盆腔脏器脱垂定量分度法对不同方式分娩初产妇产后近期盆底功能的评价

Evaluation on pelvic floor functions of primiparae in early postpartum period with different delivery modes by pelvic floor function of pelvic organ prolapse quantification

目的探讨采用盆腔脏器脱垂定量分度法(POP-Q)评分系统,对不同方式分娩初产妇产后近期盆底功能评价的差异。方法采用回顾性分析法,按照随机数字表法选择2016年1月1日至12月31日,于成都市妇女儿童中心医院分娩单胎、足月、头先露活产儿的200例初产妇为研究对象。按照分娩方式,将采取择期剖宫产分娩的100例初产妇,纳入观察组;而采取阴道分娩的100例初产妇,纳入对照组。对2组初产妇均按照《新产程标准及处理的专家共识(2014)》标准进行管理,并采取硬膜外麻醉分娩镇痛。2组初产妇均在孕前排除生殖道畸形、压力性尿失禁(SUI)和盆底功能障碍(PFD),孕期无严重内、外科并发症。于产后42d左右,对2组初产妇SUI发生率,POP-Q评分系统中的9项指标:阴道前壁脱垂、阴道后壁脱垂、子宫脱垂分度,以及Ⅰ、Ⅱ类盆底肌纤维肌力分级等进行检测。采用成组t检验,对2组初产妇POP-Q评分系统中的9项指标测定结果进行比较。采用χ~2检验,对2组初产妇产后近期SUI发生率及Ⅰ～Ⅲ度阴道前壁脱垂、阴道后壁脱垂、子宫脱垂发生率进行比较。采用Wilcoxon秩和检验,对2组初产妇Ⅰ、Ⅱ类盆底肌纤维肌力分级构成比进行比较。本研究遵循的程序符合成都市妇女儿童中心医院人体试验委员会所制定的伦理学标准,得到该委员会批准。结果 (1)2组初产妇胎膜早破、妊娠期糖尿病和亚临床甲状腺功能减退等主要产科并发症发生率,以及年龄、孕前人体质量指数(BMI)、孕期体重增加值、新生儿出生体重等一般临床资料比较,差异均无统计学意义(P>0.05)。(2)观察组与对照组初产妇的POP-Q评分系统测定结果显示:gh(生殖道裂隙),长度分别为(2.8±0.4)cm与(3.0±0.6)cm,pb(会阴体)长度分别为(3.6±0.3)cm与(3.5±0.3)cm,tvl(阴道总长度)分别为(8.4±0.6)cm与(7.4±3.9)cm,Aa点(阴道前壁中线距离处女膜3cm处)分别位于(-2.0±0.8)cm与(-1.3±0.8)cm处,Ba点(阴道前壁脱出距离处女膜最远处)分别位于(-2.1±0.8)cm与(-1.4±0.7)cm处,Bp点(阴道后壁脱出距离处女膜最远处)分别位于(-2.9±0.4)cm与(-2.7±0.5)cm处,上述测定结果分别比较,差异均有统计学意义(t=-2.774,P=0.006;t=2.537,P=0.019;t=-2.534,P=0.012;t=-6.187,P<0.001;t=-6.585,P<0.001;t=-3.123,P=0.002);而Ap点(阴道后壁中线距离处女膜3cm处)、C点(阴道前穹窿或阴道残端距离处女膜处)、D点(阴道后穹窿距离处女膜处)的测定结果分别比较,差异均无统计学意义(P>0.05)。(3)观察组初产妇Ⅰ～Ⅲ度阴道前壁脱垂发生率为21.0%(21/100),显著低于对照组的98.0%(98/100);Ⅰ～Ⅲ度阴道后壁脱垂发生率为13.0%(13/100),显著低于对照组的26.0%(26/100);2组Ⅰ～Ⅲ度阴道前壁、阴道后壁脱垂发生率分别比较,差异均有统计学意义(χ~2=119.846,P<0.001;χ~2=5.383,P=0.016)。2组Ⅰ～Ⅲ度子宫脱垂发生率比较,差异无统计学意义(P>0.05)。(4)2组初产妇产后近期SUI发生率及Ⅰ、Ⅱ类盆底肌纤维肌力分级构成比比较,差异均无统计学意义(P>0.05)。结论采取择期剖宫产分娩和阴道分娩的初产妇,产后近期SUI发生率、盆底肌纤维肌力分级和子宫脱垂分度比较无差异。但是,POP-Q评分系统评价结果显示,阴道分娩可能成为产后PFD的高危因素。

Objective To investigate affects on the pelvic floor functions of primiparae in early postpartum period with different delivery modes by pelvic floor function of pelvic organ prolapse quantification(POP-Q)scoring system.Methods From January 1 to December 31,2016,a total of 200 primiparae who were with single birth,full-term pregnancy and cephalic presentations in Chengdu Women and Children′s Central Hospital were chosen as study subjects by retrospective analysis method and random digits table method.According to different delivery modes,they were divided into observation group(n=100,with elective cesarean section delivery mode)and control group(n=100,with transvaginal delivery mode).All the primiparae received epidural anesthesia during labor and were managed in accordance with the Standard of New Production Process and Expert Consensus(2014).Primiparae with genital malformation,stress urinary incontinence(SUI),pelvic floor dysfunction(PFD)before pregnancy,and with internal and external severe complications were excluded from this study.At about 42 d after delivery,the incidences of SUI,9 indicators in POP-Q scoring system,grades of vaginae anterior prolapse,vaginae posterior prolapse and uterine prolapse,muscle strength classification inⅠandⅡtypes of pelvic floor muscle fiber in two groups were detected.Independent sample t test was used to compare the results of 9 indicatons in POP-Q scoring system of two groups.Chi-square test was used to compare the incidences of SUI in early postpartum period and gradeⅠ-Ⅲvaginae anterior prolapse,vaginae posterior prolapse and uterine prolapse of two groups.Wilcoxon rank sum test was used to compare constituent ratios of muscle strength classification inⅠandⅡtypes of pelvic floor muscle fibers in two groups.The study protocol was approved by the Ethical Review Board of Investigation in Human Being of Chengdu Women and Children′s Central Hospital.Results①There were no significant differences between two groups among the incidences of obstetrical complications,such as premature rupture of membranes,gestational diabetes mellitus and subclinical hypothyroidism,as well as age,body mass index(BMI)before pregnancy,weight gain during pregnancy,and birth weight of newborns,respectively(P>0.05).②The results of POP-Q scoring system of primiparae in two groups showed as follows.The lengths of gh(genital hiatus)in observation group and control group were(2.8±0.4)cm and(3.0±0.6)cm,respectively;lengths of pb(perineal body)were(3.6±0.3)cm and(3.5±0.3)cm,respectively;tvl(total vaginal length)were(8.4±0.6)cm and(7.4±3.9)cm,respectively;point Aa(point in the anterior vaginal wall,3 cm from hymen)were located at(-2.0±0.8)cm and(-1.3±0.8)cm,respectively;point Ba(point in the anterior vaginal prolapse,farthest from hymen)were located at(-2.1±0.8)cm and(-1.4±0.7)cm,respectively;point Bp(point in the posterior vaginal prolapse,farthest from hymen)were located at(-2.9±0.4)cm and(-2.7±0.5)cm,respectively;and all the differences between two groups in the measurement results were statistically significant(t=-2.774,P=0.006;t=2.537,P=0.019;t=-2.534,P=0.012;t=-6.187,P<0.001;t=-6.585,P<0.001;t=-3.123,P=0.002).There were no significant differences between two groups in the measurement results of point Ap(point in the posterior vaginal wall,3 cm from hymen),point C(point in the anterior fornix of vagina or vaginal stump),and point D(point in the vaginal posterior fornix)(P>0.05).③The incidence of gradeⅠ-Ⅲvaginae anterior prolapse in observation group was 21.0%(21/100),which was significantly lower than that in control group 98.0%(98/100);and the incidence of gradeⅠ-Ⅲvaginae posterior prolapse was 13.0%(13/100),which was significantly lower than that in control group 26.0%(26/100),and both the differences were statistically significant(χ2=119.846,P<0.001;χ2=5.383,P=0.016).But there was no significant difference between two groups in the incidence of gradeⅠ-Ⅲuterus prolapse(P>0.05).④There were no significant differences between two groups in the incidence of SUI in early postpartum period and constituent ratio of muscle strength classification inⅠandⅡtypes of pelvic floor muscle fibers(P>0.05).Conclusions As to primiparae in early postpartum period with elective cesarean section and transvaginal delivery,there are no differences in the incidences of SUI,muscle strength classification in pelvic floor muscle fibers and uterus prolapse.But the evaluation results of POP-Q scoring system show that transvaginal delivery may be the high risk factor of PFD.