椎管内分娩镇痛不是宫内胎儿死亡产妇会阴撕裂的独立预测因素
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Neuraxial labor analgesia is not an independent predictor of perineal lacerations after vaginal delivery of patients with intrauterine fetal demise
背景与目的
椎管内分娩镇痛在活胎分娩中对会阴损伤的影响是有争议的，还没有研究评估其在宫内死亡胎儿分娩中与会阴损伤的关系，我们评估了此类产妇椎管内分娩镇痛与会阴撕裂之间的关系。
方 法
本回顾性病例对照研究纳入了2007年1月至2015年12月期间诊断为妊娠20周以上胎儿死亡，且经阴道分娩和分娩后Apgar评分为0的病例。记录会阴撕裂及其严重程度，并根据2014年美国妇产医师学会指南分I至IV级。
结 果
329/422（78％）患者接受了椎管内镇痛，93/422（22％）非椎管内镇痛。23％椎管内镇痛患者发生会阴撕裂，而非椎管内镇痛组为10％，差异13％（95％CI：4％〜20％，P = 0.005）。调整混杂偏倚后，胎儿体重较大（OR 4.22,95％CI 3.00〜5.92，P <0.001），胎产次少（OR 0.44,95％CI 0.24〜0.82，P = 0.009）是会阴撕裂的独立预测因素，而椎管内镇痛（OR 1.29， 95％CI 0.47〜3.57，P = 0.61）不是会阴撕裂的独立预测因素。布比卡因的维持浓度不影响会阴损伤的发生率。
结 论
椎管内分娩镇痛似乎不是宫内胎儿死亡产妇会阴撕裂的独立风险因素。我们的数据表明，椎管内镇痛不应是会阴损伤发生率增高的关注原因。
原始文献摘要
Ji H. Lee, Feyce M. Peralta, Anna Palatnik，et al. Neuraxial labor analgesia is not an independent predictor of perineal lacerations after vaginal delivery of patients with intrauterine fetal demise[J]. International Journal of Obstetric Anesthesia,2017,[Epub ahead of print]
Introduction
The role of neuraxial labor analgesia in perineal trauma following live births is controversial, and no studies have assessed the association in women delivering an intrauterine fetal demise. We evaluated the relationship between neuraxial labor analgesia and perineal laceration in these patients.
Methods
This was a retrospective case-control study of women with a diagnosis of fetal death after 20 weeks of gestation, a vaginal delivery, and an Apgar score of 0 at delivery, during the period from January 2007 through December 2015. The presence of a perineal laceration and its severity, graded from grade I to IV based on the 2014 American College of Obstetricians and Gynecologists guidelines, was recorded.
Results
A total of 329/422 (78%) patients received neuraxial, and 93/422 (22%) non-neuraxial, labor analgesia. A perineal laceration occurred in 23% in the neuraxial versus 10% in the non-neuraxial analgesia group, a difference of 13% (95% CI of difference 4% to 20%, P=0.005). After adjusting for confounder bias, greater birthweight (OR 4.22, 95% CI 3.00 to 5.92, P <0.001) and lower parity (OR 0.44, 95% CI 0.24 to 0.82, P=0.009), but not neuraxial analgesia (OR 1.29, 95% CI 0.47 to 3.57, P=0.61) were independent predictors of perineal laceration. The maintenance concentration of bupivacaine did not affect the rate of perineal injury.
Conclusions
Neuraxial labor analgesia does not appear to be an independent risk for a perineal laceration in patients with intrauterine fetal demise. Our data suggests that the use of neuraxial analgesia should not raise concern about increased rates of perineal injury.
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