低浓度罗哌卡因复合小剂量芬太尼在妊娠期高血压疾病分娩镇痛中的应用效果分析
张宝林
兰州市安宁区人民医院 麻醉科730070
【摘要】 目的:探讨低浓度罗哌卡因复合小剂量芬太尼在妊娠期高血压疾病分娩镇痛中的应用效果。方法:选择妊娠期高血压疾病孕妇120例,根据随机数字法分为观察组和对照组。收集两组孕妇分娩过程中收缩压和舒张压、VAS评分;分娩方式、缩宫素应用、产程、新生儿Apgar评分、产后出血等资料。结果:观察组孕妇的年龄、孕周、体重、孕次和对照组比较差异无统计学意义(P>0.05)。观察组麻醉后10min、活跃期、第二产程收缩压和舒张压(135.76±11.64mmHg、136.57±7.68mmHg、141.23±9.78mmHg;84.56±6.57mmHg、85.46±7.21mmHg、85.47±7.27mmHg)低于对照组(156.35±14.37mmHg、158.71±8.2mmHg、172.15±14.65mmHg;107.58±7.68mmHg、108.68±9.04mmHg、113.24±11.53mmHg)(t=8.674、8.253、9.934;15.476、14.278、17.054,P均=0.000);观察组麻醉后10min、麻醉后40min、麻醉后80min、麻醉后120min VAS评分(6.23±1.12分、1.67±0.82分、1.16±0.64分、1.63±0.75分)低于对照组(7.18±1.08分、7.37±0.99分、7.68±0.94分、7.58±0.87分)(t=4.758、33.264、41.867、35.286,P均=0.000);观察组剖宫产率(28.3%)低于对照组(56.7%)(Χ2=9.855,P=0.002),观察组阴道分娩率和缩宫素应用率(46.7%、55.0%)高于对照组(21.7%、28.3%)(Χ2=8.336、8.777,P=0.004、0.003);观察组第一产程、第二产程、第三产程、1min Apgar评分、5min Apgar评分、产后出血和对照组比较差异均无统计学意义(P=0.410、0.376、0.207、0.289、0.243、0.486)。结论:低浓度罗哌卡因复合小剂量芬太尼用于妊娠期高血压疾病孕妇分娩镇痛可降低分娩过程中血压、减轻分娩疼痛、降低剖宫产率、提高阴道分娩率。
【关键词】妊娠期高血压疾病;罗哌卡因;芬太尼;分娩镇痛。
Effect of low concentration ropivacaine combined with low dose fentanyl on labor analgesia in hypertensive disorder complicating pregnancy
Zhang bao lin
Department of Anesthesiology 730070, people's Hospital, Anning District, Lanzhou City
Abstract: Objective To investigate the effect of low concentration ropivacaine combined with low dose fentanyl on labor analgesia in hypertensive disorder complicating pregnancy.Methods 120 cases of pregnant women with hypertension were selected,and were divided into observation group and control group according to the random number method.The systolic blood pressure, diastolic blood pressure, VAS score, delivery mode, oxytocin application, labor, neonatal Apgar score, postpartum hemorrhage during the delivery of the two groups of pregnant women were collected.
Results There was no significant difference of age, gestational age, body weight, gestational age between the observation group and the control group (P> 0.05).
The systolic blood pressure and diastolic blood pressure at 10 minutes after anesthesia, active period, the second stage of labor in the observation group (135.76 ± 11.64 mmHg, 136.57 ± 7.68mmHg, 141.23 ± 9.78mmHg; 84.56 ± 6.57mmHg, 85.46 ± 7.21mmHg, 85.47 ± 7.27mmHg) were lower than those in the control group(156.35 ± 14.37mmHg, 158.71 ± 8.2mmHg, 172.15 ± 14.65mmHg; 107.58 ± 7.68mmHg, 108.68 ± 9.04mmHg, 113.24 ± 11.53mmHg) (t = 8.674,8.253,9.934; 15.476,14.278,17.054, = 0.000).The scores of VAS at the 10 min after anesthesia, 40 min after anesthesia, 80 min after anesthesia, 120 min after anesthesia in the observation group (6.23 ± 1.12, 1.67 ± 0.82, 1.16 ± 0.64 and 1.63 ± 0.75) were significantly lower than those in the control group(7.18 ± 1.08, 7.37 ± 0.99 min, 7.68 ± 0.94 min, 7.58 ± 0.87 min) (t = 4.758, 33.264, 41.867, 35.286, P = 0.000).The rate of cesarean section in the observation group(28.3%) was lower than that in the control group (56.7%) (χ2 = 9.855, P = 0.002).The rate of vaginal delivery and oxytocin application in the observation group(46.7%, 55.0%) were higher than that in the control group (21.7%, 28.3%) (Χ2 = 8.336,8.777, P = 0.004, 0.003).There was no significant difference of the first stage of labor, the second stage of labor, the third stage of labor, the 1 minute Apgar score, the 5 min Apgar score and the postpartum hemorrhage between the observation group and the control group (P = 0.410,0.376,0.207,0.289,0.243,0.486).Conclusion The Low concentration of ropivacaine compound small dose of fentanyl for the labor analgesia of pregnant women with pregnancy hypertensive disorder can reduce blood pressure, reduce childbirth pain, reduce cesarean section rate, improve vaginal delivery rate during delivery.
【Key words】 Hypertensive disease in pregnancy; ropivacaine; fentanyl; labor analgesia.
妊娠期高血压疾病是孕产妇和围产儿死亡的主要原因之一,是严重的妊娠期并发症之一,对母婴安全造成严重威胁,妊娠期高血压疾病孕妇在分娩期间宫缩的加剧可引起产妇血液动力学的变化,加上产妇的恐惧、忧虑和焦虑情绪,可增加子痫的发生风险[1-2],因此妊娠期高血压疾病孕妇是需要剖宫产终止妊娠还是进行阴道试产仍有一定争议。分娩疼痛是分娩的正常生理过程,分娩疼痛可引起孕妇紧张、激素水平失调、血压升高、耗能耗氧增加、通气量增加、胎盘血供减少等,对母婴带来不良影响。良好的分娩镇痛可减少孕妇的过度通气,降低剖宫产率[3]。硬膜外麻醉安全性高、成本低、可控性好、并发症少,是被广泛应用的分娩镇痛方式,但不合理用药增加试产失败、产程延长等并发症或副作用。有研究发现低浓度罗哌卡因辅以镇痛药物进行分娩镇痛的镇痛效果比较好[4-6],本文对低浓度罗哌卡因复合小剂量芬太尼在妊娠期高血压疾病分娩镇痛中的效果进行研究。
1 资料与方法
1.1 临床资料
选择兰州市安宁区人民医院2015年1月-2018年6月妊娠期高血压疾病孕妇120例,根据随机数字法分为观察组和对照组,每组60例。观察组孕妇给予0.075%罗哌卡因+2µg/ml芬太尼镇痛,对照组不采用任何镇痛,两组孕妇年龄、孕周、体重、孕次等一般资料比较差异无统计学意义,具有可比性。纳入标准:均为单胎、孕37-41周、资料完整、我院产检及分娩;排除标准:双胎及以上妊娠、拒绝参与研究、资料不完整、有麻醉禁忌症、产前子痫、其它内外科合并症及产科并发症。本研究经兰州市安宁区人民医院伦理委员会审批,所有孕妇签署知情同意书。
1.2 研究方法
观察组孕妇在宫口开大2-3cm时给予面罩吸氧并进行硬膜外麻醉,L2-3间隙穿刺成功后,固定硬膜外导管,翻身平卧后给予3毫升1%利多卡因观察产妇有无麻药中毒及脊麻等情况,经硬膜外导管给予6毫升0.075罗哌卡因和芬太尼复合液(复合液的制备:0.2毫克芬太尼+7.5mg罗哌卡因,用生理盐水稀释到100ml),硬膜外导管和自控镇痛泵连接;对照组不进行镇痛。记录两组孕妇麻醉前、麻醉后10min、活跃期、第二产程收缩压和舒张压;麻醉前、麻醉后10min、麻醉后40min、麻醉后80min、麻醉后120min VAS评分;分娩方式和缩宫素应用;产程、新生儿Apgar评分和产后出血等资料(对照组未进行麻醉,以宫口开大2-3cm的时间点作为对应的麻醉时间点)。
镇痛评分:采用VAS评分标准进行镇痛评分,总分为10分,评分<3分为无痛,评分3-4分为轻微疼痛,评分5-6分为中度疼痛,7-10分为剧烈疼痛。
1.3 统计学方法
采用SPSS20.0软件进行分析,均数比较采用t检验,率的比较采用卡方检验,取P<0.05为差异有统计学意义。
2 结果
2.1 两组孕妇一般资料比较
观察组孕妇的年龄、孕周、体重、孕次和对照组比较差异无统计学意义(P>0.05)。见表1。
表1 两组孕妇一般资料比较
|
观察组(n=60) |
对照组(n=60) |
t值 |
P值 |
年龄(岁) |
27.46±2.98 |
26.54±3.12 |
0.085 |
0.713 |
孕周(周) |
38.45±1.24 |
38.73±1.32 |
0.064 |
0.802 |
体重(kg) |
78.98±10.21 |
80.02±9.79 |
0.165 |
0.547 |
孕次(次) |
1.43±0.62 |
1.38±0.57 |
0.126 |
0.613 |
2.2 两组孕妇血压情况比较
观察组和对照组孕妇麻醉前收缩压和舒张压比较差异无统计学意义(P>0.05),观察组麻醉后10min、活跃期、第二产程收缩压和舒张压分别为135.76±11.64mmHg、136.57±7.68mmHg、141.23±9.78mmHg;84.56±6.57mmHg、85.46±7.21mmHg、85.47±7.27mmHg,对照组麻醉后10min、活跃期、第二产程收缩压和舒张压分别为156.35±14.37mmHg、158.71±8.2mmHg、172.15±14.65mmHg;107.58±7.68mmHg、108.68±9.04mmHg、113.24±11.53mmHg,两组麻醉后10min、活跃期、第二产程收缩压和舒张压比较差异有统计学意义(t=8.674、8.253、9.934;15.476、14.278、17.054,P均=0.000),观察组麻醉后10min、活跃期、第二产程收缩压和舒张压均低于对照组;观察组麻醉后10min、活跃期、第二产程收缩压和舒张压也均低于麻醉前。
表2 两组孕妇血压情况比较
|
观察组(n=60) |
对照组(n=60) |
t值 |
P值 |
麻醉前 |
|
|
|
|
收缩压(mmHg) |
156.44±11.23 |
157.63±10.76 |
0.043 |
0.874 |
舒张压(mmHg) |
102.64±7.65 |
104.02±7.14 |
0.085 |
0.586 |
麻醉后10min |
|
|
|
|
收缩压(mmHg) |
135.76±11.64a |
156.35±14.37 |
8.674 |
0.000 |
舒张压(mmHg) |
84.56±6.57a |
107.58±7.68 |
15.476 |
0.000 |
活跃期 |
|
|
|
|
收缩压(mmHg) |
136.57±7.68a |
158.71±8.2 |
8.253 |
0.000 |
舒张压(mmHg) |
85.46±7.21a |
108.68±9.04 |
14.278 |
0.000 |
第二产程 |
|
|
|
|
收缩压(mmHg) |
141.23±9.78a |
172.15±14.65 |
9.934 |
0.000 |
舒张压(mmHg) |
85.47±7.27a |
113.24±11.53 |
17.054 |
0.000 |
注:与麻醉前比较,aP<0.05.
2.3 观察组和对照组VAS评分比较
观察组麻醉前VAS评分和对照组比较差异无统计学意义(P=0.437),观察组麻醉后10min、麻醉后40min、麻醉后80min、麻醉后120min VAS评分分别为6.23±1.12分、1.67±0.82分、1.16±0.64分、1.63±0.75分,对照组麻醉后10min、麻醉后40min、麻醉后80min、麻醉后120min VAS评分分别为7.18±1.08分、7.37±0.99分、7.68±0.94分、7.58±0.87分,两组麻醉后10min、麻醉后40min、麻醉后80min、麻醉后120min VAS评分比较差异有统计学意义(t=4.758、33.264、41.867、35.286,P均=0.000),观察组麻醉后10min、麻醉后40min、麻醉后80min、麻醉后120min VAS评分均低于对照组,观察组麻醉后10min、麻醉后40min、麻醉后80min、麻醉后120min VAS评分也低于麻醉前。见表3。
表3 观察组和对照组VAS评分比较(分)
|
观察组(n=60) |
对照组(n=60) |
t值 |
P值 |
麻醉前 |
7.16±0.57 |
7.11±0.63 |
0.074 |
0.437 |
麻醉后10min |
6.23±1.12 |
7.18±1.08 |
4.758 |
0.000 |
麻醉后40min |
1.67±0.82 |
7.37±0.99 |
33.264 |
0.000 |
麻醉后80min |
1.16±0.64 |
7.68±0.94 |
41.867 |
0.000 |
麻醉后120min |
1.63±0.75 |
7.58±0.87 |
35.286 |
0.000 |
注:与麻醉前比较,aP<0.05.
2.4 观察组和对照组分娩方式和缩宫素应用比较
观察组和对照组机械助产率比较差异无统计学意义(P=0.666),观察组阴道分娩率、剖宫产率和缩宫素应用率分别为46.7%、28.3%和55.0%,对照组阴道分娩率、剖宫产率和缩宫素应用率分别为21.7%、56.7%和28.3%,两组阴道分娩率、剖宫产率和缩宫素应用率比较差异有统计学意义(Χ2=8.336、9.855、8.777,P=0.004、0.002、0.003),观察组剖宫产率低于对照组,观察组阴道分娩率和缩宫素应用率高于对照组。见表4。
表4 观察组和对照组分娩方式和缩宫素应用比较[n(%)]
|
观察组(n=60) |
对照组(n=60) |
Χ2值 |
P值 |
阴道分娩 |
28(46.7) |
13(21.7) |
8.336 |
0.004 |
机械助产 |
15(25.0) |
13(21.7) |
0.186 |
0.666 |
剖宫产 |
17(28.3) |
34(56.7) |
9.855 |
0.002 |
缩宫素应用 |
33(55.0) |
17(28.3) |
8.777 |
0.003 |
2.5 观察组和对照组产程、新生儿Apgar评分和产后出血比较
观察组第一产程、第二产程、第三产程、1min Apgar评分、5min Apgar评分、产后出血和对照组比较差异均无统计学意义(P=0.410、0.376、0.207、0.289、0.243、0.486)。见表5。
表5 观察组和对照组产程、新生儿Apgar评分和产后出血比较
|
观察组(n=60) |
对照组(n=60) |
t值 |
P值 |
产程(min) |
|
|
|
|
第一产程 |
168.97±29.65 |
175.24±33.25 |
0.536 |
0.410 |
第二产程 |
52.14±12.64 |
55.46±10.45 |
0.647 |
0.376 |
第三产程 |
5.97±2.43 |
5.86±2.52 |
0.856 |
0.207 |
Apgar评分(分) |
|
|
|
|