多胎妊娠减胎术临床特征及妊娠结局分析——历时12年的队列研究

Clinical characteristics and pregnancy outcomes of multifetal pregnancy reduction: a 12-year cohort study

目的分析多胎妊娠减胎术患者的妊娠结局及影响活产的因素,为减胎策略提供参考依据。方法回顾性队列研究纳入2009年1月1日至2020年12月31日期间于北京大学第三医院妇产科生殖医学中心进行多绒毛膜性多胎妊娠减胎术的患者,分析患者临床特征,随访妊娠结局,分为活产组(n=1555)和非活产组(n=205),并应用多因素logistic回归分析影响活产的因素。并进一步亚组分析,将多胎妊娠分为双绒毛膜双羊膜囊、三胎妊娠、四胎及以上多胎妊娠三组。结果纳入1925例多胎妊娠减胎病例,完成妊娠结局随访1760例。数据显示12年来减胎多胎类型中双绒毛膜双羊膜囊增多,经腹减胎比例逐年增加,年减胎患者活产率波动于83%~94%。四胎及以上多胎妊娠减胎后活产率[75.8%(72/95)]分别低于双绒毛膜双羊膜囊减胎后[90.0%(796/884),P<0.001]、双绒毛膜三羊膜囊减胎后[89.9%(241/268),P<0.001]和三绒毛膜三羊膜囊减胎后[86.9%(446/513),P=0.005]。经腹部超声引导下减胎术后活产率[91.4%(655/717)]分别高于经阴道氯化钾(KCl)胎心搏动区注射减胎后活产率[84.9%(304/358),P=0.001]及经阴道胚胎抽吸减胎后活产率[87.0%(596/685),P=0.009],经阴道KCl胎心搏动区注射减胎与经阴道抽吸减胎活产率差异无统计学意义(P=0.351)。减胎术后保留单胎的患者活产率[89.7%(1062/1184)]高于保留双胎患者[85.6%(493/576),P=0.012]。在调整了年龄、助孕方式、多胎类型、保留胚胎数等混杂因素后,中孕期经腹部超声引导下减胎为活产率的保护因素(P=0.040,OR=1.604,95%CI:1.021~2.519)。结论随移植策略的改变,双绒毛膜双羊膜囊妊娠减胎比例增加,中孕期经腹部超声引导下减胎术的比例增加,经腹部减胎可能是多胎妊娠减胎术更好的选择;早孕期经阴道抽吸减胎法与KCl胎心搏动区注射法减胎妊娠结局相似;四胎及以上多胎妊娠减胎后妊娠结局较差,临床上需严格控制胚胎移植数目,规范诱导排卵方案。

Objective:To analyze the clinical characteristics,pregnancy outcomes and factors affecting live birth of patients undergoing multifetal pregnancy reduction(MFPR),in order to provide reference for clinical strategies.Methods:A retrospective cohort study was conducted on all patients who underwent multifetal pregnancy reduction among polychorionic multifetal pregnancy patients at the Center for Reproductive Medicine,Department of Obstetrics and Gynecology of Peking University Third Hospital during a period of 12 years from January 1,2009 to December 31,2020.The overall and annual clinical characteristics were analyzed,pregnancy outcomes were followed up.Patients were divided into live birth group(n=1555)and not live birth group(n=205),and factors affecting live birth were analyzed by multivariate logistic.Through further subgroup analysis,multiple pregnancies were divided into three subgroups:dichorionic diamniotic twin,triplet pregnancy,and four or more high sequence multiple pregnancy.Results:A total of 1925 patients who underwent MFPR were included,and 1760 pregnancy outcomes were followed up.In the past 12 years,there had been an increase in dizygotic twins,and the proportion of transabdominal fetal reduction had significantly increased,from 3%in 2009 to 77%in 2020.The annual live birth rate of reduction patients fluctuated between 83%and 94%.The live birth rate of patients with MFPR was related with the type of multiple pregnancies,the method of reducing pregnancies,and the number of retained embryos.The live birth rate of four or more high sequence multiple pregnancies[75.8%(72/95)]was lower than that of dichorionic diamniotic twins[90.0%(796/884),P<0.001],the dichorionic diamniotic twins[89.9%(241/268),P<0.001],the trichorionic triamniotic triplet pregnancy[86.9%(446/513),P=0.005].The live birth rate of transabdominal fetal reduction[91.4%(655/717)]was higher than that of transvaginal fetal reduction with fetal cardiac activity area injection of KCl[84.9%(304/358),P=0.001],and vaginal embryo aspiration[87.0%(596/685),P=0.009].There was no statistically significant difference in the live birth rate between vaginal KCl injection and vaginal aspiration(P=0.351).The survival rate of patients with retained singletons[89.7%(1062/1184)]was higher than that of patients with retained twins[85.6%(493/576),P=0.012].After adjusting for confounding factors such as age,assisted pregnancy method,type of multiple pregnancies,and number of retained embryos,transabdominal fetal reduction was an independent protective factor for live birth rate(P=0.040,OR=1.604,95%CI:1.021-2.519).Conclusion:With the change of transplantation strategy,the proportion of dichorionic diamniotic twins increased,and the proportion of transabdominal fetal reduction increased,which pregnancy outcomes might be better.There was no difference in pregnancy outcomes between those who underwent vaginal aspiration and transvaginal fetal reduction with fetal cardiac activity area injection of KCl.The outcomes of four or more high sequence multiple pregnancies were poor,and it was necessary to strictly control the number of embryo transfers and optimize ovulation promotion plans in clinical practice.