多次妊娠，对于剖宫产后再次尝试阴道分娩（TOLAC）是有利还是有弊？
Grand multiparity, is it a help or a hindrance in a trial of labor after cesarean section (TOLAC)?
机构信息
Department of Obstetrics and Gynecology, Mayanei Hayeshua Medical Center, Bnei Brak, Israel.
Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
出版信息
J Matern Fetal Neonatal Med. 2023 Dec;36(1):2190835. doi: 10.1080/14767058.2023.2190835.
OBJECTIVE
Parity is a prognostic variable when considering trial of labor after cesarean section (TOLAC). This study aimed to determine whether grandmultiparous patients are at increased risk of poor TOLAC outcomes such as uterine rupture.
STUDY DESIGN
A retrospective cohort was conducted at a single university-affiliated medical center with approximately 10,000 deliveries per year. The study group included women post one cesarean section who attempted TOLAC carrying a singleton fetus in vertex presentation. We divided the cohort into three groups: group 1 - women who had a parity of 1; group 2 - parity of 2-4; group 3 - parity of 5 and above. The primary outcome was successful VBAC. Secondary outcomes included mode of delivery, uterine rupture, and combined maternal and neonatal adverse outcomes. Data were analyzed using Fisher's exact test, Chi-square test, ANOVA, and paired -test.
RESULTS
Five thousand four hundred and forty-seven women comprised the study group: group 1 - 879 patients, group 2 - 2374 patients, and group 3 - 2194 patients. No significant between-group differences were found in gestational age at delivery. Rates of a successful VBAC were 80.6%, 95.4%, and 95.5%, respectively. Group 1 were more likely to have a failed TOLAC compared to group 2 (OR 5.02, 95% CI 3.9-6.5, <.001) and group 3 (OR 5.17, 95% CI 4.0-6.7, <.001). There was no increased risk of failed TOLAC when comparing groups 2 and 3 (OR 1.03; 95% CI 0.8-1.4, =.89). Operative delivery rate differed significantly between all three groups; 25.1%, 6.2%, and 3.6%, for groups 1, 2, and 3, respectively (<.001). The rate of uterine rupture was significantly higher in group 1 compared to group 2 (1.02% vs. 0.29% =.02) and group 3 (1.02% vs. 0.2%, =.01, respectively). There were no differences between group 2 and group 3 (0.29% vs. 0.2% =.78).
CONCLUSIONS
Grandmultiparity is not associated with an increased risk of uterine rupture during TOLAC.
目的
当考虑剖宫产后试产（TOLAC）时，均等是一个预后变量。本研究旨在确定多产妇是否有更高的不良 TOLAC 结局风险，如子宫破裂。
研究设计
这是在一家每年约有 10000 次分娩的单一大学附属医院进行的回顾性队列研究。研究组包括剖宫产后尝试 TOLAC 的单胎头位产妇。我们将队列分为三组：第 1 组-产妇生育 1 次；第 2 组-生育 2-4 次；第 3 组-生育 5 次及以上。主要结局是 VBAC 成功。次要结局包括分娩方式、子宫破裂以及母婴不良结局的综合发生率。数据使用 Fisher 确切检验、卡方检验、方差分析和配对 t 检验进行分析。
结果
共有 5447 名女性纳入研究组：第 1 组 879 例，第 2 组 2374 例，第 3 组 2194 例。各组间分娩时的孕周无显著差异。VBAC 成功率分别为 80.6%、95.4%和 95.5%。与第 2 组（OR 5.02，95%CI 3.9-6.5，<.001）和第 3 组（OR 5.17，95%CI 4.0-6.7，<.001）相比，第 1 组 TOLAC 失败的可能性更高。与第 2 组相比，第 2 组和第 3 组之间 TOLAC 失败的风险无显著差异（OR 1.03；95%CI 0.8-1.4，=.89）。三组间手术分娩率差异显著；分别为第 1 组 25.1%、第 2 组 6.2%和第 3 组 3.6%（<.001）。与第 2 组（1.02%比 0.29%，=.02）和第 3 组（1.02%比 0.2%，=.01）相比，第 1 组的子宫破裂发生率显著更高。第 2 组和第 3 组之间无差异（0.29%比 0.2%，=.78）。
结论
多产妇在 TOLAC 期间发生子宫破裂的风险无增加。
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