超级肥胖女性经阴道分娩与剖宫产的对比试验

Trial of Labor Compared With Cesarean Delivery in Superobese Women.

作者信息

Grasch Jennifer L, Thompson Jennifer L, Newton J Michael, Zhai Amy W, Osmundson Sarah S

机构信息

Vanderbilt University Medical Center, Nashville, Tennessee.

出版信息

Obstet Gynecol. 2017 Nov;130(5):994-1000. doi: 10.1097/AOG.0000000000002257.

DOI:10.1097/AOG.0000000000002257

PMID:29016512

Abstract

OBJECTIVE

To examine whether labor compared with planned cesarean delivery is associated with increased maternal and neonatal morbidity.

METHODS

We conducted a retrospective cohort study of all women with body mass indexes (BMIs) at delivery of 50 or greater delivering a live fetus at 34 weeks of gestation of greater between January 1, 2008, and December 31, 2015. Pregnancies with multiple gestations and major fetal anomalies were excluded. The primary outcome was a composite of maternal and neonatal morbidity and was estimated to be 50% in superobese women based on institutional data. A sample size of 338 women determined the study period and was selected to show a 30% difference in the incidence of the primary outcome between the two groups. Multivariate logistic regression adjusted for potential confounders.

RESULTS

There were 344 women with BMIs of 50 or greater who met eligibility criteria, of whom 201 (58%) labored and 143 (42%) underwent planned cesarean delivery. Women who labored were younger, more likely to be nulliparous, and less likely to have pre-existing diabetes. Among women who labored, 45% underwent a cesarean delivery, most commonly for labor arrest (61%) or nonreassuring fetal status (28%). Composite maternal and neonatal morbidity was reduced among women who labored even after adjusting for age, parity, pre-existing diabetes, and prior cesarean delivery (adjusted odds ratio 0.42, 95% CI 0.24-0.75). In the subgroup of women (n=234) who underwent a cesarean delivery, whether planned (n=143) or after labor (n=91), there were no differences in maternal and neonatal morbidity except that severe maternal morbidity was increased in women (n=12) who labored (8.8% compared with 2.1%, relative risk 4.2, 95% CI 1.14-15.4).

CONCLUSION

Despite high rates of cesarean delivery in women with superobesity, labor is associated with lower composite maternal and neonatal morbidity. Severe maternal morbidity may be higher in women who require a cesarean delivery after labor.

摘要

目的

探讨与择期剖宫产相比，经阴道分娩是否会增加孕产妇和新生儿的发病率。

方法

我们对2008年1月1日至2015年12月31日期间所有分娩时体重指数（BMI）为50或更高、孕34周及以上分娩活胎的妇女进行了一项回顾性队列研究。排除多胎妊娠和严重胎儿畸形的妊娠。主要结局是孕产妇和新生儿发病率的综合指标，根据机构数据估计，超级肥胖妇女的这一指标为50%。确定了338名妇女的样本量以确定研究周期，并选择该样本量以显示两组主要结局发生率存在30%的差异。采用多因素逻辑回归对潜在混杂因素进行校正。

结果

共有344名BMI为50或更高的妇女符合入选标准，其中201名（58%）经阴道分娩，143名（42%）接受择期剖宫产。经阴道分娩的妇女更年轻，更可能为初产妇，且患糖尿病前期的可能性更小。在经阴道分娩的妇女中，45%接受了剖宫产，最常见的原因是产程停滞（61%）或胎儿状况不佳（28%）。即使在对年龄、产次、糖尿病前期和既往剖宫产进行校正后，经阴道分娩的妇女其孕产妇和新生儿发病率综合指标仍降低（校正比值比0.42，95%可信区间0.24 - 0.75）。在接受剖宫产的妇女亚组（n = 234）中，无论是择期剖宫产（n = 143）还是经阴道分娩后剖宫产（n = 91），孕产妇和新生儿发病率均无差异，但经阴道分娩后剖宫产的妇女（n = 12）严重孕产妇发病率增加（8.8% 对比2.1%，相对危险度4.2，95%可信区间1.14 - 15.4）。