本文選題：剖宮產(chǎn)后陰道試產(chǎn) + 剖宮產(chǎn)后再次擇期剖宮產(chǎn)�。� 參考：《蘇州大學(xué)》2014年碩士論文

【摘要】：目的： 探討剖宮產(chǎn)后再次分娩的最佳方式及國外剖宮產(chǎn)后陰道分娩的風(fēng)險預(yù)測公式在我國的適用性，進(jìn)而探索適合我國人群使用的剖宮產(chǎn)后陰道分娩的預(yù)測公式。 方法： 選取2002年2月1日至2012年11月30日在蘇州大學(xué)附屬第一醫(yī)院、蘇州市立醫(yī)院本部、無錫市婦幼保健院分娩的疤痕子宮孕婦1439例，其中陰道試產(chǎn)（trial oflabor after cesarean, TOLAC）組255例，擇期再次剖宮產(chǎn)（elective repeat cesareandelivery, ERCD）組1184例。入選標(biāo)準(zhǔn)為距上次剖宮產(chǎn)手術(shù)時間超過2年，有且僅有一次剖宮產(chǎn)史，術(shù)式為子宮下段橫切口，單活胎，無內(nèi)外科合并癥及妊娠并發(fā)癥的健康待產(chǎn)婦。 1.回顧性分析這1439例剖宮產(chǎn)后再次妊娠孕婦產(chǎn)前、產(chǎn)時、產(chǎn)后的資料，比較不同分娩方式對母兒的影響及并發(fā)癥的發(fā)生。 2.利用國外Flamm、Grobman、Gonen、Smith公式分別對TOLAC組進(jìn)行風(fēng)險計算及分析，比較公式計算理論值及實際情況,驗證各公式的適用性。 3.利用多因素Logistic回歸分析，結(jié)合國外公式與臨床實際，我們隨機(jī)挑選60%的TOLAC患者（153名），對試產(chǎn)者的年齡，職業(yè)有無，陰道分娩史，宮口開大情況，羊水污染情況，建卡情況，身高，分娩前體重，是否孕足月，新生兒體重進(jìn)行多因素Logistic回歸分析。篩選出適合我國,對預(yù)測剖宮產(chǎn)后陰道分娩(vaginalbirth after cesarean, VBAC)和ERCD風(fēng)險有意義的因素，進(jìn)而探索新的預(yù)測公式。 統(tǒng)計學(xué)處理： 數(shù)值變量以（X±S）表示，采用SAS9.2統(tǒng)計軟件，計量資料比較采用Z檢驗，t檢驗，計數(shù)資料比較采用χ2檢驗、Fisher確切概率法，Kappa檢驗，受試者工作特性（receiver operating characteristic, ROC）曲線及多因素Logistic回歸分析，非參數(shù)資料比較采用秩和檢驗。 結(jié)果： 1.255例選擇TOLAC，其中233例VBAC，22例失敗行急診剖宮產(chǎn)，1184例ERCD，其中131例為臨產(chǎn)后剖宮產(chǎn)終止妊娠，孕婦的主觀意愿對分娩方式的選擇起著很大的主導(dǎo)作用。 2. TOLAC組比ERCD組無業(yè)率高，未建卡產(chǎn)檢率高，急診入院率高，孕婦臨產(chǎn)前體重輕，新生兒出生體重輕，分娩孕周小，有陰道分娩史的人數(shù)多，，差異均有統(tǒng)計學(xué)意義（P均＜0.05）。 3. TOLAC組與ERCD組中孕產(chǎn)婦并發(fā)癥的發(fā)生（子宮破裂，輸血，產(chǎn)后出血，產(chǎn)褥感染，子宮不全破裂，切口部位子宮內(nèi)膜異位癥，產(chǎn)后不全腸梗阻，手術(shù)致膀胱損傷）除不全子宮破裂外[0%（0/255）比1.01%（12/1184）]（χ2＝4.53，P＝0.03），其余差異均無統(tǒng)計學(xué)意義；但TOLAC組的住院天數(shù)、總住院費用、抗生素使用情況、失血量均明顯少于ERCD組，而分娩前后血紅蛋白丟失量TOLAC組多于ERCD組，差異均有統(tǒng)計學(xué)意義（P＜0.05）。 4. TOLAC組與ERCD組中新生兒并發(fā)癥的發(fā)生：以足月兒及未足月兒分開比較，兩組新生兒出生后1分鐘Apgar評分≤7分以及新生兒轉(zhuǎn)院/轉(zhuǎn)科率均無統(tǒng)計學(xué)差異（P＞0.05）。 5.對各公式的驗證中，F(xiàn)lamm公式的AUC為0.52，P=0.71。以試產(chǎn)結(jié)局分組對結(jié)果進(jìn)行t檢驗，t=-0.72，P=0.48，提示該公式診斷效能較低；Grobman公式的AUC為0.67，P＜0.05，以試產(chǎn)結(jié)局分組對結(jié)果進(jìn)行t檢驗，t=2.58，P＜0.05，提示該公式具有一定診斷價值；Gonen公式AUC為0.51，P=0.90，以試產(chǎn)結(jié)局分組對結(jié)果進(jìn)行t檢驗，t=-0.19，P=0.85，提示該公式診斷效能較低；Smith公式中校正胎兒性別前的AUC為0.66，P＜0.05，臨界值42.16%。校正胎兒性別后的AUC為0.65，P＜0.05，臨界值39.65%，以試產(chǎn)結(jié)局分組對結(jié)果進(jìn)行t檢驗，得到校正胎兒性別前的t=-2.32，P＜0.05，校正胎兒性別后的t=-2.26，P＜0.05，以40%為界，對預(yù)測結(jié)果和實際結(jié)果進(jìn)行Kappa檢驗，得到校正胎兒性別前的Kappa系數(shù)=0.20，P＜0.05。校正胎兒性別后的Kappa系數(shù)=0.24，P＜0.05，提示我們的實驗結(jié)果與Smith公式有一致性，即Smith公式具有一定診斷價值，且以40%界定為高危人群同樣適用于我國。 6.多因素Logistic回歸分析中，羊水污染情況、是否孕足月與新生兒體重為有意義因素，P均＜0.05。根據(jù)這個結(jié)果建立新的預(yù)測評分系統(tǒng)，并用ROC分析，曲線下面積為0.89，P＜0.05。將新預(yù)測評分系統(tǒng)與Grobman公式及校正胎兒性別后的Smith公式的ROC曲線進(jìn)行比較，發(fā)現(xiàn)新預(yù)測評分系統(tǒng)的ROC曲線下面積與后兩者的ROC曲線下面積有統(tǒng)計學(xué)差異，P均＜0.05，提示新預(yù)測評分系統(tǒng)的診斷效能優(yōu)于Grobman及Smith公式。 結(jié)論： 1.在能實施緊急剖宮產(chǎn)手術(shù)，并備有隨時可參與搶救的產(chǎn)科醫(yī)生，麻醉醫(yī)生的醫(yī)院，嚴(yán)格掌握VBAC指征的條件下實施剖宮產(chǎn)后的陰道試產(chǎn)是安全的，且有著費用較低，縮短患者住院天數(shù)，降低剖宮產(chǎn)率等多項益處。 2.孕產(chǎn)婦的主觀意愿對分娩方式的選擇起著很大的主導(dǎo)作用。由此提示患者的主觀意愿也是造成再次剖宮產(chǎn)率升高的原因之一，如何指導(dǎo)有剖宮產(chǎn)史的孕婦正確的看待VBAC也應(yīng)是產(chǎn)前保健的一項重要內(nèi)容。 3. Flamm、Grobman、Gonen、Smith預(yù)測公式中，Smith公式更適用于我國人群，國外以評分結(jié)果40%界定為高危人群同樣適用于我國。我們的實驗結(jié)果提示新的預(yù)測公式診斷價值優(yōu)于Smith公式及Grobman公式，但是新預(yù)測評分系統(tǒng)尚有待進(jìn)一步完善與驗證。
[Abstract]:Purpose :

This paper discusses the best mode of re - delivery after cesarean section and the formula of predicting the risk of vaginal delivery after cesarean section in our country , and then explores the formula of predicting vaginal delivery after cesarean section .

Method :

A total of 1439 pregnant women were selected from January 1 , 2002 to Nov . 30 , 2012 at the First Affiliated Hospital of the University of Suzhou , the Department of Suzhou State Hospital and the Wuxi Municipal Maternal and Child Health Hospital . Among them , there were 255 cases of vaginal trial of labor after cesarean section , and 1184 cases of cesarean section .

1 . The data of prenatal , postnatal and post - natal period after cesarean section in 1439 patients with cesarean section were analyzed retrospectively , and the effects of different delivery methods on the mother and the occurrence of complications were compared .

2 . Using the foreign Flamm , Grobman , Gonen and Smith formula to calculate and analyze the TOLAC group respectively , compare the theoretical value and the actual situation of the formula , and verify the applicability of each formula .

3 . Using multi - factor logistic regression analysis , combining the foreign formula and clinical practice , we randomly selected 60 % of patients with TOLAC ( 153 ) , the age , the occupation , the vaginal delivery history , the opening of the uterus , the condition of water pollution , the condition of building the card , height , the weight before giving birth , whether or not the birth weight of the pregnant woman and the body weight of the newborn were analyzed . The factors which were suitable for our country and the prediction of vaginalbirth after birth ( VBAC ) and ERCD risk were screened out , and then the new prediction formula was explored .

Statistical Processing :

The numerical variables are represented by ( X 鹵 S ) . The statistical software of SAS9.2 is used . The comparison of the measurement data adopts the Z test , the t test and the counting data are compared by 蠂2 test , Fisher exact probability method , Kappa test , receiver operating characteristic ( ROC ) curve and multi - factor logistic regression analysis , and the non - parametric data is compared with the rank sum test .

Results :

1.255 cases of TOLAC were selected , 233 cases of VBAC , 22 cases failed emergency cesarean section and 1184 ERCD , 131 cases were caesarean section after cesarean section , and the subjective willingness of pregnant women played a leading role in the choice of delivery mode .

2 . The group of TOLAC was higher than ERCD group , the rate of non - constructed card was high , the rate of emergency hospitalization was high , the weight of the pregnant woman was light , the birth weight of the newborn was light , the birth pregnant week was small , there was a large number of women with vaginal delivery history , the difference was statistically significant ( P < 0.05 ) .

3 . The incidence of maternal complications in the TOLAC group and ERCD group ( uterine rupture , blood transfusion , postpartum hemorrhage , puerperal infection , incomplete rupture of uterus , endometriosis of incision site , postpartum non - total intestinal obstruction , operation - induced bladder injury ) were 0 % ( 0 / 255 ) vs 1.01 % ( 12 / 1184 ) ( 蠂 2 = 4.53 , P = 0.03 ) except for incomplete uterine rupture ( 蠂 2 = 4.53 , P = 0.03 ) , and the remaining differences were not statistically significant ;
However , the number of days of hospitalization , total hospitalization expense , antibiotic usage and blood loss of TOLAC group were significantly lower than those in ERCD group , and there was significant difference in the amount of hemoglobin lost before and after delivery ( P < 0.05 ) .

4 . The incidence of neonatal complications in the TOLAC group and ERCD group was not statistically significant ( P > 0.05 ) .

5 . In the verification of each formula , the AUC of the Flamm formula was 0.52 , P = 0.71 . The results were t - tested by trial - production outcome grouping , t = - 0.72 , P = 0.48 , which suggested that the formula was lower in diagnosis efficiency .
The AUC of Grobman formula was 0.67 , P < 0.05 , t - test was performed on the result of trial - production outcome grouping , t = 2.58 , P < 0.05 , suggesting that the formula has certain diagnostic value ;
The AUC of Gonen formula was 0.51 , P = 0.90 , t - test was performed on the result of trial - production outcome grouping , t = - 0.19 , P = 0.85 , which suggested that the formula was lower in diagnosis efficiency .
In Smith ' s formula , the AUC was 0.66 , P & lt ; 0.05 , and the critical value was 42.16 % . The corrected fetal sex ratio was 0.65 , P & lt ; 0.05 , and the critical value was 39.65 % . The Kappa coefficient before the sex of the fetus was corrected = - 2.32 , P & lt ; 0.05 . The Kappa coefficient of the corrected fetal sex was 0 . 24 , P < 0 . 05 .

6.澶氬洜绱燣ogistic鍥炲綊鍒嗘瀽涓

本文編號：2072132