目的:主要目的是对首次阴道分娩时发生产科肛门括约肌损伤(OASI)的预测因素进行系统评价,通过超声(US-OASI)进行诊断。次要目标是报告超声检查AS创伤的发生率,包括分娩时没有临床报道的创伤,在为我们的主要终点提供数据的研究中。
方法:我们对MEDLINE进行了系统搜索,Embase,WebofScience,Cinahl,Cochrane库和Clinicaltrials.gov数据库。观察性队列研究和介入试验均符合纳入条件。研究资格由两名作者独立评估。进行随机效应荟萃分析,以汇集来自类似预测因素报告的研究的效应估计值。以95%CI报告总赔率(OR)或平均差异(MD)。使用I2统计量评估异质性。使用预后研究质量工具评估方法学质量。
结果:筛选了2805条记录,其中21条符合纳入标准(16个前瞻性队列,三项回顾性队列和两项干预性非随机试验)。分娩时胎龄增加(MD0.34w[0.04,0.64]),产前会阴体长较短(MD-0.60cm[-1.09,-0.11]),劳动力增加(OR1.81[1.21-2.71]),仪器交付(OR2.13[1.13-4.01]),特别是镊子拔除(OR3.56[1.31-9.67]),肩难产(OR12.07[1.06-137.6]),使用会阴切开术(OR1.85[1.11-3.06])和较短的会阴切开术长度(MD-0.40cm[-0.75,-0.05])与US-OASI相关。当汇集发病率时,26%的女性首次阴道分娩,有AS创伤的超声检查证据(95CI20-32%,20项研究,I2=88%)。在报告临床和超声OASI率的研究中,20%的女性在超声检查中有AS外伤,分娩时没有报告(95CI14-28%,16项研究,I2=90%)。产妇年龄没有差异,BMI,体重,耻骨下弓角,引产,硬膜外镇痛,第一/第二/活动第二阶段的持续时间,真空萃取,新生儿出生体重或头围。此外,产前会阴按摩和使用产时盆底肌肉扩张器不影响US-OASI的发生几率.大多数研究(81%)被认为在至少一个领域存在高偏倚风险,只有4项研究(19%)总体偏倚风险较低.
结论:鉴于有26%的首次阴道分娩的女性的超声证据显示AS结构受损,临床医生应有较低的怀疑门槛.我们的系统评价确定了几个预测因素。本文受版权保护。保留所有权利。
The primary objective was to perform a systematic
review of predictive factors for obstetric anal sphincter injury (OASI) occurrence at first vaginal delivery, with the diagnosis made by ultrasound (US-OASI). The secondary objective was to report on incidence rates of sonographic anal sphincter (AS) trauma, including trauma that was not clinically reported at childbirth, among the studies providing data for our primary objective.
We conducted a systematic search of MEDLINE, EMBASE, Web of Science, CINAHL, The Cochrane Library and ClinicalTrials.gov databases. Both observational cohort studies and interventional trials were eligible for inclusion. Study eligibility was assessed independently by two authors. Random-effects meta-analyses were performed to pool effect estimates from studies reporting on similar predictive factors. Summary odds ratio (OR) or mean difference (MD) is reported with 95% CI. Heterogeneity was assessed using the I2 statistic. Methodological quality was assessed using the Quality in Prognosis Studies tool.
A total of 2805 records were screened and 21 met the inclusion criteria (16 prospective cohort studies, three retrospective cohort studies and two interventional non-randomized trials). Increasing gestational age at delivery (MD, 0.34 (95% CI, 0.04-0.64) weeks), shorter antepartum perineal body length (MD, -0.60 (95% CI, -1.09 to -0.11) cm), labor augmentation (OR, 1.81 (95% CI, 1.21-2.71)), instrumental delivery (OR, 2.13 (95% CI, 1.13-4.01)), in particular forceps extraction (OR, 3.56 (95% CI, 1.31-9.67)), shoulder dystocia (OR, 12.07 (95% CI, 1.06-137.60)), episiotomy use (OR, 1.85 (95% CI, 1.11-3.06)) and shorter episiotomy length (MD, -0.40 (95% CI, -0.75 to -0.05) cm) were associated with US-OASI. When pooling incidence rates, 26% (95% CI, 20-32%) of women who had a first vaginal delivery had US-OASI (20 studies; I2 = 88%). In studies reporting on both clinical and US-OASI rates, 20% (95% CI, 14-28%) of women had AS trauma on ultrasound that was not reported clinically at childbirth (16 studies; I2 = 90%). No differences were found in maternal age, body mass index, weight, subpubic arch angle, induction of labor, epidural analgesia, episiotomy angle, duration of first/second/active-second stages of labor, vacuum extraction, neonatal birth weight or head circumference between cases with and those without US-OASI. Antenatal perineal massage and use of an intrapartum pelvic floor muscle dilator did not affect the odds of US-OASI. Most (81%) studies were judged to be at high risk of bias in at least one domain and only four (19%) studies had an overall low risk of bias.
Given the ultrasound evidence of structural damage to the AS in 26% of women following a first vaginal delivery, clinicians should have a low threshold of suspicion for the condition. This systematic
review identified several predictive factors for this. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.