摘要
目的:探讨妊娠期糖尿病(GDM)患者发生产后出血(PPH)的危险因素并构建预测模型。方法:选择2021年1月至2023年12月在郑州大学第三附属医院建档并分娩的GDM患者为研究对象,选取GDM并发PPH的患者137例为病例组,GDM未发生PPH的患者190例为对照组。采用单因素分析、多因素Logistic回归分析筛选GDM患者发生PPH的独立危险因素,并构建列线图模型,通过Hosmer-Lemeshow拟合优度检验、受试者工作特征(ROC)曲线、Bootstrap重复抽样法及决策曲线分析(DCA)评估模型的预测效能。结果:单因素分析结果显示:两组年龄≥35岁、孕前体质量指数(BMI)≥24 kg/m^(2)、血糖控制不佳、辅助生殖、妊娠期贫血、羊水过多、巨大儿、急性绒毛膜羊膜炎、妊娠期高血压、产前空腹血糖(FBG)、产前糖化血红蛋白(HbA1c)、纤维蛋白原(FIB)、产后出血量、难产、新生儿入住ICU、新生儿Apgar 1 min评分、Apgar 5 min评分差异有统计学意义(P<0.05)。多因素Logistic回归分析结果表明,年龄≥35岁、孕前BMI≥24 kg/m^(2)、血糖控制不佳、妊娠期贫血、巨大儿、羊水过多、产前HbA1c升高是PPH的独立危险因素(OR>1,P<0.05),FIB升高是PPH的保护性因素(OR<1,P<0.05)。构建列线图预测模型后Hosmer-Lemeshow拟合优度检验显示,模型有良好的校准能力(χ^(2)=6.367,DF=8,P=0.606)。ROC曲线下面积(AUC)0.821(95%CI 0.774~0.868),敏感度和特异度分别为71.5%、83.7%,表明模型有良好的区分度。Bootstrap重复抽样法内部验证显示C-index为0.821,表明模型具有良好的一致性和预测准确性,DCA曲线显示模型具有理想的临床应用价值。结论:年龄≥35岁、孕前BMI≥24 kg/m^(2)、血糖控制不佳、妊娠期贫血、巨大儿、羊水过多、产前HbA1c水平升高是GDM患者发生PPH的独立危险因素,FIB水平升高是GDM患者发生PPH的保护性因素,据此构建的GDM患者发生PPH预测模型区分度、校准度及预测效能良好,临床实用性较高。
Objective:To identify the risk factors for postpartum hemorrhage(PPH)in patients with gestational diabetes mellitus(GDM)and to develop and validate a predictive model.Methods:A retrospective study was conducted on GDM patients who delivered at The Third Affiliated Hospital of Zhengzhou University between January 2021 and December 2023.A total of 137 GDM patients with PPH were included in the case group,and 190 GDM patients without PPH were included in the control group.Univariate analysis and multivariate Logistic regression analysis were used to identify independent risk factors for PPH in GDM patients.Anomogram prediction model was subsequently constructed.The predictive performance of the model was evaluated by the Hosmer-Leme-show goodness-of-fit test,receiver operating characteristic(ROC)curve,Bootstrap resampling method,and decision curve analysis(DCA).Results:Univariate analysis revealed statistically significant differences between the two groups in multiple factors(P<0.05),including age≥35 years,pre-pregnancy body mass index(BMI)≥24 kg/m^(2),suboptimal glycemic control,assisted reproduction,gestational anemia,polyhydramnios,macrosomia,acute chorioamnionitis,gestational hypertension,prenatal fasting blood glucose(FBG),prenatal glycosylated hemoglobin(HbA1c),fibrinogen(FIB),postpartum blood loss,dystocia,neonatal admission to ICU,neonatal Apgar score at 1 minute,and Apgar score at 5 minutes.Multivariate Logistic regression analysis indicated that age≥35 years,pre-pregnancy BMI≥24 kg/m^(2),suboptimal glycemic control,gestational anemia,macrosomia,polyhydramnios,and elevated prenatal HbA1c levels were independent risk factors for PPH(OR>1,P<0.05),while elevated FIB levels were identified as a protective factor for PPH(OR<1,P<0.05).The nomogram demonstrated good calibration(Hosmer-Lemeshow test:χ^(2)=6.367,DF=8,P=0.606).The area under the ROC curve(AUC)was 0.821(95%CI 0.774-0.868),with a sensitivity of 71.5%and a specificity of 83.7%,indicating good discriminative ability of the model.Internal validation using the Bootstrap resampling method showed a C-index of 0.821,suggesting good consistency and predictive accuracy.DCA curve further confirmed that the model had favorable clinical application value.Conclusions:age≥35 years,pre-pregnancy BMI≥24 kg/m^(2),suboptimal glycemic control,gestational anemia,macrosomia,polyhydramnios,and elevated prenatal HbA1c levels are independent risk factors for PPH in GDM patients,while elevated FIB levels are identified as an independent protective factor.The constructed prediction model for PPH in GDM patients exhibits good discriminative ability,calibration,and predictive performance,demonstrating high clinical application value.
作者
韩宁
王一展
常鑫媛
闫康禄
杨柳
原子莉
李晴晴
HAN Ning;WANG Yizhan;CHANG Xinyuan(Department of Obstetrics and Gynecology,The Third Affiliated Hospital of Zhengzhou University,Zhengzhou Henan 450052,China)
出处
《实用妇产科杂志》
北大核心
2025年第11期928-934,共7页
Journal of Practical Obstetrics and Gynecology
基金
河南省科技攻关计划(编号:222102310129,252102310201)。
关键词
妊娠期糖尿病
产后出血
危险因素
列线图
Gestational diabetes mellitus
Postpartum hemorrhage
Risk factors
Nomogram
