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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(四)

2019-09-16 14:49 来源: 中国乐虎app官网网 作者: 审校:郑剑兰 译者:田迪雅 汪文雁 陈琼 张茜 浏览量: 1123

译者:田迪雅 汪文雁 陈琼 张茜 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)

对未来妊娠的考虑

随着剖宫产妇女人数的增加,前置胎盘,胎盘粘连,胎盘植入或穿透等异常胎盘的发生率也增加。因此,重要的是要讨论重复剖宫产对所有妇女的长期潜在影响,特别是那些计划生育2个以上孩子的妇女。

母亲一生中的计划生育数是一个可能影响决定尝试TOLAC的重要因素。考虑3次或更多剖宫产的孕产妇风险增加,只要合适,计划更多胎产次的孕产妇,可能更有动力在第一次剖宫产后考虑TOLAC。

前置胎盘

2010年的一篇203项研究的综述发现,接受过1次剖宫产孕产妇,估计前置胎盘绝对风险为1.0%(95%CI为0.6%-1.3%),2次剖宫产的为1.7%(95%CI 01.1% - 2.3%),2次或更多剖宫产的为2.6%(95%CI 1.1%-4.8%),3次或更多剖宫产的为 3.0%(95%CI 2.1%-4.5%)。[28]既往剖宫产史的孕产妇与无剖宫产史的相比,前置胎盘的风险显着增加,具有统计学意义,OR为1.48-3.95。[28]

对于前置胎盘的孕产妇,既往剖宫产史是孕产妇发病率的重要危险因素。既往1次剖宫产并发前置胎盘的孕产女与既往没有剖宫产史并发前置胎盘的相比,输血率(15%对32.2%),子宫切除术率(0.7%~4%对10%) 和综合孕产妇发病率(15%对23%至30%),风险增加具有统计学意义。既往3次或更多次剖宫产并发前置胎盘的孕产妇,子宫切除术的风险(0.7%至4%对50%至67%)和综合孕产妇发病率(分别为15%和83%)显着增加。[28]

胎盘植入

随着既往剖宫产次数的增加,胎盘植入的发生率上升。对于有2次或更多次剖宫产史的孕产妇,结果具有统计学意义(OR 8.6-29.8)。[28]

前置胎盘存在时,胎盘植入的风险增加,并且随着既往剖宫产次数的增加而增加。有3次以上的剖宫产史并发前置胎盘的孕产妇,胎盘植入发生率为50%~67%。[28]

建议

22、应告知孕产妇,随着剖宫产次数的增加,前置胎盘和胎盘植入的风险增加(II-2A)。

产前注意事项

孕产妇及其医疗卫生保健提供者必须共同决定是否存在适合TOLAC的情况。评估和讨论应解决下面列出的问题,并应在产前记录或图表中记载。最好能取得关于既往剖宫产子宫切口位置和类型的资料记录。[10] 在大多数情况下,可以通过查看既往手术记录获得。该记录中的其他信息,例如剖宫产适应症和术中外科医生的意见,也可能有助于咨询。产前记录中应清楚地记下已经复查没有TOLAC禁忌症。[121]复习既往子宫切开或子宫肌瘤切除手术报告的情况也应详细记录。如果无法获得手术记录,则认为瘢痕“未知”。

根据临床情况和当地实践,产前咨询产科医生是明智的。

孕产妇需要了解能对计划TOLAC或ERCS做出明智决定的证据。剖宫产后未来妊娠分娩方式的讨论和决定也应早在产后就根据个体情况考虑好。

今天,对于意愿TOLAC孕产妇的知情同意都应包括ERCS与TOLAC的风险和益处的讨论记录。

TOLAC候选人的选择取决于临床情况,并在整个妊娠期间持续不断地重新评估。

在与意愿TOLAC或ERCS的孕产妇讨论时,应提供适当的信息,以帮助她们根据自己的具体情况做出选择。越来越多的证据表明,使用合适的决策辅助工具可以非常直观解释TOLAC和ERCS相关的风险和收益。[122]

有一些优秀资源可帮助那些考虑TOLAC的孕产妇。不列颠哥伦比亚省最好分娩诊所的一个称为“剖宫产后阴道分娩和计划重复剖宫产” 的讲义,可能有用。[123 ]渥太华卫生决策中心的决策支持工具可能有帮助。这两个中心都设立了特定的产前咨询和信息部门,目前正在评估它们对VBAC成功率的影响。

这可能也有助于专业人员理解孕产妇选择的一些基本原理。一项对孕产妇计划TOLAC或ERCS的影响因素的研究确定了以下问题:医生的影响力;恢复时间和重新照顾其孩子的需求;种族差异;母婴安全。[124]

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建议

23、包括TOLAC和ERCS的风险和益处的适当讨论的知情同意书,应成为剖宫产后孕产妇护理计划的一部分( III-A)。

24、TOLAC或ERCS的孕产妇的意愿都应明确,并应在产前记录上清楚标明既往子宫瘢痕的情况。(III-A)

产时管理

分娩早期

TOLAC的管理包括以下内容:仔细观察:充分宫缩2至3小时产程无进展,需要重新评估分娩方式、胎儿健康、孕产妇健康、一般情况可用硬膜外或其他镇痛。

活跃期的胎儿心电监护(EFM)。EFM描记异常是子宫破裂的最佳标志。无需限制活动(远程连续监测的情况下可促进活动)[15],我们建议整个护理团队注意到在分娩单元有TOLAC的孕产妇,以获得最佳的情景意识。

活跃期分娩

医疗卫生保健团队对子宫破裂的警惕和早期识别是TOLAC的重要组成部分。

虽然危险因素可能有助于识别子宫破裂风险较高的孕产妇,但子宫破裂的诊断具有挑战性,因为没有单一的迹象能可靠地表明破裂的发生。在接受TOLAC的孕产妇中,胎心率的复杂和简单的可变减速,持续性腹痛和频繁的心动过速常常发生在子宫破裂之前。这些产时因素可能是子宫瘢痕分离的早期或开始的信号。[125]

胎儿心率模式和子宫破裂

胎心率描记异常,特别是复杂的可变或晚期减速和心动过缓(据报道子宫破裂率33%-100%)是子宫破裂最常见的迹象,通常在破裂前30至60分钟出现。[57,126]

Leung等分析78例子宫破裂前FHR和子宫收缩模式[127] 71%的子宫破裂孕产妇出现延长减速(单纯或先于重复晚期或复杂的可变减速)。此外,胎儿完全挤压的FHR描记中100%出现持续减速。[127] 同样,Ayres等报道,子宫破裂最常见的胎心率异常是复发性晚期减速和心动过缓。[128 ]复发性晚期减速的出现可能是即将发生子宫破裂的早期征兆。

某些情况下,就胎心率变化而言,心动过缓之前似乎很少有警告。然而,多中心病例对照研究分析了TOLAC期间子宫破裂前2小时内FHR描记,发现在子宫破裂前1小时,常有明显的FHR异常。这就导致我们在面对可危及母婴预后的终末期心动过缓前的非典型或异常FHR描记时,尽早考虑剖宫产的可能性。[126]

如果分娩机构无法提供快速干预,可能会出现不良后果。

由此可知,虽然异常的EFM描记并不总是意味着子宫破裂,但仍然是子宫破裂发生的最佳单一标记物。[7,8,129] 经典的三联征:异常FHR,腹部疼痛和出血仅占完全子宫破裂的9%。仅有1项小型试验在TOLAC中将间歇性听诊(IA)与连续EFM进行比较。[130 ]在IA被证实可以有效地检测子宫破裂并具有与EFM的可靠性相当前,强烈建议在分娩活跃期连续EFM以密切观察FHR模式。[129,130] 这得到了多个国家指南的支持。[7,8,15]

子宫破裂的其他迹象

典型的子宫破裂的其他体征和症状包括:阴道出血

瘢痕疼痛或压痛的急性发作(很少被硬膜外掩盖;这个症状既不敏感也不具体)

其他症状和体征可能包括

血尿

产妇心动过速,低血压或低血容量性休克

腹部很容易就触到胎儿部位

先露部分意外上升

胸痛,肩痛和/或突然呼吸急促

子宫收缩的变化(减少或增加)是一种罕见且不可靠的征兆。

建议

25、整个医疗卫生保健小组都应知道在分娩单元有一名孕产妇在TOLAC(III-A)。

26、对TOLAC的孕产妇进行连续电子胎儿监测是必要的,因为胎心率描记的变化是发现子宫破裂的关键指标之一(II-2A)。

子宫破裂的时机

Holmgren等2012年的一项关于子宫破裂和决定分娩时间的研究,发现在怀疑子宫破裂后18分钟内分娩的新生儿有正常的脐血pH水平或5分钟Apgar评分大于7.[131 ]分娩时间超过30分钟的3例新生儿出现远期预后不良。[131 ]然而,如Bujold和Gauthier(2002)所述。[132]即使从延长减速到分娩开始的干预时间少于18分钟,仍有2例严重酸中毒新生儿的运动发育受损。

资源(手术室团队)

TOLAC总是伴随子宫破裂的风险,无论多小,在任何情况下都不能保证良好的结局。广泛接受的及时紧急剖宫产标准(在30分钟内启动)虽然合理,但可能无法预防严重的新生儿发病率和死亡率。[133,134]

Bujold和Gauthier[132]研究显示,延长减速与分娩之间的快速干预(<18分钟)并不总能预防严重代谢性酸中毒和严重新生儿疾病,但可能限制了新生儿死亡的发生。[132 ]一项研究发现,所有怀疑子宫破裂后18分钟内分娩的新生儿脐带pH正常(> 7.0)或5分钟Apgar评分大于7。3名决定至分娩时间超过30分钟(范围31-42分钟)[131  ]的新生儿远期预后不佳。

上述证据表明,在一个内部有产科,麻醉科和手术人员的机构中进行TOLAC是最佳的,以减少对疑似子宫破裂的决定至分娩的间隔时间。SOGC承认,这在加拿大各地的分娩单位可能无法做到。在没有内部手术室团队和紧急剖宫产手术条件的情况下,需要仔细考虑VBAC与子宫破裂时延长决定至分娩间隔时间的风险之间的平衡,并有明确记录的护理计划。[7 ]生活在当地医院无法提供紧急剖宫产的地区的孕产妇,应有机会进行产前(或分娩前)转诊,并在有提供这些服务的医疗机构进行分娩管理。[135]

所有机构都应制定处理子宫破裂的计划。定期应急演习或其他模拟练习可能有助于团队在这些罕见的紧急情况下做好准备。

建议

27、怀疑子宫破裂需立即剖宫产终止妊娠,以降低母婴的发病率和死亡率(III-B)。

28、为了改善子宫破裂情况下的母婴结局,应该在有资质施行紧急剖宫产手术的医院进行TOLAC。(III-B)

30、孕产妇及其医疗卫生保健工作者必须了解选择分娩地点的产科,麻醉科,儿科和手术室工作人员的可用情况(III-A)。

结论

对经过适当讨论后没有禁忌症的孕产妇推荐TOLAC。在能够提供紧急剖宫产的机构中,适当选择的孕产妇进行TOLAC的有效性和安全性已得到了很好的支持。建议在她们分娩时,密切观察产程进程,并持续EFM。

自然临床和既往阴道分娩史是VBAC的最佳预测指标。TOLAC与ERCS风险的知情,记录和共同决策至关重要。所有中心都应制定处理子宫破裂的计划。演习或其他模拟训练可能有助于为这些罕见的紧急情况做好准备。


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