胎儿畸形孕妇终止妊娠的医学和非医学影响因素

Medical and non-medical factors influencing termination of pregnancy in Chinese women with fetal malformation

目的调查产前诊断胎儿畸形孕妇选择终止妊娠的比例，分析医学因素和非医学因素对终止妊娠决定的影响。方法采用前瞻性队列研究，以2012年9月12日至2013年5月2日期间在复旦大学附属妇产科医院因“胎儿畸形”参加多学科会诊并填写的调查问卷的孕妇为研究对象，排除染色体疾病或单纯超声软指标异常的患者。在多学科联合会诊后，采用问卷调查的方法了解患者的背景和态度。于2014年和2016年分别进行1次电话随访，了解孕妇是否提前终止妊娠（以孕妇选择为准）；若继续妊娠，则询问围产儿预后。采用t检验、z。检验（或Fisher精确概率法）、Mann—Whitney或Wilcoxon秩和检验以及Logistic回归分析等统计学方法，对数据进行统计学分析。结果（1）实际纳入本研究者229例，其中lO例（4．4％）失访，故随访到妊娠结局的219例最终纳入统计分析。219例患者的终止妊娠率为35．6％（78／219）。（2）根据疾病类型和严重程度，219例中，预测预后好122例（55．7％），预后中20例（9．1％），预后差17例（7．8％），预后不明确60例（27．4％）。（3）选择终止妊娠的孕妇，其平均年龄比继续妊娠者低『分别为（27.8±4．1）和（29．0±3．9）岁，t=2．257，P〈0．05】；会诊时孕龄〈24周者选择终止妊娠的比例也高于会诊时孕龄≥24周的孕妇【52．5％（31／59）和29．4％（47／160），X^2=10．089，P〈0．011。（4）校正孕妇年龄、咨询孕龄、预后评估等因素后，有胎儿生长受限者终止妊娠的风险是无胎儿生长受限者的2．850倍（OR=2．850，95％CI：1．323-6．140，P〈0．01）。以预后好的孕妇为参考，预后不明、中、差的孕妇选择终止妊娠的风险分别升高1．354（OR=2．354，95％a：1．108～5．004）、15．188倍（OR=16．188，95％CI：4．732-55．372）和13．515倍（OR=14．515，95％CI：3．610～58．359）（P值均〈0．05）。（5）在明确回答了终止妊娠原因（可复选）的63例中，57例（90．5％）担心胎儿预后的不确定性，10例（15．9％）为感情因素。这是终止妊娠最主要的2个原因。（6）选择继续妊娠和选择终止妊娠的孕妇对于预测预后的满意度差异明显。其中，预测预后好或不明的选择终止妊娠的孕妇预后满意度中位数（10分制）往往要比相同预测预后选择继续妊娠的孕妇低2分，预后中的孕妇中预后满意度差距甚至达到5分（P值均〈0．05），而在预测预后差的孕妇中，差异无统计学意义。结论在产前诊断胎儿畸形的孕妇中，选择终止妊娠的比例仍然很高。影响终止妊娠的因素包括诊断咨询孕周、预测预后以及孕妇的态度。对胎儿远期预后的不确定性是影响孕妇对预后满意度评分的主要因素。

Objective To investigate the rate of termination of pregnancy （TOP） in gravidas with prenatally diagnosed fetal malformation and to analyze the influences of medical and non-medical factors on decision making. Methods This was a prospective cohort study. Gravidas who took part in a multidisciplinary consultation due to fetal malformation and finished a questionnaire after consulting from September 12, 2012 to May 2, 2013 were recruited. Exclusion criteria were chromosomal disorders and isolated abnormal ultrasound soft markers. The questionnaire survey was conducted to understand the patient＇s backgrounds and to collect their feedbacks on the consultation. Decisions of the gravidas on TOP were followed up by phone in 2014 and 2016. If a gravida chose to continue her pregnancy, her baby＇s outcome was also recorded. T test, Chi-square test or Fisher＇s exact test, or rank-sum tests （Mann-Whitney or Wilcoxon） or Logistic regression was used for statistical analysis. Results （1） Altogether 229 gravidas were recruited and 10 of them were lost to follow-up, so 219 cases were finally analyzed. Among the 219 cases, 35.6% （78/219） chose to terminate their pregnancies. （2） Neonatal prognosis was predicted based on the type and severity of the disease and was divided into four levels including good prognosis （122 cases, 55.7%）, medium prognosis （20 cases, 9.1%）, poor prognosis （17 cases, 7.8%） and unsure prognosis （60 cases, 27.4%）. （3） Gravidas who chose to terminate their pregnancies were younger than their counterparts choosing to continue to term （average age： 27.8 ±4.1 vs 29.0±3.9, t=-2.257, P〈0.05）. Gravidas who went to the consultation before the 24th gestational week carried double risk of TOP than those after the 24th gestational week [termination rate： 52.5% （31/59） vs 29.4% （47/160）, 2,2=10.089, P〈0.01）. （4） Gravidas with fetal growth restriction （FGR） were at triple risk of TOP than those without （OR=2.850, 95%CI： 1.323-6.140） after adjusting for maternal age, gestational age at consultation and prognostic evaluation. Comparing with the good prognosis group, in which the rate of TOP was 19%, the unsure （OR=2.354, 95%CI： 1.108-5.004）, medium （OR=1 6.188, 95%CI： 4.732-55.372） and poor （OR=14.515, 95%CI： 3.61-58.359） prognosis groups had higher risk of TOP. （5） There were 63 women informed us their reasons for TOP （multiple choices）, among which 57 （90.5%） were due to unsure neonatal outcomes, and 10 （15.9%） were due to emotional factors. （6） Maternal satisfaction with neonatal prognosis was 2 to 5 points （medium score, ten-point system） lower in gravidas choosing to TOP than in those choosing to continue pregnancy regardless of good, unsure, or medium neonatal prognosis. No significant difference in maternal satisfaction was found among gravidas with poor neonatal prognosis. Conclusions The rate of TOP in gravidas with prenatally diagnosed fetal malformation remains high in China. Factors that can negatively influence the rate of TOP are consultation after the 24th gestational week, better perceived neonatal prognosis and higher maternal satisfaction with neonatal prognosis. Uncertainty of the neonatal prognosis is the leading cause of maternal dissatisfaction.