剖宫产病人产后严重大出血的危险因素：病例对照研究
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Risk Factors for Severe
Postpartum Hemorrhage After Cesarean Delivery: Case-Control Studies
背景与目的
与产前剖宫产相比，产时剖宫产的产妇发生产后严重大出血（PPH）的危险性更高。为了研究产前与产时行剖宫产的产妇间个体危险因素与PPH之间的关系，我们有必要采用分层分析的方法。
方 法
为了研究两组剖宫产（产前剖宫产与产时剖宫产）产妇发生PPH的危险因素，我们设计了两组病例对照研究组。每组中的产妇均于2002年-2012年间在美国三级产科中心分娩，且这些产妇出血量≧1500ml或分娩后48小时内接受了术中或术后输血。采用独立逻辑回归分析来评价产前或产时行剖宫产的产妇产后发生PPH的危险因素。
结 果
我们纳入了269例产前行剖宫产的病例组和550例对照组。发生PPH比率最高的危险因素为全身麻醉（优势比=22.3；95%可信区间=4.9-99.9；对照组=蛛网膜下腔阻滞麻醉），其他危险因素：多胎妊娠（优势比=8.0；95%可信区间=4.2-15.0；对照组=单胎妊娠）、前置胎盘（优势比=6.3；95%可信区间=3.4-11.8）。我们纳入了278例产时行剖宫产的病例组和572例对照组。发生PPH比率最高的危险因素也为全身麻醉(优势比=5.4；95%可信区间=1.7-17.1)，其他危险因素为：多胎妊娠（优势比=3.2；95%可信区间=1.7-6.3）；一例分娩前血红蛋白≤9.9g／dl（优势比=3.0；95%可信区间=1.3-6.9），对照组血红蛋白=分娩前血红蛋白≧11g／dl.
结 论
无论是产前行剖宫产的产妇，还是产时行剖宫产的产妇，发生PPH都有同样的危险因素：全身麻醉与多胎妊娠。然而，研究组中发生PPH的危险因素还是存在些许区别，了解这些差异，在对产前或产时行剖宫产的高危产妇进行麻醉计划和干预措施时尤为重要。
原始文献摘要
Butwick A J, Ramachandran B, Hegde P, et al. Risk Factors for Severe Postpartum Hemorrhage After Cesarean Delivery: Case-Control Studies[J]. Anesthesia & Analgesia, 2017, 125(2):523.
BACKGROUND: Women who undergo intrapartum caesarean delivery (CD) are at increased risk of postpartum hemorrhage (PPH) compared with those undergoing prelabor CD. To determine whether the presence and strength of the associations between individual risk factors and severe PPH vary among women undergoing prelabor CD or intrapartum CD, stratified analyses are needed according to CD subtype.
METHODS: To identify risk factors for severe PPH within 2 distinct CD populations, prelabor CD and intrapartum CD, we performed 2 case-control studies. Women in each study cohort delivered at a tertiary obstetric center in the United States between 2002 and 2012. For each study, cases were women who had a blood loss ≥1500 mL or who received an intraoperative or postoperative transfusion up to 48 hours after delivery. Risk factors for severe PPH among women undergoing prelabor CD or intrapartum CD were examined in separate logistic regression models.
RESULTS: For prelabor CD, we identified 269 cases and 550 controls. Clinical factors with the highest adjusted odds for severe PPH during prelabor CD were general anesthesia (adjusted odds ratio [aOR] = 22.3; 95% confidence interval [CI], 4.9–99.9; reference group = spinal anesthesia), multiple pregnancies (aOR = 8.0; 95% CI, 4.2–15.0; reference group = singleton pregnancy), and placenta previa (aOR = 6.3; 95% CI, 3.4–11.8). For intrapartum CD, we identified 278 cases and 572 controls. Clinical factors with the highest adjusted odds for severe PPH during intrapartum CD were general anesthesia (aOR = 5.4; 95% CI, 1.7–17.1), multiple pregnancies (aOR = 3.2; 95% CI, 1.7–6.3), and a predelivery hemoglobin
≤ 9.9 g/dL (aOR = 3.0; 95% CI, 1.3–6.9; reference group = predelivery hemoglobin ≥ 11 g/dL).
CONCLUSIONS: Women who undergo prelabor CD and intrapartum CD have several shared risk factors for severe PPH (general anesthesia and multiple pregnancies). However, the risk factor profiles for severe PPH differed between these CD cohorts. Recognizing these differences may be important when planning resources and interventions for high-risk patients undergoing either prelabor or intrapartum CD.
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