探索性构建孕产妇难治性产后出血的风险预测模型，并初步评价其预测效能。

选取临海市妇幼保健院2024年1月1日至2025年1月1日临海市妇幼保健院收治的符合纳入、排除标准的500例孕产妇患者，年龄20~42岁[（30.71±5.02）岁]。再按照7∶3比例随机划分为训练组（n=350）和验证组（n=150），评估训练组患者出现难治性产后出血情况，分为难治性产后出血组（n=32）和无难治性产后出血组（n=318）。识别孕产妇难治性产后出血发生的风险因素，构建Nomogram预测模型，受试者工作特征曲线（ROC）衡量模型的预测准确性，临床决策曲线分析（DCA）评估模型的临床效用。

两组患者瘢痕子宫史、前置胎盘、胎盘早剥、胎盘粘连/植入/穿透、凝血功能障碍、宫缩乏力、产前血清凝血因子Ⅶ（FⅦ）、纤维蛋白原（FIB）方面比较，差异有统计学意义（P<0.05）。多因素Logistic分析显示，瘢痕子宫史、前置胎盘、胎盘早剥、胎盘粘连/植入/穿透、凝血功能障碍、宫缩乏力、产前FⅦ≥161 U、产前FIB≥3.0 g/L是孕产妇发生难治性产后出血的独立危险因素（P<0.05）。Nomogram模型应用于训练组、验证组的曲线下面积（AUC）分别为0.862（95%CI：0.833~0.925）、0.834（95%CI：0.754~0.887），ROC曲线分析确定最优截断值为风险概率28%，该阈值下训练组的灵敏度、特异性分别为81.17%和78.64%，验证组分别为75.33%和72.54%。DCA分析显示，当临床决策者设定的阈值概率为28%时，模型较全干预或无干预策略具有更高的净获益，提示其具有一定的临床决策价值。

孕产妇难治性产后出血发生与瘢痕子宫史、前置胎盘、胎盘早剥、胎盘粘连/植入/穿透、凝血功能障碍、宫缩乏力、产前FⅦ、产前FIB等因素有关，构建预测模型可为后续开展高危人群风险评估及干预研究提供参考。

To explore and construct a risk prediction model for refractory postpartum hemorrhage in postpartum women and to preliminarily evaluate its predictive efficacy.

A total of 500 postpartum patients who met the inclusion and exclusion criteria and were admitted to Linhai Maternal and Child Health Hospital from January 1, 2024 to January 1, 2025 were selected as the study subjects, aged 20~42 years [(30.71±5.02) years]. They were randomly divided into a training group (n=350) and a validation group (n=150) in a 7∶3 ratio. The incidence of refractory postpartum hemorrhage in the training group was assessed, and patients were divided into a refractory postpartum hemorrhage group (n=32) and a non-refractory postpartum hemorrhage group (n=318). Risk factors for refractory postpartum hemorrhage were identified, and a Nomogram prediction model was constructed. Receiver operating characteristic (ROC) curves were used to measure the predictive accuracy of the model, and clinical decision curve analysis (DCA) was used to evaluate the clinical utility of the model.

There were statistically significant differences between the two groups in history of scarred uterus, placenta previa, placental abruption, placental adhesion/invasion/penetration, coagulation dysfunction, uterine atony, prenatal serum coagulation factor Ⅶ (FⅦ) and fibrinogen (FIB) (P<0.05). Multivariate logistic regression analysis showed that history of scarred uterus, placenta previa, placental abruption, placental adhesion/implantation/penetration, coagulation dysfunction, uterine atony, prenatal FVII≥161 U, and prenatal FIB≥3.0 g/L were independent risk factors for refractory postpartum hemorrhage in women who had given birth (P<0.05). The area under the curve (AUC) of the nomogram model was 0.862 (95%CI: 0.833-0.925) in the training group and 0.834 (95%CI: 0.754-0.887) in the validation group. ROC curve analysis determined an optimal risk probability cutoff of 28%. At this threshold, the sensitivity and specificity were 81.17% and 78.64% in the training group, and 75.33% and 72.54% in the validation group, respectively. DCA analysis showed that when the threshold probability set by clinical decision-makers was 28%, the model had a higher net benefit than the full-intervention or no-intervention strategy, suggesting that it has certain clinical decision-making value.

The occurrence of refractory postpartum hemorrhage in postpartum women is associated with factors such as history of scarred uterus, placenta previa, placental abruption, placental adhesion/implantation/penetration, coagulation dysfunction, uterine atony, FVII, and FIB. Constructing a predictive model can provide a reference for subsequent risk assessment and intervention studies of high-risk groups.