Holley J L, Bernardini J, Quadri K H, Greenberg A, Laifer S A
Renal-Electrolyte Division, University of Pittsburgh Medical Center, PA, USA.
Clin Nephrol. 1996 Feb;45(2):77-82.
Assessment and comparison of pregnancy outcomes in women with renal disease and women with high risk pregnancies due to medical illness without renal disease.
A prospective, matched controlled study.
The High Risk Obstetrical Clinics of Magee Women's Hospital, a primary and referral center where approximately 9,500 deliveries occur per year.
Two groups of pregnant women, all identified in the first trimester. The study group included 43 pregnancies in 40 women with renal disease as defined by: 1) known renal disease antedating pregnancy, 2) prepregnant proteinuria > or = 150 mg/24 hours, or 3) first trimester serum creatinine > or = 0.8 mg/dl or proteinuria > or = 300 mg/24 hours. The 43 controls included women with medical problems other than renal disease that placed them at high obstetrical risk. Control women were matched to study women for parity, advanced maternal age, race, and insulin-dependent diabetes mellitus.
For all patients, blood pressure was recorded once at approximately 10, 20, and 30 weeks gestation. For study patients, serum creatinine, 24-hour urinary protein, and creatinine clearance were obtained at least once in each trimester. Pregnancy outcomes were recorded as favorable if gestation was > or = 36 weeks and without evidence of intrauterine growth retardation. Adverse pregnancy outcomes included prematurity, intrauterine growth retardation, intrauterine fetal death, spontaneous abortion, or neonatal death.
Forty-two percent of study and control patients were diabetic. First trimester renal function was normal (creatinine < 0.8 mg/dl) in 12 study patients, mildly impaired in 24 (creatinine 0.8-1.4 mg/dl) and moderately impaired in 5 (creatinine > or = 1.4 mg/dl). Compared with controls, first and third trimester hypertension was more prevalent in the study patients (p = 0.003, p = 0.012); overall mean blood pressure was also higher in study patients (92 +/- 11 mmHg vs 85 +/- 8 mmHg, p = 0.002). The mean gestational age was shorter in the study patients (33.4 +/- 6.9 weeks vs 37.2 +/- 4 weeks, p = 0.001). Overall pregnancy loss was more common in the study patients (14/43 vs 3/43, p = 0.003) with spontaneous abortion contributing half of those pregnancy losses (7/14). Hypertension in any trimester was associated with adverse pregnancy outcome in study but not control patients. In the subset of study patients, adverse fetal outcome was directly associated with degree of renal dysfunction and proteinuria.
Pregnancy outcome in women with renal disease was significantly worse than in the control group and showed no improvement over retrospective reports from the 1970's and 1980's. Specifically, fetal deaths were more common in women with renal disease and were predicted by proteinuria and the degree of renal dysfunction. The uncommonly low number of spontaneous abortions in the control group may have contributed to the worse fetal outcome in the study patients compared with controls. Women with diabetes mellitus and hypertension are at particularly high risk for relatively poor pregnancy outcome. These higher risks should be discussed when counseling women with renal disease who contemplate pregnancy.
评估并比较肾病女性与因非肾病性内科疾病导致高危妊娠的女性的妊娠结局。
一项前瞻性配对对照研究。
马吉妇女医院高危产科诊所，这是一家每年约有9500例分娩的主要及转诊中心。
两组孕妇，均在孕早期确定。研究组包括40名患有肾病的女性的43次妊娠，肾病定义为：1）妊娠前已知的肾病；2）孕前蛋白尿≥150mg/24小时；或3）孕早期血清肌酐≥0.8mg/dl或蛋白尿≥300mg/24小时。43名对照组女性患有除肾病外的其他内科疾病，这些疾病使她们处于高危产科状态。对照女性在产次、高龄产妇、种族和胰岛素依赖型糖尿病方面与研究女性相匹配。
对所有患者，在妊娠约10、20和30周时各记录一次血压。对于研究患者，在每个孕期至少获取一次血清肌酐、24小时尿蛋白和肌酐清除率。如果孕周≥36周且无宫内生长受限证据，则将妊娠结局记录为良好。不良妊娠结局包括早产、宫内生长受限、宫内胎儿死亡、自然流产或新生儿死亡。
42%的研究组和对照组患者患有糖尿病。12名研究患者孕早期肾功能正常（肌酐<0.8mg/dl），24名轻度受损（肌酐0.8 - 1.4mg/dl），5名中度受损（肌酐≥1.4mg/dl）。与对照组相比，研究组患者孕早期和孕晚期高血压更为普遍（p = 0.003，p = 0.012）；研究组患者总体平均血压也更高（92±11mmHg对85±8mmHg，p = 0.002）。研究组患者的平均孕周较短（33.4±6.9周对37.2±4周，p = 0.001）。研究组患者总体妊娠丢失更常见（14/43对3/43，p = 0.003），其中自然流产占妊娠丢失的一半（7/14）。任何孕期的高血压在研究组患者中与不良妊娠结局相关，但在对照组患者中并非如此。在研究组患者亚组中，不良胎儿结局与肾功能不全程度和蛋白尿直接相关。
肾病女性的妊娠结局明显比对照组差，且与20世纪70年代和80年代的回顾性报告相比没有改善。具体而言，肾病女性胎儿死亡更常见，且可由蛋白尿和肾功能不全程度预测。对照组自然流产数量异常低可能导致研究组患者与对照组相比胎儿结局更差。患有糖尿病和高血压的女性妊娠结局相对较差的风险尤其高。在为考虑妊娠的肾病女性提供咨询时，应讨论这些更高的风险。
