背景:在中期妊娠中宫颈逐渐缩短的双胎妊娠增加了自发性早产(SPTB)的风险。目前没有已知的有效方法来预防这些妇女的早产,在双胎妊娠中使用超声指示环扎术(UIC)仍存在争议.
目的:评估超声指示环扎(UIC)的组合是否,吲哚美辛和抗生素在18-26周之间的双胎妊娠可以延长妊娠,降低自发性早产(sPTB)的风险,改善围产期和新生儿结局。
方法:进行回顾性队列研究。UIC组包括在妇女医院妊娠18-26周时接受TVCL(经阴道宫颈长度)<25mm环扎术的双胎妊娠,浙江大学,医学院,从2015年12月到2021年8月。在我们的研究中,接受环扎术的双胞胎也接受了抗生素和吲哚美辛。对照组为双胎妊娠,预期管理与治疗组相匹配,根据诊断时±3mm的最短TVCL,诊断时的GA为±3周,母亲年龄为±5岁。通过TVCL<15mm和15-24mm将患者分成两个亚组进行额外的亚分析。主要结果是分娩时的胎龄(GA)。次要结果是妊娠潜伏期,在<28,<32,<34,<36周,和新生儿结局。
结果:90例TVCL<25mm的双胎妊娠采用环扎(UIC组:n=45)或期待治疗(对照组:n=45)。两组的人口统计学特征没有显着差异。与对照组相比,分娩时的GA显着升高(33.11±3.16vs30.22±4.12周,p=0.001),妊娠潜伏期明显更长(72.40±22.51vs45.56±28.82天,在UIC组中p<0.001)。在<28、<32、<34和<36周时,UIC组的sPTB发生率显著低于对照组。对于新生儿结局,围产期总死亡率显着降低:(4.4%vs20.0%,p<0.001);NICU入院:(69.0%vs92.6%,p<0.001);和复合不良新生儿结局:(43.7%vs64.7%,p=0.010),在UIC和对照组中进行比较。在TVCL15-24mm的女性亚组中(包括21个UICvs21个对照),在调整了产妇年龄后,孕前体重指数(BMI),IVF,宫腔镜手术,之前的宫颈手术,先前的sPTB,WBC,CRP,NLR和诊断时最短的TVCL。在UIC组中,分娩时的GA显着升高(32.95±3.81vs30.24±4.01周,贝特:3.34,95%置信区间(CI):0.14-6.55,p=0.042),妊娠潜伏期明显延长(77.19±24.81vs48.52±29.67天,贝特:33.81,95%CI:12.29-55.34,p=0.003),<36周时的sPTB发生率:(57.1%vs95.2%,OR:0.03,95CI:0.01-0.69,p=0.029)显着减少,新生儿结局,NICU入院显着减少:(53.7%vs96.7%,OR:0.04,95CI:0.01-0.32,p=0.003);和复合不良新生儿结局:(39.0%vs73.3%,OR:0.24,95CI:0.08-0.68,p=0.008)在UIC组比对照组。在TVCL<15mm的女性亚组中,分娩时的GA更高(33.25±2.52vs30.00±4.33周,贝特:3.96,95CI:1.51-6.42,p=0.002),妊娠潜伏期明显延长(68.21±19.85vs42.96±28.43天,贝特:30.11,95%CI:12.42-47.81,p=0.001),<32周时的sPTB发生率(16.7%vs54.2%,OR:0.10,95CI:0.01-0.61,p=0.020)和<34周(54.2%vs83.3%,OR:0.08,95CI:0.01-0.66,p=0.019)显着降低,新生儿出生体重显着加重(2023.96±510.35vs1421.77±611.40g,Bate:702.40;95CI:297.02-1107.78,p=0.001)在UIC组高于对照组。
结论:与期待管理相比,在TVCL<25mm的双胎妊娠中进行环扎术可以降低sPTB的发生率并改善围产期和新生儿结局。值得注意的是,即使在短TVCL15-24mm中,环扎会显著降低<36周时的分娩风险,并延长妊娠潜伏期。在短的TVCL<15毫米的情况下,环扎会显著降低<32、<34周的分娩风险,并延长妊娠潜伏期。
Twin pregnancies with a progressively shortening cervix in the midterm pregnancy have an increasing risk for spontaneous preterm birth. Currently, there is no known effective method to prevent preterm birth among those women, and the use of an ultrasound-indicated cerclage in twin pregnancies is still controversial.
This study aimed to estimate whether a combination of ultrasound-indicated cerclage, indomethacin, and antibiotics in twin pregnancies between 18 and 26 weeks\' gestation could extend the pregnancy, reduce the risk for spontaneous preterm birth, and improve perinatal and neonatal outcomes.
A retrospective cohort study was conducted. The ultrasound-indicated cerclage group included twin pregnancies with a transvaginal cervical length <25 mm that underwent cerclage at 18 to 26 weeks of gestation in the Women\'s Hospital, Zhejiang University School of Medicine, from December 2015 through August 2021. Twin pregnancies in our study that underwent cerclage also received antibiotics and indomethacin. A control group of twin pregnancies that were managed expectantly were matched with the treatment group in terms of transvaginal cervical length at diagnosis (±3 mm), gestational age at presentation of diagnosis (±3 weeks), and maternal age (±5 years). An additional subanalysis was performed in which the patients were divided into 2 subgroups based on transvaginal cervical length of either <15 mm or between 15 and 24 mm. The primary outcome was gestational age at delivery. The secondary outcomes were pregnancy latency, the rate of spontaneous preterm birth at <28, <32, <34, <36 weeks\' gestation, and neonatal outcomes.
A total of 90 twin pregnancies with a transvaginal cervical length <25 mm were managed with either a cerclage (ultrasound-indicated cerclage group, n=45) or expectantly (control group, n=45). Demographic characteristics were not significantly different between the groups. When compared with the control group, the gestational age at delivery was significantly higher (33.11±3.16 vs 30.22±4.12 weeks; P=.001) and the pregnancy latency was significantly longer (72.40±22.51 vs 45.56±28.82 days; P<.001) in the ultrasound-indicated cerclage group. The rates of spontaneous preterm birth at <28, <32, <34, and <36 weeks\' gestation were significantly lower in the ultrasound-indicated cerclage group than in the control group. In terms of neonatal outcomes, there were significant reductions in the overall perinatal mortality (4.4% vs 20.0%; P<.001), neonatal intensive care unit admissions (69.0% vs 92.6%; P<.001), and composite adverse neonatal outcomes (43.7% vs 64.7%; P=.010) for the ultrasound-indicated cerclage group when compared with the control group. In the subgroup of women with a transvaginal cervical length of between 15 and 24 mm (with 21 in the ultrasound-indicated cerclage group vs 21 controls), the data were adjusted for maternal age, pregestational body mass index, in vitro fertilization, operative hysteroscopy, previous cervical surgery, previous spontaneous preterm birth, white blood cell counts, C-reactive protein level, neutrophil to lymphocyte ratio, and the shortest transvaginal cervical length measured at diagnosis. In ultrasound-indicated cerclage group, gestational age at delivery was significantly higher (32.95±3.81 vs 30.24±4.01 weeks; beta, 3.34; 95% confidence interval, 0.14-6.55; P=.042), pregnancy latency was significantly prolonged (77.19±24.81 vs 48.52±29.67 days; beta, 33.81; 95% confidence interval, 12.29-55.34; P=.003), and the rates of spontaneous preterm birth <36 weeks\' gestation (57.1% vs 95.2%; adjusted odds ratio, 0.03; 95% confidence interval, 0.01-0.69; P=.029) was significantly decreased, and for neonatal outcomes, there were significant reductions in neonatal intensive care unit admissions (53.7% vs 96.7%; adjusted odds ratio, 0.04; 95% confidence interval, 0.01-0.32; P=.003) and the composite adverse neonatal outcomes (39.0% vs 73.3%; adjusted odds ratio, 0.24; 95% confidence interval, 0.08-0.68; P=.008) in the ultrasound-indicated cerclage group when compared with the control group. In the subgroup of women with a transvaginal cervical length <15 mm, gestational age at delivery was higher (33.25±2.52 vs 30.00±4.33 weeks; beta, 3.96; 95% confidence interval, 1.51-6.42; P=.002), pregnancy latency was significantly prolonged (68.21±19.85 vs 42.96±28.43 days; beta, 30.11; 95% confidence interval, 12.42-47.81; P=.001), rates of spontaneous preterm birth at <32 weeks (16.7% vs 54.2%; adjusted odds ratio, 0.10; 95% confidence interval, 0.01-0.61; P=.020) and <34 weeks (54.2% vs 83.3%, adjusted odds ratio, 0.08; 95% confidence interval, 0.01-0.66; P=.019) of gestation was significantly decreased, and neonatal birthweight was significantly increased (2023.96±510.35 vs 1421.77±611.40 g; beta, 702.40; 95% confidence interval, 297.02-1107.78; P=.001) in the ultrasound-indicated cerclage group when compared with the control group.
Cerclage among women with twin pregnancies with a transvaginal cervical length <25 mm may reduce the rate of spontaneous preterm birth and improve perinatal and neonatal outcomes when compared with expectant management. It is worth noting that even with a short transvaginal cervical length of 15 to 24 mm, cerclage will significantly decrease the risk of delivery at <36 weeks\' gestation and prolong pregnancy latency. Among women with a short transvaginal cervical length <15 mm, cerclage will significantly decrease the risk of delivery at <32 and <34 weeks\' gestation and prolong pregnancy latency.