1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece; Laboratory of Experimental Surgery and Surgical Research N.S Christeas, National and Kapodistrian University of Athens, Athens, Greece.
1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece.
Am J Obstet Gynecol. 2021 Aug;225(2):128.e1-128.e13. doi: 10.1016/j.ajog.2021.04.231. Epub 2021 Apr 21.
Cesarean delivery is the most prevalent surgical procedure worldwide, reaching approximately 29.7 million cases in 2015. It is directly associated with an increased risk of maternal and neonatal morbidity rates in the absence of malpresentation. Several techniques have been investigated, and there is evidence that cephalad-caudad expansion of the uterine incision might be associated with improved maternal outcomes compared with traditional transverse blunt expansion. The purpose of this meta-analysis was to evaluate the impact of cephalad-caudad expansion on adverse maternal outcomes, including intraoperative blood loss, risk of uterine vessel injury, and tearing of the lower uterine segment.
We searched Medline, Scopus, the Cochrane Central Register of Controlled Trials, Google Scholar, and Clinicaltrials.gov databases from inception to January 2021.
Randomized controlled trials that assessed the impact of the cephalad-caudad blunt expansion of the low transverse uterine incision during cesarean delivery rather than those of transverse blunt expansion were selected for inclusion.
Effect sizes were calculated with the Hartung-Knapp-Sidik-Jonkman random-effects model in R. Trial sequential analysis was performed to evaluate the adequacy of sample sizes.
Cephalad-caudad blunt expansion of the uterine incision was associated with a lower prevalence of unintended incision extension (relative risk, 0.62; 95% confidence interval, 0.45-0.86) and uterine vessel injury (relative risk, 0.55; 95% confidence interval 0.41-0.73). However, these complications were not accompanied by the increased need for additional suture placement (relative risk, 0.62; 95% confidence interval, 0.31-4.12) or transfusion rates (relative risk, 0.75; 95% confidence interval, 0.28-2.03). Similarly, the intraoperative duration was comparable with cases treated with transverse blunt expansion (mean difference = -0.45 minutes; 95% confidence interval -2.12 to 1.21) and the risk of intentional incision extension in the form of an inverted T (relative risk, 0.38; 95% confidence interval, 0.09-1.52). Trial sequential analysis revealed that the required sample size was reached in the unintended incision extension and uterine vessel injury outcomes.
The findings of our study suggested that cephalad-caudad blunt expansion of the uterine incision is superior to transverse expansion in terms of reducing unintended incision extension and uterine vessel injury.
剖宫产术是全球最常见的手术，2015 年约有 2970 万例。如果不存在胎位不正，它会直接增加产妇和新生儿发病率的风险。已经研究了几种技术，有证据表明，与传统的横向钝性扩张相比，子宫切口的头侧尾侧扩张可能与改善产妇结局相关。本荟萃分析的目的是评估头侧尾侧扩张对不良产妇结局的影响，包括术中失血量、子宫血管损伤风险和子宫下段撕裂。
我们检索了 Medline、Scopus、Cochrane 中央对照试验注册库、Google Scholar 和 Clinicaltrials.gov 数据库，检索时间从建库至 2021 年 1 月。
选择评估剖宫产术中子宫下段横向切口的头侧尾侧钝性扩张对母婴结局影响的随机对照试验，而非评估横向钝性扩张的试验。
使用 R 中的 Hartung-Knapp-Sidik-Jonkman 随机效应模型计算效应量。进行试验序贯分析以评估样本量是否充足。
子宫切口的头侧尾侧钝性扩张与非计划切口延伸的发生率较低相关（相对风险，0.62；95%置信区间，0.45-0.86）和子宫血管损伤（相对风险，0.55；95%置信区间 0.41-0.73）。然而，这些并发症并不需要额外的缝合（相对风险，0.62；95%置信区间，0.31-4.12）或输血率（相对风险，0.75；95%置信区间，0.28-2.03）增加。同样，术中时间与经横向钝性扩张治疗的病例相当（平均差值=-0.45 分钟；95%置信区间-2.12 至 1.21），且以倒 T 型切口形式的计划性切口延伸的风险也相当（相对风险，0.38；95%置信区间，0.09-1.52）。试验序贯分析显示，在非计划性切口延伸和子宫血管损伤结局方面，所需的样本量已达到。
本研究结果表明，与横向扩张相比，子宫切口的头侧尾侧钝性扩张在减少非计划性切口延伸和子宫血管损伤方面具有优势。
