背景:将一次剖宫产的个体引产与期待管理进行比较的研究显示出相互矛盾的结果。
目的:在全国低危剖宫产患者样本中,确定临床结局与39周时引产之间的关系。
方法:这项横断面研究分析了2016年至2021年美国生命统计出生证明数据。具有顶点的个人,包括单胎妊娠和一次剖宫产。先前阴道分娩的患者,在妊娠42周和6天分娩,并排除了医疗合并症。感兴趣的主要暴露是在39周0天至39周6天引产,而期待管理从40周0天至42周6天分娩。主要结果是阴道分娩。主要次要结局是单独的孕产妇和新生儿发病率复合。孕产妇发病率复合包括子宫破裂,手术阴道分娩,围产期子宫切除术,重症监护室入院,和输血。新生儿复合发病率包括新生儿重症监护病房入院,阿普加5分钟得分小于5分,立即通风,长时间通风,癫痫或严重的神经功能障碍。进行了未调整和调整的对数二项回归模型,这些模型考虑了人口统计学变量和感兴趣的暴露(诱导与预期管理)。结果表示为未调整风险比(RR)和调整风险比(aRR),95%置信区间(CI)。
结果:从2016年到2021年,共有198,797个人具有顶点,单胎妊娠和一次剖宫产被纳入主要分析.在这些人中,25,915(13.0%)从39周0天至39周6天进行了引产,而172,882(87.0%)则在40周0天至42周6天之间进行了分娩。在调整后的分析中,与预期管理的患者相比,在39周时诱导的患者更有可能进行阴道分娩(38.0%vs.31.8%;RR1.32,95%CI1.28至1.36)。在那些阴道分娩的人中,引产与手术阴道分娩的可能性增加相关(11.1%vs.10.0;RR1.15,95%CI1.07,1.24)。在诱导和期待管理组中,产妇发病率复合发生率为0.9%(RR0.92,95%CI0.79,1.06)。子宫破裂率(0.3%),围产期子宫切除术(0.04%vs.0.05%),和重症监护病房入院(0.1%与0.2%)均相对较低,组间没有显着差异。诱导和期待管理组之间的新生儿发病率综合也没有显着差异(7.3%vs.6.7%;ARR1.04,95%CI0.98,1.09)。
结论:与预期管理相比,有一次剖宫产的低危患者在39周时择期引产与阴道分娩的可能性显著较高相关,而孕产妇和新生儿复合发病率结局无差异.需要进行前瞻性研究,以更好地阐明该患者人群引产的风险和收益。
BACKGROUND: Studies that have compared induction of labor in individuals with 1 prior cesarean delivery to expectant management have shown conflicting results.
OBJECTIVE: To determine the association between clinical outcomes and induction of labor at 39 weeks in a national sample of otherwise low-risk patients with 1 prior cesarean delivery.
METHODS: This cross-sectional study analyzed 2016 to 2021 US Vital Statistics birth certificate data. Individuals with vertex, singleton pregnancies, and 1 prior cesarean delivery were included. Patients with prior vaginal deliveries, delivery before 39 weeks 0 days or after 42 weeks 6 days of gestation, and medical comorbidities were excluded. The primary exposure of interest was induction of labor at 39 weeks 0 days to 39 weeks 6 days compared to expectant management with delivery from 40 weeks 0 days to 42 weeks 6 days. The primary outcome was vaginal delivery. The main secondary outcomes were separate maternal and neonatal morbidity composites. The maternal morbidity composite included uterine rupture, operative vaginal delivery, peripartum hysterectomy, intensive care unit admission, and transfusion. The neonatal morbidity composite included neonatal intensive care unit admission, Apgar score less than 5 at 5 minutes, immediate ventilation, prolonged ventilation, and seizure or serious neurological dysfunction. Unadjusted and adjusted log binomial regression models accounting for demographic variables and the exposure of interest (induction vs expectant management) were performed. Results are presented as unadjusted and adjusted risk ratios with 95% confidence intervals.
RESULTS: From 2016 to 2021, a total of 198,797 individuals with vertex, singleton pregnancies, and 1 prior cesarean were included in the primary analysis. Of these individuals, 25,915 (13.0%) underwent induction of labor from 39 weeks 0 days to 39 weeks 6 days and 172,882 (87.0%) were expectantly managed with deliveries between 40 weeks 0 days and 42 weeks 6 days. In adjusted analyses, patients induced at 39 weeks were more likely to have a vaginal delivery when compared to those expectantly managed (38.0% vs 31.8%; adjusted risk ratio 1.32, 95% confidence interval 1.28, 1.36). Among those who had vaginal deliveries, induction of labor was associated with increased likelihood of operative vaginal delivery (11.1% vs 10.0; adjusted risk ratio 1.15, 95% confidence interval 1.07, 1.24). The maternal morbidity composite occurred in 0.9% of individuals in both the induction and expectant management groups (adjusted risk ratio 0.92, 95% confidence interval 0.79, 1.06). The rates of uterine rupture (0.3%), peripartum hysterectomy (0.04% vs 0.05%), and intensive care unit admission (0.1% vs 0.2%) were all relatively low and did not differ significantly between groups. There was also no significant difference in the neonatal morbidity composite between the induction and expectant management groups (7.3% vs 6.7%; adjusted risk ratio 1.04, 95% confidence interval 0.98, 1.09).
CONCLUSIONS: When compared to expectant management, elective induction of labor at 39 weeks in low-risk patients with 1 prior cesarean delivery was associated with a significantly higher likelihood of vaginal delivery with no difference in composite maternal and neonatal morbidity outcomes. Prospective studies are needed to better elucidate the risks and benefits of induction of labor in this patient population.