McDonald子宫颈环扎术与腹腔镜子宫峡部环扎术治疗子宫颈机能不全的围产结局比较

Comparison of maternal-fetal outcomes between laparoscopic cervicoisthmic cerclage and McDonald cerclage in women with cervical insufficiency

目的比较McDonald子宫颈环扎术(MC)与腹腔镜子宫峡部环扎术(LCC)治疗子宫颈机能不全(CI)的围产结局,为CI孕妇行子宫颈环扎术手术方式的选择提供依据。方法回顾性分析2010年1月至2020年12月于中山大学附属第一医院分娩的行子宫颈环扎术孕妇211例,根据术式、行LCC孕妇是否有MC史分为MC组(54例)、有MC史LCC组(28例)、无MC史LCC组(129例)。比较3组孕妇的一般临床资料、妊娠合并症及并发症、妊娠结局。结果(1)一般临床资料:MC组、有MC史LCC组和无MC史LCC组孕妇于妊娠期行子宫颈环扎术的比例分别为100.0%(54/54)、7.1%(2/28)、27.1%(35/129),3组比较,差异有统计学意义(P<0.001);3组的环扎术指征占比比较,差异有统计学意义(P=0.003),但最主要的环扎术指征均为妊娠中晚期流产史[分别为75.9%(41/54)、89.3%(25/28)、84.5%(109/129)]。MC组、有MC史LCC组及无MC史LCC组获活产环扎成功率分别为94.4%(51/54)、82.1%(23/28)、93.8%(121/129),3组比较,差异无统计学意义(χ^(2)=5.649;P=0.059)。(2)环扎成功孕妇(195例)的妊娠合并症及并发症:与MC组孕妇比较,有MC史LCC组和无MC史LCC组孕妇胎位异常[分别为7.8%(4/51)、17.4%(4/23)和19.8%(24/121)]、胎盘植入[分别为5.9%(3/51)、13.0%(3/23)和11.6%(14/121)、子宫破裂[分别为0、4.3%(1/23)和5.8%(7/121)]的发生率均较高,但分别比较,差异均无统计学意义(P均>0.05)。MC组孕妇绒毛膜羊膜炎或宫内感染(15.7%,8/51)、胎膜早破(23.5%,12/51)的发生率均高于有MC史LCC组[分别为0、4.3%(1/23)]和无MC史LCC组[分别为0.8%(1/121)、0],分别比较,差异均有统计学意义(P均<0.001)。(3)妊娠结局:MC组孕妇的剖宫产率[41.2%(21/51)]显著低于有MC史LCC组[100.0%(23/23)]和无MC史LCC组[100.0%(121/121);P<0.001];其环扎术费用均显著低于有MC史LCC组和无MC史LCC组(中位数分别为12169、26438、27783元;P<0.001)。3组的新生儿出生体重及新生儿窒息、转入新生儿重症监护病房的比例分别比较,差异均无统计学意义(P均>0.05)。结论MC和LCC均为治疗CI的有效方式,两者的获活产环扎成功率相近。但MC具有剖宫产率低、经济、易操作的优势。CI孕妇建议首选MC,对于MC失败者可考虑LCC。

Objective To compare the maternal and fetal outcomes of women with cervical insufficiency(CI)undergoing McDonald cerclage(MC)and laparoscopic cervicoisthmic cerclage(LCC),so as to provide evidence for the selection of cerclage methods.Methods A retrospective trial was carried out in the First Affiliated Hospital of Sun Yat-sen University from January 2010 to December 2020.A total of 221 women who underwent the prophylactic cerclage were divided into MC group(n=54),LCC with MC history group(n=28)and LCC without MC history group(n=129)by the mode of operation and whether the pregnant women who underwent LCC had MC history.General clinical data,pregnancy complications and pregnancy outcomes were compared between the three groups.Results(1)General clinical data:the proportion of women accepted cervical cerclage during pregnancy in MC group,LCC with MC history group and LCC without MC history group were 100.0%(54/54),7.1%(2/28)and 27.1%(35/129),respectively(P<0.001).The indications of the three groups showed statistical significance(P=0.003),and the main indication was the history of abortion in the second and third trimester[75.9%(41/54)vs 89.3%(25/28)vs 84.5%(109/129)].(2)Pregnancy complications:the incidence of abnormal fetal position[7.8%(4/51)vs 17.4%(4/23)vs 19.8%(24/121)],placenta accrete[5.9%(3/51)vs 13.0%(3/23)vs 11.6%(14/121)],uterine rupture[0 vs 4.3%(1/23)vs 5.8%(7/121)]in the MC group were all lower than those in LCC with MC history and LCC without MC history groups.However,there were no statistical significances(all P>0.05).Intrauterine inflammation or chorioamnionitis[15.7%(8/51)vs 0 vs 0.8%(1/121)]and premature rupture of membrane[23.5%(12/51)vs 4.3%(1/23)vs 0]were both significantly higher in MC group than those in LCC with MC history and LCC without MC history groups(all P<0.001).(3)Pregnancy outcomes:the cesarean section rate was significantly lower in MC group(41.2%,21/51)than that in LCC with MC history group(100.0%,23/23)and LCC without MC history group(100.0%,121/121;P<0.001).MC group was associated with lower expenditure than LCC with MC history and LCC without MC history groups(12169 vs 26438 vs 27783 yuan,P<0.001).The success rates of live birth cerclage did not differ significantly in MC(94.4%,51/54),LCC with MC history(82.1%,23/28)and LCC without MC history(93.8%,121/129)groups(χ^(2)=5.649,P=0.059).There was no significant difference in neonatal intensive care unit occupancy,neonatal birth weight and neonatal asphyxia between the three groups(all P>0.05).Conclusions Both LCC and MC are the treatment choice for women with CI,which may get similar liver birth.However,MC has the advantages of low cesarean section rate,economical and easy operation.Therefore,MC is recommended as the first choice for CI patients,and LCC is for women with failed MC.