Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, Ohio.
JAMA Netw Open. 2023 Aug 1;6(8):e2328335. doi: 10.1001/jamanetworkopen.2023.28335.
Despite the increased perinatal risks associated with pregnancies conceived with infertility treatment, there are no recommendations for timing of delivery among this at-risk population.
To identify the gestational age at which the ongoing risks of stillbirth are optimally balanced with the risks of neonatal comorbidities and infant deaths in term singleton pregnancies conceived with infertility treatment.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study used birth and death data from January 1, 2014, to December 31, 2018, in the US obtained from the National Center for Health Statistics. Singleton pregnancies conceived with infertility treatment delivered at term (37-42 weeks' gestation) were eligible for inclusion. The exclusion criteria were deliveries at less than 37 weeks' or at least 43 weeks' gestation and pregnancies with unknown history of infertility treatment, congenital anomalies, pregestational diabetes, pregestational hypertension, gestational hypertension, and preeclampsia. Data were analyzed from July 22, 2022, to June 24, 2023.
Gestational age at delivery between 37 and 42 weeks.
The primary outcome was optimal timing of delivery. To ascertain this timing, the risk of delivery (rate of neonatal morbidity and infant death) at a given gestational week was compared with the risk of delivery in the subsequent week of gestation for an additional week (rate of stillbirth during the given week per 10 000 ongoing pregnancies plus rate of neonatal morbidity and infant death in the subsequent week of gestation per 10 000 deliveries). The rates of stillbirth, neonatal morbidity, and infant death (within 1 year of life) were compared at each week. Neonatal morbidity included an Apgar score of 3 or lower at 5 minutes, requirement of ventilation for 6 hours or more, neonatal intensive care unit admission, and seizures.
Of the 178 448 singleton term pregnancies conceived with infertility treatment (maternal mean [SD] age, 34.2 [5.2] years; mean [SD] gestational age, 39.2 [1.2] weeks; 130 786 [73.5%] were non-Hispanic White patients). The risk of delivery in the subsequent week of gestation was lower than the risk of delivery at both 37 weeks (628 [95% CI, 601-656] vs 1005 [95% CI, 961-1050] per 10 000 live births) and 38 weeks (483 [95% CI, 467-500 vs 625 [95% CI, 598-652] per 10 000 live births). The risks of delivery in subsequent week of gestation significantly exceeded the risk of delivery at 39 weeks (599 [95% CI, 576-622] vs 479 [95% CI, 463-495] per 10 000 live births) and were not significant at 40 weeks (639 [95% CI, 605-675] vs 594 [95% CI, 572-617] per 10 000 live births) and 41 weeks (701 [95% CI, 628-781] vs 633 [95% CI, 599-669] per 10 000 live births).
Results of this study suggest that, in pregnancies conceived with infertility treatment, delivery at 39 weeks provided the lowest perinatal risk when comparing risk of delivery at this week of gestation vs the subsequent week of gestation.
尽管与不孕治疗相关的围产期风险增加，但对于高危人群，目前没有关于分娩时机的建议。
确定在患有不孕治疗的足月单胎妊娠中，何时出生可以使死产的持续风险与新生儿合并症和婴儿死亡的风险达到最佳平衡。
设计、地点和参与者：本队列研究使用了美国国家卫生统计中心 2014 年 1 月 1 日至 2018 年 12 月 31 日的出生和死亡数据。本研究纳入了足月（37-42 周）且患有不孕治疗的单胎妊娠。排除标准为孕 37 周前或至少 43 周分娩以及未知不孕治疗史、先天性异常、孕前糖尿病、孕前高血压、妊娠期高血压和子痫前期的妊娠。数据分析时间为 2022 年 7 月 22 日至 2023 年 6 月 24 日。
分娩时的胎龄在 37 至 42 周之间。
主要结局是最佳分娩时机。为了确定这一时机，在特定妊娠周，分娩的风险（新生儿发病率和婴儿死亡的发生率）与随后一周的分娩风险进行了比较，即该周的死产风险（每 10000 例持续妊娠的死产率）与随后一周的分娩风险（每 10000 例分娩的新生儿发病率和婴儿死亡率）。每周比较死产、新生儿发病率和婴儿死亡（出生后 1 年内）的发生率。新生儿发病率包括 5 分钟时 Apgar 评分为 3 或更低、需要通气 6 小时或更长时间、新生儿重症监护病房入院和癫痫发作。
在 178448 例患有不孕治疗的足月单胎妊娠中（产妇平均[标准差]年龄为 34.2[5.2]岁；平均[标准差]胎龄为 39.2[1.2]周；130786[73.5%]为非西班牙裔白人患者）。与孕 37 周（628[95%可信区间，601-656]比 1005[95%可信区间，961-1050]每 10000 例活产）和孕 38 周（483[95%可信区间，467-500]比 625[95%可信区间，598-652]每 10000 例活产）相比，下一孕周分娩的风险较低。下一孕周分娩的风险显著高于孕 39 周（599[95%可信区间，576-622]比 479[95%可信区间，463-495]每 10000 例活产），而与孕 40 周（639[95%可信区间，605-675]比 594[95%可信区间，572-617]每 10000 例活产）和孕 41 周（701[95%可信区间，628-781]比 633[95%可信区间，599-669]每 10000 例活产）无显著差异。
本研究结果表明，在患有不孕治疗的妊娠中，与下一孕周相比，39 周分娩的围产期风险最低。
