Induction factors of hypotension during cesarean section for perilous placenta previa under combined spinal-epidural anesthesia and construction of a nomogram prediction model
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摘要:目的
探讨腰硬联合麻醉(CSEA)下凶险性前置胎盘剖宫产术中低血压发生的诱导因素并构建列线图预测模型。
方法选取玉林市妇幼保健院2020年1月—2023年12月收治的腰硬联合麻醉(CSEA)下凶险性前置胎盘剖宫产术产妇130例作为研究对象，采用自编的一般资料调查表对研究对象基本资料及低血压发生情况进行调查，并依据术中低血压发生情况将其分为低血压组47例和无低血压组83例。对2组一般资料进行单因素分析，采用多因素Logistic回归分析法探讨术中发生低血压的诱导因素。
结果单因素分析显示, 2组体质量指数、麻醉平面情况、是否为多胎妊娠、术前收缩压情况、手术时间、是否出现Bezold-Jarisch反射比较，差异有统计学意义(P < 0.05)。多因素Logistic回归分析显示，体质量指数≥24 kg/m2、麻醉平面≥T8、多胎妊娠、术前收缩压 < 90 mmHg、手术时间>1.5 h、出现Bezold-Jarisch反射是CSEA下凶险性前置胎盘产妇剖宫产术中发生低血压的独立危险因素(P < 0.05)。构建CSEA下凶险性前置胎盘剖宫产术中低血压发生的诱导因素回归方程: Logit(P)=-23.211+1.079×(体质量指数≥24 kg/m2)+1.101×麻醉平面(≥ T8)+3.193×多胎妊娠+2.214×术前收缩压(< 90 mmHg)+4.606×手术时间(>1.5 h)+2.011×出现Bezold-Jarisch反射。分析发现列线图对于存在术前收缩压 < 90 mmHg人群均有较高区分度及准确度; 对列线图模型进行Bootstrap重复抽样1 000次, 获得校准曲线，计算得到的一致性指数为0.850, 说明该列线图模型具备较好的校准度; 绘制受试者工作特征(ROC)曲线，其曲线下面积为0.896, 95%CI为0.802~0.956, 提示预测效能较好。
结论体质量指数≥24 kg/m2、麻醉平面≥T8、多胎妊娠、术前收缩压 < 90 mmHg、手术时间>1.5 h、出现Bezold-Jarisch反射是CSEA下凶险性前置胎盘产妇剖宫产术中低血压发生的诱导因素。
Abstract:ObjectiveTo investigate the induction factors of hypotension during cesarean section for perilous placenta previa under combined spinal-epidural anesthesia (CSEA) and to construct a nomogram prediction model.
MethodsA total of 130 parturients who underwent cesarean section for perilous placenta previa under CSEA from January 2020 to December 2023 in Yulin Maternity and Child Healthcare Hospital were selected as study subjects. A self-designed general information questionnaire was used to investigate the basic information and the occurrence of hypotension of the subjects. According to the occurrence of intraoperative hypotension, the patients were divided into hypotension group (47 cases) and non-hypotension group (83 cases). Univariate analysis was performed on the general information of the two groups, and multivariate Logistic regression analysis was used to explore the induction factors of intraoperative hypotension.
ResultsUnivariate analysis showed that there were statistically significant differences in body mass index, anesthesia level, presence of multiple pregnancy, preoperative systolic blood pressure, operative time, and the occurrence of Bezold-Jarisch reflex between the two groups (P < 0.05). Multivariate Logistic regression analysis revealed that body mass index≥ 24 kg/m2, anesthesia level was in the eighth thoracic vertebra(T8) or above, multiple pregnancy, preoperative systolic blood pressure < 90 mmHg, operative time >1.5 h, and the occurrence of Bezold-Jarisch reflex were independent risk factors for hypotension during cesarean section for perilous placenta previa under CSEA (P < 0.05). A regression equation for the induction factors of hypotension during cesarean section for perilous placenta previa under CSEA was constructed: Logit(P)=-23.211+1.079×(body mass index ≥ 24 kg/m2)+1.101×anesthesia level (≥T8)+3.193×multiple pregnancy+2.214×preoperative systolic blood pressure (< 90 mmHg)+4.606×operative time (>1.5 h)+2.011×occurrence of Bezold-Jarisch reflex. The nomogram showed high discrimination and accuracy for patients with preoperative systolic blood pressure < 90 mmHg. After 1, 000 times of Bootstrap resampling for the nomogram model, a calibration curve was obtained, and the consistency index was calculated as 0.850, indicating good calibration of the nomogram model. The receiver operating characteristic (ROC) curve was plotted, with an area under the curve of 0.896 and 95% confidence interval of 0.802 to 0.956, suggesting good predictive performance.
ConclusionBody mass index ≥24 kg/m2, anesthesia level ≥ T8, multiple pregnancy, preoperative systolic blood pressure < 90 mmHg, operative time >1.5 h, and the occurrence of Bezold-Jarisch reflex are induction factors for hypotension during cesarean section for perilous placenta previa under CSEA.
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表 1 2组CSEA下凶险性前置胎盘剖宫产产妇一般资料比较(x ±s)[n(%)]
一般资料 分类 低血压组(n=47) 无低血压组(n=83) χ2/t P 年龄/岁 28.46±2.31 28.67±2.59 0.461 0.465 孕周/周 39.78±1.52 40.02±1.37 0.922 0.358 体质量指数 < 24 kg/m2 18(38.30) 58(69.88) 12.325 < 0.001 ≥24 kg/m2 29(61.70) 25(30.12) ASA分级 Ⅰ级 23(48.94) 40(48.19) 0.007 0.935 Ⅱ级 24(51.06) 43(51.81) 麻醉平面情况 < T8 17(36.17) 55(66.27) 10.999 0.001 ≥T8 30(63.83) 28(33.73) 羊水情况 >500 mL 29(61.70) 53(63.86) 0.060 0.807 ≤500 mL 18(38.30) 30(36.14) 胎儿体质量 >4 kg 14(29.79) 22(26.51) 0.161 0.688 ≤4 kg 33(70.21) 61(73.49) 是否贫血 否 36(76.60) 63(75.90) 0.008 0.929 是 11(23.40) 20(24.10) 吸烟史 有 1(2.13) 2(2.41) 0.011 0.918 无 46(97.87) 81(97.59) 饮酒史 有 5(10.64) 8(9.64) 0.033 0.855 无 42(89.36) 75(90.36) 多胎妊娠 否 38(80.85) 78(93.98) 5.379 0.020 是 9(19.15) 5(6.02) 合并妊娠期糖尿病 否 38(80.85) 62(74.70) 0.640 0.424 是 9(19.15) 21(25.30) 术前收缩压情况 ≥90 mmHg 18(38.30) 56(67.47) 10.414 0.001 < 90 mmHg 29(61.70) 27(32.53) 距前次剖宫产时间 < 2年 16(34.04) 26(31.33) 0.101 0.750 ≥2年 31(65.96) 57(68.67) 手术时间 < 1.5 h 19(40.43) 59(71.08) 11.753 < 0.001 ≥1.5 h 28(59.57) 24(28.92) 出现Bezold-Jarisch反射 否 16(34.04) 54(65.06) 11.617 0.001 是 31(65.96) 29(34.94) CSEA: 腰硬联合麻醉; ASA: 美国麻醉师协会。 
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表 2 变量赋值表
自变量 赋值 体质量指数 <24 kg/m2=0, ≥24 kg/m2=1 麻醉平面情况 < T8=0, ≥T8=1 是否为多胎妊娠 否=0, 是=1 术前收缩压情况 ≥90 mmHg=0, < 90 mmHg=1 手术时间 ≤1.5 h=0, >1.5 h=1 是否出现Bezold-Jarisch反射 否=0, 是=1
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表 3 CSEA下凶险性前置胎盘产妇剖宫产术中低血压发生的危险因素及Logistic回归模型
变量 分类 β SE Wald χ2 P OR 95%CI 体质量指数 ≥24 kg/m2 1.079 0.347 19.083 < 0.001 2.942 1.561~8.211 < 24 kg/m2* — — — — — — 麻醉平面情况 ≥T8 1.101 0.421 6.840 0.009 3.006 1.982~8.621 < T8* — — — — — — 多胎妊娠 是 3.193 1.198 7.109 0.008 24.366 2.330~23.212 否* — — — — — — 术前收缩压情况 < 90 mmHg 2.214 0.633 12.217 < 0.001 9.150 2.644~31.660 ≥90 mmHg* — — — — — — 手术时间 >1.5 h 4.606 1.181 15.200 < 0.001 18.211 3.212~56.211 ≤1.5 h* — — — — — — 出现Bezold-Jarisch反射 是 2.011 0.621 10.486 < 0.001 8.211 2.801~10.456 否* — — — — — — * 提示与该分类项进行对照。
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