Rath Werner, Hellmeyer Lars, Tsikouras Panagiotis, Stelzl Patrick
Medizinische Fakultät, Gynäkologie und Geburtshilfe, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany.
Klinik für Gynäkologie und Geburtsmedizin, Vivantes Klinikum im Friedrichshain, Berlin, Germany.
Geburtshilfe Frauenheilkd. 2022 Mar 16;82(7):727-735. doi: 10.1055/a-1731-7441. eCollection 2022 Jul.
There are currently no up-to-date evidence-based recommendations on the preferred method to induce labour after previous Caesarean section, especially for patients with unripe cervix, as randomised controlled studies are lacking. Intravenous oxytocin and misoprostol are contraindicated in these women because of the high risk of uterine rupture. In women with ripe cervix (Bishop Score > 6), intravenous administration of oxytocin is an effective procedure with comparable rates of uterine rupture to those with spontaneous onset of labour. Vaginal prostaglandin E (PGE ) and mechanical methods (balloon catheters, hygroscopic cervical dilators) are effective methods to induce labour in pregnant women with unripe cervix and previous Caesarean section. According to current guidelines, the administration of PGE is associated with a higher rate of uterine rupture compared to balloon catheters. Balloon catheters are therefore a suitable alternative to PGE to induce labour after previous Caesarean section, even though this is an off-label use. In addition to two meta-analyses published in 2016, 12 mostly retrospective cohort/observational studies with low to moderate levels of evidence have been published on mechanical methods of cervical ripening after previous Caesarean section. But because of the significant heterogeneity of the studies, substantial differences in study design, and insufficient numbers of pregnant women included in the studies, it is not possible to make any evidence-based recommendations based on these studies. According to a recent meta-analysis, the average rate using balloon catheters is approximately 53% and the average rate after spontaneous onset of labour is 72%. The uterine rupture rate was 0.2-0.9% for vaginal PGE and 0.56-0.94% for balloon catheters and is therefore comparable to the uterine rupture rate associated with spontaneous onset of labour. According to the product informations, hygroscopic cervical dilators (Dilapan-S) are currently the only method which is not contraindicated for cervical ripening/induction of labour in women with previous Caesarean section, although data are insufficient. Well-designed, randomised, controlled studies with sufficient case numbers comparing balloon catheters and hygroscopic cervical dilators with mechanical methods and vaginal prostaglandin E /oral misoprostol are therefore necessary to allow proper decision-making.
目前，对于既往剖宫产术后引产的首选方法，尚无最新的循证医学推荐，尤其是对于宫颈未成熟的患者，因为缺乏随机对照研究。由于子宫破裂风险高，静脉注射缩宫素和米索前列醇在这些女性中是禁忌的。对于宫颈成熟（ Bishop评分>6）的女性，静脉注射缩宫素是一种有效的方法，其子宫破裂率与自然临产者相当。阴道前列腺素E（PGE）和机械方法（球囊导管、吸湿宫颈扩张器）是既往剖宫产且宫颈未成熟孕妇引产的有效方法。根据现行指南，与球囊导管相比，PGE给药的子宫破裂率更高。因此，球囊导管是既往剖宫产术后引产的一种合适的PGE替代方法，尽管这属于超说明书用药。除了2016年发表的两项荟萃分析外，还发表了12项大多为低至中等证据水平的回顾性队列/观察性研究，涉及既往剖宫产术后宫颈成熟的机械方法。但由于研究的显著异质性、研究设计的实质性差异以及纳入研究的孕妇数量不足，无法基于这些研究提出任何循证医学推荐。根据最近的一项荟萃分析，使用球囊导管的平均引产成功率约为53%，自然临产的平均成功率为72%。阴道PGE的子宫破裂率为0.2 - 0.9%，球囊导管的子宫破裂率为0.56 - 0.94%，因此与自然临产相关的子宫破裂率相当。根据产品信息，吸湿宫颈扩张器（Dilapan - S）目前是既往剖宫产女性宫颈成熟/引产唯一无禁忌的方法，尽管数据不足。因此，有必要开展设计良好、随机、对照且病例数充足的研究，比较球囊导管和吸湿宫颈扩张器与机械方法及阴道前列腺素E/口服米索前列醇，以便做出恰当决策。
