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指南速递 | SOGC临床实践指南 NO.382 剖宫产术后再次妊娠阴道试产(三)

2019-09-16 11:34 来源: 中国乐虎app官网网 作者: 审校:郑剑兰 译者:张茜 汪文雁 陈琼 田迪雅 浏览量: 852

译者:张茜 汪文雁 陈琼  田迪雅 厦门大学附属成功医院(解放军陆军第七十三集团军医院)

审校:郑剑兰 厦门大学附属成功医院(解放军陆军第七十三集团军医院)

2次或2次以上剖宫产史的孕产妇

有2次剖宫产史的孕产妇的VBAC成功率似乎与只有1次剖宫产史的相似[78-81]。一项包括17项研究的系统回顾,比较了1次和2次剖宫产后选择TOLAC和选择第三次重复剖宫产的母婴结局[78]。其中6项研究报道50685名1次剖宫产史VBAC和4565名2次剖宫产史VBAC孕产妇,其VBAC成功率相似(76.5% vs. 71.7%; OR 1.48 [1.23−1.78])[80-85]。然而,1次剖宫产史孕产妇的子宫破裂、输血和子宫切除率低于2次剖宫产史的孕产妇,(0.72% vs. 1.59%; OR 0.42 [0.29−0.60];1.21% vs. 1.99%; OR 0.56 [0.40−0.77]; 0.19% vs.0.56%; OR 0.29 [0.13−0.61]),但两组的新生儿结局似乎相似。与选择第三次重复剖宫产的10897名孕产妇相比,有2次剖宫产史的TOLAC(2829名)孕产妇发生子宫破裂风险(1.09% vs.0.11%)更高[80,81,86-91],而输血、子宫切除和新生儿结局似乎无统计学差异[78]。

Miller等探讨了有1次剖宫产史(4100名)与有2次剖宫产史(152名)的孕产妇IOL的差异[79]。在这两组中,VBAC成功率(69%和65%)同样比总体的估计值低。研究表明,有2次剖宫产史的孕产妇选择IOL和TOLAC与有1次剖宫产史的孕产妇ERCS的母婴结局相似。值得注意的是,尽管本研究中的总样本量较大(10262名孕产妇),但有2次剖宫产史TOLAC的孕产妇仅152名[79]。

建议

13、有2次剖宫产史的与有1次剖宫产史的孕产妇的VBAC相似。但在剖宫产史超过1次的情况下,应告知孕产妇在TOLAC过程中出现子宫破裂的风险较高(II-2B)。   

14、关于2次以上剖宫产史孕产妇的研究有限。

臀位

Hannah等的大型多中心研究表明:臀位的足月择期剖宫产与良好的母婴结局密切相关[92]。

虽然,SOGC及其他国际组织的确支持选择合适的孕产妇进行阴道试产。但还没有解决臀位TOLAC后阴道分娩问题的数据。因此,应单独考虑这些情况。对有剖宫产史的孕产妇,可以采用臀位倒转术[93,94]。

建议

15、TOLAC并不是臀位孕产妇的绝对禁忌症。但应告知孕产妇,目前没有足够的资料来评估臀位TOLAC的风险(III-B)。

多胎妊娠

9项研究中1533名多胎妊娠孕产妇选择TOLAC的的研究表明[95-98],双胎妊娠的TOLAC成功率与单胎妊娠看起来相似,而且临床上子宫破裂的发生率也没有显著增加。因此,TOLAC对双胎妊娠孕产妇是可行的,其结局与单胎妊娠的相似[7,57,99]。

建议

16、多胎妊娠不是TOLAC的禁忌症(II-2B)。

分娩间隔

6项在9040名孕产妇中探讨分娩间隔与TOLAC成功率和子宫破裂风险之间关系的研究[100-105]。有1次剖宫产史的单胎、足月妊娠的孕产妇中,VBAC成功率似乎与分娩间隔无关[102]。然而,较短的分娩间隔与子宫破裂风险增加有关。最准确的估计范围为分娩间隔小于12个月的绝对破裂风险为4.8%[101,106],间隔小于15个月的绝对破裂风险为4.7%[101]。Bujold等2010年的一项研究结果显示,调整混杂因素后,分娩间隔小于18个月时,子宫破裂发生率显著增加(OR 3.0;95%CI 1.3−7.2),而分娩间隔在18至24个月之间时,子宫破裂发生率无明显增加(OR 1.1;95%CI 0.4−3.2)。因此,分娩间隔小于18个月是子宫破裂的危险因素之一;然而,与超过24个月(1.3%)的子宫破裂率相比,18至24个月(绝对风险1.9%)的子宫破裂率没有显著差异[100]。

建议

17、分娩间隔小于18个月的孕产妇应被告知TOLAC过程中发生子宫破裂的风险增加(II-2A)。

子宫厚度

有许多变量会影响VBAC成功率和子宫破裂风险。大多数研究采用回归分析来更好地评估个体变量的影响然而,每个变量的实际影响程度仍然不确定。更重要的是,常同时发挥作用的多因素综合影响更加不确定。

建议

超声测量子宫下段厚度可用于预测子宫破裂的风险。然而,重要的是要识别不同的测量方法,即测量子宫下段全层厚度或仅子宫肌层厚度。医务工作者必须认识到这些测量方法之间的差异。

2013年,Kok等进行包括21项研究2776名孕产妇的的荟萃分析,评估产前超声测量子宫下段厚度在预测TOLAC过程中子宫破裂风险的准确性[107]。研究表明,测量子宫下段厚度用于临床实践前,必须先分解决分析其临床有效性和实用性的问题[107]。最近的荟萃分析表明,测量子宫下段全层厚度和子宫肌层厚度的方法是等效的。然而,每种方法都有不同的推荐值、特异性和敏感性。预测子宫破裂似乎没有明确的界限,表6列出了TOLAC过程中出现子宫破裂的较强的阴性预测值,可用于临床指导咨询[107]。

同时,我们不能仅仅通过超声测量子宫下段厚度来明确告知孕产妇TOLAC可行或不可行。尽管,子宫下段厚度的测量对预测子宫破裂的发生具有重要意义,但其临床适用性还需在前瞻性观察研究中使用标准化的测量方法进行评估[28,107]。

建议

18、尽管子宫下段厚度与子宫破裂风险相关,但TOLAC安全或不安全的绝对界限并不存在。因此,目前,我们还不能仅仅通过超声测量子宫下段厚度来明确告知患者TOLAC可行或不可行(II-2B)。

切口类型

古典式剖宫产切口

古典式剖宫产切口的孕产妇子宫破裂的风险增加(4%-9%)[17,23,108]。与前次子宫下段横切口相比,前次子宫下段纵切口或不确定切口类型的孕产妇子宫裂开或破裂的风险没有明显增加。 

不确定切口类型

应认真查阅与既往剖宫产相关的所有可用或可取的记录。若没有,关于剖宫产情况的信息将有助于确定子宫纵切口的的可能性[109,110]。大多数不确定切口类型是子宫下段横切口(92%),故子宫破裂的风险较低[111]。如果手术记录提示有古典式切口可能性时,明智的做法是建议重复剖宫产,但在病史提示是子宫下段横切口可能且孕产妇希望咨询后决定时,TOLAC是可以接受的。

子宫下段横切口单层和双层缝合比较

1997年,Chapman等发表了一篇145名孕产妇接受TOLAC治疗的的综述,她们在之前的剖宫产术中被随机分为子宫切口单层缝合组和双层缝合组[112]。研究表明,下一次的妊娠结局没有显著差异[112]。2002年,Bujold等回顾分析了2142名接受TOLAC的孕产妇,指出单层锁边缝合比双层缝合子宫破裂的风险增加(3.1 % vs. 0.5%;P < 0.001; OR 3.95; 95% Cl 1.35−11.49)[106]。2011年,Roberge等回顾了包括5810名孕产妇在内的9项研究,发现子宫切口单层锁边缝合与双层缝合相比,可能会增加未来妊娠中接受TOLAC的孕产妇子宫破裂的风险。无锁边单层缝合的子宫破裂风险似乎与双层缝合相当[113]。

建议

19、采用古典式剖宫产术或T型切口的孕产妇不建议TOLAC(II-2A)。

20、既往剖宫产子宫采用单层缝合的孕产妇,如欲尝试TOLAC,应注意子宫破裂的风险可能增加(II-2A)。

21、应尽一切努力取得既往的剖宫产手术记录,以确定子宫切口的类型。在切口类型未知的情况下,有关既往分娩情况的信息将有助于确定子宫下段横切口的可能性。如果子宫下段横切口的可能性高,则可TOLAC(II-2B)。

孕产妇肥胖

肥胖孕产妇VBAC成功率低于BMI正常的孕产妇。指未孕期BMI>30,OR为0.66 (CI 0.54 - 0.80);或孕期BMI>35,OR为0.38 (CI 0.30 - 0.38)的孕产妇[114-116]。此外,1项研究指出肥胖妇女子宫破裂/裂开的风险增加了5倍(2.1% vs.0.4%; OR 5.6;95% CI 2.7−11.7)[115]。而且,与ERCS相比,体重指数高的TOLAC后的孕产妇的发病率增加(OR 1.8; CI 1.3−2.5)[115]。同时,体重指数较高的孕产妇,决定分娩的时间可能更长,因此在有意向TOLAC时应予以考虑。

其他因素

曾因第二产程难产而剖宫产的孕产妇,在下次分娩时发生第二产程子宫破裂的风险更高,特别是在怀疑巨大胎儿或第二产程延长的情况下[117]。如子宫扩张、剖宫产后发热[118]、缝线类型、米勒管发育异常[119]、产妇年龄[120]等与子宫破裂风险相关的因素已在小样本中检测了,但尚未得出明确结论。

新生儿结局

新生儿死亡率和发病率主要与子宫破裂有关。基于中等质量的研究,TOLAC比ERCS的新生儿死亡率(1.1 per 1000 vs. 0.55 per 1000)和围产期死亡率(1.3 per 1000 vs. 0.5 per 1000)均显著增加(RR 2.06; 95%CI 1.35−3.13; and RR 1.82; 95% CI 1.24−2.67)[26]。与ERCS(小于1/10000)相比,TOLAC(8/10000)的新生儿永久性神经损伤的风险同样增加。值得注意的是, 60%的TOLAC的新生儿缺氧缺血性脑病与子宫破裂有关。据报道,由子宫破裂导致的围产期死亡率的总风险为6.2%[29]。在新生儿败血症、Apgsr评分、新生儿入住重症监护病房和母乳喂养等其他新生儿结局方面,没有显著差异。

加拿大最近的大型研究一致表明,TOLAC的新生儿发病率风险增加,包括新生儿死亡、辅助通气和新生儿癫痫[3]。据报告,ERCS的新生儿总死亡率和发病率为14.5%,而TOLAC的新生儿总死亡率和发病率为20.8%(aRR 1.49,95%CI 1.38-1.61)[3]。与孕产妇的发病率相似,在TOLAC后再次剖宫产时,新生儿的发病率显著增加。呼吸窘迫综合征是TOLAC显著降低的一种新生儿结局,(aRR为0.90,95%置信区间为0.86−0.94)[3]。

建议

22、计划VBAC的孕产妇应注意,与ERCS相比,VBAC的孕产妇围产期死亡率和发病率的相对风险较高,但绝对风险较低。

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