双胎妊娠孕期宫颈长度测量及宫颈环扎术临床意义探讨

Preliminary study on clinical significance of cervical length measurement and cerclage in twin pregnancy

目的初步探讨双胎妊娠孕期宫颈长度测量及宫颈环扎术对妊娠结局的影响及临床意义。方法选取2002年1月至2017年1月于北京大学人民医院进行产前检查的双胎妊娠孕妇800例进行回顾性分析,有病史可诊断宫颈机能不全的患者,孕15周左右进行预防性宫颈环扎3例,无宫颈机能不全病史的双胎妊娠患者孕中期进行宫颈长度测量327例,并进行动态监测,如发现宫颈长度(CL)进行性缩短进行超声为指征环扎(12例),如出现无痛性宫颈扩张行紧急/救援性环扎(7例)。以未进行宫颈长度测量的双胎妊娠患者470例作为对照,对患者分娩孕周、是否环扎、环扎孕周至分娩孕周间隔时间、CL、宫缩抑制剂使用情况等进行回顾性分析。结果根据双胎妊娠患者孕中期是否进行宫颈长度测量,比较分娩孕周及相关情况,测量组流产患者18例(5.50%),非测量组为37例(7.87%),差异有统计学意义(P=0.010)。测量组足月分娩患者172例(52.60%),非测量组为217例(46.17%,P=0.011)。测量组宫缩抑制剂使用患者193例(59.02%),非测量组为394例(83.83%,P=0.000)。测量组胎儿丢失29例(8.87%),非测量组为69例(14.68%),差异有统计学意义(P=0.016)。测量组进行超声为指征环扎12例(3.67%),紧急/救援性环扎患者7例(2.14%),非测量组4例(0.85%)行紧急/救援性环扎。CL≤2.5cm组行超声为指征环扎12例(22.64%)和CL>2.5cm组(0例)相比,差异有统计学意义(P=0.000)。而紧急/救援性环扎数量方面,CL≤2.5cm组为2例(3.77%),CL>2.5cm组为5例(1.82%),两组相比差异无统计学意义。在CL>2.5cm组,环扎组流产率为60.00%多于非环扎组(2.60%)。在CL≤2.5cm组中,环扎组早产率(85.71%)高于非环扎组(53.85%,P=0.031)。足月分娩率无论CL≤2.5cm还是CL>2.5cm,环扎组都低于非环扎组,在CL≤2.5cm组中差异有统计学意义(P=0.023)。在分娩孕周方面,CL≤2.5cm时无论环扎与否,分娩孕周都在32周左右,环扎组平均延长孕周(6.9±4.3)周。而CL>2.5cm时,环扎组平均分娩孕周最小,为(29.2±4.09)周。结论孕中期对双胎妊娠患者宫颈长度进行监测,有助于减少流产的发生,并增加足月分娩率,减少宫缩抑制剂的使用,减少胎儿丢失率,对于双胎妊娠预后有所改善。双胎妊娠根据宫颈长度测量情况进行环扎手术是否有助于改善妊娠结局尚需进一步探讨。

Objective To investigate the influence of cervical length measurement and cerclage on pregnancy outcome and its clinical significance in twin pregnancy.Methods Retrospective analysis was made in 800 women with twin pregnancy who received prenatal examinations from January 2002 to January 2017 in Peking University People’s HospitalThree cases received prophylactic cervical cerclage at around 15 weeks’pregnancy because of the histories of cervical incompetence.Totally 327 patients without cervical incompetence histories were measured cervical length(CL)in second trimester.If the patients had progressive shortening of CL during the dynamic monitoring,they would undergo ultrasound-guided cerclage(12 cases),or if the patients had painless cervical dilatation,they would undergo emergency/resue cerclage(7 cases).Compare these partients with 470 cases without CL measurement,and retrospectively analyze the final delivery gestational age,with or without cerclage,the interval between weeks of cerclage and delivery weeks,CL and use of uterine contraction inhibitors.Results According to the measurement of CL in the second trimester of pregnancy,we compared the gestational age and related conditions.There were 18 cases(5.50%)of abortion in the measurement group and 37 cases(7.87%)in the nonmeasurement group,there being statistical difference(P=0.010).In the measurement group,172 cases(52.60%)had fullterm delivery,217 cases in the non-measurement group(46.17%,P=0.011).Totally 193 patients(59.02%)in the measurement group used uterine contraction agents,394 patients in the non-measurement group(83.83%,P=0.000).There were 29 cases of fetal loss in the measurement group(8.87%)and 69 cases in the non-measurement group(14.68%,P=0.016).Totally 12 cases(3.67%)had ultrasound-guided cerclage and 7 cases(2.14%)had emergency/rescue cerclage in measurement group.In non-measurement group 4 patients(0.85%)had emergency/rescue cerclage.In CLc 2.5 cm group12 cases(22.64%)received ultrasound-guided cerclage,and compared with CL>2.5 cm group(0 case),there had statistical difference(P=0.000).But the number of emergency/rescue cerlage in CL≤2.5 cm group was 2(3.77%),and in CL>2.5 cm group it was 5(1.82%),there being no statistical difference.In the CL>2.5 cm group,the rate of abortions was60.00%in the cerclage group,which was higher than that in the non-cerclage group(2.60%).In the CL≤2.5 cm group,the premature delivery rate in the cerclage group(85.71%)was higher than that in the non-cerclage group(53.85%,P=0.031).As to full-term delivery rate,both in the CL≤2.5 cm group and CL>2.5 cm group,the cerclage group was lower than the non-cerclage group,and it had statistical difference in CL≤2.5 cm group(P=0.023).Regarding the gestational weeks of delivery,the CLc 2.5 cm group had a gestational week of 32 weeks regardless of whether cerclage was performed,and the gestational weeks of the cerclage group were prolonged by(6.9±4.3)weeks on average.In the CL>2.5 cm group,the average gestational age of delivery in the cerclage group was the smallest,which was(29.2±4.09)weeks.Conclusion Monitoring the CL during mid-trimester can help to reduce the risk of miscarriage and increase the full-term delivery rate.It decreases the use of uterine contraction inhibitors and fetal loss rate.So CL monitoring improves the prognosis of twin pregnancies.Whether cervical cerclage can improve pregnancy outcomes in twin pregnancies based on CL measurements remains to be further explored.