摘要
目的建立妊娠期特异性血浆D-二聚体正常参考区间,并评估其对妊娠相关静脉血栓栓塞症的预测价值。方法回顾性选取自2010年1月至2020年12月在首都医科大学附属北京友谊医院西城院区产科住院分娩的1890例孕产妇的病例资料,其中包括50例静脉血栓栓塞症(VTE)病例[病例组,包括在妊娠期发生VTE的患者24例(其中16例深静脉血栓形成、8例肺栓塞)及在产褥期发生VTE的患者26例(其中21例深静脉血栓形成、5例肺栓塞)]和随机抽取的同期住院分娩的1840例非VTE病例(非VTE组),均从孕早期直至孕晚期多次测量血浆D-二聚体水平。采用多因素logistic回归分析探讨非VTE组血浆D-二聚体水平变化趋势及其影响因素,计算妊娠期特异性血浆D-二聚体水平的正常值参考区间,采用受试者操作特征(ROC)曲线评价血浆D-二聚体水平对妊娠相关VTE的预测价值。结果随着妊娠进展,非VTE组血浆D-二聚体水平逐渐升高,至孕晚期血浆D-二聚体水平升高最为显著;孕早期及孕晚期血浆D-二聚体的M(P2.5,P97.5)分别为0.60(0.30,1.50)μg/ml、1.70(0.80,4.89)μg/ml。多因素logistic回归分析显示,经产妇和体外受精-胚胎移植(IVF-ET)是孕早期血浆D-二聚体水平升高的独立危险因素(P<0.05);双胎妊娠、IVF-ET、产后出血是孕晚期血浆D-二聚体水平升高的独立危险因素(P<0.05),其中双胎妊娠的风险最高[OR(95%CI)∶8.359(3.708~18.844)]。按照病例组1∶2~3匹配在纳入背景人群中随机选择112例患者为对照组,病例组和对照组的孕晚期血浆D-二聚体分别为4.15(3.20,5.80)μg/ml和1.60(1.15,2.23)μg/ml,经比较差异有统计学意义(P<0.001)。ROC曲线分析显示,孕晚期血浆D-二聚体水平预测VTE的曲线下面积为0.843,最佳截断值为3.40μg/ml,敏感度为0.643,特异度为0.964。结论血浆D-二聚体水平随着孕周增加而逐渐升高,IVF-ET、经产妇、双胎妊娠及产后出血与血浆D-二聚体水平升高相关。以血浆D-二聚体水平3.40μg/ml为最佳截断值,诊断孕晚期VTE的特异度为0.964,故可用于预测妊娠期VTE的发生,尤其在排除诊断方面具有重要价值。
Objective This study established a normal reference interval for pregnancy-specific plasma D-dimer through retrospective analysis and evaluated its predictive value for pregnancy-related venous thromboembolism.Method A retrospective selection was made of the data of 1890 cases who were hospitalized and delivered in the Obstetrics Department of Xicheng Campus of Beijing Friendship Hospital,Capital Medical University from January 2010 to December 2020,including 50 cases of venous thromboembolism(VTE)[Case group,this included 24 patients with VTE who developed during pregnancy(including 16 cases of deep vein thrombosis and 8 cases of pulmonary embolism),26 patients with VTE who developed during the puerperium(including 21 cases of deep vein thrombosis and 5 cases of pulmonary embolism)],and 1840 non-VTE cases(non-VTE group)who were randomly selected and delivered in hospital during the same period.The plasma D-dimer levels were measured multiple times from the first trimester to the third trimester of pregnancy.Multivariate logistic regression analysis was used to explore the changing trend of plasma D-Dimer levels and its influencing factors in the non-VTE group.The normal reference range of pregnancy-specific plasma D-dimer levels was calculated,and the receiver operating characteristic(ROC)curve was drawn to evaluate the predictive value of plasma D-dimer levels for pregnancy-related VTE.Result With the progression of pregnancy,the plasma D-dimer level in the non-VTE group gradually increased until the increase was most significant in the third trimester of pregnancy.The M(P2.5,P97.5)of plasma D-dimer in the first and third trimesters of pregnancy were established as 0.60(0.30,1.50)μg/ml and 1.70(0.80,4.89)μg/ml,respectively.Multiparous pregnancy and in vitro fertilization-embryo transfer(IVF-ET)are independent risk factors for elevated plasma D-dimer levels in the first trimester(P<0.05).Twin pregnancy,IVF-ET,and postpartum hemorrhage were independent risk factors for elevated plasma D-dimer levels in the third trimester of pregnancy(P<0.05),among which twin pregnancy had the highest risk[OR(95%CI):8.359(3.708-18.844)].According to the 1∶2-3 matching of the case group,112 patients were randomly selected from the included background population as the control group.The plasma D-dimer in the third trimester of pregnancy in the case group and the control group was 4.15(3.20,5.80)μg/ml and 1.60(1.15,2.23)μg/ml,respectively.The difference was statistically significant after comparison(P<0.001).The results of ROC curve analysis showed that the area under the curve for predicting VTE by plasma D-dimer level in the third trimester of pregnancy was 0.843,the optimal cut-offvalue was 3.40μg/ml,the sensitivity was 0.643,and the specificity was 0.964.Conclusion The plasma D-dimer level gradually increases with the increase of gestational weeks.IVF-ET,multiparous pregnancies,twin pregnancies and postpartum hemorrhage are associated with the increase of plasma D-dimer levels.Taking 3.40μg/ml as the optimal cut-offvalue in the third trimester of pregnancy,the specificity for diagnosing VTE was 0.964.Due to its high specificity,the plasma D-dimer level can be used to predict the occurrence of VTE during pregnancy,especially having significant value in the exclusion diagnosis.
作者
张超
梁如霞
龙燕
Zhang Chao;Liang Ruxia;Long Yan(Department of Obstetrics and Gynecology,Beijing Friendship Hospital,Capital Medical University,Beijing 100050,China)
出处
《中国医刊》
2025年第11期1296-1301,共6页
Chinese Journal of Medicine
