胎盘血流灌注超声检测联合凝血功能指标预测妊娠期高血压患者围产儿不良结局的列线图模型

Nomogram model combining placental blood flow perfusion ultrasound detection and coagulation function indicators to predict adverse perinatal outcomes in patients with hypertensive disorders of pregnancy

摘要

目的 构建基于胎盘血流灌注超声检测[子宫动脉搏动指数（PI）、脐动脉血流阻力指数(RI)]联合凝血功能指标(D-二聚体、血栓弹力图)预测妊娠期高血压孕妇围产儿不良结局的列线图模型。方法 选择2021年12月至2024年12月在承德市中心医院行常规产检的600例孕妇作为研究对象（其中妊娠期高血压组382例，子痫前期组218例），选择同期进行常规产检的妊娠期血压正常孕妇600例作为妊娠正常血压组。比较各组的PI、RI、D-二聚体和血栓弹力图参数[凝血因子激活时间（R值）、血块形成速率（K值）、弹力图最大切角（α角）最大血块强度（MA值）]等指标。采用logistic回归分析探讨妊娠期高血压孕妇围产儿不良结局的影响因素；采用R语言建立围产儿不良结局的风险列线图预测模型；采用受试者操作特征（ROC）曲线评价预测模型内部效能，校正曲线评价模型的预测概率与实测概率的一致性；采用临床决策曲线评估列线图模型的临床实用性。结果 与妊娠正常血压组比较，子痫前期和妊娠期高血压组的D-二聚体、α、MA、PI、RI较高，而R、K较低，差异均有统计学意义（P＜0.05）。妊娠期高血压疾病孕妇600例，发生围产儿不良结局176例（29.3%），包括胎儿窘迫16例（9.1%），胎儿生长受限24例（13.6%），早产70例（39.8%）、羊水过少23例（13.1%）、低出生体重43例（24.4%）。与无围产儿不良结局组比较，围产儿不良结局的血清D-二聚体、α、MA、PI和RI较高，而R、K较低，差异均有统计学意义（P＜0.05）。多因素logistic回归分析显示，PI（OR=1.416，95%CI：1.047～1.915）、RI（OR=1.988，95%CI：1.204～3.283）、D-二聚体（OR=2.113，95%CI：1.284～3.476）、R（OR=0.614，95%CI：0.410～0.920）、K（OR=0.655，95%CI：0.475～0.903）、α（OR=1.097，95%CI：1.011～1.192）、MA（OR=1.100，95%CI：1.023～1.182）是孕妇发生围产儿不良结局的影响因素（均P＜0.05）。预测妊娠期高血压围产儿不良结局的列线图模型ROC曲线下面积为0.85（95%C1：0.77～0.89），灵敏度为83%，特异度为80%，约登指数为0.61，具有较好的区分度。预测妊娠期高血压围产儿不良结局的校准曲线结果显示预测概率与实测概率趋势一致。Hosmer-Lemeshow检验χ²=3.124，P=0.879。决策曲线结果表明，阈值概率在0.10～0.85，模型具有良好的分辨力。结论 本研究基于胎盘血流灌注超声检测联合凝血功能指标构建了妊娠期高血压患者围产儿不良结局的列线图风险预测模型，区分度与校准度均较好。

Abstract

Objective To construct a nomogram model for predicting adverse perinatal outcomes in hypertensivedisorders of pregnancy based on placental blood flow perfusion ultrasound measturements [uterine artery pulsatility index(PI),umbilical artery resistance index (RI)] combined with coagulation function indicators (D-dimer，thromboelasto-graphy). Methods A total of 600 pregnant women who underwent routine prenatal examinations at Chengde CentralHospital from December 2021 to December 2024 were selected(including 382 in the gestational hypertension group and 218in the preeclampsia group).Additionally,600 pregnant women with normal blood pressure during pregnancy who underwent routine prenatal examinations during the same period were selected as the normal blood pressure group.Parameters such asPI,RI, D-dimer, and thromboelastography indicators (reaction time [R], kinetic time [K], alpha angle [a], and maxiumamplitude [MA]) were compared across the different groups. Logistic regression analysis was used to explore theinfluencing factors of pregnancy outcomes in women with gestational hypertension. R language was employed to establish arisk nomogram prediction model for adverse pregnancy outcomes. The internal performance of the prediction model was evaluated using receiver operating characteristic (ROC) curves， and the consistency between preaced and oosenveuprobabilities was assessed usig calibration curves. The clinical utility of the nomogram model was evaluated usimng clmicaldecision curve analysis. Results Compared with the normotensive pregnancy group, the preeclampsia and gestational hypertension groups had higher levels of D-dimer, a,MA,PI, and RI, and lower levels of R and K, with all differences beingstatistically significant (all P ＜0.05).Among 600 pregnant women with hypertensive disorders in pregnancy, 176(29.4%)experienced adverse pregnancy outcomes，including 16 cases of fetal distress (9.1%),24 cases of fetal growth restriction(13.6%),10 cases of postpartum hemorrhage (5.7%), 60 cases of preterm birth (34.1%),18 cases of oligohydramnios (10.2%), and 38 cases of low birth weiglt (21.6%).Compared with the group without adverse pregnancy outcomes, theadverse pregnancy outcome group had higher serum levels of D-dimer, a,MA,PI, and RI, and lower levels of R and K, withall differences being statistically significant (all P＜0.05).Multivariate logistic regression analysis showed that Pl(OR=1.416,95%CI: 1.047-1.915),RI(OR= 1.988,95%CI:1.204-3.283), D-dimer (OR = 2.113,95%CI: 1.284-3.476),R (OR=0.614,95%CI:0.410-0.920),K (OR =0.655,95%CI: 0.475-0.903), α(OR = 1.097,95%CI 1.011-1.192), and MA(OR =1.100,95%CI: 1.023-1.182) were influencing factors for adverse perinatal outcomes in pregnant women (all P＜0.05).Thearea under the ROC curve of the nomogram model for predicting adverse perinatal outcomes in gestational hypertension was0.85(95%CI: 0.77-0.89), with a sensitivity of 83%, a specificity of 80%, and a Youden index of 0.61, indicating gooddiscriminative ability. The calibration curve results for predicting adverse perinatal outcomes in gestational hypertensionshowed that the predicted probabilities were consistent with the observed probabilities. The Hosmer-Lemeshow test yielded χ²=3.124 and P=0.879. Decision curve analysis results indicated that the model had good discriminative ability within athreshold probability range of 0.10-0.85. Conclusion This study developed a nomogram risk prediction model foradverse perinatal outcomes in patients with gestational hypertension, based on placental blood perfusion ultrasound detectioncombined with coagulation function indicators.The model demonstrated good discrimination and calibration.

关键词

子宫动脉搏动指数 / 脐动脉血流阻力指数 / 血栓弹力图 / D-二聚体 / 妊娠期高血压 / 子痫前期 / 围产儿不良结局

Key words

uterine artery pulsatility index / umbilical artery blood flow resistance index / thromboelastography / D-dimer / gestational hypertension / preeclampsia / pregnancy outcome

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基金资助

河北省承德市科技计划项目(202303A016)