| BackgroundPreterm birth is a global public health issue,and the number of premature babies in China ranks second in the world.A shortened cervix in the second trimester(length≤25 mm)is a good predictor of preterm birth,but not all women with a short cervix in the second trimester will experience spontaneous preterm birth.For pregnant women with short cervix in the second trimester,how to accurately predict spontaneous preterm birth and how to choose effective intervention methods for different types of pregnant women with short cervix in the second trimester is still unclear.Method1.From January 2020 to December 2020,2084 pregnant women with abnormal cervix were screened by transvaginal ultrasound in the premature cohort of the First Affiliated Maternal and Infant Health Hospital of Tongji University.Among them,1013 pregnant women with short cervix met the inclusion and exclusion criteria,according to 1: 2 ratio matched 2026 pregnant women with normal cervical length,and a total of3039 cases were included in the study.The general demographic data,past obstetric medical history,cervical surgery history,and vaginal discharge examination during pregnancy were compared between women with short cervix and normal cervix to explore and analyze the occurrence of the second trimester.Risk factors for short cervix.2.In order to further analyze the high risk factors of spontaneous preterm birth in pregnant women with short cervix in the second trimester,879 pregnant women with short cervix who met the inclusion and exclusion criteria were included.Medical history,cervical surgery history,results of vaginal secretions during pregnancy,etc.were used to discuss and analyze the high-risk factors of spontaneous preterm birth in pregnant women with short cervix,and finally,a nomogram combined with cross-validation was used to build a risk prediction model for preterm birth.3.For 160 cases of singleton pregnant women with a history of single-term abortion in the second trimester,84 cases of singleton pregnant women with a history of cervical surgery,and 114 cases of singleton pregnant women with a first pregnancy,three groups of special short-term cervix groups in the second trimester were compared.Expectant treatment,The effects of progesterone and cervical cerclage on pregnancy outcomes and perinatal outcomes were evaluated,and the efficacy of the three treatment regimens was evaluated.4.From January 2020 to December 2020,110 eligible subjects were selected from the preterm birth cohort of the First Affiliated Maternal and Infant Health Hospital of Tongji University including 34 cases with short cervix in the second trimester and 76 cases with normal cervical length in the second trimester.Vaginal secretions were collected from 14 to 16 weeks of gestation,and 16 S r RNA gene pyrosequencing was used to analyze the vaginal flora during pregnancy and the relationship between different colony types of vaginal flora and short cervix and spontaneous preterm birth in the second trimester.Result1.High-risk factors for short cervix in the second trimester:(1)Analysis of the high-risk factors for short cervix in the second trimester of the whole population.After the Logistic regression model was adjusted for confounding factors,the risk of short cervix increased correspondingly with the increase in the number of miscarriages in the second trimester.AOR3.13(95%CI 2.50-3.92)for a short cervix in the history of a single second-trimester abortion,aOR5.24(95%CI 3.06-8.97)for a history of two second-trimester abortions;a history of cervical conization Short cervix risk aOR2.57(95%CI 1.33-4.98);twins had short cervix risk aOR2.23(95%CI 1.73-2.87);obese pregnant women had short cervix risk aOR1.99(95%CI 1.43-2.77);risk of short cervix in pregnant women with artificial insemination aOR1.88(95%CI 1.03-3.41);risk of short cervix aOR1.65(95%CI 1.06-2.58)for uterine malformation;short cervix with a history of ≥3 hysteroscopic operations Risk aOR 1.61(95%CI 1.08-2.40);increased risk of short cervix in women with vaginal discharge mold,mycoplasma-positive and BV-positive women.(2)High-risk factors for short cervix in the second trimester of singleton pregnancy.After the Logistic regression model was adjusted for confounding factors,the risk of short cervix increased correspondingly with the increase in the number of abortions in the second trimester,and the risk of short cervix in the history of a single second-trimester abortion was aOR3.21(95%CI 2.54-4.05),aOR 5.25(95%CI 3.05-9.03)for a short cervix with a history of 2 second-trimester miscarriages;aOR 2.59(95%CI 1.33)for a short cervix with a history of cervical conization-5.05);the risk of short cervix in obese pregnant women is 2.18(95%CI 1.52-3.12);the risk of short cervix is 1.84 times(95%CI 1.20-2.83)with a history of ≥3 hysteroscopic procedures;vaginal secretions Mold,mycoplasma-positive,and BV-positive pregnant women are at increased risk of developing a short cervix.(3)High-risk factors for short cervix in the second trimester of twin pregnancy,after the Logistic regression model adjusted for confounding factors,the risk of short cervix in pregnant women with ≥3times of pregnancy was aOR 1.89(95%CI1.04-3.43),and the risk of short cervix was≥4 times.The risk of short cervix was aOR 3.94(95%CI 1.71-9.09);the risk of short cervix was aOR 2.50(95%CI 1.13-5.55)for a single second-trimester miscarriage,and the risk of short cervix for women with artificial insemination was aOR 5.84(95%CI1.43)-23.83),vaginal discharge mold and BV-positive pregnant women have an increased risk of short cervix.2.Analysis of high-risk factors for spontaneous preterm birth in pregnant women with short cervix in the second trimester:(1)Analysis of high-risk factors for spontaneous preterm birth in all pregnant women with short cervix in the second trimester,Logistic regression model was used to correct for confounding factors,and the risk of spontaneous preterm birth was aOR3.35(95%CI: 1.80-6.25),embryo transfer risk aOR1.74(95%CI: 1.28-2.38),twin pregnancy risk aOR9.53(95%CI: 6.07-14.96),The risk of preterm birth in pregnant women with positive vaginal secretions for Mycoplasma was aOR1.48(95%CI: 1.02-2.13),the risk of preterm birth in women with positive vaginal secretions for BV was aOR1.71(95%CI: 1.08-2.71),and the risk of premature rupture of membranes was aOR1.71(95%CI: 1.08-2.71).The risk of preterm birth was aOR2.83(95%CI: 1.98-4.03);the risk of preterm birth in the group using progestin was aOR1.73(95%CI: 1.11-2.7),and the risk of preterm birth in the group using a course of glutathione was aOR4.94(95%CI: 2.97-8.23),the risk of preterm birth was aOR20.72(95%CI: 11.74-36.56)in the group using two courses of dexamethasone,and the risk of preterm birth in the group using magnesium sulfate was aOR3.19(95 %CI: 2.27-4.49),the risk of preterm birth in the secondary cerclage population was aOR5.29(95%CI: 2-13.96);while the cervical length aOR value was0.92,(95%CI: 0.9-0.94),gestational weight The increase aOR value was 0.9(95%CI:0.87-0.94),and the aOR value of the number of obstetric inspections was 0.84(95%CI:0.82-0.87).(2)Analysis of high risk factors for spontaneous preterm birth in singleton pregnant women with short cervix in the second trimester.After the logistic regression model was adjusted for confounding factors,the risk of preterm birth in multiparous women was aOR2.20(95%CI: 1.51-3.19),and the history of cervical electrocautery was 2.20(95%CI: 1.51-3.19).The risk of preterm birth in pregnant women was aOR13.49(95%CI: 1.50-121.47),the risk of preterm birth in women with positive vaginal secretions was aOR1.67(95%CI: 1.16-2.41),and the risk of preterm birth in women with positive vaginal secretions was aOR1.82(95%CI: 1.17-2.84),the risk of premature rupture of membranes was aOR2.78(95%CI: 1.93-4.01),and the risk of preterm birth in the group using tocolytics was aOR3.22(95%CI: 1.64)-6.33),the risk of preterm birth was aOR5.12(95%CI: 2.91-9.01)in the group using one course of dexamethasone,and aOR17.94(95%CI: 9.82-)in the group using two courses 32.77),the risk of preterm birth in the magnesium sulfate group was aOR4.38(95%CI: 2.99-6.42),and the risk of preterm birth in the second cerclage group was aOR9.73(95%CI:4.23-22.41).(3)Analysis of high-risk factors for preterm birth in pregnant women with short cervix in the second trimester of twin pregnancy.After the logistic regression model was adjusted for confounding factors,the risk of premature rupture of membranes in the twin population was aOR26.42(95%CI: 3.49-199.77),The risk of preterm birth in the group using progestin was aOR2.82(95%CI: 1.09-7.29),and the risk of preterm birth in the group using one course of dexamethasone was aOR3.08(95%CI: 1.08-8.76),using two courses The risk of preterm birth in the DM population was aOR8.42(95%CI: 2.59-27.36).3.High risk factors for spontaneous preterm birth with short cervix in the second trimester: LASSO analysis found that height,pre-pregnancy weight,weight gain during pregnancy,number of obstetric examinations,parity,number of fetuses,history of cervical electrocautery,history of cervical cerclage,cervical length,location Dexamethasone and premature rupture of membranes are variables with predictive value.Based on this,a predictive model was constructed and the ROC curve was drawn.The overall data AUC value was 0.9054(95% CI: 0.8722-0.9306),and the training set data AUC value was 0.9026(95% CI: 0.875)-0.9303),the AUC value of the test set data is 0.9113(95% CI: 0.8343-0.9444),and the AUC values of the three data sets are all greater than 0.9.The degree of correlation between predicted and actual probabilities was good,with AUCs of 0.911(95% CI: 0.8343-0.9444)and 0.905(95% CI: 0.8722-0.9306),respectively4.Comparison of expectant treatment,cervical cerclage and progesterone suppository on the prevention of spontaneous preterm birth in pregnant women with short cervix in the second trimester:(1)Pregnant women with short cervix in the second trimester with a history of single second trimester abortion: gestational age of delivery in the cervical cerclage group Greater than the progesterone group,significantly higher than the expectant treatment group.There was no significant difference between the cervical cerclage group and the progesterone group in the rate of preterm birth and the rate of preterm birth at <34 weeks,but it was significantly lower than that in the expectant care group(P<0.001).The intervention-delivery interval in the cervical cerclage group was longer than that in the progestin group,and was significantly higher than that in the expectant treatment group(P<0.001).The neonatal weight of the cervical cerclage group and the progestogen group was significantly larger than that of the expectant treatment group(P<0.001),and there was no statistical difference between the progestogen group and the cervical cerclage group.The 5-minute Apgar score of the neonates in the cervical cerclage group was significantly higher than that in the progestin group and expectant treatment group(P<0.001);the perinatal mortality rate in the cervical cerclage group was lower than that in the progestin treatment group and expectant care group(P<0.001).(2)Pregnant women with short cervix with history of cervical surgery in the second trimester: there was no significant difference in the gestational age of delivery among the three groups,and the premature birth rate in the cervical cerclage group was higher than that in the other two groups(P<0.05);the progesterone and cervical cerclage groups were 34-36+ The 6-week preterm birth rate was higher than that in the expectant treatment group,and the OR value between the cervical cerclage group and the expectant treatment group was 7.50(1.28-44.09).The preterm birth rate at <34 weeks was significantly higher in the progesterone group than in the expectant treatment and cervical cerclage groups(P=0.028,P=0.004),and there was no difference between the expectant treatment and cervical cerclage groups.There were no significant differences in cervical length,intervention-delivery interval,gestational age at delivery,neonatal weight,5-minute Apgar score,and perinatal mortality when the cervix was short.(3)Pregnant women with short cervix in the second trimester of the first pregnancy: the interventional delivery interval in the cervical cerclage group was longer than that in the other two groups(P=0.044),and there was no difference between the other two groups.The gestational age of delivery in the cervical cerclage group was significantly greater than that in the expectant treatment group(P=0.003),and there was no difference between the other two groups.The delivery rate of <34 weeks in the cervical cerclage group was significantly lower than that in the expectant treatment group,the OR value between the two groups was0.241(0.067-0.865).Value 0.087(0.010-0.745).There was no statistical difference between the three groups in the rate of preterm birth and the rate of preterm birth <34weeks.The birth weight of the newborns in the cervical cerclage group was significantly larger than that in the expectant treatment group(P<0.001),and there was no statistical difference between the progesterone treatment group and the cervical cerclage group.The rate of neonatal asphyxia and perinatal mortality in the cervical cerclage group were significantly lower than those in the expectant treatment group(P<0.001)and lower than those in the progesterone group(P=0.015),and there was no difference between the other two groups.5.The vaginal secretions of 110 high-risk singleton pregnant women with spontaneous preterm birth were subjected to 16 S r RNA gene pyrosequencing after clustering of six vaginal flora community types.There were no significant differences in the incidence of cervical shortening,preterm birth rate,and gestational age at delivery.There was still no statistical difference in the stratified analysis of gestational age at delivery.Further analysis of the six community types in the short cervix population also showed no statistically significant difference between preterm birth and delivery gestational age.Conclusion1.In addition to the common risk factors for short cervix in the second trimester,this study found that the history of multiple hysteroscopic operations before pregnancy was a high risk factor for short cervix in the second trimester.Such pregnant women need to be monitored for cervical length during pregnancy.2.In this study,11 variables were constructed including height,pre-pregnancy weight,weight gain during pregnancy,number of obstetric examinations,parity,number of fetuses,history of cervical electrocautery,history of cervical cerclage,cervical length,dexamethasone,and premature rupture of membranes.For the risk prediction model,the ROC curve AUC of both the test group and the training group was >0.9,and the model could better assess the risk of spontaneous preterm birth.3.Research on the efficacy of different treatment methods in special populations with short cervix: women with short cervix in the second trimester with a history of single-term miscarriage,cervical cerclage is better than progesterone therapy and expectant treatment in improving pregnancy outcomes;women with short cervix in the second trimester with a history of cervical surgery,cervical cerclage did not improve outcomes,expectant treatment was better than progesterone treatment in reducing preterm birth before 34 weeks of gestation;cervical cerclage intervention and perinatal outcomes were better than progesterone treatment in people with short cervix in the first pregnancy.4.The six types of vaginal flora in the short cervix population had no effect on cervical shortening,spontaneous preterm birth and gestational age of delivery in pregnant women with high risk of preterm birth. |
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