)儿，将其分为A组(n＝399，分娩SGA儿PE孕妇组)和B组(n＝334，分娩AGA儿PE孕妇组)。采用成组t检验，对2组孕妇的年龄、孕前人体质量指数(BMI)、分娩孕龄、新生儿出生体重、糖化血红蛋白(HbA1c)、三酰甘油(TG)、低密度脂蛋白(LDL)、舒张压、收缩压、白天收缩压(dSBP)、夜间收缩压(nSBP)、24 h平均收缩压(24-h SBP)、白天舒张压(dDBP)、夜间舒张压(nDBP)和24 h平均舒张压(24-h DBP)等指标进行比较。采用Mann-Whitney U检验，对2组孕妇的收缩压夜间压下降率(SBP-DR)和舒张压夜间压下降率(DBP-DR)等指标进行比较。采用单因素和多因素非条件logistic回归分析，对分娩SGA儿PE孕妇血压的相关影响因素进行分析。采用Stata 15.0统计学软件中的"roccomp"命令，对差异有统计学意义(P<0.05)的各项参数构成预测模型，计算受试者工作特征(ROC)曲线下面积(ROC-AUC)，并进行多重ROC曲线比较。本研究遵循程序符合2013年修订的《世界医学协会赫尔辛基宣言》要求，并与所有受试者签署临床研究知情同意书。

结果

①单因素分析结果显示，2组PE孕妇的年龄、孕前BMI、分娩孕龄、新生儿出生体重、HbA1c、TG、TC、LDL、舒张压，以及24-h ABPM监测参数中的nSBP、24-h SBP、dDBP、nDBP、24-h DBP、SBP-DR、DBP-DR比较，差异均有统计学意义(t＝3.112、2.564、13.901、27.073、3.436、－2.165、－3.690、－3.021、－3.825、－2.557、－4.836、－7.423、－6.024，Z＝4.221、5.703；P<0.05)。②单因素logistic回归分析结果显示，PE孕妇的舒张压、nSBP、SBP、dDBP、nDBP、和24-h DBP，均是其分娩SGA儿的独立危险因素(OR＝1.118，95%CI：1.039～1.203，P＝0.003；OR＝1.216，95%CI: 1.098～1.347，P<0.001；OR＝1.172, 95%CI: 1.036～1.326，P＝0.011；OR＝1.221, 95%CI: 1.123～1.327，P<0.001；OR＝1.287, 95%CI: 1.198～1.383，P<0.001；OR＝1.282，95%CI: 1.178～1.296，P<0.001)。多因素非条件logistic回归分析的结果显示，nSBP、24-h SBP、dDBP、nDBP和24-h DBP，均是PE孕妇分娩SGA儿的独立危险因素(OR＝1.265，95%CI：1.135～1.410，P<0.001；OR＝1.238，95%CI：1.085～1.412，P＝0.002；OR＝1.221，95%CI：1.120～1.331，P<0.001；OR＝1.289，95%CI：1.197～1.388，P<0.001；OR＝1.289，95%CI：1.197～1.388，P<0.001)。③多重ROC曲线分析结果显示，24-h ABPM参数中，基础模型合并nDBP的ROC-AUC为0.694，显著大于基础模型合并CBP舒张压的0.646，并且差异有统计学意义(χ2＝8.982，P＝0.003)。

结论

24-h ABPM参数中的nDBP与PE孕妇是否分娩SGA儿密切相关，这为PE孕妇的血压管理提供了新思路。

关键词: 子痫前期, 血压测定, 高血压，妊娠性, 婴儿，小于胎龄, 孕妇
Objective

To explore the values of 24-h ambulatory blood pressure monitoring (ABPM) in predicting delivery of small for gestational age (SGA) infants of pregnant women with preeclampsia (PE).

Methods

A total of 733 pregnant women with PE who gave birth in Guangdong Maternal and Child Health Hospital from June 2015 to June 2017 were selected into this study. According to SGA infants and AGA infants delivered by PE pregnant women, they were divided into group A (n=399, PE pregnant women delivered SGA infants) and group B (n=334, PE pregnant women delivered AGA infants). The following items, such as maternal age, pre-pregnancy body mass index (BMI), gestational age at delivery, fetal birth weight, glycosylated hemoglobin (HbA1c), triacylglycerol (TG), low-density lipoprotein (LDL), diastolic blood pressure, systolic blood pressure, day systolic blood pressure (dSBP), night systolic blood pressure (nSBP), 24-h systolic blood pressure (24-h SBP), day diastolic blood pressure (dDBP), night diastolic blood pressure (nDBP), and 24-h diastolic blood pressure (24-h DBP), were compared by independent-samples t test between two groups. The indexes, such as systolic nocturnal pressure drop rate (SBP-DR) and diastolic nocturnal pressure drop rate (DBP-DR), were compared between two groups by using Mann-Whitney U test. Univariate and multivariate unconditional logistic regression analysis were used to analyze the relative factors associated with blood pressure in pregnant women with PE. The area under the receiver operating characteristic (ROC) curve (ROC-AUC) was calculated using the prediction model constituted by each parameter with statistically significant difference by using the " roccomp" command in Stata 15.0 statistical software, and multiple ROC curve comparisons were performed. The procedures followed in this study were in accordance with the World Medical Association Declaration of Helsinki as revised in 2013, and informed consent for the clinical study was obtained from all subjects.

Results

① Univariate analysis showed that there were significant differences in age, pre-pregnancy BMI, gestational age at delivery, fetal birth weight, HbA1c, TG, TC, LDL, diastolic blood pressure, and nSBP, 24-h SBP, dDBP, nDBP, 24-h DBP, 24-h DBP, SBP-DR, and DBP-DR between two groups (t=3.112, 2.564, 13.901, 27.073, 3.436, -2.165, -3.690, -3.021, -3.825, -2.557, -4.836, -7.423, -6.024, Z=4.221, 5.703; P<0.05). ②Univariate logistic regression analysis showed that diastolic pressure, nSBP, SBP, dDBP, nDBP, and 24-h DBP of PE pregnant women were independent risk factors for SGA (OR=1.118, 95%CI: 1.039-1.203, P=0.003; OR=1.216, 95%CI: 1.098-1.347, P<0.001; OR=1.172, 95%CI: 1.036-1.326, P=0.011; OR=1.221, 95%CI: 1.123-1.327, P<0.001; OR=1.287, 95%CI: 1.198-1.383, P<0.001; OR=1.282, 95%CI: 1.178-1.296, P<0.001). Multivariate unconditional logistic regression analysis showed that nSBP, 24-h SBP, dDBP, nDBP and 24-h DBP of PE pregnant women were independent risk factors for SGA (OR=1.265, 95%CI: 1.135-1.410, P<0.001; OR=1.238, 95%CI: 1.085-1.412, P=0.002; OR=1.221, 95%CI: 1.120-1.331, P<0.001; OR=1.289, 95%CI: 1.197-1.388, P<0.001). ③ The results of multiple ROC curve analysis showed that the ROC-AUC of nDBP in 24-h ABPM parameters was 0.694, which was significantly larger than 0.646 of CBP diastolic pressure, and the difference was statistically significant (χ2=8.982, P=0.003).

Conclusions

The nDBP in 24-h ABPM parameters is closely related to the delivery of SGA of pregnant women with PE, which provides a new idea for blood pressure management in pregnant women with PE.

Key words: Pre-eclampsia, Blood pressure determination, Hypertension, pregnancy-induced, Infant, small for gestational age, Pregnant women
表1 2组子痫前期孕妇单因素分析结果比较
项目 A组(n＝334) B组(n＝399) t值 P值
年龄(岁，±s) 30.0±5.0 31.2±5.3 t＝3.112 0.001
孕前BMI(kg/m2，±s) 21.1±3.0 21.7±3.0 t＝2.564 0.011
分娩孕龄(周，±s) 33.8±3.3 37.0±3.0 t＝13.901 <0.001
胎儿出生体重(g，±s) 1 534.3±555.6 2 852.8±730.6 t＝27.073 <0.001
HbA1c(%，±s) 5.3±0.3 5.4±0.5 t＝3.436 0.001
TG(mg/dL，±s) 3.7±1.7 3.4±1.6 t＝－2.165 0.031
LDL(mg/dL，±s) 3.5±1.2 3.2±0.9 t＝－3.690 <0.001
CBP参数 ? ? ? ?
? 收缩压(mmHg，±s) 140.7±14.1 139.6±13.2 t＝－1.072 0.284
? 舒张压(mmHg，±s) 90.0±10.1 87.8±10.0 t＝－3.021 0.003
24-h ABPM参数 ? ? ? ?
? dSBP(mmHg，±s) 141.2±11.6 139.7±12.0 t＝－1.682 0.093
? nSBP(mmHg，±s) 137.3±14.7 133.2±14.4 t＝－3.825 <0.001
? 24-h SBP(mmHg，±s) 140.2±11.6 137.9±12.3 t＝－2.557 0.011
? dDBP(mmHg，±s) 89.8±9.2 86.6±8.9 t＝－4.836 <0.001
? nDBP(mmHg，±s) 87.0±11.3 81.0±10.8 t＝－7.423 <0.001
? 24-h DBP(mmHg，±s) 89.1±9.2 85.1±8.9 t＝－6.024 <0.001
? SBP-DR[%，M(P25～P75)] 2.9 (－1.3～14.2) 4.8 (1.3～14.7) Z＝4.221 <0.001
? DBP-DR[%，M(P25～P75)] 3.2 (－2.3～17.48) 5.7 (1.8～19.7) Z＝5.703 <0.001
表2 子痫前期孕妇分娩小于胎龄儿的血压相关影响因素的单因素logistic回归分析
影响因素 B SE Wald值 P值 OR值 OR值95%CI
收缩压(每升高10 mmHg) 0.058 0.054 1.148 0.284 1.060 0.953～1.180
舒张压(每升高5 mmHg) 0.112 0.037 8.807 0.003 1.118 1.039～1.203
dSBP(每升高10 mmHg) 0.106 0.063 2.822 0.093 1.112 0.982～1.259
nSBP(每升高10 mmHg) 0.196 0.052 13.377 <0.001 1.216 1.098～1.347
24-h SBP(每升高10 mmHg) 0.159 0.063 6.465 0.011 1.172 1.036～1.326
dDBP(每升高5 mmHg) 0.200 0.426 22.607 <0.001 1.221 1.123～1.327
nDBP(每升高5 mmHg) 0.252 0.036 31.763 <0.001 1.287 1.198～1.383
24-h DBP(每升高5 mmHg) 0.249 0.043 47.393 <0.001 1.282 1.178～1.296
表3 子痫前期孕妇分娩小于胎龄儿的血压相关影响因素的多因素非条件logistic回归分析
影响因素 B SE Wald值 P值 OR值 OR值95%CI
收缩压(每升高10 mmHg) 0.103 0.058 3.170 0.075 1.108 0.990～1.240
舒张压(每升高5 mmHg) 0.129 0.039 10.828 0.001 1.137 1.054～1.228
dSBP(每升高10 mmHg) 0.156 0.067 5.327 0.021 1.168 1.024～1.333
nSBP(每升高10 mmHg) 0.235 0.055 5.867 <0.001 1.265 1.135～1.410
24-h SBP(每升高10 mmHg) 0.213 0.067 9.550 0.002 1.238 1.085～1.412
dDBP(每升高5 mmHg) 0.200 0.044 20.291 <0.001 1.221 1.120～1.331
nDBP(每升高5 mmHg) 0.254 0.038 44.476 <0.001 1.289 1.197～1.388
24-h DBP(每升高5 mmHg) 0.254 0.038 29.115 <0.001 1.289 1.197～1.388
表4 不同指标预测子痫前期孕妇分娩小于胎龄儿的受试者工作特征曲线下面积
预测模型 ROC-AUC ROC-AUC 95%CI χ2值 P值a
基础模型＋舒张压 0.646 0.607～0.686 － －
基础模型＋nSBP 0.658 0.619～0.697 0.761 0.383
基础模型＋24-h SBP 0.645 0.606～0.685 0.013 0.918
基础模型＋dDBP 0.658 0.619～0.697 1.023 0.312
基础模型＋nDBP 0.694 0.656～0.732 8.982 0.003
基础模型＋24-h DBP 0.673 0.634～0.711 3.952 0.047
图1 不同指标预测子痫前期孕妇分娩小于胎龄儿的受试者工作特征曲线下面积
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