瘢痕子宫阴道试产成功的影响因素及妊娠结局：前瞻性队列研究  

Associated factors and pregnancy outcomes of trial of labor after cesarean： a prospective cohort study

作　　者：魏素花[1] 叶晓东[1] 仇黎丽[1] 戴毅敏[1] 王志群[1] 李洁[1] 岳嫒媛 张斐然[1] 郑明明[1] 

机构地区：[1]南京大学医学院附属鼓楼医院妇产科,210008

出　　处：《中华围产医学杂志》2017年第9期649-655,共7页Chinese Journal of Perinatal Medicine

基　　金：基金项目：南京市医学科学发展项目（YKK13060）;江苏省临床医学中心（创新平台）建设单位（yxzxb2016004）;南京妇产及遗传临床医学中心

摘　　要：目的探讨瘢痕子宫孕妇阴道分娩试产成功的影响因素，比较不同分娩方式的产妇及新生儿结局。方法本研究为前瞻性队列研究。研究对象为2014年1月至2014年12月期间在南京大学医学院附属鼓楼医院分娩的剖宫产术后再次妊娠产妇。排除子宫下段瘢痕愈合不良、子宫下段厚度〈3mm，或有其他严重产科并发症、合并症或此次妊娠新出现的剖宫产指征（如前置胎盘、胎盘植入、双胎妊娠、臀位、重度子痫前期等）的产妇，符合剖宫产后阴道试产（trialoflaboraftercesarean，TOLAC）纳入标准的产妇共287例，其中142例选择TOLAC，其余145例选择再次剖宫产（electiverepeatcaesareansection，ERCS）终止妊娠。收集TOLAC组、ERCS组患者临床资料，分析影响试产成功的因素。采用t检验、秩和检验、矿检验（或Fisher精确概率法），对数据资料进行统计学分析。结果（1）TOLAC组阴道试产成功率为90．8％（129／142）。TOLAC成功组与失败组孕妇年龄、孕周、子宫下段厚度、距前次剖宫产分娩时间、新生儿体重无明显差异，2组发生产后出血和新生儿窒息的比例差异也无统计学差异（户值均〉0．05），但TOLAC失败组产后的失血量高于成功组[425（195～675）ml与200（50～1400）ml]，羊水胎粪污染率高于成功组[6／13与17．1％（22／129）1（P值均〈0．05）。TOLAC组142例中，141例（99．3％）产程中持续胎心监护；1例发生子宫不全破裂，转急诊剖宫产，其母婴结局良好。13例TOLAC失败，原因分别为难忍疼痛、产程异常、胎儿窘迫和先兆子宫破裂。（2）TOLAC组距上次分娩间隔时间短于ERCS组[5（2-18）与6（2～19）年]，年龄小于ERCS组[（31±4）与（33±4）岁]，产后出血量也少于ERCS组[200（50～1400）与300（100～1500）m1]（P值均〈0．05）。结论本研究人群中，距上次分娩间隔时间较短、年龄较轻的孕妇，更�Objective To investigate the safety of trial of labor after cesarean （TOLAC） and clinical factors associated with successful TOLAC and to compare TOLAC with elective repeat caesarean section （ERCS） in terms of obstetric and neonatal outcomes. Methods A prospective cohort study was conducted among gravidas who had a history of lower segment cesarean section and were hospitalized in the Department of Obstetrics and Gynecology, the Affiliated Drum Tower Hospital of Medical School of Nanjing University from January to December 2014. Exclusioncriteria included indications for caesarean section （such as placenta previa, placenta accreta, twin pregnancy, breech presentation and severe preeclampsia）, serious maternal complications after cesarean section, lower uterine segment thinner than 3 mm and poor healing of uterine incision. Totally, 287 gravidas were enrolled. Among them, 142 chose TOLAC and the other 145 requested ERCS. Clinical data of those gravidas were collected and statistically analyzed by t-test, Log-rank test, Chi-square or Fisher＇s exact test. Results （1） The success rate of TOLAC was 90.8% （129/142）. There was no significant difference in maternal age, gestational age, thickness of lower uterine segment, interval between the two deliveries and neonatal birth weight and asphyxia rate between the successful （n=129） and unsuccessful （n=13） groups （all P〉0.05）. Although the two groups had no significant difference in postpartum hemorrhage （PPH） rate, the gravidas who failed in TOLAC lost more blood than those who succeeded [425 （195- 675） vs 200 （50 -1 400） ml, P〈0.05]. Moreover, higher amniotic fluid contamination rate was observed in the unsuccessful group [6/13 vs 17.1% （22/129）, P〈0.05]. In the TOLAC group, 99.3% （141/142） were under continuous fetal heart rate monitoring. Incomplete uterine rupture occurred in one women without serious maternal or neonatal outcomes. The reasons for 13 failed TOLAC cases were unbearable pain during labor, abnor

关 键 词：剖宫产后阴道分娩 试分娩 剖宫产术 再 外科手术 选择性 妊娠结局 前瞻性研究 

分 类 号：R714.2[医药卫生—妇产科学]