Belghiti Jérémie, Kayem Gilles, Dupont Corinne, Rudigoz René-Charles, Bouvier-Colle Marie-Hélène, Deneux-Tharaux Catherine
INSERM U953 Epidemiological Research Unit on Perinatal Health and Women's and Children's Health, Université Pierre et Marie Curie Paris 6, Paris, France.
BMJ Open. 2011 Dec 21;1(2):e000514. doi: 10.1136/bmjopen-2011-000514. Print 2011.
Objectives Postpartum haemorrhage (PPH) is a major cause of maternal mortality and morbidity worldwide. Experimental studies support the hypothesis that oxytocin administration during labour, a common although not evidence-based practice, may increase the risk of atonic PPH. The clinical studies, however, are inconclusive. The objectives of this study was to investigate the association between the level of oxytocin exposure during labour and the risk of severe PPH and to explore whether the prophylactic use of oxytocin after birth modifies this association. Design Population-based, cohort-nested case-control study. Setting 106 French hospitals from December 2004 through November 2006. Participants Women with term singleton vaginal deliveries, after an uncomplicated pregnancy. Cases were 1483 women with severe PPH, defined by peripartum change in haemoglobin of ≥4 g/dl or need for blood transfusion. Controls were 1758 women from a random sample of parturients without PPH. Main outcome measures The independent association between the level of oxytocin during labour and the risk of severe PPH was tested and quantified with ORs through two-level multivariable logistic regression modelling. Results Oxytocin was administered during labour to 73% of cases and 61% of controls (crude OR: 1.7, 95% CI 1.5 to 2.0). After adjustment for all potential confounders, oxytocin during labour was associated with a significantly higher risk of severe PPH (adjusted OR: 1.8, 95% CI 1.3 to 2.6) in women who did not receive prophylactic oxytocin after delivery; the OR for haemorrhage increased from 1 to 5 according to the level of oxytocin exposure. In women who had prophylactic oxytocin after delivery, this association was significant only for the highest exposure categories. Conclusions Oxytocin during labour appears to be an independent risk factor for severe PPH. The results emphasise the need for guidelines clarifying the evidence-based indications for this procedure and the minimal useful regimens.
目的 产后出血（PPH）是全球孕产妇死亡和发病的主要原因。实验研究支持这样一种假设，即分娩期间使用缩宫素（这是一种常见但缺乏循证依据的做法）可能会增加宫缩乏力性产后出血的风险。然而，临床研究尚无定论。本研究的目的是调查分娩期间缩宫素暴露水平与严重产后出血风险之间的关联，并探讨产后预防性使用缩宫素是否会改变这种关联。
设计 基于人群的队列嵌套病例对照研究。
设置 2004年12月至2006年11月期间法国的106家医院。
参与者 妊娠结局正常的足月单胎阴道分娩妇女。病例为1483例严重产后出血妇女，定义为围产期血红蛋白下降≥4 g/dl或需要输血。对照是从无产后出血的产妇随机样本中选取的1758名妇女。
主要结局指标 通过二级多变量逻辑回归模型，用比值比（OR）检验并量化分娩期间缩宫素水平与严重产后出血风险之间的独立关联。
结果 73%的病例和61%的对照在分娩期间使用了缩宫素（粗OR：1.7，95%可信区间1.5至2.0）。在对所有潜在混杂因素进行调整后，未在产后接受预防性缩宫素的妇女中，分娩期间使用缩宫素与严重产后出血风险显著升高相关（调整后OR：1.8，95%可信区间1.3至2.6）；根据缩宫素暴露水平，出血的OR从1增加到5。在产后接受预防性缩宫素的妇女中，这种关联仅在最高暴露类别中显著。
结论 分娩期间使用缩宫素似乎是严重产后出血的一个独立危险因素。结果强调需要制定指南，明确该操作基于证据的适应证和最小有效方案。
