病史指征与超声指征单胎妊娠孕妇子宫颈环扎术的疗效比较及影响因素分析

Analysis of clinical effect and influencing factors of history-indicated cerclage or ultrasound-indicated cerclage in singleton pregnancy

目的分析病史指征及超声指征的单胎妊娠孕妇行子宫颈环扎术的临床疗效及影响因素。方法收集2010年1月至2021年2月于北京大学第一医院因病史指征或超声指征行McDonald子宫颈环扎术的子宫颈机能不全单胎妊娠孕妇共272例的临床资料进行回顾性分析,比较病史指征组(141例)和超声指征组(131例)孕妇的一般临床资料和母儿结局。进一步根据分娩孕周,将272例子宫颈环扎术孕妇分为≥孕34周分娩组(225例)和<孕34周分娩组(47例),分析孕34周前早产的影响因素。结果(1)病史指征组和超声指征组的中位环扎孕周分别为16.6、23.4周,分娩时较环扎时的中位延长孕周分别为21.4周、14.7周,分别比较,差异均有统计学意义(P均<0.05)。(2)病史指征组和超声指征组孕妇的足月产率分别为76.6%(108/141)和71.0%(93/131),活产率分别为97.2%(137/141)和97.7%(128/131),活产儿中位出生体重分别为3155和3055 g,分别比较,差异均无统计学意义(P均>0.05)。272例子宫颈环扎孕妇的新生儿存活共计265例(97.4%,265/272),7例未获活产儿孕妇的分娩孕周均≤孕25周(范围:孕19+1~25周),孕妇均为临床宫内感染或组织学证实的绒毛膜羊膜炎或孕期病原微生物携带,家属放弃。存活新生儿的最低出生体重为850 g(分娩孕周为26+6周)。(3)单因素分析结果显示,与≥孕34周分娩组比较,<孕34周分娩组孕妇孕6~7周体重指数(BMI)更高(中位数分别为24.5、25.4 kg/m2)、环扎术后1~2周子宫颈长度(CL)更短[分别为(31.1±8.4)、(26.1±11.0)mm]、术后孕26~28周CL更短(中位数分别为26.3、16.0 mm)、术前、术后、分娩前C反应蛋白(CRP)升高的发生率均更高,分别比较,差异均有统计学意义(P均<0.05)。多因素logistic回归分析结果显示,孕34周前早产与环扎术后孕26~28周CL呈显著负相关(OR=0.902,95%CI为0.858~0.947;P<0.001),与分娩前CRP升高呈显著正相关(OR=3.492,95%CI为1.652~7.381;P=0.001);与术前及术后CRP升高、术后1~2周CL、孕6~7周BMI无显著相关性(P均>0.05)。结论子宫颈机能不全的单胎妊娠孕妇行病史指征或超声指征的子宫颈环扎术,均获得了良好的临床疗效,且两组的母儿结局无显著差异。子宫颈环扎术后孕34周前早产的影响因素是术后孕26~28周CL及分娩前CRP升高。

Objective To investigate the clinical effect and the influencing factors of ultrasound-indicated cerclage and history-indicated cerclage in singleton gestation.Methods The clinical data of 272 singleton pregnant women with cervical incompetence who underwent McDonald cervical cerclage due to medical history indication(history-indicated group)or ultrasound indication(ultrasound-indicated group)in Peking University First Hospital from January 2010 to February 2021 were retrospectively analyzed.The general clinical data and maternal and fetal outcomes were compared between the history-indicated group(141 cases)and ultrasound-indicated group(131 cases).According to the gestational age at delivery,272 pregnant women who underwent cervical cerclage were further divided into≥34 weeks group(225 cases)and<34 weeks group(47 cases),and the influencing factors of preterm birth before 34 weeks of gestation were analyzed.Results(1)The median gestational age at cerclage was 16.6 weeks in the history-indicated group and 23.4 weeks in the ultrasound-indicated group,and the median gestational age extension at delivery was 21.4 weeks and 14.7 weeks,respectively,with statistically significant differences between the two groups(all P<0.05).(2)The full-term birth rate was 76.6%(108/141)in the history-indicated group and 71.0%(93/131)in the ultrasound-indicated group,the live birth rate was 97.2%(137/141)and 97.7%(128/131),and the median birth weight of live birth was 3155 g and 3055 g,respectively.The differences were not statistically significant(all P>0.05).Among 272 pregnant women with cervical cerclage,265 neonates survived(97.4%,265/272).The gestational age of 7 pregnant women who did not have live birth was≤25 weeks of gestation(range:19+1-25 weeks),and they were all clinically infected or confirmed chorioamnionitis or pathogenic microorganisms carrying during pregnancy,and their families gave up.The minimum birth weight of the surviving neonate was 850 g(gestational week of delivery was 26+6 weeks).(3)Univariate analysis showed that compared with≥34 weeks group,the body mass index(BMI)of pregnant women in<34 weeks group was higher at 6-7 weeks of gestation(median:24.5 vs 25.4 kg/m2),shorter cervical length(CL)at 1-2 weeks after surgery[(31.1±8.4)vs(26.1±11.0)mm],shorter CL at 26-28 weeks of gestation after surgery(median:26.3 vs 16.0 mm),and higher incidence of elevated C-reactive protein(CRP)before and after surgery and before delivery.The differences were all statistically significant(all P<0.05).Multivariate logistic regression analysis showed that preterm birth before 34 weeks was negatively associated with CL at 26-28 weeks of gestation after cerclage(OR=0.902,95%CI:0.858-0.947;P<0.001),and was positively correlated with elevated CRP before delivery(OR=3.492,95%CI:1.652-7.381;P=0.001).There were no significant correlations between preterm birth and preoperative or postoperative CRP elevation,CL at 1-2 weeks after surgery,and BMI at 6-7 weeks of gestation(all P>0.05).Conclusions Cervical cerclage for singleton pregnant women with cervical incompetence indicated by history or ultrasound both have good clinical efficacy,and there is no significant difference in maternal and fetal outcomes between the two groups.CL at 26-28 weeks of gestation and CRP before delivery are risk factors for preterm birth before 34 weeks of gestation after cervical cerclage.