高龄孕产妇剖宫产术后再次妊娠阴道分娩的妊娠结局分析

Outcome of vaginal birth after cesarean section in women with advanced maternal age

目的 探讨剖宫产术后再次妊娠阴道分娩（VBAC）的高龄产妇的妊娠结局.方法 收集2013年7月至2017年2月在昆明医科大学第一附属医院住院,分娩孕周≥28周、既往有≥1次剖宫产史的产妇2 587例;选择其中既往有1次剖宫产史、单胎、剖宫产术后再次妊娠阴道试产（TOLAC）的产妇共909例为观察对象,其中分娩年龄≥35岁者237例为高龄组,分娩年龄＜35岁者672例为低龄组.对两组产妇的一般临床资料及妊娠结局进行比较分析.结果 高龄组产妇的VBAC率为88.2％（209/237）,低龄组为82.4％（554/672）,高龄组产妇的VBAC率显著高于低龄组（P＜0.05）.高龄组产妇中孕前体质指数（BMI）、前次剖宫产距本次妊娠间隔的时间、本科及以上学历者的比例、妊娠期高血压疾病和妊娠期糖尿病者的比例及其新生儿转新生儿ICU者的比例均高于低龄组[分别为（22.4±3.0）、（21.7±3.1） kg/m2,（69±38）、（54±34）个月,55.7％（132/237）、35.6％（239/672）,8.4％ （20/672）、3.4％（23/672）,34.6％（82/237）、15.0％（101/672）,18.1％（43/237）、12.1％（81/672）;P均＜0.05].未发生产妇及其新生儿严重并发症或死亡事件.两组产妇的产后出血率、产后出血≥1 500 ml率、产后输血率、产褥病率、其新生儿出生体质量及新生儿5分钟Apgar评分＜7分、新生儿脐动脉血pH值＜7.0、新生儿气管插管和新生儿呼吸窘迫综合征者的比例分别比较,差异均无统计学意义（P均＞0.05）.全部TOLAC产妇中,发生子宫破裂1例（为高龄组产妇）,子宫破裂率为0.1％（1/909）.结论 对于既往有1次剖宫产史、单胎的高龄孕妇,VBAC是可供选择的安全可行的分娩方式.

Objective To explore the perinatal outcome of vaginal birth after cesarean （VBAC） in women with advanced age.Methods Totally 2 587 women delivered after one or two prior cesarean sections （gestational age≥28 weeks） in the First Affiliated Hospital of Kunming Medical University from July 2013 to February 2017.909 trial of labor after cesarean（TOLAC） cases of singleton pregnancy with one prior cesarean section were studied retrospectively.According to the age,of the 909 TOLAC cases,237 were the advanced age group,and 672 cases were the low age group.The maternal and neonatal outcomes between the two groups were compared.Results The percentage of TOLAC in women with advanced age was 32.4% （237/731）,and VBAC rate was 88.2% （209/237）.The percentage of TOLAC in younger women was 36.2% （672/1 856）,and VBAC rate was 82.4% （554/672）.The difference of the TOLAC rate between the two groups was not significant （P〉0.05）,and the VBAC rate of the advanced age group was higher than the low age group （P〈0.05）.In the comparison of the two groups,the proportion of bachelor degree or above（55.7%,132/ 237）,the prepregnancy BMI （22.4±3.0） kg/m2,pregnant interval time （68.5±38.3） months,the proportion of gestational hypertension （8.4%,20/237）,the proportion of gestational diabetes（34.6%,82/237） and the rate of the neonatal ICU admission （18.1%,43/237） in the advanced age group were higher than those of the low age group （P〈0.05）,respectively.And there were no significant differences in the rate of postpartum hemorrhage,the rate of postpartum hemorrhage≥1 500 ml,the rate of postpartum transfusion,puerperal morbidity,neonatal birth weight,neonatal 5 min Apgar score〈7 score,umbilical artery blood pH〈7.0,neonatal tracheal intubation and respiratory distress syndrome （all P〉0.05）.In all TOLAC cases,the rate of uterine rupture was 0.11%（1/909） and there was no maternal and neonatal death.Conclusion VBAC is a safe and feasible way of delivery for singleton pregnancy after one prior cesarean section in women with advanced age.