查看更多>>摘要：目的 探讨妊娠中期胎膜早破孕妇不同程度阴道流液给予期待治疗的可行性。 方法 采用回顾性队列研究方法，收集2012年7月至2022年7月于山西白求恩医院诊断为妊娠中期胎膜早破并坚决要求继续妊娠的孕妇103例，根据阴道流液程度分为破裂组（有典型阴道流液，48例）和渗漏组（无典型阴道流液，55例）。比较两组孕妇的破膜潜伏期（胎膜破裂至终止妊娠的间隔时间）、终止妊娠孕周、终止妊娠指征及方式、孕妇感染相关指标及围产儿结局。采用单因素回归模型比较不同程度阴道流液胎膜早破孕妇的母儿结局。 结果 （1）产科相关指标：渗漏组与破裂组孕妇的破膜孕周比较，差异无统计学意义（P>0.05）；但渗漏组孕妇的破膜潜伏期>28 d的占比显著高于破裂组［分别为42%（23/55）、13%（6/48）；χ2=33.673，P<0.001］，终止妊娠孕周≥28周的发生率显著高于破裂组［分别为47%（26/55）、19%（9/48）；χ2=9.295，P=0.002］。（2）终止妊娠指征及方式：渗漏组孕妇以羊水进行性减少为终止妊娠指征的发生率显著低于破裂组［分别为22%（12/55）、42%（20/48）；χ2=4.715，P=0.030］，足月终止妊娠的发生率显著高于破裂组［分别为31%（17/55）、13%（6/48）；χ2=5.008，P=0.025］；而以羊膜腔感染、宫缩无法抑制及胎儿窘迫为终止妊娠指征两组分别比较，差异均无统计学意义（P均>0.05）。终止妊娠方式，渗漏组中期引产或自发宫缩的发生率显著低于破裂组［分别为53%（29/55）、81%（39/48）；χ2=9.295，P=0.002］；剖宫产率及阴道分娩率两组分别相比，差异均无统计学意义（P均>0.05）。（3）感染相关指标：渗漏组孕妇羊膜腔感染的发生率显著高于破裂组［分别为31%（17/55）、13%（6/48）；χ 2=4.003，P=0.045］；但两组孕妇的炎症指标升高程度、子宫颈分泌物细菌培养阳性率及组织绒毛膜羊膜炎的发生率分别比较，差异均无统计学意义（P均>0.05）。（4）围产儿结局：渗漏组的新生儿活产率显著高于破裂组［分别为51%（28/55）、27%（13/48）；χ2=5.119，P=0.024］，活产新生儿1分钟Apgar评分>7分的比例显著高于破裂组［分别为38%（21/55）、17%（8/48）；χ2=4.850，P=0.028］；但两组活产新生儿出生体重及新生儿合并症的发生率分别比较，差异均无统计学意义（P均>0.05）。（5）单因素回归分析结果显示，与破裂组比较，渗漏组孕妇终止妊娠孕周≥28周（RR=2.521，95%CI为1.314~4.838；P=0.002）、羊膜腔感染（RR=2.473，95%CI为1.061~5.764；P=0.025）、围产儿存活（RR=1.880，95%CI为1.104~3.199；P=0.014）的发生率均显著升高。 结论 与妊娠中期有典型阴道流液的胎膜早破孕妇比较，无典型阴道流液的孕妇给予期待治疗更具可行性，可有效延长孕周，减少羊膜腔感染的发生，提高围产儿活产率。 Objective To investigate the feasibility of expectant management of different degrees of vaginal fluid in pregnant women with premature rupture of membranes in the second trimester. Methods A retrospective cohort study was conducted to collect 103 pregnant women who were diagnosed with premature rupture of membranes in the second trimester of pregnancy and insisted on continuing the pregnancy in Shanxi Bethune Hospital from July 2012 to July 2022. According to the degree of vaginal fluid, pregnant women were divided into rupture group (with typical vaginal fluid, 48 cases) and leakage group (without typical vaginal fluid, 55 cases). The rupture latency (the time from rupture of membranes to termination of pregnancy), gestational weeks of termination, indications and methods of termination of pregnancy, maternal infection related indicators and perinatal outcomes were compared between the two groups. Univariate regression model was used to analyze the correlation between different degrees of vaginal fluid in pregnant women with premature rupture of membranes and maternal and neonatal outcomes. Results (1) Obstetric indicators: there was no significant difference in the gestational age of rupture of membranes between the two groups (P>0.05). However, the proportion of rupture latency >28 days in the leakage group was significantly higher than that in the rupture group [42% (23/55) vs 13% (6/48) χ2=33.673, P<0.001], and the incidence of pregnancy termination ≥28 weeks was significantly higher [47% (26/55) vs 19% (9/48) χ2=9.295, P=0.002]. (2) Indications and methods of termination: the incidence of progressive reduction of amniotic fluid as the indication for termination in the leakage group was significantly lower than that in the rupture group [22% (12/55) vs 42% (20/48) χ2=4.715, P=0.030], and the incidence of full-term termination in the leakage group was significantly higher than that in the rupture group [31% (17/55) vs 12% (6/48) χ2=5.008, P=0.025], while there were no significant differences in the indications of termination of pregnancy, including amniotic cavity infection, uterine contraction failure and fetal distress between the two groups (all P>0.05). The incidence of induced labor or spontaneous contraction in the leakage group was significantly lower than that in the rupture group [53% (29/55) vs 81% (39/48) χ2=9.295, P=0.002], while the cesarean section rate and vaginal delivery rate were similar between the two groups (both P>0.05). (3) Infection related indicators: the incidence of amniotic cavity infection in the leakage group was significantly higher than that in the rupture group [31% (17/55) vs 13% (6/48) χ2=4.003, P=0.045]. However, there were no significant differences in the elevation of inflammatory indicators, the positive rate of cervical secretion bacterial culture and the incidence of tissue chorioamnionitis between the two groups (all P>0.05). (4) Perinatal outcomes: the live birth rate in the leakage group was significantly higher than that in the rupture group [51% (28/55) vs 27% (13/48) χ2=5.119, P=0.024]. The proportion of live births with 1-minute Apgar score >7 in the leakage group was significantly higher than that in the rupture group [38% (21/55) vs 17% (8/48) χ2=4.850, P=0.028]. However, there were no significant differences in the birth weight of live births and the incidence of neonatal complications between the two groups (all P>0.05). (5) Univariate regression analysis showed that compared with the rupture group, the leakage group had a higher risk of pregnancy termination at ≥28 gestational weeks (RR=2.521, 95%CI: 1.314-4.838 P=0.002), amniotic infection (RR=2.473, 95%CI: 1.061-5.764 P=0.025), perinatal survival (RR=1.880, 95%CI: 1.104-3.199 P=0.014). Conclusion Compared with pregnant women with typical vaginal fluid in the second trimester of premature rupture of membranes, expectant treatment for pregnant women with atypical vaginal fluid is more feasible, which could effectively prolong the gestational weeks and improve the perinatal live birth rate.
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