规律间断与持续硬膜外注射分娩镇痛用于瘢痕子宫阴道试产的临床观察

Efficacy of intermittent and continuous epidural injection labor analgesia for scar uterus and vagina trial labor

将2017年7月至2019年10月于北京美中宜和妇儿医院采用分娩镇痛方式行瘢痕子宫阴道试产(TOLAC)的120例产妇,应用随机数字表分为间断给药组和持续给药组,各60例,年龄分别为(35.1±4.4)和(35.4±4.6)岁,身高分别为(165.2±4.3)和(165.9±5.3)cm,体重分别为(67.6±5.7)和(69.2±5.2)kg。均于TOLAC宫口开2 cm时予蛛网膜下腔注射0.3%罗哌卡因1 ml,然后间断给药组每60分钟予硬膜外单次注射8 ml芬太尼(2μg/ml)与0.1%罗哌卡因混合液,持续给药组每小时硬膜外匀速注入8 ml芬太尼(2μg/ml)与0.1%罗哌卡因混合液,两组产妇自控镇痛剂量均为8 ml/次,间隔时间15 min。间断给药组和持续给药组产妇自控镇痛次数分别为(1.10±1.05)和(2.78±2.30)次,罗哌卡因总量分别为(47.2±26.0)和(64.1±31.6)mg,芬太尼总量分别为(944.0±500.1)和(1282.1±631.5)μg。间断给药组和持续给药组分娩镇痛240 min后改良Bromage评分0~3级者分别为11(9%)和9例(8%)、42(35%)和24例(20%)、6(5%)和16例(13%)、1(1%)和11例(9%),两组差异均有统计学意义(均P<0.05);疼痛视觉模拟评分0~3分者,分娩镇痛后5 min时分别为29(48%)和31例(52%)、13(22%)和11例(18%)、35(58%)和29例(48%)、13(22%)和14例(23%),两组差异均无统计学意义(P>0.05),分娩镇痛后240 min时分别为51(85%)和51例(85%)、6(10%)和0例(0)、1(2%)和7例(12%)、2(3%)和2例(3%),两组差异有统计学意义(P<0.05)。提示间断硬膜外给药较持续硬膜外注射用于瘢痕子宫产妇阴道试产腰-硬联合阻滞分娩镇痛,罗哌卡因及芬太尼用量较低,自控镇痛次数较少,下肢运动神经阻滞发生率更低。

One hundred and twenty pregnant women with scar uterus having trial vaginal delivery who underwent combined lumbar and epidural analgesia were selected and randomly divided into two groups.Labor analgesia should be given when the uterine orifice is opened to 2 cm.Each group was injected with 1 ml 0.3%ropivacaine in subarachnoid space;and 8 ml(2μg/ml fentanyl+0.1%ropivacaine)epidural injection was given in a single time every hour in the intermittellt administration group(group A);the continuous administration group(group B)continued epidural administration at the rate of 8 ml/h(fentanyl 2μg/ml+0.1%ropivacaine).The patient-controlled analgesia(PCA)dose in both groups was 8 ml,and the time was locked for 15 min.Visual analog scale(VAS)was used as the main observation index to evaluate the pain degree,and the lower extremity motor nerve block was evaluated by modified Bromage score.The frequency of PCA in group A and group B was 1.10±1.05 and 2.78±2.30,respectively.The total ropivacaine dosage was(47.2±26.0)and(64.1±31.6)mg,respectively.The total amount of fentanyl was(944.0±500.1)and(1282.1±631.5)μg,respectively.The modified Bromage score 0(after labor analgesia for 240 min)was in 11(9%)and 9(8%)cases of group A and group B;level 1 was in 42(35%)and 24(20%);level 2 was in 6(5%)and 16(13%);level 3 was in 1(1%)and 11(9%);the difference between the two groups was statistically significant(P<0.05).The age of patients in group A and group B was(35.1±4.4)and(35.4±4.6)years,respectively.The height was(165.2±4.3)and(165.9±5.3)cm,the body weight was(67.6±5.7)and(69.2±5.2)kg,respectively.The VAS score of 0,1,2 and 3 points at 5 min after labor analgesia in group A and group B was in 29(48%)and 31(52%)case,in 13(22%)and 11(18%)cases,in 35(58%)and 29(48%)cases,in 13(22%)and 14(23%),respectively.The VAS score of 0,1,2 and 3 points at 240 min after labor analgesia in group A and group B was in 51(85%)and 51(85%)cases,6(10%)and 0 cases,1(2%)and 7(12%)cases,2(3%)and 2(3%)cases,respectively.There was no significant difference in VAS score between two groups at monitoring time points(all P>0.05).The results indicate that the regular intermittent administration for epidural analgesia in scar uterus trial vaginal delivery has better analgesia effect,less dosage of ropivacaine and fentanyl,less number of PCA,and lower incidence of lower limb motor nerve block,which is more suitable for labor analgesia in scar uterus trial vaginal delivery.