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中华产科急救电子杂志

中华产科急救电子杂志 ›› 2023, Vol. 12 ›› Issue (02) : 85 -92. doi: 10.3877/cma.j.issn.2095-3259.2023.02.005

论著

子痫前期合并胎儿生长受限的妊娠结局及胎盘病理改变的研究
郑晓芳, 魏宋荃, 黄真轩, 吴文诗, 李桂民, 张红霞, 江庆萍, 陈敦金, 余琳†()   
  1. 广州医科大学附属第三医院妇产科　广州重症孕产妇救治中心　广东省产科重大疾病重点实验室，广州　510150
    广州医科大学附属第三医院病理科，广州　510150
  • 收稿日期:2022-12-15 出版日期:2023-05-18
  • 通信作者: 余琳
  • 基金资助:
    国家自然科学基金重点项目(81830045)

Pregnancy outcome and pathological changes of the placenta in preeclampsia with fetal growth restriction

Xiaofang Zheng, Songquan Wei, Zhenxuan Huang, Wenshi Wu, Guimin Li, Hongxia Zhang, Qingping Jiang, Dunjin Chen, Lin Yu†()   

  1. Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Key Laboratory for Major Obstetric Diseases of Guangdong Province, Guangzhou Medical Center for Critical Pregnant Women, Guangzhou 510150, China
    Department of Pathology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou 510150, China
  • Received:2022-12-15 Published:2023-05-18
  • Corresponding author: Lin Yu
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引用本文：

郑晓芳, 魏宋荃, 黄真轩, 吴文诗, 李桂民, 张红霞, 江庆萍, 陈敦金, 余琳. 子痫前期合并胎儿生长受限的妊娠结局及胎盘病理改变的研究[J]. 中华产科急救电子杂志, 2023, 12(02): 85-92.

Xiaofang Zheng, Songquan Wei, Zhenxuan Huang, Wenshi Wu, Guimin Li, Hongxia Zhang, Qingping Jiang, Dunjin Chen, Lin Yu. Pregnancy outcome and pathological changes of the placenta in preeclampsia with fetal growth restriction[J]. Chinese Journal of Obstetric Emergency(Electronic Edition), 2023, 12(02): 85-92.

目的

了解子痫前期(preeclampsia，PE)合并胎儿生长受限(fetal growth restriction，FGR)孕产妇的母婴不良结局情况、胎盘病理变化及胎盘病变严重程度与母婴不良结局的相关性。

方法

回顾性分析2019年1月至2022年6月在广州医科大学附属第三医院产科住院并分娩的148例PE孕产妇的妊娠结局情况和胎盘病理资料，根据孕妇是否合并FGR将孕产妇分为两组：合并FGR组(44例，29.7%)为观察组，不合并FGR组(104例，70.3%)为对照组。

结果

(1)两组孕产妇的年龄、基础体质指数差异无统计学意义，但观察组的初产妇比例、既往有高血压和FGR病史的比例均高于对照组分别为[61.36%(27/44)vs 37.50%(39/104)，11.36%(5/44)vs 2.88%(3/104)，4.55%(2/44)vs 0%(0/104)；P<0.05]，差异有统计学意义。(2)观察组的新生儿出生体重轻于对照组[(1434.6±536.4)g vs (2288.7±976.7)g，t＝ 5.456，P<0.001]，观察组的新生儿早产和出生后入住新生儿科的发生率均高于对照组[79.5%(35/44)vs 50.0%(52/104)，86.4%(38/44)vs 46.2%(48/104)；P<0.001]，差异有统计学意义。(3)观察组孕妇并发症的发生率均高于对照组，尤其是低蛋白血症的发生率[29.6%(13/44)vs 10.6%(11/104), χ2＝8.188，P＝0.004]，差异有统计学意义。观察组患者的肝肾功能异常和胸腹腔积液的发生率均高于对照组[11.4%(5/44) vs 3.9%(4/104)，13.6%(6/44) vs 6.7%(7/104)，9.1%(4/44) vs 5.8%(6/104)；P>0.05]。(4)观察组孕妇的胎盘重量明显低于对照组[(345.93±101.06)g vs(436.78±125.70)g，t ＝4.246，P<0.001]，而胎盘系数高于对照组，[(0.26±0.09)vs(0.21±0.08)，t＝3.181，P＝0.002]，差异均有统计学意义。(5)观察组的各种胎盘病变的发生率较对照组增高，尤其是蜕膜血管病和绒毛发育不全的发生率较对照组增高2倍左右，且观察组中的胎盘病变多为严重病变或弥漫性病变。

结论

观察组孕妇并发症的发生率整体高于对照组，其围产儿发生早产和低出生体重的情况也更严重，观察组胎盘病变情况更严重，相关胎盘病变的发生概率更高，且以弥漫性病变或严重病变为主；严重的胎盘病理改变可能与更差的围产儿不良结局相关。

关键词: 子痫前期, 胎儿生长迟缓, 胎盘, 妊娠结局
Objective

To analyze and compare the adverse outcomes of women and infants with Preeclampsia (PE) combined with fetal growth restriction (FGR) and the pathological changes of maternal placenta, and explore whether the adverse outcomes of women and infants with PE combined with FGR are worse. In the case of PE pregnant women with FGR, whether the maternal placenta has more serious lesions, and explore the correlation between the severity of maternal placenta lesions and adverse maternal and infant outcomes.

Methods

The pregnancy outcomes and maternal placenta pathology data of 148 women with PE who were hospitalized and gave birth in the Obstetrics Department of The Third Affiliated Hospital of Guangzhou Medical University from January 2019 to June 2022 were retrospectively analyzed, and 148 women were divided into two groups according to whether the pregnant women were combined with FGR: The FGR group (44 cases, 29.7%) was the observation group, and the non-FGR group (104 cases, 70.3%) was the control group.

Results

(1) There was no significant difference in age and basic body mass index between the two groups. However, the proportion of first-time mothers and previous history of hypertension or FGR in the FGR group were higher than those in the non-FGR group [61.36% (27/44) vs 37.50% (39/104), 11.36% (5/44) vs 2.88% (3/104), 4.55% (2/44) vs 0% (0/104)], (all P<0.05), the difference was statistically significant. (2) The birth weight of newborns in the FGR group was lower than that in the non-FGR group [(1434.6±536.4) g vs (2288.7±976.7) g, t= 5.456, P<0.001], and the difference was statistically significant. The incidence of preterm birth and admission to neonatal department after birth in the FGR group was higher than that in the non-FGR group [79.5% (35/44) vs 50.0% (52/104) and 86.4% (38/44) vs 46.2% (48/104), P<0.001], the difference was statistically significant. (3) The incidence of related maternal complications in the FGR group was higher than that in the non-FGR group, especially the incidence of hypoproteinemia, which was significantly higher in the FGR group than in the non-FGR group [29.6% (13/44) vs10.6% (11/104)] (χ2=8.188, P=0.004). The difference was statistically significant. The incidence of liver and kidney dysfunction and thoracoabdominal effusion in patients with FGR was higher than that in patients without FGR [11.4% (5/44) vs. 3.9% (4/104), 13.6% (6/44) vs. 6.7% (7/104) and 9.1% (4/44) vs. 5.8% (6/104)]. There was no significant difference (P>0.05). (4) The placental weight in the FGR group was significantly lower than that in the non-FGR group [(345.93±101.06) g vs (436.78±125.70) g, t=4.246, P<0.001], and the placental coefficient was higher than that in the non-FGR group. [(0.26±0.09) vs (0.21±0.08), t=3.181, P=0.002], the differences were statistically significant, indicating that the placental hypoplasia of pregnant women with FGR was more significant. (5) The incidence of various placental lesions in the FGR group was higher than that in the non-FGR group, especially the incidence of decidua vascular disease and villus hypoplasia was about 2 times higher than that in the non-FGR group, and the placental lesions in the FGR group were mostly severe or diffuse.

Conclusions

The overall incidence of maternal complications in the FGR group was higher than that in the non-FGR group, and the perinatal preterm birth and low birth weight were more serious. The placental lesions in the FGR group were more serious, that is, the incidence of related placental lesions was higher, and the lesions were mainly diffuse or severe. Severe placental pathology is likely to be associated with worse perinatal adverse outcomes.

Key words: Preeclampsia, Fetal growth retardation, Placenta, Pregnancy outcome
表1 两组孕产妇的一般情况比较
组别 例数 年龄[岁，(±s)] BMI[kg/m2, (±s)] 既往有高血压病史[例(%)] 既往有FGR病史[例(%)] 初产妇构成比[例(%)]
观察组 44 30.73±2.12 22.54±1.35 5(11.36) 2(4.55) 27(61.36)
对照组 104 31.86±2.15 22.33±1.21 3(2.88) 0(0) 39(37.50)
统计值   t＝0.122 t＝0.932 χ2＝4.374 χ2＝4.792 χ2＝8.385
P值   0.099 0.352 0.037 0.029 0.003
表2 两组新生儿出生体重及围产儿结局比较
组别 例数 新生儿出生体重[(±s)g] <37周早产[例(%)] 胎儿窘迫[例(%)] 1 min Apgar评分≤7分[例(%)] 入住新生儿科[例(%)] 羊水过少[例(%)]
观察组 44 1434.6±536.4 35(79.5) 12(27.3) 10(22.8) 38(86.4) 6(13.6)
对照组 104 2288.7±976.7 52(50.0) 27(25.9) 16(15.3) 48(46.2) 9(8.7)
统计值   t＝5.456 χ2＝11.139 χ2＝0.027 χ2＝1.151 χ2＝20.536 χ2＝0.842
P值   <0.001 <0.001 0.868 0.283 <0.001 0.358
表3 两组孕产妇并发症及妊娠结局比较[例(%)]
组别 例数 胎盘早剥 HELLP综合征 肝功能异常 肾功能异常 心力衰竭或肺水肿 胸腹腔积液 低蛋白血症 产后转重症监护病房
观察组 44 4(9.1) 3(6.8) 5(11.4) 6(13.6) 3(6.8) 4(9.1) 13(29.6) 4(9.1)
对照组 104 8(7.7) 6(5.8) 4(3.9) 7(6.7) 7(6.7) 6(5.8) 11(10.6) 9(8.7)
χ2值   0.081 0.060 3.059 1.0840 0.000 0.541 8.188 0.007
P值   0.776 0.807 0.080 0.175 0.985 0.462 0.004 0.932
图1 子痫前期孕妇的胎盘组织HE染色结果　①蜕膜血管病：血管重塑不良，管壁变厚(箭头所示，×200倍)；②蜕膜血管病：血管壁纤维素样坏死(箭头所示，×200倍)；③蜕膜血管病：急性动脉粥样硬化(箭头所示，×400倍)；④绒毛大片梗死(×20倍)；⑤绒毛过度成熟(×400倍)；⑥合体结节数量显著增加(×100倍)；⑦远端绒毛发育不良(×100倍)；⑧绒毛周围出现大量的纤维素样物(箭头所示，×200倍)；⑨钙化(箭头所示，×200倍)；⑩干绒毛管壁增厚，管腔狭小(箭头所示，×100倍)；⑪绒毛血管扩张，淤血(×100倍)；⑫绒毛间质发生纤维化样改变(箭头所示，×400倍)
表4 两组孕产妇不同胎盘病变的发生率比较[例(%)]
组别 例数 蜕膜血管病 胎盘梗死 远端绒毛发育不全 绒毛加速成熟 合体结节增多 纤维蛋白沉积 钙化 绒毛间隙狭窄 胎儿血管灌注不良
观察组 44 27(61.4) 29(65.9) 26(59.1) 29(65.9) 42(95.5) 39(88.6) 20(45.5) 26(59.1) 23(52.3)
对照组 104 34(32.6) 59(56.7) 25(24.0) 40(38.5) 65(62.5) 87(83.7) 54(51.9) 55(52.8) 22(21.1)
χ2值   10.49 1.081 16.821 9.36 16.765 0.607 0.517 0.481 14.15
P值   <0.001 0.299 <0.001 <0.001 <0.001 0.436 0.472 0.488 <0.001
表5 两组孕产妇胎盘组织病变的分布情况[例(%)]
组别 例数 蜕膜血管病 胎盘梗死 远端绒毛发育不全
胎盘病理评分(分)   0 1 2 0 1 2 0 1 2
观察组 44 17(38.6) 21(47.7) 6(13.6) 15(34.1) 13(29.5) 16(36.4) 18(40.9) 16(36.4) 10(22.7)
对照组 104 70(67.4) 29(27.8) 5(4.8) 45(43.2) 36(34.6) 23(22.1) 79(76.0) 22(21.1) 3(2.9)
组别 例数 绒毛加速成熟 合体结节增多 纤维蛋白沉积
胎盘病理评分(分) 0 1 2 0 1 2 0 1 2
观察组 44 15(34.1) 18(40.9) 11(25) 2 (4.5) 11(25 ) 31(70.5) 5 (11.4) 29(65.9) 10(22.7)
对照组 104 64(61.5) 36(28.9) 4(9.6) 39(37.5) 39(37.5) 26(25) 17(16.3) 64(61.5) 23(22.1)
组别 例数 钙化 绒毛间隙狭窄 胎儿血管灌注不良
胎盘病理评分(分) 0 1 2 0 1 2 0 1 2
观察组 44 24(54.5) 20(45.5) － 18(40.9) 26(59.1) － 21(47.7) 23(52.3) －
对照组 104 50(48) 54(51.9) － 49(47.1) 55(52.8) － 82(78.8) 22(21.1) －
表6 两组孕妇胎盘组织病变的评分比较
组别 例数 总分(分) 平均分(分) 胎盘病变得分≥10分[例(%)]
观察组 44 364 8.27(364/44) 12(27.27)
对照组 104 569 5.47(569/104) 10(9.62)
χ2值   － － 7.688
P值   － － 0.003
表7 两组孕产妇胎盘重量和系数比较
组别 例数 胎盘重量(±s)g 胎盘系数(±s)
观察组 44 345.93±101.06 0.26±0.09
对照组 104 436.78±125.70 0.21±0.08
t值   4.246 3.181
P值   <0.001 0.002
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