硬膜外分娩镇痛对产妇阴道分娩后认知功能的影响:前瞻性队列研究

Influences of epidural labor analgesia on maternal postpartum cognitive function after vaginal delivery: a prospective cohort study

目的探讨接受硬膜外分娩镇痛与非药物镇痛的产妇产后认知功能障碍的发生情况及其影响因素。方法对2017年1月至2018年1月在上海交通大学医学院附属国际和平妇幼保健院阴道分娩的1618例产妇进行前瞻性队列研究。根据孕妇是否愿意接受硬膜外分娩镇痛,将自愿接受硬膜外分娩镇痛的803例产妇作为镇痛组,不愿意接受硬膜外镇痛而采用导乐分娩镇痛的815例产妇作为对照组。在产妇阴道分娩后1及42d,采用蒙特利尔认知评估(Montreal cognitive assessment,MoCA)量表及符号数字转换测验(symbol digit modalities test,SDMT90)进行随访。比较2组产妇认知功能障碍的发生率和SDMT90分值,以及产妇在宫口开至3、6、10cm时的视觉模拟评分(visual analogue scroe,VAS)。采用独立样本t检验、χ^2检验及logistic回归分析进行统计学分析。结果镇痛组产妇阴道分娩后1d的MoCA量表和SDMT90的评分均大于对照组[分别为(27.1±1.5)与(26.2±1.8)分,(49.1±2.4)与(42.5±3.6)分,t值分别为3.775和16.956,P值均<0.05],但认知功能障碍的发生率较低[13.9%(112/803)与21.2%(173/815),χ^2=14.769,P=0.002]。镇痛组产妇宫口开至3、6及10cm时的VAS评分均低于对照组[分别为(2.3±0.6)与(6.9±1.3)分,(3.3±0.9)与(8.7±0.9)分,(5.7±0.9)与(9.7±0.4)分,t值分别为0.013、0.011及0.015,P值均<0.001]。Logistic相关分析发现,宫口开至3、6、10cm的VAS评分≤3分是产后1d认知功能障碍的保护因素[OR值(95%CI)分别为0.238(0.198~0.287)、0.180(0.145~0.222)及0.112(0.088~0.142),P值均<0.001],未接受药物镇痛是产后1d认知功能障碍的危险因素(OR=4.698,95%CI:1.812~11.321,P<0.001)。结论硬膜外分娩镇痛可降低阴道分娩1d时认知功能障碍发生风险,接受硬膜外镇痛和分娩期间的VAS评分是阴道分娩后认知功能障碍发生的影响因素。

Objective To investigate the incidence of cognitive dysfunction in postpartum women who underwent epidural or no ndrug labor an algesia and the influence factors. Methods A prospective cohort study was performed in 1 618 uneventful singleton pregnancies in International Peace Maternity and Child Health Hospital from January 2017 to January 2018. Women who received epidural labor analgesia were assigned to the epidural group (n=803), and those who received Doula technique non-drug labor an algesia rather than labor analgesia to the control group (n=815). Cognitive function was assessed using symbol digit modalities test (SDMT90) and Montreal cognitive assessment (MoCA) 1 d and 42 d after delivery. Incidence of maternal cognitive dysfunction. SDMT90 scores and pain intensity measured by visual analogue score (VAS) at the cervical dilatation of 3, 6 and 10 cm between the two groups were compared using independent sample t-test, Chi-square test or logistic regression analysis. Results MoCA and SDMT90 scores of the epidural group were significantly higher than those of the control group 1 d after delivery (27.1 ± 1.5 vs 26.2 ± 1.8, 49.1 土 2.4 vs 42.5 ±3.6;t=3.775 and 16.956, both P<0.05), but the incidence of postoperative cognitive dysfunction (POCD) in the epidural group was remarkably lower comparing to the control group [13.9%(112/803) vs 21.2%(173/815),X^2= 14.769, P=0.002]. The VAS scores of the epidural group at the cervical dilatation of 3, 6 and 10 cm were all lower than those of the control group (2.3 + 0.6 vs 6.9± 1.3, 3.3 + 0.9 vs 8.7 + 0.9, 5.7土0.9 vs 9.7 + 0.4;t=0.013, 0.011 and 0.015;all P<0.001). Logistic regression analysis indicated that VAS scores W 3 at the cervical dilatation of 3. 6 and 10 cm were protective factors against the incidence of POCD 1 d after delivery [OR(95%Cl): 0.238 (0.198-0.287), 0180 (0.145-0.222) and 0.112 (0.088-0.142), all P<0.001], while the absence of epidural labor analgesia was a risk factor (OR=4.69& 95%Cl: 1.812-11.321. P<0.001). Conclusions Epidural labor analgesia can reduce the incidence of postpartum cognitive dysfunction in women 1 d after delivery. The incidence of POCD has close relationship with the VAS scores at the cervical dilatation of 3, 6 and 10 cm and epidural labor analgesia.