足月及近足月胎膜早破临床最佳干预时机的探讨

Timing of clinical interventions on full-term or near-term pregnancy complicated with premature rupture of membranes

目的探讨妊娠35周以上胎膜早破孕妇的临床最佳干预时机。方法对2005年1月1日至2009年12月31日在我院分娩的903例足月及近足月（孕周≥35周）、单胎头位且无其他合并症的胎膜早破孕妇的临床资料进行回顾性分析。按自然临产和缩宫素引产的不同时间分6组：1组为破膜后O～6h自然临产孕妇269例；2组为破膜6～12h自然临产孕妇161例；3组为破膜12～24h自然临产孕妇75例；4组为破膜6～12h未临产行缩宫素引产孕妇124例；5组为破膜12～24h未临产行缩宫素引产孕妇98例；6组为破膜〉24h未临产行缩宫素引产孕妇176例。分析各组孕妇的分娩结局及母婴并发症与破膜至分娩时间的关系。结果（1）903例胎膜早破孕妇中，破膜24h内临床未干预的共681例，其中自然临产共505例，占74．2％。未干预者中430例在破膜12h内自然临产，占63．2％，剖宫产率为20．7%（89／430）；75例于破膜12～24h自然临产，占11．0％，剖宫产率50．7％（38／75）；176例破膜后24h内仍未临产，占25．8％，剖宫产率为70．5％（124／176）。（2）903例孕妇中破膜6、12、24h行缩宫素引产者共398例（44．1％）。破膜12h缩宫素引产组（5组）的剖宫产率、宫内感染率、产褥病率和围产儿病率均低于破膜24h缩宫素引产组（6组）[剖宫产率：52．0％（51／98）和70．5％（124／176）；宫内感染率：6．1％（6／98）和22．7％（40／176）；产褥病率：6．1％（6／98）和19．9％（35／176）；围产儿病率：7．1％（7／98）和20．5％（36／176），P均〈0．01]，但产后出血发生率两组之间比较差异无统计学意义[1．0％（1／98）和4．0％（7／176），P〉0．05]。结论足月及近足月胎膜早破孕妇破膜12h内自然临产率高，结局良好，故临床不必干预。破膜12h仍未临产者，应积极引产。等待破膜24h后再引产，则增加剖宫产率及母婴并发症的发生率。

Objective To explore the optimal time for clinical interventions on full-term or near-term pregnant women with premature rupture of membranes（PROM）. Methods A retrospective study was conducted on clinical data of 903 healthy, full-term or near-term （gestational age ≥35 weeks）, singleton pregnant women with PROM, who admitted to our hospital from January 1, 2005 to December 31, 2009. All subjects were divided into 6 groups： women in group 1 were those fell into spontaneous labor within 6 h after PROM （n=269, 29.8%） ; women in group 2 were in spontaneous labor between 6 to 12 h after PROM （n=161, 17.8%） ; women in group 3 were in spontaneous labor at 12 to 24 h after PROM （n=75, 8.3%）; In group 4 oxytocin was administered for induction for women not in labor at 6 to 12 h after PROM （n=124, 13.7%） ; Group 5 included those women who were not in labor at 12 to 24 h after PROM and oxytocin induction was offered （n= 98, 10. 9%）; Group 6 consisted of those women who were not in labor over 24 h after PROM and oxytoein induction was offered （n = 176, 19. 5%）. The maternal and neonatal complications and outcomes of all pregnancies were reviewed and compared. Results Among the 903 cases, the total number of women without any medical interventions was 681, among which 505 （74.2%） fell into spontaneous labor, including 430 （63.2%） within 12 h with a cesarean section rate（CSR） of 20.7%（89/430）, 75 （11.0%） at 12-24 h after PROM with the CSR of 50.7% （38/75）, and 176 （25.8G） did not go into labor spontaneously （group 6） with a CSR of 70.5% （124/176）. （2） Among the 930 women, 398 were induced at 6, 12 and 24 h after PROM. The CSR, incidence of intrauterine infection, puerperal morbidity and perinatal mortality rate in group 5 were significantly lower than those of group 6 [CSR： 52.0%（51/98） vs 70. 5% （124/176）; intrauterine infection： 6. 1% （6/98） vs 22. 7% （40/176）; puerperal morbidity： 6. 1%（6/98） vs 19. 9% （35/176）;perinatal mortality： 7. 1% （7/98） vs 20.5% （36/176） ,all P〈0. 01], but no difference was found in the incidence of postpartum hemorrhage [1.0% （1/98） vs 4.0% （7/176）, P〉0. 05]. Conclusions Intervention is not recommended within 12 h after PROM in full term or near term gravidas. However, induction of labor should be offered thereafter. However, the CSR and incidence of maternal and neonatal complications rise up if induction of labor postponed to 24 h after PROM.