臀位分娩第一胎与新生儿死亡率和发病率以及计划分娩方式。

First Twin in Breech Presentation and Neonatal Mortality and Morbidity According to Planned Mode of Delivery.

机构信息

Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM, INRA, the Department of Obstetrics and Gynecology, Robert Debré Hospital, APHP, and Port-Royal maternity unit, Cochin Hospital, APHP, Paris, the Department of Gynecology-Obstetric and Reproductive Medicine, Hôpital La Conception/Hôpital Nord, AP-HM, and Aix Marseille Univ, UM 63, CNRS 7278, IRD 198, INSERM 1095, Marseille, Inserm, UMR1027, Equipe SPHERE, the Université de Toulouse III, UMR1027, and CHU Toulouse, Pôle de gynécologie obstétrique, Hôpital Paule de Viguier, Toulouse, the Obstetrical Care Unit, Hôpital Couple Enfant, Grenoble University Hospital, CS 10217, 38043, Grenoble, the Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, and the Department of Obstetrics and Gynecology, CHU de Rouen, Université de Rouen, Rouen, France.

出版信息

Obstet Gynecol. 2020 May;135(5):1015-1023. doi: 10.1097/AOG.0000000000003785.

DOI:10.1097/AOG.0000000000003785

PMID:32282609

Abstract

OBJECTIVE

To compare neonatal mortality and morbidity of first twins according to the planned mode of delivery when the first twin is in breech presentation, in a country where planned vaginal delivery is an option.

METHODS

This is a planned secondary analysis of the JUMODA (JUmeaux MODe d'Accouchement) cohort, a national prospective population-based study of twin deliveries conducted in 176 French hospitals. We analyzed pregnancies with first twins in breech presentation and applied the inclusion criteria of the Twin Birth Study (except the criterion for first-twin presentation): both fetuses alive, with a birth weight between 1,500 g and 4,000 g, at or after 32 0/7 weeks of gestation. The primary outcome was a composite of neonatal mortality and morbidity. We used multivariate Poisson regression models to control for potential confounders and propensity score analyses, that is, matching and inverse probability of treatment weighting to control for indication bias.

RESULTS

Among the 1,467 women with a breech-presenting first twin included in this analysis, 1,169 (79.7%) had planned cesarean and 298 (20.3%) planned vaginal births, of whom 185 (62.1%) delivered both twins vaginally. The neonatal mortality and severe morbidity rate for first twins was 1.7% (5/298) in the planned vaginal and 1.9% (22/1,169) in the planned cesarean delivery groups (crude relative risk [RR] 0.90, 95% CI 0.34-2.34). Planned vaginal delivery was not associated with higher neonatal mortality and morbidity than planned cesarean delivery, regardless of the statistical method used: adjusted RR 0.71, 95% CI 0.27-1.86; RR 0.61, 95% CI 0.20-1.83 after matching for propensity score; RR 0.63, 95% CI 0.23-1.74 with inverse probability of treatment weighting. Analyses of neonatal mortality and morbidity of second twins yielded similar results.

CONCLUSION

Although our sample size precluded a robust assessment for small differences in outcomes between planned cesarean and planned vaginal delivery in twin pregnancies in which the first twin was in breech presentation, in our cohort planned vaginal delivery was not associated with higher neonatal mortality and morbidity for either twin.

摘要

目的

在首选阴道分娩是一种选择的国家，比较头位先露第一胎儿的计划性分娩方式对臀位先露第一胎儿的新生儿发病率和死亡率的影响。

方法

本研究为 JUMODA（JUmeaux MODe d'Accouchement）队列的二次分析，这是一项在法国 176 家医院进行的头位先露双胎分娩的全国前瞻性基于人群的研究。我们分析了头位先露臀位的第一胎儿妊娠，并应用了双胞胎分娩研究的纳入标准（除了第一胎儿先露的标准）：两个胎儿均存活，出生体重在 1500g 至 4000g 之间，在 32 周零 7 天或以上。主要结局为新生儿发病率和死亡率的复合指标。我们使用多变量泊松回归模型来控制潜在的混杂因素，并进行倾向评分分析，即匹配和治疗逆概率加权来控制适应证偏倚。

结果

在这项分析中，纳入了 1467 例臀位先露的第一胎儿孕妇，其中 1169 例（79.7%）计划行剖宫产，298 例（20.3%）计划行阴道分娩，其中 185 例（62.1%）阴道分娩了两个胎儿。臀位第一胎儿的新生儿死亡率和严重发病率为阴道分娩组 1.7%（5/298），剖宫产组 1.9%（22/1169）（粗相对风险 [RR] 0.90，95%CI 0.34-2.34）。无论使用何种统计方法，计划性阴道分娩与计划性剖宫产相比，新生儿死亡率和发病率均无显著差异：调整 RR 0.71，95%CI 0.27-1.86；倾向评分匹配后 RR 0.61，95%CI 0.20-1.83；治疗逆概率加权后 RR 0.63，95%CI 0.23-1.74。对第二胎儿的新生儿死亡率和发病率的分析得出了类似的结果。