系统评价和时间反应荟萃分析择期剖宫产的最佳时机，以获得最佳母婴健康结局。
A systematic review and time-response meta-analysis of the optimal timing of elective caesarean sections for best maternal and neonatal health outcomes.
机构信息
Institute for Research in Operative Medicine, Witten/Herdecke University, Ostmerheimer Str. 200, 51109, Cologne, Germany.
Department of Obstetrics and Gynecology, Witten/Herdecke University, Marien Hospital Witten, Marienplatz 2, 58452, Witten, Germany.
出版信息
BMC Pregnancy Childbirth. 2020 Jul 8;20(1):395. doi: 10.1186/s12884-020-03036-1.
BACKGROUND
The rate of caesarean sections (CS) has increased in the last decades to about 30% of births in high income countries. Many CSs are electively planned without an urgent medical reason for mother or child. An early CS though may harm the newborn. Our aim was to evaluate the gestational time point after the 37 + 0 week of gestation (WG) (after prematurity = term) of performing an elective CS with the lowest morbidity for mother and child by assessing the time course from 37 + 0 to 42+ 6 WG.
METHODS
We performed a systematic literature search in MEDLINE, EMBASE, CENTRAL and CINAHL in November 2018. We included studies that compared different time points of elective CS at term no matter the reason for elective CS. Our primary outcomes were the rate of admissions to the neonatal intensive care unit (NICU), neonatal death and maternal death in early versus late term elective CS. Various binary and dose response random effects meta-analyses were performed.
RESULTS
We identified 35 studies including 982,749 women. Except one randomised controlled trial, all studies were cohort studies. We performed a linear time-response meta-analysis on the primary outcome NICU admission on 14 studies resulting in a decrease of the relative risk (RR) to 0.63 (95% CI 0.56, 0.71) from 37 + 0 to 39 + 6 WG. RR for neonatal death showed a decrease to 39 + (0-6) WG (RR 0.59 95% CI 0.43 to 0.83) and increase from then on (RR 2.09 95% CI 1.18 to 3.70) assuming a U-shape course and using a cubic spline model for meta-analysis of four studies. We only identified one study analyzing maternal death resulting in RR of 0.38 (95% CI 0.04 to 3.40) for 37 + 0 + 38 + 6 WG versus ≥39 + 0 WG.
CONCLUSION
Our systematic review showed that elective CS (primary and repeated) before the 39 + 0 WG lead to more NICU admissions and neonatal deaths, although death is rare and increases again after 39 + 6 WG. We did not find enough evidence on maternal outcomes. There is a need for more research, considering maternal outcomes to provide a balanced decision between neonatal and maternal health.
SYSTEMATIC REVIEW REGISTRATION
Registered in PROSPERO (CRD42017078231).
背景
在过去几十年中，剖宫产率（CS）已上升到高收入国家约 30%的分娩率。许多 CS 是在没有母婴紧急医疗原因的情况下选择性计划的。然而，过早的 CS 可能会对新生儿造成伤害。我们的目的是通过评估从 37+0 周到 42+6 周的时间过程，评估在 37+0 周后（早产=足月）进行选择性 CS 的时间点，以获得母婴发病率最低的时间点。
方法
我们于 2018 年 11 月在 MEDLINE、EMBASE、CENTRAL 和 CINAHL 中进行了系统的文献检索。我们纳入了比较不同时间点选择性 CS 的研究，无论选择 CS 的原因如何。我们的主要结局是在早期和晚期足月选择性 CS 中新生儿重症监护病房（NICU）入院、新生儿死亡和产妇死亡的发生率。进行了各种二项和剂量反应随机效应荟萃分析。
结果
我们确定了 35 项研究，包括 982749 名女性。除了一项随机对照试验外，所有研究均为队列研究。我们对 14 项研究的主要结局 NICU 入院进行了线性时间反应荟萃分析，结果显示，从 37+0 周到 39+6 周，相对风险（RR）降低至 0.63（95%CI 0.56，0.71）。新生儿死亡的 RR 显示，从 39+（0-6）周（RR 0.59 95%CI 0.43 至 0.83）开始下降，然后增加（RR 2.09 95%CI 1.18 至 3.70），假设为 U 形曲线，并使用四次研究的三次样条模型进行荟萃分析。我们只发现了一项分析产妇死亡的研究，结果显示，从 37+0+38+6 周到≥39+0 周，RR 为 0.38（95%CI 0.04 至 3.40）。
结论
我们的系统评价显示，在 39+0 周之前进行选择性 CS（原发性和重复性）会导致更多的 NICU 入院和新生儿死亡，尽管死亡很少见且在 39+6 周后再次增加。我们没有发现足够的产妇结局证据。需要进行更多的研究，考虑到产妇的结局，在新生儿和产妇健康之间做出平衡的决策。
系统评价注册
在 PROSPERO（CRD42017078231）中注册。
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