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中华产科急救电子杂志 ›› 2024, Vol. 13 ›› Issue (02) : 93 -99. doi: 10.3877/cma.j.issn.2095-3259.2024.02.007

论著

体外受精-胚胎移植妊娠合并绒毛膜下血肿患者妊娠结局的临床研究
刘文易1, 高晓彤1, 汤景1, 麦卓瑶1, 祝丽琼1, 陈慧1,†()   
  1. 1. 510120　广州，中山大学孙逸仙纪念医院妇科生殖内分泌专科
  • 收稿日期:2024-04-23 出版日期:2024-05-18
  • 通信作者: 陈慧
  • 基金资助:
    国家重点研发计划(2019YFA0801403); 北京健康促进会2022年生殖医学中青年医生研究-临床研究项目(BJHPA-2022-SHZHYXZHQNYJ-LCH-011); 广东省自然科学基金(2023A1515010515)

Analysis of pregnancy outcomes in patients with in vitro fertilization-embryo transfer-assisted conception combined with subchorionic hematoma

Wenyi Liu1, Xiaotong Gao1, Jing Tang1, Zhuoyao Mai1, Liqiong Zhu1, Hui Chen1,†()   

  1. 1. Department of Obstetrics and Gynecology, Specialized in Reproductive Endocrinology, Sun Yat-sen Memorial Hospital, 510120, China
  • Received:2024-04-23 Published:2024-05-18
  • Corresponding author: Hui Chen
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引用本文：

刘文易, 高晓彤, 汤景, 麦卓瑶, 祝丽琼, 陈慧. 体外受精-胚胎移植妊娠合并绒毛膜下血肿患者妊娠结局的临床研究[J]. 中华产科急救电子杂志, 2024, 13(02): 93-99.

Wenyi Liu, Xiaotong Gao, Jing Tang, Zhuoyao Mai, Liqiong Zhu, Hui Chen. Analysis of pregnancy outcomes in patients with in vitro fertilization-embryo transfer-assisted conception combined with subchorionic hematoma[J]. Chinese Journal of Obstetric Emergency(Electronic Edition), 2024, 13(02): 93-99.

目的

探究接受体外受精-胚胎移植妊娠合并绒毛膜下血肿患者的临床特点与妊娠结局。

方法

收集2021年1月至2023年5月于中山大学孙逸仙纪念医院接受体外受精-胚胎移植助孕并诊断为绒毛膜下血肿的79例患者的临床资料，对其进行回顾性分析。以妊娠结局分为妊娠丢失组(13例)和活产组(66例)，比较两组患者的一般情况、血肿与妊娠相关资料及实验室检查情况；以妊娠是否达到12周为时间节点，分为早期流产组(11例)和未发生早期流产组(68例)；79例患者中获得可计算血肿/孕囊体积比详细数据者共71例，以血肿/孕囊体积比分组，分析小血肿(37例)、中血肿(9例)和大血肿(25例)患者的病史资料与妊娠结局。

结果

早期流产组血肿/孕囊体积比大于未发生早期流产组(2.83 vs 0.13，Z＝－3.147)、诊断绒毛膜下血肿孕周早于未发生早期流产组(6.1周vs 8.0周，t＝－2.266)、体质指数低于未发生早期流产组(19.5 vs 21.7，t＝－2.202)，差异均有统计学意义(P<0.05)。按血肿/孕囊体积比分组，大血肿组妊娠丢失率明显高于小、中血肿组(32.0% vs 5.4%、22.2%, χ2＝4.480)，差异具有统计学意义(P<0.05)；既往晚期流产次数和引产次数对绒毛膜下血肿的大小有影响。妊娠丢失组与活产组相比，B淋巴细胞水平较高(19.0% vs 15.7%，t＝2.007)，抗β2糖蛋白抗体IgG型较高(5.1 U/ml vs 2.37 U/ml，Z＝－2.075)，补体C3水平较高(1651.2 mg/L vs 1087.8 mg/L，t＝2.128)，补体C4水平较低(196.0 mg/L vs 231.5 mg/L，Z＝－2.106)，差异均有统计学意义(P<0.05)。妊娠丢失组与活产组凝血指标均在正常范围内。

结论

血肿/孕囊体积比越大、诊断绒毛膜下血肿时孕周越小，早期流产率越高；诊断绒毛膜下血肿孕周<8周早期流产率高，出现大血肿的几率大；有晚期流产史和引产史患者更容易出现中、小血肿；对于妊娠丢失与活产患者存在部分免疫状况差异，临床诊疗中应给予关注。

关键词: 体外受精, 胚胎移植, 绒毛膜, 血肿, 妊娠结局
Objective

To investigate the clinical characteristics and pregnancy outcomes of patients who underwent in vitro fertilization-embryo transfer for assisted conception combined with subchorionic hematoma (SCH).

Methods

A retrospective analysis was conducted on 79 patients diagnosed with SCH who underwent IVF-ET at Sun Yat-sen Memorial Hospital, Zhongshan University, from January 2021 to May 2023.Grouped by pregnancy outcome, general clinical data, hematoma and pregnancy-related data, and laboratory indexes were compared in the pregnancy loss group (13 cases) and the live birth group (66 cases). The group was divided into an early miscarriage group (11 cases) and a group without early miscarriage (68 cases), using whether or not the pregnancy had reached 12 weeks as the timeline. Among 79 patients, a total of 71 obtained detailed data that can calculate the hematoma/gestational sac volume ratio. The hematoma/gestational sac volume ratio was used as a subgroup to analyze the pregnancy outcomes and past medical history of small hematoma (37 cases), medium hematoma (9 cases) and large hematoma (25 cases) patients.

Results

The hematoma/gestational sac volume ratio was greater in the early miscarriage group than in the group without early miscarriage (2.83 vs 0.13, Z=-3.147), the gestational week of diagnosis of subchorionic hematoma was earlier than in the group without early miscarriage (6.1 vs 8.0 weeks, t=-2.266), and the body mass index was lower than in the group without early miscarriage (19.5 vs 21.7, t=-2.202), and the differences were statistically significant (P<0.05). Grouped by hematoma/gestational sac volume ratio, the pregnancy loss rate was significantly higher in the large hematoma group than in the small and medium hematoma groups (32.0% vs 5.4%, 22.2%, χ2=4.480), and the differences were statistically significant (P<0.05); the number of previous late miscarriages and induced abortions affected the size of SCH. The pregnancy loss group had higher levels of B-lymphocytes (19.0% vs 15.7%, t=2.007), higher anti-β2 glycoprotein antibody IgG type (5.1 U/ml vs 2.37 U/ml, Z=-2.075), higher levels of complement C3(1651.2 mg/L vs 1087.8 mg/L, t=2.128), and lower levels of complement C4(196.0 mg/L vs 231.5 mg/L, Z=-2.106) compared with the live birth group, and the differences were statistically significant (P<0.05). Coagulation indices were within the normal range in the pregnancy loss and live birth groups.

Conclusions

A higher hematoma/sac volume ratio and smaller gestational age at SCH diagnosis are associated with a higher rate of early miscarriage. The early miscarriage rate is higher in the patients with SCH diagnosis <8 weeks, with a greater likelihood of large hematomas occurring. Patients with a history of late miscarriages and induced abortions are more likely to have medium or small hematomas. Partial differences in immune status existed between patients with pregnancy loss and those with live birth, warranting attention in clinical diagnosis and treatment.

Key words: Fertilization in vitro, Embryo transfer, Chorion, Hematoma, Pregnancy outcome
表1 79例不同妊娠结局患者基本情况比较
妊娠结局分组 例数 血肿/孕囊体积比[M(P25，P75)] 诊断血肿孕周(周，±s) 体质指数(kg/m2，±s) 流产史(次，±s) 腹痛[例(%)] 妊娠合并糖尿病[例(%)] 产后出血[例(%)]
早期流产 晚期流产
早期流产 11 2.83(0.39，3.41) 6.1±1.0 19.5±3.1 1.3±1.8 0.2±0.4 1(1/11)a 0 0
未发生早期流产 68 0.13(0.05，0.59) 8.0±2.8 21.7±3.1 1.4±1.8 0.2±0.4 30(44.1) 15(22.1) 4(5.9)
统计值   Z＝－3.147 t＝－2.266 t＝－2.202 t＝－0.137 t＝0.039 χ2＝4.872 χ2＝1.733 －
P值   0.002 <0.001 0.031 0.891 0.969 0.027 0.188 0.542b
妊娠丢失 13 2.58(0.35，3.38) 6.9±2.7 20.1±3.2 1.2±1.7 0.2±0.4 3(3/13)a 0 0
活产 66 0.12(0.05，0.61) 7.9±2.7 21.7±3.2 1.4±1.8 0.2±0.4 28(42.4) 15(22.7) 4(6.1)
统计值   Z＝－3.084 t＝－1.235 t＝－1.64 t＝－0.243 t＝0.505 χ2＝1.705 χ2＝2.319 －
P值   0.002 0.221 0.105 0.808 0.615 0.192 0.128 0.480b
早产 9 0.08(0.02，0.44) 8.9±3.3 20.5±3.0 1.6±1.2 0.4±0.5 5(5/9)a 3(3/9)a 0
足月产 57 0.13(0.05，0.99) 7.8±2.6 21.9±3.2 1.3±1.9 0.1±0.4 23(40.4) 12(21.1) 4(7.0)
统计值   Z＝－0.738 t＝1.128 t＝－1.228 t＝0.338 t＝2.228 χ2＝0.736 χ2＝0.151 －
P值   0.46 0.263 0.224 0.736 0.029 0.391 0.697 0.548b
表2 71例不同大小血肿患者妊娠结局及既往病史资料比较
组别 例数 妊娠结局[例(%)] 既往病史(次，±s)
妊娠丢失 早产 足月产 早期流产 晚期流产 引产
小血肿 37 2(5.4) 4(10.8) 31(83.8) 1.4±1.6 0.2±0.5 0.1±0.3
中血肿 9 2(2/9)a 2(2/9)a 5(5/9)a 0.6±1.0 0.3±0.5 0.3±0.5
大血肿 25 8(32.0) 1(4.0) 16(64.0) 1.6±2.2 0 0
统计值   χ2＝4.480 χ2＝0.267 χ2＝2.368 F＝1.028 F＝3.651 F＝4.533
P值   0.021 0.288 0.001 0.36 0.031 0.014
表3 妊娠丢失组与活产组实验室免疫功能指标比较
组别 例数 B淋巴细胞(%，±s) 自然杀伤细胞(%，±s) 抗体定量[U/ml, M(P25，P75)] 补体C3(mg/L, ±s) 补体C4[mg/L，M(P25，P75)]
抗β2糖蛋白抗体IgM型 抗β2糖蛋白抗体IgG型 抗β2糖蛋白抗体IgA型 抗心磷脂抗体
妊娠丢失 13 19.0±6.6 13.5±9.5 0.14(0.09, 23.80) 5.10(1.65, 7.52) 0.75(0.28, 1.74) 5.36(3.06, 9.00) 1651.2±2159.8 196.0(134.5, 227.0)
活产 66 15.7±5.1 11.5±5.3 0.47(0.29, 2.32) 2.37(1.07, 3.47) 0.59(0.23, 0.86) 3.21(2.31, 5.10) 1087.8±201.8 231.5(170.5, 272.3)
统计值   t＝2.007 t＝1.056 Z＝－1.041 Z＝－2.075 Z＝－0.435 Z＝－2.136 t＝2.128 Z＝－2.106
P值   0.048 0.294 0.298 0.038 0.495 0.033 0.037 0.044
表4 妊娠丢失组与活产组凝血功能指标比较(±s)
组别 例数 纤维蛋白原(g/L) 活化部分凝血活酶时间(s) 凝血酶时间(s) 抗凝血酶Ⅲ活性(%) 血小板聚集功能(%) 蛋白C(%) 蛋白S(%)
妊娠丢失 13 3.18±0.76 25.31±2.45 17.71±1.91 93.38±10.91 40.30±7.16 104.31±23.39 66.94±29.20
活产 66 2.98±0.65 25.18±2.38 18.22±1.25 90.66±12.15 42.00±8.86 111.54±27.84 60.32±19.45
t值   1.007 0.171 －1.236 0.751 －0.652 －0.876 1.025
P值   0.317 0.864 0.22 0.455 0.516 0.384 0.309
表5 妊娠丢失组与活产组患者OGTT比较[mmol/L, M(P25，P75)]
组别 例数 空腹 1 h 2 h
妊娠丢失 13 4.40(2.70, 4.75) 10.00(7.95, 11.80) 8.00(5.80, 8.75)
活产 66 4.60(4.20, 4.90) 7.90(6.50, 9.93) 6.30(5.80, 8.00)
Z值   －1.461 －2.409 －0.946
P值   0.144 0.016 0.344
表6 妊娠丢失组与活产组患者内分泌功能指标比较(±s)
组别 例数 空腹胰岛素(mmol/L) 总甲状腺素(nmol/L) 游离甲状腺素(pmol/L) 促甲状腺素(mU/L)
妊娠丢失 13 8.00±4.14 127.43±22.73 15.96±2.99 1.59±0.78
活产 66 9.32±3.38 139.60±27.64 17.31±2.25 1.64±1.08
t值   －1.244 －1.489 －1.867 －0.177
P值   0.217 0.140 0.066 0.860
[1]
庾广聿，范嘉琪，余晴，等. IVF-ET助孕妊娠后发生绒毛膜下血肿影响因素分析[J]. 中国计划生育学杂志，2023，31(12)：2962-2966.
[2]
Khan RI, Taimoor A, Nazir A, et al. Association of subchorionic hematoma with preterm labour in patients with threatened abortion[J]. J Ayub Med Coll Abbottabad，2021，33(3)：451-455.
[3]
Yue M, Ma L, Cao Y, et al. Application of a nomogram for predicting the risk of subchorionic hematoma in early pregnancy with in vitro fertilization-embryo transfer/frozen embryo transfer[J]. Front Endocrinol，2021，12：1-9.
[4]
Asato K, Mekaru K, Heshiki C, et al. Subchorionic hematoma occurs more frequently in in vitro fertilization pregnancy[J]. Eur J Obstet Gynecol Reprod Biol，2014，181：41-44.
[5]
Günay T, Yardimci OD. How does subchorionic hematoma in the first trimester affect pregnancy outcomes？[J]. Arch Med Sci，2021，18(3)：639-646.
[6]
Fu Z, Ding X, Wei D, et al. Impact of subchorionic hematoma on pregnancy outcomes in women with recurrent pregnancy loss[J]. Biomol Biomed，2023，23(1)：170-175.
[7]
Yin R, Wang K, Li L, et al. Association between first-trimester subchorionic hematoma detected at 6－8 weeks of gestation and pregnancy outcomes after fresh embryo transfers: a propensity score-matching cohort study[J]. Arch Gynecol Obstet，2022，306(6)：2167-2175.
[8]
West BT, Kavoussi PK, Odenwald KC, et al. Factors associated with subchorionic hematoma formation in pregnancies achieved via assisted reproductive technologies[J]. J Assist Reprod Genet，2020，37(2)：305-309.
[9]
Mei Y, Lin Y, Guo X, et al. The risk factors and impact of subchorionic hematoma in the first trimester in IVF twin pregnancies: a prospective cohort study[J]. Front Med，2023，10：1-7.
[10]
Anderson KL, Jimenez PT, Omurtag KR, et al. Outcomes of in vitro fertilization pregnancies complicated by subchorionic hematoma detected on first-trimester ultrasound[J]. F S Rep, 2020，1(2)：149-153.
[11]
戚添媛，冀晓慧，高晓彤，等. 单胎妊娠合并绒毛膜下血肿妊娠结局的临床研究[J]. 岭南急诊医学杂志，2024，29(1)：33-37.
[12]
Bennett GL, Bromley B, Lieberman E, et al. Subchorionic hemorrhage in first-trimester pregnancies: prediction of pregnancy outcome with sonography[J]. Radiol，1996，200(3)：803-806.
[13]
Heller HT, Asch EA, Durfee SM, et al. Subchorionic hematoma: correlation of grading techniques with first-trimester pregnancy outcome[J]. J Ultrasound Med，2018，37(7)：1725-1732.
[14]
Ylöstalo P, Ammälä P, Seppälä M. Intrauterine haematoma and placental protein 5 in patients with uterine bleeding during pregnancy[J]. Br J Obstet Gynaecol，1984，91(4)：353-356.
[15]
Anderson KL, Jimenez PT, Omurtag KR, et al. Outcomes of in vitro fertilization pregnancies complicated by subchorionic hematoma detected on first-trimester ultrasound[J]. F S Rep，2020，1(2)：149-153.
[16]
Kurjak A, Schulman H, Zudenigo D, et al. Subchorionic hematomas in early pregnancy: clinical outcome and blood flow patterns[J]. J Matern Fetal Med，1996，5(1)：41-44.
[17]
黄启涛，钟梅. 易栓症与妊娠期血栓栓塞性疾病的关系、筛查及预防研究[J/OL]. 中华产科急救电子杂志，2023，12(2)：71-75.
[18]
丁小雨，魏海明. 妊娠早期母胎界面免疫微环境与妊娠相关疾病[J]. 中国科学：生命科学，2024，54(1)：147-160.
[19]
Truong A, Sayago MM, Kutteh WH, et al. Subchorionic hematomas are increased in early pregnancy in women taking low-dose aspirin[J]. Fertil Steril，2016，105(5)：1241-1246.
[20]
Xu T, Lun W, Wang P, et al. Analysis of risk factors and pregnancy outcomes in pregnant women with subchorionic hematoma[J]. Medicine，2023，102(47)：1-5.
[21]
陈曼绮，高远，陈慧，等. 系统性红斑狼疮合并绒毛膜下血肿治疗1例并文献复习[J]. 岭南急诊医学杂志，2022，27(1)：92-94.
[22]
Ulcová-Gallová Z, Bouse V, Krizanovská K, et al. Beta 2-glycoprotein I is a good indicator of certain adverse pregnancy conditions[J]. Int J Fertil Womens Med，2001，46(6)：304-308.
[23]
梁伟璋，李佳，贺芳. 妊娠合并系统性红斑狼疮伴发神经精神狼疮一例[J/OL]. 中华产科急救电子杂志，2022，11(4)：241-245.
[24]
Tabacco S, Giannini A, Garufi C, et al. Complementemia in pregnancies with antiphospholipid syndrome[J]. Lupus，2019，28(13)：1503-1509.
[25]
Wang H, Liu M. Complement C4, infections, and autoimmune diseases[J]. Front Immunol，2021，12：1-15.
[26]
Cortés-Hernández J, Ordi-Ros J, Paredes F, et al. Clinical predictors of fetal and maternal outcome in systemic lupus erythematosus: a prospective study of 103 pregnancies[J]. Rheumatology，2002，41(6)：643-650.
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