宫颈机能不全患者孕期腹腔镜和经阴道宫颈环扎术后的疗效分析

Analysis of therapeutic effect of laparoscopic cervical cerclage and transvaginal cervical cerclage in patients with cervical incompetence during pregnancy

摘要:

目的 探讨子宫颈机能不全（cervical incompetence，CI）患者孕期行腹腔镜子宫颈环扎术（laparoscopic cervical cerclage，LAC）和经阴道子宫颈环扎术（transvaginal cervical cerclage，TVC）后的妊娠结局及超声监测妊娠期子宫颈长度的变化，进一步探讨LAC的适应证。方法 回顾性分析2016年6月至2022年2月因CI孕期在本院行子宫颈环扎术的患者共115例，其中行LAC 65例（LAC组），既往TVC失败35例，既往行子宫颈锥切术30例；TVC 50例（TVC组），均无既往TVC失败史，既往行子宫颈锥切术20例。对2组患者的妊娠结局、术中情况、术后并发症及妊娠期超声测量的子宫颈长度进行比较。结果 LAC组既往TVC失败率高于TVC组（53.8% vs. 0.0%，P<0.05），差异有统计学意义，LAC组、TVC组既往子宫颈锥切手术率差异无统计学意义（46.1% vs. 40.0%，P>0.05）；LAC组的足月产率、新生儿存活率、分娩孕周、延长孕周［83.0%、100.0%、（36.5±4.0）周、（17.0±4.2）周］均明显高于TVC组［44.0%、76.2%、（32.0±5.2）周、（13.2±4.3）周］，差异有统计学意义（P<0.05）；TVC组的早产率、难免流产率（40.0%、16.0%）均明显高于LAC组（12.3%、4.6%），差异有统计学意义（P<0.05）；LAC组无术后并发症，TVC组术后发生并发症8例（16.0%），其中子宫颈裂伤1例，术后感染7例，TVC组术后并发症发生率较LAC组高（P<0.05）。2组术前子宫颈长度相似。行子宫颈环扎术后，2组环扎带与子宫颈外口之间的距离比较，差异有统计学意义［LAC组：（28.7±4.6）mm vs. （12.3±4.2） mm，P<0.05］，妊娠期间，TVC组子宫颈长度明显缩短［分娩时，由术前的（25.0±2.0） mm缩短为（12.0±4.5） mm，P<0.05］，而LAC组子宫颈长度保持不变。结论 CI患者孕期行LAC安全、有效，妊娠结局较TVC好，原因可能是与TVC相比，LAC能更好地保留妊娠期间的子宫颈长度，推荐对既往TVC失败及既往子宫颈锥切术后子宫颈过短的患者首选LAC。

Abstract:

Objective To investigate the pregnancy outcomes and ultrasonic changes of cervical length in patients with cervical incompetence（CI） after laparoscopic cervical cerclage（LAC） and transvaginal cervical cerclage（TVC） during pregnancy，and to further explore the indications of laparoscopic cerclage.Methods We retrospective analyzed the data of 115 patients who underwent cervical cerclage in our hospital due to CI during pregnancy from June 2016 to February 2022. Among them，there were 65 patients who underwent LAC（LAC group），35 patients with previous TVC failure，and 30 patients with previous cervical conization；there were 50 patients who underwent TVC（TVC group），none of which had previous TVC failure， and 20 patients had previous cervical conization. Pregnancy outcomes，intraoperative conditions，postoperative complications and cervical length measured by ultrasound during pregnancy were compared between the two groups.Results The previous TVC failure rate in LAC group was significantly higher than that in TVC group （53.8% vs. 0.0%，P<0.05），and there were no statistically significant differences in the rate of previous cervical conization between the two groups（46.1% vs. 40.0%，P>0.05）. The full-term delivery rate， neonatal survival rate，gestational weeks of delivery and postoperative prolongation of gestational weeks［83.0%，100.0%，（36.5±4.0） weeks，（17.0±4.2） weeks］ in LAC group were significantly higher than those in TVC group［44.0%，76.2%，（32.0±5.2） weeks，（13.2±4.3）weeks］（P<0.05）. The rates of premature birth and inevitable abortion in TVC group（40.0%，16.0%） were significantly higher than those in LAC group（12.3%，4.6%）（P<0.05）. There were no postoperative complications in the LAC group，but 8 cases （16.0%） in the TVC group，including 1 case of cervical laceration and 7 cases of postoperative infection. The incidence of postoperative complications in the TVC group was higher than that in the LAC group（P<0.05）. The cervix length prior to surgery was similar in both groups. After cervical cerclage placement，there was a statistical difference in the distance between the tape and the external cervical orifice between the two groups［LAC group：（28.7±4.6） mm vs. （12.3±4.2） mm，P<0.05］. During pregnancy，the cervical length was significantly shortened in the TVC group［from （25.0±2.0） mm before surgery to （12.0±4.5） mm at delivery，P<0.05］，while in the LAC group，the cervical length remained unchanged.Conclusion In patients with CI during pregnancy，LAC is safe and effective，and its pregnancy outcomes are better than those of TVC，possibly because LAC can better preserve the length of the cervix throughout pregnancy as compared to TVC. LAC is recommended as the first choice for patients with previous TVC failure and a short cervix after previous cervical conization.