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既往剖宫产女性的宫颈成熟和引产

Author
Deborah A Wing, MD, MBA
Section Editor
Charles J Lockwood, MD, MHCM
Deputy Editor
Vanessa A Barss, MD, FACOG
Translators
周建政, 副主任医师

引言

对于进行既往剖宫产后试产(trial of labor after a previous cesarean delivery, TOLAC)的女性，临床医生在治疗时所担心的主要问题是引产失败和子宫破裂风险。尚未确定这一人群宫颈成熟和/或引产的最佳方式、有效性和安全性[1]。由于尚无随机试验比较既往剖宫产女性与择期重复剖宫产(elective repeat cesarean delivery, ERCD)女性的引产结局，并且数据主要来自中等至较差质量回顾性研究的结果，所以，根据现有证据不能得出确定性结论。造成这些数据可信度不足的原因有多种，包括：子宫破裂和裂开定义的不一致、引产方案变化很大(如，前列腺素和/或缩宫素给药的时机和剂量)、患者人群的异质性和主要结局指标不一致[2]。

尝试TOLAC女性的宫颈成熟和引产将总结在此。与TOLAC相关的其他问题将单独讨论。 (参见“剖宫产术后分娩方式的选择”)

分娩进程

与既往剖宫产后经历自然临产的女性相比，既往剖宫产后引产的女性潜伏期更长，但活跃期相似[3]。在既往剖宫产后引产的女性中确定产程延长或迟滞的诊断时，临床医生需要采用与无既往剖宫产女性相同的标准。 (参见“正常分娩和产程延长及停滞的概述”)

成功引产的可能性

对既往剖宫产女性的引产至少有50%是成功的，在既往经历过阴道分娩且宫颈成熟的女性中，成功引产的机会最高。目前已有可估计既往剖宫产女性成功引产可能性的计算器。 (参见“Use of calculators and models for predicting vaginal birth after a previous cesarean delivery”)

大多数有关既往剖宫产引产结局的研究比较了接受引产的女性和自然临产的女性。来自这些研究的主要证据表明，与自然临产相比，引产后的阴道分娩率更低(平均阴道分娩率68% vs 80%[4])。两种因素可显著增加成功阴道分娩的机会：(1)既往阴道分娩史和(2)宫颈成熟(改良的Bishop评分≥6)。一项大型研究显示，在既往阴道分娩且宫颈成熟的女性中成功引产的比例为91%，在既往阴道分娩但宫颈不良的女性中为77%，在无既往阴道分娩但宫颈成熟的女性中为69%，而在无既往阴道分娩且宫颈不成熟的女性中为45%[5]。

         

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Literature review current through: 2017-06 . | This topic last updated: 2016-09-22.
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