辅助生殖技术受孕双绒毛膜双胎手术减胎与自然减胎活产儿母婴结局分析

Analysis of maternal and neonatal outcomes for the living singleton of surgically and spontaneously reduced dichorionic pregnancies following assisted reproductive technology

目的探讨辅助生殖技术(assisted reproductive technology, ART)受孕的双绒毛膜双胎手术减胎与自然减胎活产儿母婴结局间的差异。方法回顾性队列分析江西省妇幼保健院生殖医学中心2014年3月至2021年10月期间共11 050个新鲜/冻融周期双胚胎移植后单胎活产周期的临床资料。患者分为手术减胎组(226例)、自然减胎组(1 506例), 同时以单胎妊娠者为对照组(9 318例)。采用单因素分析比较3组的基本临床资料、母胎并发症及新生儿出生结局的差异, 采用多因素logistic回归分析影响母婴结局的因素。结果自然减胎组胎膜早破比例为1.4%(21/1 506), 手术减胎组为1.3%(3/226), 对照组为0.6%(56/9 318), 3组间差异有统计学意义(P=0.003), 手术减胎组、自然减胎组早产率[17.3%(39/226)、11.6%(175/1 506)]、极早产率[4.0%(9/226)、1.9%(28/1 506)]、低出生体质量儿占比[15.5%(35/226)、8.6%(129/1 506)]、极低出生体质量儿占比[3.1%(7/226)、1.3%(20/1 506)]、小于胎龄儿发生率[9.3%(21/226)、9.1%(137/1 506)]与对照组[7.7%(721/9 318)、0.9%(86/9 318)、3.9%(367/9 318)、0.5%(45/9 318)、6.0%(560/9 318)]比较, 3组间差异均具有统计学意义(均P<0.001)。手术减胎组早产(aOR=2.37, 95%CI:1.64~3.42, P<0.001)、极早产(aOR=4.26, 95%CI:2.02~8.97, P=0.001)、低出生体质量(aOR=4.35, 95%CI:2.94~6.44, P<0.001)及小于胎龄儿(aOR=1.82, 95%CI:1.14~2.92, P=0.013)与自然减胎组(aOR=1.54, 95%CI:1.29~1.84, P<0.001;aOR=1.95, 95%CI:1.26~3.01, P=0.003;aOR=2.26, 95%CI:1.83~2.79, P<0.001;aOR=1.60, 95%CI:1.31~1.95, P<0.001)相比风险均更高。3组出生缺陷率差异无统计学意义(P>0.05)。结论 ART受孕的双绒毛膜双胎手术减胎及自然减胎活产儿的母胎并发症及子代出生缺陷风险与单胎妊娠近似, 胎膜早破比例更高, 且手术减胎早产及低出生体质量风险高于自然减胎, 不提倡依赖手术减胎对ART受孕双绒毛膜双胎进行补救。

Objective To analyze the difference of maternal and neonatal outcomes for the living infant of surgically and spontaneously reduced dichorionic pregnancies following assisted reproductive technology(ART).Methods We used a retrospective cohort study to analyze the clinical data of 11050 fresh/frozen-thawed double embryos transfer with singleton live birth cycles in the Center for Reproductive Medicine of Jiangxi Maternal and Child Health Hospital from March 2014 to October 2021,including 226 cases in the surgical reduction group,1506 cases in the spontaneous reduction group,and 9318 cases of singleton pregnancy in control group.The basic clinical data,maternal and fetal complications and birth outcomes of the three groups were compared by univariate analysis.Multivariate logistic regression was used to analyze the factors affecting maternal and infant outcomes.Results The rate of premature rupture of membranes in the natural fetal reduction group,the surgical reduction group and control group was 1.4%(21/1506),1.3%(3/226)and 0.6%(56/9318),respectively,with a significant difference among the three groups(P=0.003).The differences of the risk of preterm birth,very premature birth,low birth weight,very low birth weight,and small for gestational age among the surgical fetal reduction group[17.3%(39/226),4.0%(9/226),15.5%(35/226),3.1%(7/226),9.3%(21/226)],the natural fetal reduction group[11.6%(175/1506),1.9%(28/1506),8.6%(129/1506),1.3%(20/1506),9.1%(137/1506)]and control group[7.7%(721/9318),0.9%(86/9318),3.9%(367/9318),0.5%(45/9318),6.0%(560/9318)]were statistically significant(all P<0.001).Compared with the spontaneous reduction group,the surgical reduction group had a higher risk of premature birth[(aOR=2.37,95%CI:1.64-3.42,P<0.001)vs.(aOR=1.54,95%CI:1.29-1.84,P<0.001)],very preterm birth[(aOR=4.26,95%CI:2.02-8.97,P=0.001)vs.(aOR=1.95,95%CI:1.26-3.01,P=0.003)],low birth weight[(aOR=4.35,95%CI:2.94-6.44,P<0.001)vs.(aOR=2.26,95%CI:1.83-2.79,P<0.001)]and small-for-gestational age[(aOR=1.82,95%CI:1.14-2.92,P=0.013)vs.(aOR=1.60,95%CI:1.31-1.95,P<0.001)].There was no statistical difference in birth defect rate among the three groups(P>0.05).Conclusion The risk of maternal and fetal complications and birth defects for the living singletons of surgically and spontaneously reduced dichorionic diamniotic pregnancies were similar to those singleton pregnancies following ART,but the proportion of premature rupture of membranes is higher,and the risk of premature birth and low birth weight of surgical reduction were higher than that of spontaneous reduction.Surgical reduction is not recommended to use as a rescue measure of dichorionic twins conceived by ART.