子宫颈冷刀锥切术对晚期妊娠结局的影响

Analysis of adverse late-term pregnancy outcomes after cervical cold knife conization

目的:探讨子宫颈冷刀锥切术(CKC)对早产及其他妊娠并发症、新生儿结局的影响,并探究早产风险与锥切深度及体积的关系。方法:收集2002年1月至2018年3月于北京协和医院行CKC且术后成功妊娠的272例孕妇(锥切组)的临床资料(包括妊娠结局),以2019年1月至12月于北京协和医院产科建档并分娩的1647例孕妇作为对照(对照组),两组中单胎妊娠孕妇分别为264、1589例。比较两组孕妇的早产、胎膜早破及其他妊娠并发症、新生儿结局,并分析锥切深度及体积与CKC术后单胎妊娠孕妇早产风险的关系。结果:(1)一般情况:锥切组孕妇的单胎妊娠率、分娩年龄、产次及辅助生殖技术妊娠的比例分别与对照组比较,差异均无统计学意义(P均>0.05)。(2)早产及胎膜早破:锥切组单胎妊娠孕妇的早产率明显高于对照组[分别为14.8%(39/264)、5.7%(91/1589);χ^(2)=28.397,P<0.001];按照妊娠<34周及34~37周分别统计,两组之间的早产率分别比较,差异仍均有统计学意义(P均<0.01)。锥切组中单胎妊娠孕妇的胎膜早破发生率与对照组比较,差异无统计学意义[分别为23.5%(62/264)、23.4%(372/1589);χ^(2)=0.001,P=0.979];但锥切组未足月胎膜早破发生率与对照组比较,差异有统计学意义[分别为11.4%(30/264)、2.2%(35/1589);χ^(2)=56.132,P<0.001]。(3)其他妊娠并发症及新生儿结局:锥切组孕妇的剖宫产术率显著高于对照组[分别为59.6%(162/272)、38.8%(639/1647);χ^(2)=41.377,P<0.001],锥切组早产儿出生体重显著高于对照组[分别为(2409±680)、(2150±684)g;t=2.184,P=0.030];但两组间妊娠期糖尿病和妊娠期高血压疾病发生率、足月儿出生体重、小于胎龄儿发生率及入住新生儿重症监护病房的比例分别比较,差异则均无统计学意义(P均>0.05)。(4)锥切深度及体积与CKC术后单胎妊娠孕妇的早产风险:与对照组单胎妊娠孕妇的早产率(5.7%,91/1589)比较,当锥切深度>15 mm时锥切组单胎妊娠孕妇的早产率(21.1%,31/147)显著增高(RR=3.682,95%CI为2.541~5.336;P<0.001);而当锥切深度≤15 mm时锥切组单胎妊娠孕妇的早产率(6.8%,8/117)虽高于对照组,但两组比较,差异无统计学意义(RR=1.194,95%CI为0.594~2.399;P=0.620)。当锥切体积≥2 cm 3时锥切组单胎妊娠孕妇的早产率(18.8%,24/128)显著增高(RR=3.274,95%CI为2.168~4.944,P<0.001);而当锥切体积<2 cm 3时,锥切组单胎妊娠孕妇的早产率(11.0%,15/136)也显著增高(RR=1.926,95%CI为1.148~3.213;P=0.013)。锥切组CKC术后单胎妊娠孕妇中,锥切深度≤15 mm孕妇的早产率与锥切深度>15 mm孕妇比较,差异有统计学意义(RR=3.084,95%CI为1.474~6.453;P=0.001);而锥切体积<2 cm 3孕妇的早产率与锥切体积≥2 cm 3孕妇比较,差异则无统计学意义(RR=1.700,95%CI为0.935~3.092;P=0.077)。结论:CKC会增加术后妊娠的早产、未足月胎膜早破风险,且早产风险与子宫颈锥切深度有关。

Objective To investigate the effects of cervical cold knife conization(CKC)on preterm delivery,other pregnancy complications and neonatal outcomes,and explore the relationship between preterm delivery risk and the depth and volume of conization.Methods The clinical data and pregnancy outcomes of 272 women who underwent CKC in Peking Union Medical College Hospital from January 2002 to March 2018(conization group)and 1647 pregnant women who gave birth in Peking Union Medical College Hospital during January to December 2019(control group)were collected.The preterm delivery,premature rupture of membranes,other pregnancy complications and neonatal outcomes of the two groups were compared,and the relationship between the depth and volume of conization and the risk of preterm delivery in postoperative singleton pregnancy was analyzed.Results(1)There were no significant differences between the two groups in delivery age,parity,proportion of singleton pregnancy,proportion of assisted reproductive technology(all P>0.05).(2)The rate of preterm delivery in the conization group was significantly higher than that in the control group[14.8%(39/264)vs 5.7%(91/1589);χ^(2)=28.397,P<0.001].There were still significant differences in preterm delivery rates between the two groups at<34 weeks and 34-37 weeks(all P<0.01).There was no significant difference in the incidence of premature rupture of membrane between the two groups[23.5%(62/264)vs 23.4%(372/1589);χ^(2)=0.001,P=0.979],but the incidence of preterm premature rupture of membrane in the conization group was significantly higher than that in the control group[11.4%(30/264)vs 2.2%(35/1589);χ^(2)=56.132,P<0.001].(3)The rate of cesarean section in the conization group was higher than that in the control group[59.6%(162/272)vs 38.8%(639/1647);χ^(2)=41.377,P<0.001].The birth weight of preterm infants in the conization group was significantly higher than that in the control group[(2409±680)vs(2150±684)g;t=2.184,P=0.030].However,there were no statistically significant differences in the incidence of gestational diabetes mellitus,hypertensive disorders in pregnancy,the birth weight of full-term infants,incidence of small for gestational age infant and neonatal intensive care unit admission rate between the two groups(all P>0.05).(4)The preterm delivery rates of coning depth>15 mm,cone size≥2 cm3 and cone size<2 cm3 were higher than that in the control group(all P<0.05).When the coning depth≤15 mm,the preterm delivery rate in the conization group was higher than that in the control group,but there was no significant difference(P=0.620).The rate of preterm delivery of pregnant women with coning depth>15 mm was significantly higher than those with coning depth≤15 mm(RR=3.084,95%CI:1.474-6.453;P=0.001).There was no significant difference in the preterm delivery rate between pregnant women with cone size>2 cm3 and those with cone size≥2 cm3(RR=1.700,95%CI:0.935-3.092;P=0.077).Conclusion The risk of preterm delivery and preterm premature rupture of membranes in subsequent pregnancies are increased after cervical CKC,and the risk of preterm delivery is positively correlated with the depth of cervical coning.