血栓弹力图联合全身免疫炎症指数对阴道分娩产后出血的预测价值

doi:10.11958/20253593

摘要/Abstract

摘要：

目的探讨血栓弹力图（TEG）联合全身免疫炎症指数（SII）对阴道分娩产后出血（PPH）的临床预测价值。方法回顾性选取本院阴道分娩的PPH产妇199例，包括PPH组（48例）和非PPH组（151例），比较2组产妇一般临床资料、凝血功能指标、血常规指标、TEG参数及SII水平；通过受试者工作特征（ROC）曲线分析TEG参数、SII水平及联合检测对PPH的预测价值，采用多因素Logistic回归分析影响PPH发生的独立危险因素。结果与非PPH组相比，PPH组的既往PPH史、妊娠期高血压、妊娠期糖尿病、产前贫血、使用催产素、器械助产、胎盘剥离异常发生率更高，凝血酶原时间（PT）、活化部分凝血活酶时间（APTT）更长，白细胞计数（WBC）、中性粒细胞计数（NEUT）及SII水平更高，而淋巴细胞计数（LYM）、血红蛋白（Hb）、血小板计数（PLT）更低（均P<0.05）；PPH组凝固时间（K值）显著高于非PPH组，而最大振幅（MA值）、凝血指数（CI值）显著低于非PPH组（均P<0.01）；ROC曲线分析表明，K值、MA值、CI值、SII及四者联合预测PPH的曲线下面积（AUC）分别为0.706、0.795、0.746、0.766和0.917；联合预测的效能最高，其敏感度为81.63%，特异度为91.49%；多因素Logistic回归分析表明，K值、SII升高是PPH发生的独立危险因素（P<0.05），MA值、CI值升高是PPH发生的独立保护因素（P<0.05）。结论 TEG参数和SII与阴道分娩PPH的发生密切相关，两者联合检测对PPH具有良好的预测价值。

关键词: 产后出血, 血栓弹力描记术, ROC曲线, 全身免疫炎症指数

Abstract:

Objective To investigate the clinical predictive value of thromboelastography (TEG) combined with systemic immune-inflammation index (SII) for postpartum hemorrhage (PPH) in vaginal delivery. Methods A total of 199 puerperae undergoing vaginal delivery in our hospital were retrospectively enrolled, and they were divided into the PPH group (48 cases) and the non-PPH group (151 cases) according to inclusion and exclusion criteria. General clinical data, coagulation function indicators, blood routine indicators, TEG parameters and SII levels were compared between the two groups. The predictive value of TEG parameters, SII levels and their combined detection for PPH was analyzed by receiver operating characteristic (ROC) curve, and multivariate Logistic regression analysis was performed to identify independent risk factors for PPH. Results Compared with the non-PPH group, there were higher incidence of previous PPH history, pregnancy induced hypertension, pregnancy induced diabetes, prenatal anemia, oxytocin use, instrument assisted delivery and abnormal placental exfoliation in the PPH group, and longer prothrombin time (PT), activated partial thromboplastin time (APTT), higher levels of white blood cell count (WBC), neutrophil count (NEUT) and SII, and lower lymphocyte count (LYM), hemoglobin (Hb) and platelet count (PLT) in the PPH group (all P<0.05). The solidification time (K) in the PPH group was significantly higher than that in the non PPH group, while the maximum amplitude (MA) and coagulation index (CI) were significantly lower than those in the non PPH group (all P<0.01). ROC curve analysis showed that the area under the curve (AUC) for predicting PPH using K value, MA value, CI value, SII and their combined values were 0.706, 0.795, 0.746, 0.766 and 0.917, respectively. The efficiency of joint prediction is the highest, with a sensitivity of 81.63% and a specificity of 91.49%. Multivariate Logistic regression analysis revealed that elevated K value and SII were independent risk factors for PPH (all P<0.05), while elevated MA value and CI value were independent protective factors for PPH (P<0.05). Conclusion TEG parameters and SII are closely related to the occurrence of postpartum hemorrhage during vaginal delivery. The combined detection of the two has good predictive value for PPH.

Key words: postpartum hemorrhage, thrombelastography, ROC curve, systemic immune inflammatory index

中图分类号:

R714

图/表 5

参考文献 17

[1]	Patek K, Friedman P. Postpartum hemorrhage-epidemiology,risk factors,and causes[J]. Clin Obstet Gynecol, 2023, 66(2):344-356. doi:10.1097/GRF.0000000000000782.
[2]	Kou X, Li Q, Pan Z, et al. Coagulation indices for predicting hypertensive pregnancy disorders[J]. Am J Transl Res, 2025, 17(2):1106-1113. doi:10.62347/NBXU9802.
[3]	Kim S, Sohn C H, Kwon H, et al. Thromboelastography as an early prediction method for hypofibrinogenemia in emergency department patients with primary postpartum hemorrhage[J]. Scand J Trauma Resusc Emerg Med, 2024, 32(1):85. doi:10.1186/s13049-024-01263-5.
[4]	Perelman A D, Limaye M, Blakemore J, et al. Thromboelastography versus standard coagulation assays in patients with postpartum hemorrhage[J]. Am J Perinatol, 2024, 41(S01):e911-e916. doi:10.1055/a-1974-5055.
[5]	Zhao Y, Shao W, Zhu Q, et al. Association between systemic immune-inflammation index and metabolic syndrome and its components:results from the National Health and Nutrition Examination Survey 2011-2016[J]. J Transl Med, 2023, 21(1):691. doi:10.1186/s12967-023-04491-y.
[6]	Oben A G, Johnson B M, Tita A T N, et al. A systematic review of biomarkers associated with maternal infection in pregnant and postpartum women[J]. Int J Gynaecol Obstet, 2022, 157(1):42-50. doi:10.1002/ijgo.13747.
[7]	Liu C, Yu F, Xu Y, et al. Prevalence and risk factors of severe postpartum hemorrhage:a retrospective cohort study[J]. BMC Pregnancy Childbirth, 2021, 21(1):332. doi:10.1186/s12884-021-03818-1.
[8]	Yang C, Wu H. Establishment and validation of risk prediction model for postpartum hemorrhage for pregnant women ≥35 years of age in natural delivery[J]. Altern Ther Health Med, 2023, 29(8):876-881.
[9]	Ugwudike B, Kwok M. Update on gestational diabetes and adverse pregnancy outcomes[J]. Curr Opin Obstet Gynecol, 2023, 35(5):453-459. doi:10.1097/GCO.0000000000000901.
[10]	Collis R, Bell S. The role of thromboelastography during the management of postpartum hemorrhage:background,evidence,and practical application[J]. Semin Thromb Hemost, 2023, 49(2):145-161. doi:10.1055/s-0042-1757895.
[11]	Zhu X, Tang J, Huang X, et al. Diagnostic value of fibrinogen combined with thromboelastogram in postpartum hemorrhage after vaginal delivery[J]. Am J Transl Res, 2022, 14(3):1877-1883.
[12]	曹馨元, 李善凤, 任新萍, 等. 妊娠高血压孕产妇产前血清TIMP-1、TGF-β1与血栓弹力图预测产后出血的价值分析[J]. 中国现代医学杂志, 2025, 35(13):18-23.
	Cao X Y, Li S F, Ren X P. Predictive value of prenatal tissue inhibitor of matrix metalloproteinase 1,transforming growth factor-β1,and thromboelastography for postpartum hemorrhage in hypertensive pregnancies[J]. China Journal of Modern Medicine, 2025, 35(13):18-23. doi:10.3969/j.issn.1005-8982.2025.13.004.
[13]	李莉. 高龄剖宫产孕妇产前血浆纤维蛋白原及血栓弹力图参数对产后出血的预测价值[J]. 临床医学, 2024, 44(5):9-12.
	Li L. Predictive value of prenatal plasma fibrinogen and thrombus elastogram parameters for postpartum hemorrhage in elderly women with cesarean section[J]. Clinical Medicine, 2024, 44(5):9-12. doi:10.19528/j.issn.1003-3548.2024.05.003.
[14]	蒋晓颖, 周密, 席岚, 等. 血栓弹力图技术指导产后出血大量输血治疗及对临床预后的影响[J]. 中国计划生育学杂志, 2020, 28(4):596-600.
	Jiang X Y, Zhou M, Xi L, et al. The value of thrombelastography for guiding massive transfusion in postpartum hemorrhage treatment and its influence on the clinical prognosis[J]. Chin J Fam Plann, 2020, 28(4):596-600. doi:10.3969/j.issn.1004-8189.2020.04.034.
[15]	张蕾, 李智伟, 王福珍, 等. 外周血系统性免疫炎症指数在组织学绒毛膜羊膜炎中的诊断及不良妊娠结局的预测价值[J]. 实用妇产科杂志, 2023, 39(11):865-869.
	Zhang L, Li Z W, Wang F Z, et al. Diagnostic value of peripheral blood systemic immune inflammatory index in histological chorioamnionitis and prediction of adverse pregnancy outcomes[J]. Journal of Practical Obstetrics and Gynecology,2023, 39(11):865-869. doi:10.3969/j.issn.1003-6946(2023)11-0865-05.
[16]	Akay E, DonbalioğLu G Ş, Yeniocak A S, et al. Prognostic evaluation of systemic immune inflammatory index and hematological parameters in postpartum hemorrhage:a retrospective analysis[J]. Ginekol Pol, 2025, 96(4):287-293. doi:10.5603/gpl.100739.
[17]	Cao P, Ji L, Qiao C. Nomogram based on clinical characteristics and ultrasound indicators for predicting severe postpartum hemorrhage in patients with anterior placenta previa combined with previous cesarean section:a retrospective case-control study[J]. BMC Pregnancy Childbirth, 2024, 24(1):572. doi:10.1186/s12884-024-06706-6.

组别				n		年龄/岁				孕周/周			BMI/（kg/m²）							既往流产史
非PPH组				151		28.56±3.82				39.01±1.05			24.56±2.18							12（7.95）
PPH组				48		29.35±3.17				38.87±1.12			25.12±2.35							7（14.58）
t或χ²						1.429				0.813			1.526							1.857
组别					既往 PPH史			妊娠期高血压				妊娠期糖尿病				产前贫血					产程时间/h
非PPH组					2（1.32）			14（9.27）				15（9.93）				25（16.56）					8.53±3.15
PPH组					5（10.42）			13（27.08）				11（22.92）				17（29.17）					9.24±3.52
t或χ²					8.872^＊			9.854^＊＊				5.405^＊				7.781^＊					0.003
组别	羊水异常						巨大儿				使用催产素				器械助产			胎盘剥离异常
非PPH组	13（8.61）						25（16.56）				26（21.19）				32（21.19）			13（8.61）
PPH组	9（18.75）						7（14.58）				19（39.58）				21（43.75）			11（22.92）
χ²	3.809						0.105				10.410^＊				9.485^＊			7.985^＊
组别			新生儿体质量/g							PT/s				APTT/s			WBC（×10⁹/L）
非PPH组			3295.42±352.16							12.15±0.58				30.24±1.85			9.25±1.06
PPH组			3402.50±398.74							12.86±0.72				32.67±2.13			10.68±1.56
t			1.776							6.938^＊＊				7.637^＊＊			5.929^＊
组别		LYM（×10⁹/L）							NEUT（×10⁹L）					Hb（g/L）					PLT（×10⁹/L）
非PPH组		2.15±0.48							6.24±1.06					117.36±8.42					210.18±32.15
PPH组		1.62±0.42							7.19±1.13					108.65±9.17					169.42±28.67
t		6.857^＊＊							5.322^＊＊					6.107^＊＊					7.846^＊＊

组别				n		年龄/岁				孕周/周			BMI/（kg/m²）							既往流产史
非PPH组				151		28.56±3.82				39.01±1.05			24.56±2.18							12（7.95）
PPH组				48		29.35±3.17				38.87±1.12			25.12±2.35							7（14.58）
t或χ²						1.429				0.813			1.526							1.857
组别					既往 PPH史			妊娠期高血压				妊娠期糖尿病				产前贫血					产程时间/h
非PPH组					2（1.32）			14（9.27）				15（9.93）				25（16.56）					8.53±3.15
PPH组					5（10.42）			13（27.08）				11（22.92）				17（29.17）					9.24±3.52
t或χ²					8.872^＊			9.854^＊＊				5.405^＊				7.781^＊					0.003
组别	羊水异常						巨大儿				使用催产素				器械助产			胎盘剥离异常
非PPH组	13（8.61）						25（16.56）				26（21.19）				32（21.19）			13（8.61）
PPH组	9（18.75）						7（14.58）				19（39.58）				21（43.75）			11（22.92）
χ²	3.809						0.105				10.410^＊				9.485^＊			7.985^＊
组别			新生儿体质量/g							PT/s				APTT/s			WBC（×10⁹/L）
非PPH组			3295.42±352.16							12.15±0.58				30.24±1.85			9.25±1.06
PPH组			3402.50±398.74							12.86±0.72				32.67±2.13			10.68±1.56
t			1.776							6.938^＊＊				7.637^＊＊			5.929^＊
组别		LYM（×10⁹/L）							NEUT（×10⁹L）					Hb（g/L）					PLT（×10⁹/L）
非PPH组		2.15±0.48							6.24±1.06					117.36±8.42					210.18±32.15
PPH组		1.62±0.42							7.19±1.13					108.65±9.17					169.42±28.67
t		6.857^＊＊							5.322^＊＊					6.107^＊＊					7.846^＊＊

组别		n	R值/min		K值/min		α角/°
非PPH组		151	6.23±1.05		1.98±0.42		60.54±6.32
PPH组		48	6.49±1.56		2.52±0.68		58.67±5.89
t			1.100		12.397^＊＊		1.817
组别	MA值/mm			CI值		SII
非PPH组	60.31±7.09			1.25±0.36		589.42±125.68
PPH组	53.76±6.73			0.89±0.45		723.76±189.35
t	5.645^＊＊			5.660^＊＊		5.651^＊＊

组别		n	R值/min		K值/min		α角/°
非PPH组		151	6.23±1.05		1.98±0.42		60.54±6.32
PPH组		48	6.49±1.56		2.52±0.68		58.67±5.89
t			1.100		12.397^＊＊		1.817
组别	MA值/mm			CI值		SII
非PPH组	60.31±7.09			1.25±0.36		589.42±125.68
PPH组	53.76±6.73			0.89±0.45		723.76±189.35
t	5.645^＊＊			5.660^＊＊		5.651^＊＊

指标	截断值	AUC	95%CI	约登指数	特异度/%	敏感度/%
K值	2.16 min	0.706	0.604~0.795	0.373	63.83	73.47
MA值	56.31 mm	0.795	0.700~0.870	0.523	80.85	71.43
CI值	0.81	0.746	0.646~0.829	0.445	89.36	55.10
SII	771.92	0.766	0.669~0.847	0.447	95.74	48.98
联合预测	-	0.917	0.843~0.964	0.731	91.49	81.63