治疗性宫颈环扎术临床效果及影响因素分析

Analysis of clinical effect and the affecting factors of the therapeutic cervical cerclage

目的探讨治疗性宫颈环扎术的临床效果及其影响因素。方法收集2008年1月至2015年7月于北京大学第三医院接受治疗性宫颈环扎术与未接受治疗性环扎的宫颈功能不全的单胎妊娠患者132例,按孕期超声或体格检查发现的宫颈长度及宫颈内外口扩张程度进行分组。宫颈长≤2.5 cm伴宫颈内口呈V形或U形扩张,宫颈外口闭合者58例接受环扎(A组),未接受环扎23例(a组);宫颈内外口均开大,同时伴或不伴胎囊突出者39例接受环扎(B组),未接受环扎12例(b组)。B组再按宫颈外口开大程度分:B1组为1 cm≤宫颈外口开大≤3 cm(27例),B2组为3 cm<宫颈外口开大≤5 cm(9例),B3组为宫颈外口开大>5 cm(3例)。分析比较临床效果及与环扎效果有关的影响因素。结果 A组分娩孕周、妊娠延长天数、新生儿出生体重以及早期新生儿存活率均大于a组(P<0.05);34周后及37周以后的分娩率明显增加(P<0.05)。B组妊娠延长天数、分娩孕周、新生儿出生体重以及>28周、>32周、>34周的分娩率均明显大于b组(P<0.05);B组>37周的分娩率大于b组(22.5%vs.0)。宫颈外口开大程度与环扎效果分析显示:环扎治疗B1组的妊娠延长天数及分娩孕周大于B2组,>28周、>32周及>34周的分娩率明显增加(P<0.05)。环扎A组保胎天数、分娩孕周、34周以后及37周后分娩率均大于环扎B1组及B2组(P<0.05)。B3组3例中仅有1例早期新生儿存活。多因素线性回归分析显示:胎囊突出情况、未足月胎膜早破、宫内感染与术后保胎天数呈负相关(β分别为-20.869、-17.431、-14.963)。不同环扎孕周对分娩孕周、新生儿出生体重、早期新生儿存活率影响无统计学意义(P>0.05)。结论治疗性宫颈环扎术是妊娠期宫颈明显变化的宫颈功能不全抗早产的有效补救方法;宫内感染、未足月胎膜早破以及胎囊突出情况是环扎效果的影响因素,而宫颈外口开大>5 cm的环扎效果受多因素影响;手术孕周不需局限在24周内,个体化处理为宜,手术效果不受手术孕周影响。

Objective To investigate the clinical effect of the therapeutic cervical cerclage and the affecting factors.Methods Totally 132 singleton pregnant patients were collected,who were diagnosed with cervical incompetence with or without therapeutic cervical cerclage between January 2008 to July 2015 in Peking University Third Hospital.The objects were divided into groups by the cervical length and the premature cervical dilatation according to B ultrasonography or physical examination.The 58 patients who were defined as cervical length shorter than 25 mm with internal ostium‘U＇or‘V＇type opening but without external orifice dilatation received therapeutic cervical cerclage（group A）.There were 23 cases who received conservative treatment（group a）.The 39 patients were defined as group B with opening of cervical external orifice more than 10 mm.Among the group B cases,27 cases had opening of cervical external orifice between 10 mm to 30mm（group B1）,9 between 30 mm to 50mm（group B2）and 3 more than 50mm（group B3）.There were 12 cases who received conservative treatment（group b）.The clinical effect of the therapeutic cervical cerclage and the affecting factors were investigated. Results The delivery gestational week,days of tocolytic therapy,birth weight of newborn and the survival rate of newborn in group A were higher than those in group a（P〈0.05）.The rate of cases delivered after 34 wks and 37 wks in group A was higher than thaht in group a（P〈0.05）.The delivery gestational week,days of tocolytic therapy and birth weight of newborn in group B were higher those in group b（P〈0.05）.The rate of cases deliveried after 28 wks,32wks and 34 wks in group B were higher than that in group b（P〈0.05）.The rate of cases delivered after 37 wks in group Bwere higher than that in group b（22.5% vs.0）.Analysis of the cervical cerclage effect at different extent of cervical dilatation were as follows：the gestational week and days of tocolytic therapy in group B1 was higher than in group B2（P〈0.05）;meanwhile,rate of cases delivered after 28 wks,32wks,34 wks in group B1 were higher than that in group B2（P〈0.05）;the days of tocolytic therapy and the delivery gestational week of group A were higher than that of group B1 and group B2;the rate of cases delivered after 34 wks in group A were higher than that in group B1 and group B2（P〈0.05）;only 1 of 3 cases in group B3 had newborn survival.Protrusion of amniotic sac（β=-20.869）,PPROM（β=-17.431）and intrauterine infection（β=-14.963）were associated with days of tocolytic therapy negatively.There was no statistically significance in gestational weeks of delivery,birth of newborn,survival rate of newborn or rare of delivery after 28 wks,32wks,34 wks and 37 wks among the different surgical gestational age（P〉0.05）.Conclusion The cervical cerclage is an effective remedy for cervical incompetence with cervical changes during pregnancy and has the significance of resisting premature delivery.Intrauterine infection,PPROM,protrusion of amniotic sac and dilatation of cervical external orifice are all related to the outcome of operation.The effect of cerclage in patients with cervical dilatation more than 50 mm is affected by various factors.The gestational age at operation does not need to be limited within 24 wks,individualized treatment is appropriate,and the outcome is not affected by gestational age.