【罂粟摘要】椎管内、静脉和吸入麻醉对体外倒转术的影响：一项临床试验的系统回顾和Meta分析
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椎管内、静脉和吸入麻醉对体外倒转术的影响：一项临床试验的系统回顾和Meta分析
贵州医科大学 高鸿教授课题组
翻译：潘志军 编辑：佟睿 审校：曹莹
体外倒转术(ECV)是一种经常用于产科纠正胎儿臀围的手法，以避免剖宫产。椎管内、静脉和吸入麻醉技术已被研究用以减少因用力操作而引起的产妇不适。本研究比较了这些麻醉方法对ECV及剖宫产发生率的影响。
我们对已发表的无麻醉、椎管内、静脉或吸入麻醉下进行ECV的随机对照试验(RCTs)或良好的准随机试验进行了全面的文献检索。采用配对随机效应Meta分析和网状Meta分析对3种麻醉干预和非麻醉控制的围产期结局进行比较和排序，包括ECV成功率、剖宫产发生率、产妇低血压、胎儿不良反应以及产妇疼痛控制或满意度的充分性。
本研究纳入18项随机对照试验和1项准随机试验，共2296名足月分娩的非头位单胎胎儿。与对照组相比，椎管内麻醉下胎儿的ECV成功率明显提高(优势比[OR] = 2.59;与静脉麻醉相比，95%可置信区间[CI]为1.88-3.57)(OR = 2.08;95% CI, 1.36-3.16)，与吸入麻醉比较(OR = 2.30;95%可信区间,1.33 -4.00)。麻醉干预与剖宫产率之间没有相关性。椎管内麻醉与产妇低血压发生率较高相关(OR = 9.33;95%可信区间,3.14-27.68)。与对照组相比，静脉麻醉显著降低了胎儿不良反应的几率(OR = 0.36;95%可信区间,0.16-0.82)。接受椎管内麻醉的患者报告的手术相关疼痛的视觉模拟评分(VAS)明显较低(标准化均数差[SMD] =−1.61;95% CI，−1.92~−1.31)。静脉麻醉(SMD =−1.61;95% CI，−1.92~−1.31)和吸入麻醉(SMD =−1.19;95% CI，−1.58~−0.8)时，疼痛的VAS评分也显著降低。静脉麻醉组患者满意度的VAS评分显著更高(SMD = 1.53;95%可信区间,0.64-2.43)。
与对照组相比，椎管内麻醉ECV成功率明显提高;然而，孕妇发生低血压的几率显著增加。所有麻醉干预均可显著减少手术相关疼痛。静脉麻醉患者满意度得分明显较高，胎儿不良反应发生率则较低。与对照组相比，没有证据表明麻醉干预与剖宫产发生率显著降低相关。
A Systematic Review and Meta-analysis of Clinical Trials of Neuraxial, Intravenous, and Inhalational Anesthesia for External Cephalic Version
Background: External cephalic version (ECV) is a frequently performed obstetric procedure for fetal breech presentation to avoid cesarean delivery. Neuraxial, intravenous, and inhalational anesthetic techniques have been studied to reduce maternal discomfort caused by the forceful manipulation. This study compares the effects of these anesthetic techniques on ECV and incidence of cesarean delivery.
Methods: We conducted a comprehensive literature search for published randomized controlled trials (RCTs) or well-conducted quasi-randomized trials of ECV performed either without anesthesia or under neuraxial, intravenous, or inhalational anesthesia. Pairwise random-effects meta-analyses and network meta-analyses were performed to compare and rank the perinatal outcomes of the 3 anesthetic interventions and no anesthesia control, including the rate of successful version, cesarean delivery, maternal hypotension, nonreassuring fetal response, and adequacy of maternal pain control/satisfaction.
Results: Eighteen RCTs and 1 quasi-randomized trial involving a total of 2296 term parturients with a noncephalic presenting singleton fetus were included. ECV under neuraxial anesthesia had significantly higher odds of successful fetal version compared to control (odds ratio [OR] = 2.59; 95% confidence interval [CI], 1.88–3.57), compared to intravenous anesthesia (OR = 2.08; 95% CI, 1.36–3.16), and compared to inhalational anesthesia (OR = 2.30; 95% CI, 1.33–4.00). No association was found between anesthesia interventions and rate of cesarean delivery. Neuraxial anesthesia was associated with higher odds of maternal hypotension (OR = 9.33; 95%
CI, 3.14–27.68). Intravenous anesthesia was associated with significantly lower odds of nonreassuring fetal response compared to control (OR = 0.36; 95% CI, 0.16–0.82). Patients received neuraxial anesthesia reported significantly lower visual analog scale (VAS) of procedure-related pain (standardized mean difference [SMD] = −1.61; 95% CI, −1.92 to −1.31). The VAS scores of pain were also significantly lower with intravenous (SMD = −1.61; 95% CI, −1.92 to −1.31) and inhalational (SMD = −1.19; 95% CI, −1.58 to −0.8) anesthesia. The VAS of patient satisfaction was significantly higher with intravenous anesthesia (SMD = 1.53; 95% CI, 0.64–2.43).
Conclusions: Compared to control, ECV with neuraxial anesthesia had a significantly higher successful rate; however, the odds of maternal hypotension increased significantly. All anesthesia interventions provided significant reduction of procedure-related pain. Intravenous anesthesia had significantly higher score in patient satisfaction and lower odds of nonreassuring fetal response. No evidence indicated that anesthesia interventions were associated with significant decrease in the incidence of cesarean delivery compared to control.