早孕期甲状腺疾病筛查模式探讨  

One-step or two-step screening for thyroid diseases during early pregnancy： which is better？

作　　者：张莉[1,4] 孙伟杰[1] 高莹[2] 朱赛楠[3] 黄有媛[2] 张杨[2] 杨慧霞[1] 

机构地区：[1]北京大学第一医院妇产科,100034 [2]北京大学第一医院内分泌科,100034 [3]北京大学第一医院医学统计科,100034 [4]北京市大兴区妇幼保健院妇产科,102600

出　　处：《中华围产医学杂志》2016年第3期182-187,共6页Chinese Journal of Perinatal Medicine

摘　　要：目的探讨早孕期孕妇甲状腺疾病的适宜筛查模式。方法2013年9月1日至2014年9月30日在北京大学第一医院产科建档并分娩，且早期在我院筛查甲状腺功能的4044例孕妇，孕期均采用一步法[同时筛查促甲状腺激素（thyroid stimulating hormone，TSH）、游离甲状腺素（free thyroxine，FL）和甲状腺过氧化物酶抗体（thyroid peroxidase antibody，TPOAb）]进行甲状腺疾病筛查。本研究将这4044例孕妇的筛查结果按照两步法（先筛查TSH，异常者再检测FT4和TPOAb）进行模拟分析，以不同的界值[美国甲状腺学会（American Thyroid Association，ATA）推荐的和本单位特异的参考范围（0．23～4．08mU／L）]，比较2种筛查模式（一步法和两步法）诊断的甲状腺疾病的患病率、漏治率、漏诊者的妊娠结局、筛查费用等。根据TSH水平将4044例孕妇分为3组：TSH≥0.1-〈2．5mU／L组、TSH≥2．5～〈4．08mU／L组和TSH≥4．08mU／L组，比较3组TPOAb阳性率。采用埔金验、z。检验或精确概率检验进行统计学分析。结果（1）一步法筛查结果：采用A]脯推荐的参考范围时，需要治疗者占7．9％（320／4044），显著高于以本单位特异的参考范围时的3．2％（128／4044）。TSH≥0．1～〈2．5mU／L组、TSH≥2．5～〈4．08mU／L组和TSH≥4．08mU／L组的TPOAb阳性率分别为7．2％（214／2976）、13．9％（103／777）和28．6％（55／192）。以TSH≥0．1～〈2．5mU／L组TPoAb阳性的OR值设为1时，TSH≥2．5～〈4．08mU／L组和TSH≥4．08mU／L组的OR值分别为1．972（95％CI：1．537～2．532）和5．181（95％CI：3．679～7．297）。（2）模拟两步法进行甲状腺疾病筛查，采用ATA推荐的参考范围时，漏治率为O．7％（27／4044），较一步法节约费用312480元，人均节约77．27元；采用本单位特异的参考范围时的漏治率为1．1％（45／4044），较一步法节约费用384720元，人均Objective To investigate the appropriate screening method for thyroid diseases during early pregnancy. Methods We collected information of 4 044 pregnant women who attended to the Department of Obstetrics and Gynecology of Peking University First Hospital from September 1, 2013 to September 30, 2014 for antenatal care and underwent one step screening for thyroid diseases in first trimester, which meant blood test for thyroid stimulating hormone（TSH）, free thyroxine（FT4） and thyroid peroxidase antibody（TPOAb） at the same time. Simulation analysis was performed on these 4 044 women with two-step screening （TSH first and then FT4 and TPOAb if TSH was abnormal）. The incidence, missed diagnosis rate, costs of screening, and outcomes of the missed diagnosed cases of women with thyroid diseases were compared between one-step and two-step screening based on the cutoff value determined by American Thyroid Association （ATA） or our hospital （0.23-4.08 mU/L）. The positivel rate of TPOAb was compared among the three groups classified according to TSH value （ ≥ 0.1- 〈 2.5 mU/L, ≥ 2,5- 〈 4.08 mU/L and ≥4.08 mU/L）. T-test, Chi-square test or Fisher＇s exact test were applied for statistical analysis. Results When the cutoff value of TSH was set at ≥ 0.1- 〈 2.5 mU/L （ATA recommendation）, 7.9% （320/4 044） of the women required medical treatment. It was significantly higher than 3.2% （129/4 044）, which was obtained when the normal reference value of TSH was set based on data from our hospital. The positive rates of TPOAb were 7.2%（214/ 2 976）, 13.9%（103/777） and 28.6%（55/192） for TSH ≥ 0.1- 〈 2.5, ≥ 2.5- 〈 4.08 mU/L and ≥ 4.08 mU/L group, respectively. When we set the OR value for TOPAb as one in the TSH ≥ 0.1- 〈 2.5 mU/L group, the OR（95%CI）s of the other two groups were 1.972（1.537-2.532） and 5.181（3.679-7.297）. If two-step screening protocol and ATA recommendations were applied, 0.7% （27/4 044） of women who needed treatment would be

关 键 词：妊娠并发症 甲状腺疾病 医师诊疗模式 妊娠初期 

分 类 号：R714.256[医药卫生—妇产科学]