剖宫产术后再次妊娠阴道试产结局与子宫瘢痕相关因素的关系

The relationship between the outcomes of trial of labor after cesarean and uterine scar associated factors

目的探讨剖宫产术后再次妊娠阴道试产结局与子宫瘢痕相关影响因素的关系。方法对2015年1月至2015年12月在山西省妇幼保健院进行阴道试产的65例既往有剖宫产史产妇的病例资料进行回顾性分析，按照TOLAC的结局分为阴道分娩组和转剖宫产组；按照既往剖宫产切口类型分组，分为子宫下段横切口组和子宫下段纵切口组；按照分娩时间间隔分组，分为分娩时间间隔≤2年组，2年〈分娩时间间隔〈10年组，分娩时间间隔≥10年组；按照B超显示子宫下段瘢痕厚度，以1．0mm为分界点，分为〈1mm组和≥1mm组；以2．0mm为分界点，分为〈2mm组和≥2mm组。研究比较阴道分娩组和转剖宫产组试产结局与子宫瘢痕相关的子宫下段切口类型、分娩时间间隔、瘢痕厚度的关系。结果59例试产顺利阴道分娩，6例转急诊剖宫产，阴道试产的成功率为90．8％，其中早产试产成功率96．6％高于足月的86．1％。产妇子宫下段横切口与子宫下段纵切口试产结局比较，阴道分娩组子宫下段横切口为79．7％，子宫下段纵切口为20．3％，两者差异没有统计学意义。分娩时间间隔2年组、3年≤时间间隔〈10年组、时间间隔≥10年组试产结局，阴道分娩组占比分别为8．5％、74．6％、16．9％，各组差异没有统计学意义。瘢痕厚度不同分界点试产结局，以1．0mm为分界点，阴道分娩组〈1mm为8．5％，≥1mm为91．5％，两者差异有统计学意义；以2．0mm为分界点，阴道分娩组〈2mm组为18．6％，≥2mm组为81．4％，两者差异没有统计学意义。结论剖宫产术后再次妊娠阴道试产的评估应遵循个体化原则，排除阴道分娩的绝对禁忌证，如果产妇发生以下情况，如早产、子宫下段的纵切口、分娩时间间隔在18～24个月或≥10年、1．0mm≤瘢痕厚度〈3mm，可以考虑阴道试产。

Objective To explore the relationship between the outcomes of trial of labor after cesarean （TOLAC） and uterine scar associated factors. Methods We retrospectively analyzed the clinical data of 65 pregnant women who had had a previous cesarean delivery and chose trial of labor admitted to our hospital from January 2015 to December 2015. The relationship between the outcomes of TOLAC and the type of incision of lower uterine segment, birth interval, and the thickness of scar of uterine segment was analyzed. Results Among the 59 women with TOLAC, the successful rate was 90.8%, with a rate of 96.6% for preterm births and a rate of 86. 1% for term births. For those with a low transverse uterine incision, the rate was 79.7%, compared with 20.3% for those with a low vertical uterine incision. Vaginal birth was 8. 5%, 74. 6%, and 16. 9% for those with a birth interval of 2 years or shorter, 2years to 10 years, and 10 years or longer, respectively. Vaginal birth was 8.5% for scar thickness of 〈 1.0 mm compared with 91.5% for scar thickness of 1.0 mm or above. Similarly, vaginal birth was 18.6% for scar thickness of 〈 2. 0 mm compared with 81.4% for scar thickness of 2. 0 mm or above. Conclusion The assessment of TOLAC should follow the principle of individualization. TOLAC may be considered with the following indications：preterm birth, low vertical uterine incision, birth interval in 18-24 months or 10 or more years, and scar thickness of 3.0 mm or below.