剖宫产术后再次妊娠阴道试产与选择性重复剖宫产母婴安全性的Meta分析

The Safety of Maternal and Perinatal of Trial of Labor after Previous Cesarean Delivery Versus Elective Repeat Cesarean Delivery: A Meta-Analysis

目的:系统性分析剖宫产术后再次妊娠阴道试产(trial of labor after previous cesarean delivery,TOLAC)与选择性重复剖宫产(elective repeat cesarean delivery,ERCD)的母婴安全性。方法:检索Cochrane临床对照试验数据库(CENTRAL)、Medline、Embase、Ovid、万方数据库、中国知网(CNKI)等数据库。收集1989—2016年有关TOLAC和ERCD的临床研究文献,采用Rev Man 5.2软件对有关数据进行统计分析。结果:共纳入11篇文献,共计91 975例研究对象,其中试验组(TOLAC组)51 428例,对照组(ERCD组)40 547例。TOLAC组发生子宫破裂风险较ERCD组高,差异有统计学意义(RR=2.78,95%CI:1.24~6.22,P=0.01);TOLAC组子宫切除的风险比ERCD组低,差异有统计学意义(RR=0.57,95%CI:0.44~0.74,P<0.000 1);而孕妇产褥感染风险(RR=1.10,95%CI:0.78~1.56,P=0.58)、孕妇输血风险(RR=1.09,95%CI:0.62~1.92,P=0.75)以及孕妇死亡风险(RR=0.71,95%CI:0.26~1.92,P=0.50),2组差异无统计学意义;新生儿窒息(RR=2.30,95%CI:1.74~3.03,P<0.000 01)及围生儿死亡(RR=1.71,95%CI:1.29~2.25,P=0.000 1),TOLAC组均比ERCD组高,差异有统计学意义。结论:在临床上,为了降低剖宫产率,应该鼓励剖宫产术后再次妊娠者进行阴道试产。为了降低相关风险,产前需要进行充分评估,产时严格且规范监测,最大限度保证母婴安全,同时还要合理、科学地评估每次剖宫产的指征。

Objective:The aim of this study was to compare the trial of labor with elective repeat cesarean delivery(ERCD)among women with previous cesarean delivery.Methods:We searched CENTRAL,Medline,Embase,Ovid,Wanfang,CNKI databases about the safety of maternal and perinatal of trial of labor after previous cesarean delivery(TOLAC)versus ERCD from1989through2016.Results:Eleven studies with a total of91975women were included.51428women undergoing TOLAC,40547women undergoing ERCD.Uterine rupture occurred more frequently among women undergoing TOLAC than among those undergoing ERCD(RR=2.78,95%CI:1.24~6.22,P=0.01).Mothers undergoing TOLAC were less likely to have hysterectomy(RR=0.57,95%CI:0.44~0.74,P<0.0001).There were no differences in maternal puerperal infection(RR=1.10,95%CI:0.78~1.56,P=0.58),require transfusion(RR=1.09,95%CI:0.62~1.92,P=0.75)and maternal mortality(RR=0.71,95%CI:0.26~1.92,P=0.50)risk between the2groups.Asphyxia of newborn(RR=2.30,95%CI:1.74~3.03,P<0.00001)and fetal or neonatal death(RR=1.71,95%CI:1.29~2.25,P=0.0001)were more frequent in the TOLAC group than the control group.Conclusions:In order to reduce the rate of cesarean section,we should encourage TOLAC.Its security is very important,which required adequate prenatal assessment,strict and standardized monitoring of the delivery process for the maximum guarantee of maternal and child safety,but also a reasonable and scientific assessment of each cesarean section indications is necessary.