系统性红斑狼疮合并妊娠145例次母婴结局及临床预测因素

目的 总结系统性红斑狼疮(SEE)合并妊娠的母婴结局,分析妊娠期问SLE病情恶化、胎儿丢失、不良胎儿结局的预测因素.方法 回顾性分析1990年1月至2007年12月在北京协和医院和深圳市人民医院住院的SEE合并妊娠临床资料.结果 120例SEE合并妊娠145例次,妊娠时年龄18～4I岁,平均(28±4)岁,SEE病程0.5～18年,平均(5±4)年.共有46例次(31.7%)妊娠期间SLE病情恶化,主要在妊娠中、晚期,常累及皮肤黏膜及关节肌肉系统.妊娠期间SEE病情恶化与妊娠前病情活动及低补体血症有关(P＜0.05).妊娠前病情活动组子痫前期及子痫的发生率明显高于病情稳定组(P＜0.01).共成功分娩104例次(71.7%,其中双胞胎2例),18例次自然流产(12.4%),10例次死产(6.9%),13例次治疗性流产(9.0%).早产36例次(34.6%),新生儿出现宫内生长迟缓(IUGR)37例次(35.6%).胎儿丢失(包括自然流产及死产)的危险因素有合并抗磷脂综合征(APS)、妊娠前病情活动(P＜0.05);引起不良胎儿结局(包括早产或IUGR)的危险因素有妊娠前抗dsDNA抗体阳性、泼尼松剂量≥10 mg/d及妊娠期间SLE病情恶化(P＜0.05).21例患者行胎盘病理学检查,其中13例发现胎盘组织血管壁纤维素样坏死、梗死表现,该组患者抗磷脂抗体阳性率明显高于胎盘病理基本健康组(P＜0.05).结论 妊娠前SEE病情活动、低补体血症与SEE妊娠期间SEE病情恶化相关.合并APS、妊娠前病情活动使胎儿丢失的危险性增加,而妊娠前抗dsDNA抗体阳性、泼尼松剂量≥10 mg/d及妊娠期间SLE病情恶化使不良胎儿结局的危险性增加.

Clinical preditors of maternal and fetal outcome of 145 pregnancies in patients with systemic lupus erythematosus

Objective To summarize the maternal and fetal outcomes of pregnancies of patients with systemic lupus erythematosus (SLE) and to evaluate the clinical predictors of SLE exacerbations,fetal loss and poor fetal outcome.MethodsOne hundred and forty five pregnancies in 120 SLE patients treated between January 1990 and December 2007 in Peking Union Medical College Hospital and Shenzhen People's Hospital were investigated retrospectively.Results One hundred and twenty cases of SLE patients had 145 pregnancies in total,their gestational age was 18 to 41 (282±4) years old and the duration of SLE was (5±4) years (0.5 to 18 years).SLE exacerbation occurred in 46 pregnancies (31.7%),mostly in the second and third trimester of pregnancy.The mucocutaneous and musculoskeletal system involvement were common.SLE exacerbation during pregnancy was related to the SLE disease activity and hypocomplementemia before pregnancy (P＜0.05).The frequency of pre-eclampsia and eclampsia in patients whose SLE was active before pregnancy was significantly higher than those whose lupus was stable before pregnancy(P＜0.01).There were 104 cases of successful delivery (71.7%,2 twin birth),18 cases of spontaneous abortion (12.4%),10 cases of stillbirth (6.9%) and 13 cases of therapeutic abortion (9.0%).Of the live-born infant births,36 cases were premature (34.6%),37 had suffered intrauterine growth retardation (IUGR) (35.6%).The predictors of fetal loss (including spontaneous abortion and stillbirth) included antiphospholipid syndrome (APS) and active SLE before pregnancy (P＜0.05).The predictors of poor fetal outcome (including prematurity or IUGR) included positive anti-dsDNA antibodies,≥10 mg/d dosage of prednisone prior to pregnancy and SLE exacerbation during pregnancy (P＜0.05).Of the 21 placenta examined pathologically,the typical fibrinoid vascular necrosis and vascular infarction was found in 13 placentas.The percentage of positive antiphos-pholipid antibody in patients with typical fibrinoid vascular necrosis and vascular infarction in their placentas was significantly higher than those with normal placentas (P＜0.05).ConclusionThe active SLE and hypocomplementemia before pregnancy in patients with SLE are associated with SLE exacerbation during pregnancy.The combined APS and active SLE before pregnancy increases the risk of fetal loss,while positive anti-dsDNA antibody,≥10 mg/d dosage of prednisone before pregnancy and SLE exacerbation during pregnancy increase the risk of poor fetal outcome.