Marchiano Dominic, Elkousy Mohammed, Stevens Erika, Peipert Jeffrey, Macones George
Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
Am J Obstet Gynecol. 2004 Mar;190(3):790-6. doi: 10.1016/j.ajog.2003.09.068.
We sought to determine whether women with diet-controlled gestational diabetes mellitus who attempt vaginal birth after cesarean delivery are at increased risk of failure, when compared with their non-diabetic counterparts.
We identified 13,396 women who attempted vaginal birth after cesarean delivery among 25,079 pregnant women with a previous cesarean delivery who were delivered between 1995 and 1999 at 16 community and university hospitals. Analysis was limited to 9437 women without diabetes mellitus and 423 women with diet-controlled diabetes mellitus who attempted vaginal birth after cesarean delivery with a singleton gestation and 1 previous low-flap cesarean delivery. Data that were collected by trained abstractors, included demographics, medical history, and both pregnancy and neonatal outcomes. Multivariable logistic regression analysis was performed to determine an adjusted odds ratio for vaginal birth after cesarean delivery success among women with diet-controlled gestational diabetes compared with women with no diabetes mellitus. We controlled for birth weight, maternal age, race, tobacco, chronic hypertension, hospital settings, labor management, and obstetric history.
Forty-nine percent of the women with gestational diabetes mellitus and 67% of the women with no diabetes mellitus attempted vaginal birth after cesarean delivery. The success rate for attempted vaginal birth after cesarean delivery among gestational diabetic women was 70%, compared with 74% for non-diabetic women. We found that gestational diabetes mellitus is not an independent risk factor for vaginal birth after cesarean delivery failure. The relative risk for vaginal birth after cesarean delivery success in women with gestational diabetes mellitus compared with women without gestational diabetes mellitus was 0.94 (95% CI, 0.87-1.00). After an adjustment was made for confounding, the odds ratio for success with gestational diabetes mellitus was 0.87 (95% CI, 0.68-1.10).
Women with diet-controlled gestational diabetes mellitus who were carrying singleton fetuses who had no more than 1 previous low flap cesarean delivery should be counseled that their disease does not decrease their chances for a successful vaginal birth after cesarean delivery. Among diet-controlled diabetic women, the overall success rate for vaginal birth after cesarean delivery remains acceptable, and attempted vaginal birth after cesarean delivery should not be discouraged solely on the basis of gestational diabetes mellitus.
我们试图确定与非糖尿病孕妇相比，经饮食控制的妊娠期糖尿病孕妇剖宫产术后尝试阴道分娩失败的风险是否增加。
我们在1995年至1999年间于16家社区和大学医院分娩的25079例有剖宫产史的孕妇中，确定了13396例尝试剖宫产术后阴道分娩的孕妇。分析仅限于9437例非糖尿病孕妇和423例经饮食控制的糖尿病孕妇，她们尝试单胎妊娠且既往有1次低位横切口剖宫产术后的阴道分娩。由经过培训的提取人员收集的数据包括人口统计学、病史以及妊娠和新生儿结局。进行多变量逻辑回归分析，以确定经饮食控制的妊娠期糖尿病孕妇与非糖尿病孕妇相比剖宫产术后阴道分娩成功的校正比值比。我们对出生体重、产妇年龄、种族、吸烟、慢性高血压、医院环境、产程管理和产科病史进行了控制。
49%的妊娠期糖尿病孕妇和67%的非糖尿病孕妇尝试剖宫产术后阴道分娩。妊娠期糖尿病孕妇剖宫产术后尝试阴道分娩的成功率为70%，而非糖尿病孕妇为74%。我们发现妊娠期糖尿病不是剖宫产术后阴道分娩失败的独立危险因素。与无妊娠期糖尿病的孕妇相比，妊娠期糖尿病孕妇剖宫产术后阴道分娩成功的相对风险为0.94（95%可信区间，0.87 - 1.00）。在对混杂因素进行校正后，妊娠期糖尿病孕妇成功的比值比为0.87（95%可信区间，0.68 - 1.10）。
对于经饮食控制的妊娠期糖尿病且单胎妊娠、既往低位横切口剖宫产不超过1次的孕妇，应告知她们，其疾病不会降低剖宫产术后阴道分娩成功的几率。在经饮食控制的糖尿病孕妇中，剖宫产术后阴道分娩的总体成功率仍然可以接受，不应仅因妊娠期糖尿病而不鼓励尝试剖宫产术后阴道分娩。
