剖宫产后阴道试产在无阴道分娩史妇女早产中的应用

Application of trial of labor after cesarean in preterm women without a history of vaginal delivery

摘要

目的 探讨剖宫产后阴道试产(TOLAC)在无阴道分娩史的妇女早产中的应用。方法 回顾性纳入2018年1月至2022年6月在本院接受TOLAC的无阴道分娩史且因早产住院的116名孕妇.根据TOLAC是否成功将研究对象分为TOLAC成功组(n=89)和TOLAC失败组(n=27).采用最小绝对收缩和选择算子(LASSO)回归筛选TOLAC成功率相关变量,并构建TOLAC成功率预测模型,采用一致性指数(C-index)对预测模型进行内部验证。结果 TOLAC成功组及TOLAC失败组的入院时宫颈扩张、入院时宫颈消失、破膜时间比较差异均有统计学意义(t=3.382、3.377、2.027,P<0.05),两组间的入院时硬膜外镇痛、Bishop评分<4、引产、胎膜早破、催产素给药比例比较差异均有统计学意义(χ²值分别为3.517、8.024、14.111、6.570、4.038,P<0.05).共纳入9个变量(入院时宫颈扩张、入院时宫颈消失、硬膜外镇痛、Bishop评分<4、引产、胎膜早破、破膜时间、催产素给药、分娩时宫颈扩张)用于LASSO回归筛选TOLAC成功率预测变量.应用列线图显示TOLAC成功率模型的预测因子:入院时宫颈扩张(OR=1.11,95%CI:1.04~1.19,P=0.003),引产(OR=0.89,95%CI:0.79~1.00,P=0.049),催产素给药(OR=0.71,95%CI:0.58~0.88,P=0.002),胎膜早破(OR=3.27,95%CI:2.49~4.45,P<0.001),Bishop评分<4(OR=0.33,95%CI:0.17~0.62,P=0.001)和硬膜外麻醉(OR=2.92,95%CI:1.42~6.48,P=0.005).内部验证的结果显示以C指数衡量的TOLAC成功率的预测准确性为0.89。结论 该模型对无阴道分娩史的早产妇女是否可行剖宫产后阴道试产的评估,有一定指导意义.

Abstract

Objective To investigate the application of trial of labor after cesarean (TOLAC) in preterm women without a history of vaginal delivery history. Methods A total of 116 pregnant women without a history of vaginal delivery who were hospitalized due to preterm labor and underwent TOLAC at our hospital between January 2018 and June 2022 were retrospectively included. Based on whether TOLAC was successful, the subjects were divided into TOLAC success group (n=89) and TOLAC failure group (n=27). The least absolute shrinkage and selection operator (LASSO) regression was used to screen variables related to TOLAC success rate, and a prediction model for TOLAC success rate was constructed. The concordance index (C-index) was used for internal validation of the prediction model. Results There were statistically significant differences between the TOLAC success group and the TOLAC failure group in terms of cervical dilation at admission, cervical effacement at admission and membrane rupture time (t=3.382, 3.377 and 2.027, respectively, P<0.05). There were statistically significant differences between the two groups in the rates of epidural analgesia at admission, Bishop score <4, induction of labor, premature rupture of membranes and oxytocin administration (χ²=3.517, 8.024, 14.111, 6.570 and 4.038, respectively, P<0.05). A total of 9 variables (cervical dilatation at admission, cervical effacement at admission, epidural analgesia, Bishop score <4, induction of labor, premature rupture of membranes, membrane rupture time, oxytocin administration, and cervical dilation at delivery) were included for LASSO regression to screen predictive variables for the TOLAC success rate. A nomogram was used to display the predictive factors in the TOLAC success rate model, including cervical dilation at admission (OR=1.11, 95%CI: 1.04-1.19, P=0.003), induction of labor (OR=0.89, 95%CI: 0.79-1.00, P=0.049), oxytocin administration (OR=0.71, 95%CI: 0.58-0.88, P=0.002), premature rupture of membranes (OR=3.27, 95%CI: 2.49-4.45, P=0.001), Bishop score <4 (OR=0.33, 95%CI: 0.17-0.62, P=0.001) and epidural anesthesia (OR=2.92, 95%CI: 1.42-6.48, P=0.005). The results of internal validation showed that the predictive accuracy of TOLAC success, as measured by the C-index, was 0.89. Conclusion This model has certain guiding value for evaluating the feasibility of trial of labor after cesarean preterm women without a history of vaginal delivery.

关键词

剖宫产后阴道试产 / 阴道分娩 / 早产 / 预测因子

Key words

trial of labor after cesarean / vaginal delivery / preterm birth / predictor

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基金资助

陕西省卫生健康委员会科研项目(20200215)