硬膜外分娩镇痛相关产时发热对母婴结局的影响

Effects of epidural labor analgesia-related intrapartum fever on maternal and neonatal outcomes

目的探讨硬膜外分娩镇痛相关产时发热(ELARIF)对母婴结局的影响。方法选择2019年1月至2020年12月,在镇江市妇幼保健院采取硬膜外分娩镇痛(ELA)的980例产妇为研究对象。采用回顾性队列研究方法,按照产妇是否发生ELARIF,将其分为发热组(n=74,发生ELARIF后,鼓膜温度≥38℃),对照组(n=906,无ELARIF,鼓膜温度<38℃)。对2组产妇的一般临床资料、产时及产后相关资料、ELA相关资料及新生儿相关资料,采用两独立样本t检验、Mann-Whitney U检验、χ^(2)检验、连续性校正χ^(2)检验或Fisher确切概率法进行统计学比较。本研究遵循的程序符合2013年新修订的《世界医学协会赫尔辛基宣言》要求。结果①2组产妇年龄、身高、分娩孕龄、流产次数、胎膜早破发生率,孕前、分娩时人体质量指数(BMI),孕期BMI增加值及妊娠期高血压疾病、妊娠期糖尿病、上呼吸道感染、B族链球菌感染发生率,分娩入院时白细胞计数、中性粒细胞百分比、血红蛋白水平等一般临床资料比较,差异均无统计学意义(P>0.05)。②发热组产妇人工破膜总发生率、ELARIF所致人工破膜发生率、中转剖宫产术分娩率,第一、二产程与总产程时间,产程开始至开始进行ELA时间、开始ELA至分娩时间及顺产产妇产后尿潴留(PUR)发生率,均显著高于、长于对照组,并且差异均有统计学意义(P<0.05)。③发热组中转剖宫产产妇ELA药物用量为(39.9±24.2)mL,ELA持续时间为4.8 h(3.8、6.3 h),ELA结束时疼痛《数字评价量表(NRS)》评分为6分(5、6分),均分别显著高于、长于对照组的(37.1±24.9)mL、3.6 h(2.3、5.3 h)及4分(3、5分),并且差异均有统计学意义(t=-8.18、Z=-4.22、Z=-8.48,P<0.001)。④发热组产妇分娩新生儿的羊水粪染、胎儿窘迫、生后5 min Apgar评分<10分及因感染转人新生儿科占比,均显著高于对照组,并且差异均有统计意义(P<0.05)。结论产程延长可增加产妇发生ELARIF风险,而ELARIF可导致产时干预及分娩风险增加。临床应重视ELA产妇产程管理,一旦发现异常,应及时采取有效处理措施,促进产程进展,降低母儿不良结局发生率。

Objective To investigate the effect of epidural labor analgesia-related intrapartum fever(ELARIF)on maternal and neonatal outcomes.Methods A total of 980 parturients who underwent epidural labor analgesia(ELA)in Zhenjiang Maternity&Child Health Hospital from January 2019 to December 2020 were selected as research subjects.According to whether maternal ELARIF occurred or not,they were divided into fever group(n=74,parturients with ELARIF whose tympanic temperature≥38℃),and control group(n=906,parturients without ELARIF whose tympanic temperature<38℃)by retrospective cohort study method.The general clinical data,intrapartum and postpartum related data,ELA related data and neonatal related data of two groups of parturients were compared by independent-samples t test,Mann-Whitney U test,chi-square test,continuity adjusted chi-square test or Fisher exact probability method.The procedure followed in this study met requirements of the Helsinki Declaration of the World Medical Association revised in 2013.Results①There were no significant differences between two groups in terms of age,height,gestational age at delivery,times of abortions,incidence of premature rupture of membranes,body mass index(BMI)before pregnant and at delivery,increased value of BMI during pregnancy,incidence of hypertension in pregnancy,gestational diabetes mellitus,upper respiratory tract infection,and group B streptococcal infection,white blood cell count,percentage of neutrophils and hemoglobin at delivery and other general clinical data(P>0.05).②The total incidence of artificial rupture of membranes,incidence of artificial rupture of membranes caused by ELARIF,rate of conversion to cesarean section,duration of the first and second stages of labor and total stage of labor,the time from the beginning of labor to ELA,the time from ELA to delivery,and incidence of postpartum urinary retention(PUR)of spontaneous parturients in fever group all were significantly higher or longer than those in control group,and all the differences were statistically significant(P<0.05).③In fever group,the dosage of ELA in parturients who were transferred to cesarean section was(39.9±24.2)mL,ELA duration was 4.8 h(3.8 h,6.3 h),and score of pain Numerical Rating Scale(NRS)at the end of ELA was 6 points(5 points,6 points),which were significantly higher and longer than(37.1±24.9)mL,3.6 h(2.3 h,5.3 h)and 4 points(3 points,5 points)in control group respectively,and all differences were statistically significant(t=-8.18,Z=-4.22,Z=-8.48;P<0.001).④The incidence of amniotic fluid fecal contamination,fetal distress,Apgar score<10 points at 5 min after birth,and transfer to Department of Neonatology due to infection in fever group were significantly higher than those in control group(P<0.05).Conclusions Delayed delivery can increase the risk of ELARIF,while ELARIF will lead to increased risk of intrapartum intervention and delivery.Clinicians should pay attention to the labor process management of ELA parturients.Once abnormalities are found,clinicians should timely take accurate and effective measures to promote the progress of labor process and reduce the incidence of adverse maternal and neonatal outcomes.