剖宫产不同子宫缝合方法对再次妊娠晚期子宫下段切口厚度及分娩结局的影响

Effect of different uterine suture methods for cesarean section on incision thickness and delivery outcome in the second trimester of uterus

目的探讨剖宫产后不同子宫缝合方法对再次妊娠晚期子宫下段切口厚度及分娩结局的影响。方法 2013年1月～2015年8月于我院初次分娩行剖宫产的产妇随机分为单层缝合组和双层缝合组,分别于剖宫产后行子宫单层和双层缝合。将上述产妇中于2013年7月～2016年12月期间因再次妊娠来我院就诊、分娩的孕妇973例(其中单层缝合组448例,双层缝合组525例)纳入研究。于再次妊娠34+0～38+6周期间采用超声检测子宫下段切口处厚度(LUST),并收集两组产妇分娩结局相关资料。两组产妇年龄、孕前BMI、生育间隔、首次妊娠分娩期间合并症、巨大胎儿出生率无统计学差异;对比分析两组产妇一般临床资料、再次妊娠晚期LUST值及再次妊娠分娩母儿结局,并采用多元Logistic回归分析LUST小于2.0mm的独立危险因素。结果两组产妇首次妊娠分娩手术出血量以及再次妊娠分娩时新生儿5min Apgar评分<7分、新生儿败血症、新生儿缺血缺氧脑病及围产儿死亡发生率间无统计学差异(均P> 0.05);双层缝合组初次分娩剖宫产手术时间较单层缝合组长,但术后并发症发生率较单层缝合组低,且再次妊娠分娩时VABC成功率较单层缝合组高,子宫破裂或瘢痕裂开、失血大于1500mL、输血、产后发热及新生儿呼吸窘迫综合征发生率较单层缝合组低(均P <0.05)。剖宫产后再次妊娠晚期,单层缝合组LUST大小为(3.1±1.5)mm,LUST <2.0mm比率为13.2%,而双层缝合组LUST大小为(3.6±1.1)mm,LUST <2.0mm比率为8.6%,双层缝合组LUST大于单层缝合组且LUST <2.0mm比率小于单层缝合组(均P <0.05)。多元Logistic回归分析表明双层缝合为LUST小于2.0mm(OR=0.62;95%CI为0.31～0.98)的风险降低的保护因素。而单层缝合(OR=1.62;95%CI为1.03～3.16)、生育间隔<18个月(OR=2.87;95%CI为1.62～4.95)、孕前BMI≥25kg/m^2(OR=1.22;95%CI为0.84～1.77)以及新生儿出生体重≥4kg(OR=1.37;95%CI为0.74～1.83)均与LUST小于2.0mm风险增加的危险因素。结论与单层缝合产妇相比,剖宫产后子宫双层缝合产妇再次妊娠晚期时子宫切口厚度较高,且再次分娩子宫瘢痕缺损以及新生儿并发症的风险更低。

Objective To explore the effect of different uterine suture methods after cesarean section on the incision thickness and outcome of the lower uterus in the second trimester of pregnancy. Methods From January 2013 to August 2015, the parturients who first delivmT of cesarean section in our hospital was randomly divided into single-layer suture group and double-layer suture group, and the uterus single layer and double suture were sutured after cesarean section. Among the above-mentioned women, 973 eases （including 448 eases of single-layer suture group and 525 eases of double-layer suture group） were enrolled in our hospital from July 2013 to Deeember 2016 due to re-pregnancy. Ultrasound was used to detect the thickness of the inferior incision （LUST） during the 34 ＋0 - 38 ＋6 weeks of re-pregnancy, and the data of the two groups of maternal delivery outcomes were collected. There were no significant differences in maternal age, pre-pregnaney BMI, birth spacing, eomorbidity during the first trimester of delivery, and large fetus birth rate. Comparative analysis of the general clinical data of the two groups, the late pregnancy LUST value and the maternal and child outcomes of re-pregnancy and childbirth were used. Multivariate logistic regression analysis of independent risk factors for LUST less than 2.0 mm. Results There was no significant difference between the two groups in the amount of bleeding during the first pregnancy and the 5-minute Apgar score 〈 7, neonatal sepsis, neonatal isehemie-hypoxie eneephalopathy and perinatal mortality （all P 〉 0.05）. The first eesarean seetion In the double-layer suture group was longer than that in the single-layer suture group. However, the ineidenee of eomplieations after operation was lower than that of single-layer suture group, and the sueeess rate of VABC during pregnancy and delivery was higher Than that of single-layer suture group. The incidence of uterine rupture or sear rupture, blood loss greater than 1500 mL, blood transfusion, postpartum fever and neonatal respiratory distress syndrome was lower than that of single-layer suture group （all P 〈 0.05） In the third trimester of pregnancy after cesarean section, the size of LUST in single-layer suture group was 3.1 ± 1.5 mm and the ratio of LUST 〈 2.0 mm was 13.2%. The size of LUST in double-layer suture group was 3.6 ± 1.1 mm, and the ratio of LUST 〈 2.0 mm was 8.6%. The ratio of LUST in double-layer suture group was higher than that in single-layer suture group and the ratio of LUST 〈 2.0 mm was lower than that in single-layer suture group （all P 〈 0.05）. Multivariate logistic regression analysis showed that the double-layer suture was a protective factor for the risk reduction of LUST less than 2.0 mm （OR=0.62; 95% CI 0.31-0.98）. Single-layer suture （OR=1.62; 95% CI 1.03-3.16）, birth interval 〈 18 months （OR=2.87; 95%CI 1.62-4.95）, pre-pregnaney BMI ≥ 25kg/m2 （OR=1.22; 95%CI 0.84-1.77） and the neonatal birth weight ≥ 4kg （OR=1.37; 95%CI 0.74-1.83） was assoeiated with a risk inerease for LUST less than 2.0 mm. Conclusion Compared with single-layer sutures, uterine sutures after eesarean seetion have higher uterine ineision thiekness in the seeond trimester of pregnaney, and the risk of uterine sear defeet and neonatal eomplieations is lower.