我国剖宫产术后再妊娠分娩方式及结局的系统评价

Systematic Evaluation on the Mode of Delivery and Outcome of Repregnancy after Cesarean Section in China

目的:回顾性分析不同分娩方式孕妇的现状和结果,旨在为临床提供参考依据。方法:检索国内外数据库中第一作者为我国的关于剖宫产术后再妊娠分娩方式选择的研究,按照纳入和排除标准对文献进行选择和纳入,语种限制为中文和英文,对文献基本信息和有效数据进行提取并分析。上述工作均由两位研究者独立进行,汇总时有不同意见请第三方取舍。评价偏倚以P<0.1为差异有统计学意义,结局指标分析以P<0.05为差异有统计学意义。结果:最终纳入文献22篇均为近十年内的中文文献,共得经阴道分娩(VBAC)组1301例,再次剖宫产(RCS)组3558例。现状分析结果显示剖宫产术后再妊娠分娩试产率为r=0.35,95%CI(0.28,0.44),P<0.0001。剖宫产术后再妊娠试产成功率r=0.76,95%CI(0.71,0.81),P<0.0001;产后出血量SMD=-6.41,95%CI(-6.88,-5.94),P<0.000 01;产时出血量SMD=-3.57,95%CI(-4.69,-2.44),P<0.00001;住院时间SMD=-6.86,95%CI(-8.12,-5.59),P<0.000 01;产褥感染发生率OR=0.37,95%CI(0.21,0.67),P=0.0009;子宫严重并发症发生率两组之间比较差异无统计学意义OR=0.38,95%CI(0.10,1.50),P=0.17。结论:现有研究表明国内剖宫产术后再妊娠孕妇阴道试产率较低,但满足试产条件并进行试产时试产成功率较高;经阴道成功分娩的此类孕妇大部分指标均能得到改善产,但目前临床证据还不能说明剖宫产术后选择何种分娩方式能够降低孕妇子宫严重并发症发生率。部分纳入文献质量不高,影响分析的论证强度,因此需要更深入的研究加以证实。

Objective： To review the present situation and outcomes of pregnant women with different modes of delivery, which was aim to be a reference for clinic. Method： The first author in the domestic and foreign databases for the study of the mode of delivery after cesarean section in our country were retrieved, in accordance with the inclusion and exclusion criteria for the selection and inclusion of the literature.The language was limited to Chinese and English, the basic information and effective data of the literature was extracted and analyzed.All of the above-mentioned works were done by two reviewers independently and the third party made the choice when summary the different views.Evaluation bias to P〈0.1 and the outcomes analysis to P〈0.05 for the difference was statistically significant.Result： 22 chinese studies of recent decades were included, which had 1301 pregnant women in vaginal birth after cesarean delivery （ VBAC ） group and 3558 cues in repeat cesarean section （ RCS ） group.From the analysis, the rate of trail of labor （ TOL ） was r=0.35, 95%CI （ 0.28, 0.44 ）, P〈0.0001 ; rate of TOL successful was r=0.76, 95%CI （ 0.71, 0.81 ）, P〈0.0001.The level of postpartum hemorrhage was SMD=-6.41, 95%CI （ -6.88, -5.94 ）, P〈0.000 01, hemorrhage in labor was SMD=-3.57, 95%CI （ -4.69, -2.44 ）, P〈0.000 01], time of hospitalization was SMD=-6.86, 95%CI （ -8.12, -5.59 ）, P〈0.000 01 and the rate of puerperal infection was OR=0.37, 95%CI （ 0.21, 0.67 ）, P=0.0009.There was no significant difference of two groups in the incidence of uterine severe complication 0R=0.38, 95%CI （ 0.10, 1.50 ）, P=0.17.Conclusion： The rate of trail of labor is low but the rate of successful VBAC from TOL is positive.Pregnant women who choose VBAC may have better outcomes for themselves, but the evidence of getting down the rate of uterus of complications is not powerful enough to show statistically significant difference.Some of the inclusive studies do not have enough high quality as well as the others, which may affect the power of the evaluation results, so more better studies should be done to make the certification.