会阴裂伤在孕前BMI与产后盆底肌功能障碍关联性中的中介作用
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摘要
目的探讨经阴分娩产妇孕前BMI与产后盆底肌功能障碍的相关性。方法对产后42 d复查的经阴分娩产妇进行盆底肌功能检测并针对分娩情况进行问卷调查。分别采用χ2检验、Logistic回归分析孕前BMI与盆底肌功能障碍的关联性;采用依次检验法和sobel检验法分析会阴裂伤在孕前BMI与盆底肌功能障碍关联性中的中介效应。结果经阴分娩产妇盆底肌功能障碍发生率为85. 28%(1 112/1 304)。Logistic回归分析结果显示:控制新生儿体质量、孕周、年龄、产妇学历、产次等可能的混杂因素后,经阴分娩产妇孕前肥胖可增加盆底一类肌功能障碍(OR=2. 765,95%CI:1. 441～5. 305)及盆底二类肌功能障碍(OR=2. 367,95%CI:1. 084～5. 170)发生风险;经阴分娩产妇会阴2度及以上裂伤可增加盆底一类肌功能障碍(OR=9. 159,95%CI:1. 910～43. 926)及二类肌功能障碍(OR=8. 008,95%CI:1. 346～47. 640)的发生风险;中介效应分析显示,会阴裂伤在肥胖致盆底肌功能障碍的关系中起不完全中介效应,中介效应百分比为25. 43%。结论孕前肥胖及会阴裂伤可能与产后盆底肌功能障碍的发生密切相关,会阴裂伤在孕前肥胖致盆底肌功能障碍的发生风险中起到25. 43%的中介作用。
Objective To explore the correlation between BMI before pregnancy and postpartum pelvic floor dysfunction in women undergoing vaginal delivery. Methods The pelvic floor muscle function of maternity were tested on 42-day-old after childbirth and questionnaire survey was conducted to collect relevant information. Chi-square test and Logistic regression were used to analyze the association between BMI before pregnancy and pelvic floor muscle dysfunction. The median effect of perineal laceration on the relationship between BMI before pregnancy and pelvic floor muscle dysfunction was analyzed by sequential test and sobel test. Results The incidence rate of pelvic floor muscle dysfunction in the women was 85. 28%( 1 112/1 304). After controlling of the confounding factors,such as body weight,gestational age,age,maternity education and birth times,the results of Logistic regression analysis were as follows: obesity before pregnancy increased the risk of pelvic floor type 1( OR = 2. 765,95% CI: 1. 441-5. 305) and type 2( OR = 2. 367,95%CI: 1. 084-5. 170) muscle dysfunction. The vaginal delivery of degree two and above perineal laceration increased the risk of pelvic floor type 1( OR = 9. 159,95%CI: 1. 910-43. 926) and type 2( OR = 8. 008,95%CI: 1. 346-47. 640) muscle dysfunction. Mediating effect analysis showed that the perineal laceration had an incomplete mediating effect on pelvic floor muscle dysfunction caused by obesity,and the mediating effect percentage was 25. 43%. Conclusion Obesity beforepregnancy and perineal laceration may be related to the occurrence of postpartum pelvic floor muscle dysfunction. The perineal laceration plays a partial mediating role in the risk of pelvic floor muscle dysfunction caused by obesity before pregnancy.
Objective To explore the correlation between BMI before pregnancy and postpartum pelvic floor dysfunction in women undergoing vaginal delivery. Methods The pelvic floor muscle function of maternity were tested on 42-day-old after childbirth and questionnaire survey was conducted to collect relevant information. Chi-square test and Logistic regression were used to analyze the association between BMI before pregnancy and pelvic floor muscle dysfunction. The median effect of perineal laceration on the relationship between BMI before pregnancy and pelvic floor muscle dysfunction was analyzed by sequential test and sobel test. Results The incidence rate of pelvic floor muscle dysfunction in the women was 85. 28%( 1 112/1 304). After controlling of the confounding factors,such as body weight,gestational age,age,maternity education and birth times,the results of Logistic regression analysis were as follows: obesity before pregnancy increased the risk of pelvic floor type 1( OR = 2. 765,95% CI: 1. 441-5. 305) and type 2( OR = 2. 367,95%CI: 1. 084-5. 170) muscle dysfunction. The vaginal delivery of degree two and above perineal laceration increased the risk of pelvic floor type 1( OR = 9. 159,95%CI: 1. 910-43. 926) and type 2( OR = 8. 008,95%CI: 1. 346-47. 640) muscle dysfunction. Mediating effect analysis showed that the perineal laceration had an incomplete mediating effect on pelvic floor muscle dysfunction caused by obesity,and the mediating effect percentage was 25. 43%. Conclusion Obesity beforepregnancy and perineal laceration may be related to the occurrence of postpartum pelvic floor muscle dysfunction. The perineal laceration plays a partial mediating role in the risk of pelvic floor muscle dysfunction caused by obesity before pregnancy.
引文
[1]Durnea CM,Khashan AS,Kenny LC,et al. What is toblame for postnatal pelvic floor dysfunction in primiparousw omen-Pre-pregnancy or intrapartum risk factors?[J].Eur J Obstet Gynecol Reprod Biol,2017,214:36-43.doi:10. 1016/j. ejogrb. 2017. 04. 036.
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[3]王莲萍,阚影,王芳,等. 1270例产后妇女盆底肌功能影响因素分析[J].中国妇幼保健,2014,29(1):29-31.WANG Lianping,KAN Ying,WANG Fang,et al. A-nalysis of the pelvic floor muscle function and its effectfactors among 1270 postpartum w omen[J]. M aternal&Child Health Care of China,2014,29(1):29-31.
[4]裘轶超,张珂,邱丽倩.分娩方式对再生育与初产产后盆底肌的影响观察[J].现代妇产科进展,2017,26(6):445-447.QIU Yichao,ZHANG Ke,QIU Liqian. Effect of deliverymode on re-fertility and primiparous pelvic floor muscle[J]. Modern obstetrics and gynecology,2017,26(6):445-447.
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[6]Lindo FM,Carr ES,Reyes M,et al. Randomized trial ofcesarean vs vaginal delivery for effects on the pelvic floorin squirrel monkeys[J]. Am J Obstet Gynecol,2015,213(5):735.
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[8]GünI,Dogan B,OzdamarO. Long-and short-term com-plications of episiotomy[J]. Turk J Obstet Gynecol,2016,13(3):144-148.
[9]Leeman LM,Rogers RG,Greulich B,et al. Do unsu-tured second-degree perineal lacerations affect postpartumfunctional outcomes?[J]. J Am Board Fam M ed,2007,20(5):451-457.
[10]Handa VL,Blomquist JL,Mc Dermott KC,et al. Pelvicfloor disorders after vaginal birth:effect of episiotomy,perineal laceration,and operative birth[J]. Obstet Gyne-col,2012,119(2 Pt 1):233-239.
[11]杨欣,王建六.美国妇产科学院盆腔器官脱垂临床实践指南(2009年)解读[J].中国妇产科临床杂志,2011,12(2):157-160.
[12]王帅男,黄惠娟.产后盆底肌力情况及影响因素分析[J].东南国防医药,2017,19(2):121-125.WANG Shuainan,HUANG Huijuan. The correlation a-nalysis of the female pelvic floor muscle strength andin-fluencing factors of pelvic floor muscle strength disorder[J]. Military Medical Journal of Southeast China,2017,19(2):121-125.
[13]Lee JH,Peralta FM,Palatnik A,et al. Neuraxial laboranalgesia is not an independent predictor of perineal lac-erations after vaginal delivery of patients w ith intrauterinefetal demise[J]. Int J Obstet Anesth,2017,32:21-27.doi:10. 1016/J. ijoa. 2017. 05. 008.
[14] Leeman L,Rogers R,Borders N,et al. The effect ofperineal lacerations on pelvic floor function and anatomyat 6 months postpartum in a prospective cohort of nullip-arous w omen[J]. Birth,2016,43(4):293-302.
[15]汤琼瑶,史春.不同分娩方式对产后早期盆底功能的影响及康复效果观察[J].中国妇幼保健,2018,33(1):54-57.
[16]邹惠琼,张丹丹,杨键.浅析实施会阴侧切对进行阴道分娩的初产妇盆底肌功能的影响[J].当代医药论丛,2017,15(11):42-43.
[17]Shek KL,Green K,Hall J,et al. Perineal and vaginaltears are clinical markers for occult levator ani trauma:aretrospective observational study[J]. Ultrasound ObstetGynecol,2016,47(2):224-227.
[18] Viktrup L,Rortveit G,Lose G. Risk of stress urinaryincontinence tw elve years after the first pregnancy anddelivery[J]. Obstet Gynecol,2006,108(2):248-254.
[19]OzdemlrOC,Bakar Y,Ozengln N,et al. The effect ofparity on pelvic floor muscle strength and quality of lifein w omen w ith urinary incontinence:a cross sectionalstudy[J]. J Phys Ther Sci,2015,27(7):2133-2137.
[20]张曼丽.初产妇经阴道分娩时会阴侧切和自然裂伤对盆底功能障碍的影响[J].医学临床研究,2012,29(8):1476-1477.ZHANG manli. Clinical Study of Pelvic Floor Dysfunc-tion Caused by Episiotomy and Perineal Natural Lacera-tion of Primiparaea During Vaginal Delivery[J]. M edi-cal clinical research,2012,29(8):1476-1477.
[21]李燕,孙莲莲,李淑柳.孕期体重管理对分娩结局影响研究[J].中国现代药物应用,2017,11(8):181-183.LI Yan,SUN Lianlian,LI Shuliu. Study of influence ofpregnancy w eight management on delivery outcome[J].Chinese Journal of M odern Drug Application,2017,11(8):181-183.
[22]汪玄晖.导乐式会阴不侧切无保护无创接生技术应用于初产妇的临床效果分析[J].实用医技杂志,2018,25(10):1144-1146.
[23]吴培琳,李志彬,杨丽娟.水中分娩对初产妇产程和预后的临床观察[J].世界最新医学信息文摘,2018,18(5):81.
[24]周金萍,周雪群,李慧芳.无保护会阴接生联合会阴阻滞麻醉用于自然分娩的临床分析[J].中国计划生育和妇产科,2018,10(5):89-91.ZHOU Jinping,ZHOU Xuequn,LI Huifang. Clinicalanalysis of unprotected perineum delivery combined w ithperineum anesthesia for natural childbirth[J]. ChineseJournal of Family Planning&Gynecotokology,2018,10(5):89-91.
[25]杨春仙,吴一军,郑燕飞,等.无保护会阴接生法配合双侧阴部神经阻滞麻醉在第二产程中的临床应用[J].中国妇幼保健,2018,33(7):1662-1664.
[2]阙贵珍.盆底肌肉训练对产后盆底功能障碍的效果分析[J].中国当代医药,2015(14):79-81.QUE guizhen. Analysis of the effect of pelvic floor mus-cle training in postpartum pelvic floor dysfunction.[J].Chinese contemporary medicine,2015(14):79-81.
[3]王莲萍,阚影,王芳,等. 1270例产后妇女盆底肌功能影响因素分析[J].中国妇幼保健,2014,29(1):29-31.WANG Lianping,KAN Ying,WANG Fang,et al. A-nalysis of the pelvic floor muscle function and its effectfactors among 1270 postpartum w omen[J]. M aternal&Child Health Care of China,2014,29(1):29-31.
[4]裘轶超,张珂,邱丽倩.分娩方式对再生育与初产产后盆底肌的影响观察[J].现代妇产科进展,2017,26(6):445-447.QIU Yichao,ZHANG Ke,QIU Liqian. Effect of deliverymode on re-fertility and primiparous pelvic floor muscle[J]. Modern obstetrics and gynecology,2017,26(6):445-447.
[5]Caudwell-Hall J,Kamisan Atan I,Martin A,et al. Intra-partum predictors of maternal levator ani injury[J]. ActaObstet Gynecol Scand,2017,96(4):426-431.
[6]Lindo FM,Carr ES,Reyes M,et al. Randomized trial ofcesarean vs vaginal delivery for effects on the pelvic floorin squirrel monkeys[J]. Am J Obstet Gynecol,2015,213(5):735.
[7]李雪姣,高慧娟,刘颖琳.产后盆底功能障碍的影响因素分析[J].新医学,2017,48(4):250-257.LI Xuejiao,GAO Huijuan,LIU Yinglin. Influencing fac-tors of postpartum pelvic floor dysfunction[J]. Journal ofNew M edicine,2017,48(4):250-257.
[8]GünI,Dogan B,OzdamarO. Long-and short-term com-plications of episiotomy[J]. Turk J Obstet Gynecol,2016,13(3):144-148.
[9]Leeman LM,Rogers RG,Greulich B,et al. Do unsu-tured second-degree perineal lacerations affect postpartumfunctional outcomes?[J]. J Am Board Fam M ed,2007,20(5):451-457.
[10]Handa VL,Blomquist JL,Mc Dermott KC,et al. Pelvicfloor disorders after vaginal birth:effect of episiotomy,perineal laceration,and operative birth[J]. Obstet Gyne-col,2012,119(2 Pt 1):233-239.
[11]杨欣,王建六.美国妇产科学院盆腔器官脱垂临床实践指南(2009年)解读[J].中国妇产科临床杂志,2011,12(2):157-160.
[12]王帅男,黄惠娟.产后盆底肌力情况及影响因素分析[J].东南国防医药,2017,19(2):121-125.WANG Shuainan,HUANG Huijuan. The correlation a-nalysis of the female pelvic floor muscle strength andin-fluencing factors of pelvic floor muscle strength disorder[J]. Military Medical Journal of Southeast China,2017,19(2):121-125.
[13]Lee JH,Peralta FM,Palatnik A,et al. Neuraxial laboranalgesia is not an independent predictor of perineal lac-erations after vaginal delivery of patients w ith intrauterinefetal demise[J]. Int J Obstet Anesth,2017,32:21-27.doi:10. 1016/J. ijoa. 2017. 05. 008.
[14] Leeman L,Rogers R,Borders N,et al. The effect ofperineal lacerations on pelvic floor function and anatomyat 6 months postpartum in a prospective cohort of nullip-arous w omen[J]. Birth,2016,43(4):293-302.
[15]汤琼瑶,史春.不同分娩方式对产后早期盆底功能的影响及康复效果观察[J].中国妇幼保健,2018,33(1):54-57.
[16]邹惠琼,张丹丹,杨键.浅析实施会阴侧切对进行阴道分娩的初产妇盆底肌功能的影响[J].当代医药论丛,2017,15(11):42-43.
[17]Shek KL,Green K,Hall J,et al. Perineal and vaginaltears are clinical markers for occult levator ani trauma:aretrospective observational study[J]. Ultrasound ObstetGynecol,2016,47(2):224-227.
[18] Viktrup L,Rortveit G,Lose G. Risk of stress urinaryincontinence tw elve years after the first pregnancy anddelivery[J]. Obstet Gynecol,2006,108(2):248-254.
[19]OzdemlrOC,Bakar Y,Ozengln N,et al. The effect ofparity on pelvic floor muscle strength and quality of lifein w omen w ith urinary incontinence:a cross sectionalstudy[J]. J Phys Ther Sci,2015,27(7):2133-2137.
[20]张曼丽.初产妇经阴道分娩时会阴侧切和自然裂伤对盆底功能障碍的影响[J].医学临床研究,2012,29(8):1476-1477.ZHANG manli. Clinical Study of Pelvic Floor Dysfunc-tion Caused by Episiotomy and Perineal Natural Lacera-tion of Primiparaea During Vaginal Delivery[J]. M edi-cal clinical research,2012,29(8):1476-1477.
[21]李燕,孙莲莲,李淑柳.孕期体重管理对分娩结局影响研究[J].中国现代药物应用,2017,11(8):181-183.LI Yan,SUN Lianlian,LI Shuliu. Study of influence ofpregnancy w eight management on delivery outcome[J].Chinese Journal of M odern Drug Application,2017,11(8):181-183.
[22]汪玄晖.导乐式会阴不侧切无保护无创接生技术应用于初产妇的临床效果分析[J].实用医技杂志,2018,25(10):1144-1146.
[23]吴培琳,李志彬,杨丽娟.水中分娩对初产妇产程和预后的临床观察[J].世界最新医学信息文摘,2018,18(5):81.
[24]周金萍,周雪群,李慧芳.无保护会阴接生联合会阴阻滞麻醉用于自然分娩的临床分析[J].中国计划生育和妇产科,2018,10(5):89-91.ZHOU Jinping,ZHOU Xuequn,LI Huifang. Clinicalanalysis of unprotected perineum delivery combined w ithperineum anesthesia for natural childbirth[J]. ChineseJournal of Family Planning&Gynecotokology,2018,10(5):89-91.
[25]杨春仙,吴一军,郑燕飞,等.无保护会阴接生法配合双侧阴部神经阻滞麻醉在第二产程中的临床应用[J].中国妇幼保健,2018,33(7):1662-1664.