关于剖宫产后再次分娩方式及预测公式的研究

发布时间：2018-06-27 01:23

  本文选题：剖宫产后阴道试产 + 剖宫产后再次择期剖宫产　； 参考：《苏州大学》2014年硕士论文

【摘要】：目的： 探讨剖宫产后再次分娩的最佳方式及国外剖宫产后阴道分娩的风险预测公式在我国的适用性，进而探索适合我国人群使用的剖宫产后阴道分娩的预测公式。 方法： 选取2002年2月1日至2012年11月30日在苏州大学附属第一医院、苏州市立医院本部、无锡市妇幼保健院分娩的疤痕子宫孕妇1439例，其中阴道试产（trial oflabor after cesarean, TOLAC）组255例，择期再次剖宫产（elective repeat cesareandelivery, ERCD）组1184例。入选标准为距上次剖宫产手术时间超过2年，有且仅有一次剖宫产史，术式为子宫下段横切口，单活胎，无内外科合并症及妊娠并发症的健康待产妇。 1.回顾性分析这1439例剖宫产后再次妊娠孕妇产前、产时、产后的资料，比较不同分娩方式对母儿的影响及并发症的发生。 2.利用国外Flamm、Grobman、Gonen、Smith公式分别对TOLAC组进行风险计算及分析，比较公式计算理论值及实际情况,验证各公式的适用性。 3.利用多因素Logistic回归分析，结合国外公式与临床实际，我们随机挑选60%的TOLAC患者（153名），对试产者的年龄，职业有无，阴道分娩史，宫口开大情况，羊水污染情况，建卡情况，身高，分娩前体重，是否孕足月，新生儿体重进行多因素Logistic回归分析。筛选出适合我国,对预测剖宫产后阴道分娩(vaginalbirth after cesarean, VBAC)和ERCD风险有意义的因素，进而探索新的预测公式。 统计学处理： 数值变量以（X±S）表示，采用SAS9.2统计软件，计量资料比较采用Z检验，t检验，计数资料比较采用χ2检验、Fisher确切概率法，Kappa检验，受试者工作特性（receiver operating characteristic, ROC）曲线及多因素Logistic回归分析，非参数资料比较采用秩和检验。 结果： 1.255例选择TOLAC，其中233例VBAC，22例失败行急诊剖宫产，1184例ERCD，其中131例为临产后剖宫产终止妊娠，孕妇的主观意愿对分娩方式的选择起着很大的主导作用。 2. TOLAC组比ERCD组无业率高，未建卡产检率高，急诊入院率高，孕妇临产前体重轻，新生儿出生体重轻，分娩孕周小，有阴道分娩史的人数多，，差异均有统计学意义（P均＜0.05）。 3. TOLAC组与ERCD组中孕产妇并发症的发生（子宫破裂，输血，产后出血，产褥感染，子宫不全破裂，切口部位子宫内膜异位症，产后不全肠梗阻，手术致膀胱损伤）除不全子宫破裂外[0%（0/255）比1.01%（12/1184）]（χ2＝4.53，P＝0.03），其余差异均无统计学意义；但TOLAC组的住院天数、总住院费用、抗生素使用情况、失血量均明显少于ERCD组，而分娩前后血红蛋白丢失量TOLAC组多于ERCD组，差异均有统计学意义（P＜0.05）。 4. TOLAC组与ERCD组中新生儿并发症的发生：以足月儿及未足月儿分开比较，两组新生儿出生后1分钟Apgar评分≤7分以及新生儿转院/转科率均无统计学差异（P＞0.05）。 5.对各公式的验证中，Flamm公式的AUC为0.52，P=0.71。以试产结局分组对结果进行t检验，t=-0.72，P=0.48，提示该公式诊断效能较低；Grobman公式的AUC为0.67，P＜0.05，以试产结局分组对结果进行t检验，t=2.58，P＜0.05，提示该公式具有一定诊断价值；Gonen公式AUC为0.51，P=0.90，以试产结局分组对结果进行t检验，t=-0.19，P=0.85，提示该公式诊断效能较低；Smith公式中校正胎儿性别前的AUC为0.66，P＜0.05，临界值42.16%。校正胎儿性别后的AUC为0.65，P＜0.05，临界值39.65%，以试产结局分组对结果进行t检验，得到校正胎儿性别前的t=-2.32，P＜0.05，校正胎儿性别后的t=-2.26，P＜0.05，以40%为界，对预测结果和实际结果进行Kappa检验，得到校正胎儿性别前的Kappa系数=0.20，P＜0.05。校正胎儿性别后的Kappa系数=0.24，P＜0.05，提示我们的实验结果与Smith公式有一致性，即Smith公式具有一定诊断价值，且以40%界定为高危人群同样适用于我国。 6.多因素Logistic回归分析中，羊水污染情况、是否孕足月与新生儿体重为有意义因素，P均＜0.05。根据这个结果建立新的预测评分系统，并用ROC分析，曲线下面积为0.89，P＜0.05。将新预测评分系统与Grobman公式及校正胎儿性别后的Smith公式的ROC曲线进行比较，发现新预测评分系统的ROC曲线下面积与后两者的ROC曲线下面积有统计学差异，P均＜0.05，提示新预测评分系统的诊断效能优于Grobman及Smith公式。 结论： 1.在能实施紧急剖宫产手术，并备有随时可参与抢救的产科医生，麻醉医生的医院，严格掌握VBAC指征的条件下实施剖宫产后的阴道试产是安全的，且有着费用较低，缩短患者住院天数，降低剖宫产率等多项益处。 2.孕产妇的主观意愿对分娩方式的选择起着很大的主导作用。由此提示患者的主观意愿也是造成再次剖宫产率升高的原因之一，如何指导有剖宫产史的孕妇正确的看待VBAC也应是产前保健的一项重要内容。 3. Flamm、Grobman、Gonen、Smith预测公式中，Smith公式更适用于我国人群，国外以评分结果40%界定为高危人群同样适用于我国。我们的实验结果提示新的预测公式诊断价值优于Smith公式及Grobman公式，但是新预测评分系统尚有待进一步完善与验证。
[Abstract]:Purpose :

This paper discusses the best mode of re - delivery after cesarean section and the formula of predicting the risk of vaginal delivery after cesarean section in our country , and then explores the formula of predicting vaginal delivery after cesarean section .

Method :

A total of 1439 pregnant women were selected from January 1 , 2002 to Nov . 30 , 2012 at the First Affiliated Hospital of the University of Suzhou , the Department of Suzhou State Hospital and the Wuxi Municipal Maternal and Child Health Hospital . Among them , there were 255 cases of vaginal trial of labor after cesarean section , and 1184 cases of cesarean section .

1 . The data of prenatal , postnatal and post - natal period after cesarean section in 1439 patients with cesarean section were analyzed retrospectively , and the effects of different delivery methods on the mother and the occurrence of complications were compared .

2 . Using the foreign Flamm , Grobman , Gonen and Smith formula to calculate and analyze the TOLAC group respectively , compare the theoretical value and the actual situation of the formula , and verify the applicability of each formula .

3 . Using multi - factor logistic regression analysis , combining the foreign formula and clinical practice , we randomly selected 60 % of patients with TOLAC ( 153 ) , the age , the occupation , the vaginal delivery history , the opening of the uterus , the condition of water pollution , the condition of building the card , height , the weight before giving birth , whether or not the birth weight of the pregnant woman and the body weight of the newborn were analyzed . The factors which were suitable for our country and the prediction of vaginalbirth after birth ( VBAC ) and ERCD risk were screened out , and then the new prediction formula was explored .

Statistical Processing :

The numerical variables are represented by ( X 卤 S ) . The statistical software of SAS9.2 is used . The comparison of the measurement data adopts the Z test , the t test and the counting data are compared by 蠂2 test , Fisher exact probability method , Kappa test , receiver operating characteristic ( ROC ) curve and multi - factor logistic regression analysis , and the non - parametric data is compared with the rank sum test .

Results :

1.255 cases of TOLAC were selected , 233 cases of VBAC , 22 cases failed emergency cesarean section and 1184 ERCD , 131 cases were caesarean section after cesarean section , and the subjective willingness of pregnant women played a leading role in the choice of delivery mode .

2 . The group of TOLAC was higher than ERCD group , the rate of non - constructed card was high , the rate of emergency hospitalization was high , the weight of the pregnant woman was light , the birth weight of the newborn was light , the birth pregnant week was small , there was a large number of women with vaginal delivery history , the difference was statistically significant ( P < 0.05 ) .

3 . The incidence of maternal complications in the TOLAC group and ERCD group ( uterine rupture , blood transfusion , postpartum hemorrhage , puerperal infection , incomplete rupture of uterus , endometriosis of incision site , postpartum non - total intestinal obstruction , operation - induced bladder injury ) were 0 % ( 0 / 255 ) vs 1.01 % ( 12 / 1184 ) ( 蠂 2 = 4.53 , P = 0.03 ) except for incomplete uterine rupture ( 蠂 2 = 4.53 , P = 0.03 ) , and the remaining differences were not statistically significant ;
However , the number of days of hospitalization , total hospitalization expense , antibiotic usage and blood loss of TOLAC group were significantly lower than those in ERCD group , and there was significant difference in the amount of hemoglobin lost before and after delivery ( P < 0.05 ) .

4 . The incidence of neonatal complications in the TOLAC group and ERCD group was not statistically significant ( P > 0.05 ) .

5 . In the verification of each formula , the AUC of the Flamm formula was 0.52 , P = 0.71 . The results were t - tested by trial - production outcome grouping , t = - 0.72 , P = 0.48 , which suggested that the formula was lower in diagnosis efficiency .
The AUC of Grobman formula was 0.67 , P < 0.05 , t - test was performed on the result of trial - production outcome grouping , t = 2.58 , P < 0.05 , suggesting that the formula has certain diagnostic value ;
The AUC of Gonen formula was 0.51 , P = 0.90 , t - test was performed on the result of trial - production outcome grouping , t = - 0.19 , P = 0.85 , which suggested that the formula was lower in diagnosis efficiency .
In Smith ' s formula , the AUC was 0.66 , P & lt ; 0.05 , and the critical value was 42.16 % . The corrected fetal sex ratio was 0.65 , P & lt ; 0.05 , and the critical value was 39.65 % . The Kappa coefficient before the sex of the fetus was corrected = - 2.32 , P & lt ; 0.05 . The Kappa coefficient of the corrected fetal sex was 0 . 24 , P < 0 . 05 .

6.澶氬洜绱燣ogistic鍥炲綊鍒嗘瀽涓

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