目的:评估经产大(GMP)妇女每次额外分娩对母婴结局的影响。
方法:一项多中心回顾性队列研究,检查了GMP妇女(胎次5-10,每个胎次水平分别分析)与参考组(胎次2-4)的母婴结局。研究人群包括单胎妊娠的多胎妇女,她们在一个地理区域的四个大学附属产科中心之一分娩,2003年至2021年。我们排除了未产的,奇偶校验>10的那些(由于样本量小),先前有剖宫产分娩(CD)的妇女,多胎妊娠,和院外分娩。这项研究的主要结果是产后出血(PPH,估计失血量超过1000毫升,和/或需要输血,和/或血红蛋白下降>3g/Dl)。次要结局包括非计划剖宫产,早产,以及其他不良母婴结局。单因素分析后多因素logistic回归。
结果:在研究期间,251,786例120,793例患者符合纳入和排除标准。其中,173,113(69%)属于平差2-4(参考组),27,894(11%)是平价五,19,146(8%)为平价6,13,115(5%)是平价七,8903(4%)是平差八分,5802(2%)为平差9,3813(2%)为平差10。从第8次开始,GMP妇女表现出明显更高的PPH率。平差8的调整后赔率比(aOR)为1.19(95%CI:1.06-1.34),平差9的1.17(95%CI:1.01-1.36)和平差10的1.39(95%CI:1.18-1.65)。此外,他们显示了几种产妇和新生儿结局的发生率升高,包括胎盘早剥,胎龄大(LGA)新生儿,新生儿低血糖,和新生儿癫痫发作。相反,他们表现出其他不良产妇结局的风险降低,包括早产,计划外剖宫产(CD),真空辅助分娩,和三度或四度会阴撕裂和小于胎龄(SGA)的新生儿。与新生儿低血糖的关系,新生儿癫痫发作与分娩次数呈剂量依赖性,证明每个额外的交付都与额外的,对产科并发症有显著影响。
结论:我们的研究表明,8-10次与PPH的风险显著增加相关。均等水平>5与胎盘早剥的几率增加相关,LGA新生儿,新生儿低血糖,和新生儿癫痫发作。然而,GMP妇女还显示出某些不良产妇结局的可能性降低,包括计划外剖宫产,早产,真空辅助分娩,SGA新生儿,和严重的会阴眼泪。这些发现强调了为GMP女性量身定制的产科护理的重要性,以减轻与更高的胎次相关的高风险。
OBJECTIVE: To assess the effect of each additional delivery among grand multiparous (GMP) women on maternal and neonatal outcomes.
METHODS: A multi-center retrospective cohort study that examined maternal and neonatal outcomes of GMP women (parity 5-10, analyzed separately for each parity level) compared to a reference group of multiparous women (parity 2-4). The study population included grand multiparous women with singleton gestation who delivered in one of four university-affiliated obstetrical centers in a single geographic area, between 2003 and 2021. We excluded nulliparous, those with parity > 10 (due to small sample sizes), women with previous cesarean deliveries (CDs), multifetal gestations, and out-of-hospital deliveries. The primary outcome of this study was postpartum hemorrhage (PPH, estimated blood loss exceeding 1000 ml, and/or requiring blood product transfusion, and/or a hemoglobin drop > 3 g/Dl). Secondary outcomes included unplanned cesarean deliveries, preterm delivery, along with other adverse maternal and neonatal outcomes. Univariate analysis was followed by multivariable logistic regression.
RESULTS: During the study period, 251,786 deliveries of 120,793 patients met the inclusion and exclusion criteria. Of those, 173,113 (69%) were of parity 2-4 (reference group), 27,894 (11%) were of parity five, 19,146 (8%) were of parity six, 13,115 (5%) were of parity seven, 8903 (4%) were of parity eight, 5802 (2%) were of parity nine and 3813 (2%) were of parity ten. GMP women exhibited significantly higher rates of PPH starting from parity eight. The adjusted odds ratios (aOR) were 1.19 (95 % CI: 1.06-1.34) for parity 8, 1.17 (95 % CI: 1.01-1.36) for parity 9, and 1.39 (95 % CI: 1.18-1.65) for parity 10. Additionally, they showed elevated rates of several maternal and neonatal outcomes, including placental abruption, large-for-gestational age (LGA) neonates, neonatal hypoglycemia, and neonatal seizures. Conversely, they exhibited decreased risk for other adverse maternal outcomes, including preterm deliveries, unplanned cesarean deliveries (CDs), vacuum-assisted delivery, and third- or fourth-degree perineal tears and small-for-gestational age (SGA) neonates. The associations with neonatal hypoglycemia, and neonatal seizure were correlated with the number of deliveries in a dose-dependent manner, demonstrating that each additional delivery was associated with an additional, significant impact on obstetrical complications.
CONCLUSIONS: Our study demonstrates that parity 8-10 is associated with a significantly increased risk of PPH. Parity level > 5 correlated with increased odds of placental abruption, LGA neonates, neonatal hypoglycemia, and neonatal seizures. However, GMP women also demonstrated a reduced likelihood of certain adverse maternal outcomes, including unplanned cesarean, preterm deliveries, vacuum-assisted deliveries, SGA neonates, and severe perineal tears. These findings highlight the importance of tailored obstetrical care for GMP women to mitigate the elevated risks associated with higher parity.