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指南針┃ISUOG實(shí)踐指南:小于胎齡胎兒和胎兒生長(zhǎng)受限的診斷和管理(上)

 大風(fēng)吹5olw2v63 2023-11-10 發(fā)布于海南
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臨床標(biāo)準(zhǔn)委員會(huì)

問:國際婦產(chǎn)科超聲學(xué)會(huì)的性質(zhì)和宗旨,?

答:國際婦產(chǎn)科超聲學(xué)會(huì)(?The International Society of Ultrasound in Obstetrics and Gynecology,ISUOG)是一個(gè)科學(xué)組織,,它鼓勵(lì)在女性醫(yī)療服務(wù)中開展良好的超聲臨床實(shí)踐,,以及高質(zhì)量的診斷成像教學(xué)及科研。國際婦產(chǎn)科超聲學(xué)會(huì)臨床標(biāo)準(zhǔn)委員會(huì)(Clinical Standards Committee,,CSC)有權(quán)制定實(shí)踐指南和共識(shí)聲明,,為醫(yī)療從業(yè)者提供基于專家共識(shí)的診斷成像方法的教學(xué)建議。它們旨在反映國際婦產(chǎn)科超聲學(xué)會(huì)在發(fā)布時(shí)認(rèn)為的最佳實(shí)踐,。盡管國際婦產(chǎn)科超聲學(xué)會(huì)已盡最大努力確保指南發(fā)布時(shí)準(zhǔn)確無誤,,但協(xié)會(huì)及其任何員工或成員均不對(duì)臨床標(biāo)準(zhǔn)委員會(huì)發(fā)布的任何不準(zhǔn)確或誤導(dǎo)性數(shù)據(jù)、意見或陳述的后果承擔(dān)任何責(zé)任,。國際婦產(chǎn)科超聲學(xué)會(huì)臨床標(biāo)準(zhǔn)委員會(huì)文件并非旨在建立一個(gè)醫(yī)療服務(wù)的法律標(biāo)準(zhǔn),,因?yàn)閷?duì)支持指南證據(jù)的解釋可能會(huì)受到個(gè)體情況、當(dāng)?shù)胤桨负涂捎觅Y源的影響,。經(jīng)國際婦產(chǎn)科超聲學(xué)會(huì)許可后,,可自由發(fā)布經(jīng)批準(zhǔn)的指南([email protected]),。

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前言

對(duì)胎兒生長(zhǎng)的評(píng)估是產(chǎn)前檢查的關(guān)鍵目標(biāo)之一。胎兒生長(zhǎng)取決于多種因素,,包括子宮胎盤功能,、母體疾病、母體心血管功能或心臟病,、母體營(yíng)養(yǎng),、居住海拔高度、吸煙和非法藥物的使用,,以及是否存在感染,、胎兒非整倍染色體和某些遺傳疾病等病理狀況。然而,,子宮胎盤功能不全或功能障礙是導(dǎo)致原本正常胎兒異常生長(zhǎng)的最常見原因之一,。

胎兒生長(zhǎng)受損與圍產(chǎn)期死亡率和并發(fā)癥率以及遠(yuǎn)期嬰兒不良結(jié)局的風(fēng)險(xiǎn)增加有關(guān)〔1〕??偟膩碚f,,生長(zhǎng)受限的胎兒與早產(chǎn)相關(guān)疾病的發(fā)病率較高〔2〕,神經(jīng)發(fā)育結(jié)局更差,,并且在成年后患非傳染性疾病的風(fēng)險(xiǎn)增加,,如高血壓、代謝綜合征,、胰島素抵抗,、2型糖尿病、冠心病和中風(fēng)〔3〕,。胎兒生長(zhǎng)受限( fetal growth restriction,,F(xiàn)GR)的產(chǎn)前識(shí)別是已明確的預(yù)防死胎策略中的一個(gè)主要因素,,妊娠晚期死胎的病例中高達(dá)30%與胎兒生長(zhǎng)受限或小于胎齡兒(small-for-gestational age ,SGA)相關(guān)〔4,5〕,。

本指南提供了胎兒生長(zhǎng)受限(以前稱為胎兒宮內(nèi)發(fā)育遲緩)和小于胎齡兒的定義,,并描述了基于當(dāng)前數(shù)據(jù)和認(rèn)知的最佳管理方案。在本指南中,,我們假設(shè)妊娠為單胎妊娠,妊娠日期已經(jīng)核對(duì)準(zhǔn)確(最好在妊娠早期通過超聲核對(duì)),,并且胎兒不存在病理狀況,,如胎兒染色體非整倍體、先天性畸形或感染。附錄1提供了本指南中使用的推薦等級(jí)的詳細(xì)信息,。證據(jù)水平報(bào)告不適用于本指南,。

指南

小于胎齡兒和胎兒生長(zhǎng)受限的定義與區(qū)別

問:如何確定胎兒大???

答:胎兒生長(zhǎng)是一個(gè)動(dòng)態(tài)過程,其評(píng)估需要在一定時(shí)間段對(duì)胎兒大小進(jìn)行多次觀察,。胎兒大小通過胎兒頭圍,、雙頂徑、腹圍和股骨長(zhǎng)度等生物特征來評(píng)估,,以及/或者通過不同公式計(jì)算所估計(jì)的胎兒體重來確定。國際婦產(chǎn)科超聲學(xué)會(huì)胎兒生物測(cè)量和生長(zhǎng)的超聲評(píng)估指南描述了適當(dāng)評(píng)估胎兒生物測(cè)量和診斷胎兒生長(zhǎng)異常的方法,、參考范圍,、生長(zhǎng)標(biāo)準(zhǔn)和質(zhì)量控制過程〔6〕。本指南描述了與參考范圍相關(guān)的爭(zhēng)議以及與胎兒生物測(cè)量評(píng)估相關(guān)的其他問題,。

問:小于胎齡兒是如何定義的,?

答:當(dāng)胎兒大小(生物測(cè)量評(píng)估)低于其胎齡預(yù)定義的閾值時(shí),,被視為小于胎齡兒,。小于胎齡兒最常見的定義是估計(jì)的胎兒體重或腹圍低于給定參考范圍的第10百分位數(shù),。盡管如此,,也有其他閾值被描述,,例如第5和第3百分位數(shù)(后者接近2個(gè)標(biāo)準(zhǔn)差)或Z分?jǐn)?shù)-2,。

問:胎兒生長(zhǎng)受限的定義?

答:胎兒生長(zhǎng)受限是一種常見的,、無可奈何的情況,定義為胎兒未達(dá)到其遺傳預(yù)期的生長(zhǎng)潛能,。胎兒生長(zhǎng)受限的識(shí)別通常并不簡(jiǎn)單,,因?yàn)闊o法通過對(duì)胎兒大小的單一生物測(cè)量指標(biāo)來評(píng)估,并且胎兒生長(zhǎng)潛能是假設(shè)的,。

問:小于胎齡兒和胎兒生長(zhǎng)受限之間的主要區(qū)別是什么,?

答:小于胎齡兒和胎兒生長(zhǎng)受限之間的主要區(qū)別在于,小于胎齡兒胎兒可能較小,,但不一定會(huì)增加不良圍產(chǎn)期結(jié)局的風(fēng)險(xiǎn),,而大于第10百分位數(shù)的胎兒可能有胎兒生長(zhǎng)受限,并且不良圍產(chǎn)期和遠(yuǎn)期結(jié)局的風(fēng)險(xiǎn)均增加〔7-11〕,。

出生體重低于第10百分位數(shù)的胎兒發(fā)生死胎〔12〕和圍產(chǎn)期死亡〔13-15〕的風(fēng)險(xiǎn)增加,,其中出生體重低于第3百分位數(shù)的胎兒風(fēng)險(xiǎn)最高〔12,13〕,。因此,生長(zhǎng)曲線下端的胎兒大小,,例如給定生長(zhǎng)曲線中腹圍或估計(jì)胎兒體重低于第3百分位數(shù)者,,在任何胎齡均可以作為定義胎兒生長(zhǎng)受限的獨(dú)立標(biāo)準(zhǔn)〔16〕。然而,,與最低圍產(chǎn)期死亡率相關(guān)的最適出生體重,,似乎遠(yuǎn)高于正常隊(duì)列的出生體重中位數(shù)〔13〕。事實(shí)上,,一項(xiàng)基于人群的隊(duì)列研究發(fā)現(xiàn),,即使出生體重在正常范圍內(nèi)的胎兒,圍產(chǎn)期死亡率也會(huì)增加,,出生體重在第70到第90百分位數(shù)之間的胎兒風(fēng)險(xiǎn)最低,,并且圍產(chǎn)兒死亡率與出生體重低于第80百分位數(shù)之間呈負(fù)相關(guān)〔13〕。一項(xiàng)大型蘇格蘭人群隊(duì)列研究表明,,預(yù)測(cè)出生體重低于第25百分位數(shù)的妊娠婦女,,死胎風(fēng)險(xiǎn)逐漸增加〔17〕。

問:在胎兒大小低于第10百分位數(shù)的情況下,,有什么方法可以鑒別小于胎齡兒和胎兒生長(zhǎng)受限,?

答:為了在胎兒大小低于第10百分位數(shù)的情況下區(qū)分小于胎齡兒和胎兒生長(zhǎng)受限,需要增加額外的生物物理參數(shù),。為此提出了許多方法,,如評(píng)估胎兒生長(zhǎng)速度、使用定制的生長(zhǎng)曲線,、多普勒測(cè)速評(píng)估胎盤和胎兒循環(huán)以及使用生物標(biāo)記物,。其中一些生物物理參數(shù)也用于監(jiān)測(cè)胎兒狀態(tài)和/或作為分娩決策的標(biāo)準(zhǔn)(如臍動(dòng)脈多普勒)。生物物理評(píng)估工具,,如靜脈導(dǎo)管測(cè)速,、生物物理評(píng)分和評(píng)估胎心率短期變異的胎心監(jiān)護(hù)圖,不作為胎兒生長(zhǎng)受限的診斷標(biāo)準(zhǔn),,但已用于監(jiān)測(cè)和管理妊娠,。下文將對(duì)此進(jìn)行討論。

胎兒生長(zhǎng)受限診斷,、監(jiān)測(cè)和管理工具

胎兒生長(zhǎng)速度

問:評(píng)估胎兒生長(zhǎng)速度的方法有哪些?

答:評(píng)估胎兒生長(zhǎng)速度有幾種方法,,包括使用縱向的胎兒生長(zhǎng)曲線〔18〕,、評(píng)估與生長(zhǎng)曲線的偏差〔18〕及個(gè)體化生長(zhǎng)評(píng)估〔19〕。總的來說,,目的是評(píng)估胎兒的生長(zhǎng)軌跡,,并識(shí)別那些偏離其個(gè)體化軌跡的胎兒,,表明其未達(dá)到生長(zhǎng)潛能,。有證據(jù)表明,,妊娠晚期胎兒生長(zhǎng)速度降低與不良結(jié)局風(fēng)險(xiǎn)增加有關(guān)〔11,20〕,。生長(zhǎng)速度降低通常被認(rèn)為是連續(xù)超聲檢查期間,腹圍或更常見的估計(jì)胎兒體重的下降幅度大于第50百分位數(shù)〔6〕,。

制定的胎兒生長(zhǎng)曲線

問:制定胎兒生長(zhǎng)曲線依據(jù)了哪些因素?有何建議,?

答:在制定的胎兒生長(zhǎng)曲線中,,根據(jù)已知影響胎兒大小的變量調(diào)整胎兒體重和生長(zhǎng)。這些混雜因素包括母親的身高,、體重,、年齡、產(chǎn)次,、種族以及胎兒性別,。建議對(duì)這些變量進(jìn)行調(diào)整,以便更好地識(shí)別有圍產(chǎn)期并發(fā)癥高風(fēng)險(xiǎn)的小于胎齡兒〔6〕,。國際婦產(chǎn)科超聲學(xué)會(huì)關(guān)于胎兒生物測(cè)量和生長(zhǎng)的超聲評(píng)估指南中更詳細(xì)地描述了評(píng)估胎兒生長(zhǎng)速度的方法和為此制定的胎兒生長(zhǎng)曲線的應(yīng)用〔6〕,。

多普勒測(cè)速

問:多普勒測(cè)速儀應(yīng)用于胎兒生長(zhǎng)評(píng)估的基本原理?

答:多普勒測(cè)速儀應(yīng)用于胎兒生長(zhǎng)評(píng)估的基本原理是,,它可以通過評(píng)估子宮動(dòng)脈和臍動(dòng)脈來識(shí)別子宮胎盤功能,。

問:子宮胎盤功能不全的可能原因?

答:子宮胎盤功能不全可能是由于螺旋動(dòng)脈重塑不良和絨毛血管樹的改變導(dǎo)致,。

問:多普勒測(cè)速是怎么評(píng)估胎兒的,?

答:在胎兒方面,多普勒測(cè)速可通過評(píng)估胎兒大腦中動(dòng)脈和靜脈導(dǎo)管來評(píng)估從缺氧進(jìn)展到酸血癥過程中胎兒心血管的代償變化,。

問:子宮動(dòng)脈阻力與胎盤功能不全有關(guān)嗎,?

答:子宮動(dòng)脈缺乏從高阻力血管到低阻力血管的生理轉(zhuǎn)化,被認(rèn)為反映了螺旋動(dòng)脈的滋養(yǎng)細(xì)胞浸潤(rùn)不足,,從而導(dǎo)致高阻力循環(huán),。子宮動(dòng)脈平均搏動(dòng)指數(shù)持續(xù)升高(高于第95百分位數(shù))與胎盤功能不全和母體胎盤血管灌注不良有關(guān)〔21〕。

問:臍動(dòng)脈搏動(dòng)指數(shù)與胎盤功能不全有何關(guān)系,?

答:臍動(dòng)脈搏動(dòng)指數(shù)的逐漸增加反映了用來做氣體和營(yíng)養(yǎng)物質(zhì)交換的胎盤表面積逐漸減少,,胎兒后負(fù)荷阻力增加,,并且與胎盤血管功能不全有關(guān),反映在臍動(dòng)脈舒張末期血流缺失,,在終末階段,,可見臍動(dòng)脈舒張末期逆向血流〔22〕。

問:什么是“腦保護(hù)”效應(yīng),?有何臨床意義,?

答:胎兒大腦中動(dòng)脈搏動(dòng)指數(shù)降低是血管擴(kuò)張的結(jié)果,即所謂的“腦保護(hù)”效應(yīng),。這代表了通過直接感知腦血管循環(huán)中的氧張力,,對(duì)胎兒低氧血癥的血液動(dòng)力學(xué)反應(yīng)。在其他血管床中,,胎兒心輸出血量重新分布,,優(yōu)先供應(yīng)冠狀動(dòng)脈和腎上腺〔23〕。

問:靜脈導(dǎo)管中a波缺失或反向是什么原因?qū)е碌模?/strong>

答:靜脈導(dǎo)管流速波形的改變,,尤其是a波的缺失或反向,,是由于靜脈導(dǎo)管峽部進(jìn)行性擴(kuò)張引起的,以增加流向心臟的血流量補(bǔ)償極度缺氧狀態(tài)〔24〕,。還有人認(rèn)為,,靜脈導(dǎo)管a波缺失或反向是由于心臟后負(fù)荷高(血管-胎盤阻力增加)導(dǎo)致心房?jī)?nèi)壓升高,以及/或者胎兒酸血癥對(duì)心肌細(xì)胞功能直接影響的結(jié)果〔25〕,。

問:多普勒檢查技術(shù)對(duì)胎兒生長(zhǎng)受限的臨床診療有何作用,?

答:多普勒檢查技術(shù)在胎兒生長(zhǎng)受限的識(shí)別、監(jiān)測(cè)和管理中起著核心作用,,因?yàn)樗梢宰R(shí)別子宮胎盤功能不全和/或胎兒對(duì)低氧血癥的心血管代償性反應(yīng),。重要的是,胎兒生長(zhǎng)受限的兩種表型,,早發(fā)型和晚發(fā)型,,有不同的多普勒檢查模式特征,如下所述,。

生物物理評(píng)分

問:胎兒生物物理評(píng)分包括哪些項(xiàng)目的評(píng)估,?

答:胎兒生物物理評(píng)分包括胎兒肌張力、胎動(dòng),、呼吸運(yùn)動(dòng),、羊水量和胎心反應(yīng)型的綜合評(píng)估。

問:胎兒生物物理評(píng)分對(duì)評(píng)估胎兒狀況有何價(jià)值,?

答:胎兒生物物理評(píng)分可以預(yù)測(cè)胎兒pH值和結(jié)局〔26,27〕,。生物物理評(píng)分的改變與胎兒pH值之間的關(guān)系在不同胎齡之間似乎是一致的〔26〕。評(píng)分≤4與胎兒pH值≤7.20相關(guān),而評(píng)分<2對(duì)應(yīng)酸血癥的敏感性為100%〔27〕,。即使使用僅基于胎心反應(yīng)型和羊水量評(píng)估的簡(jiǎn)化生物物理評(píng)分,,這種相關(guān)性仍然非常顯著〔28〕

胎心監(jiān)護(hù)和胎心率短期變異

問:胎兒低氧血癥時(shí)胎心監(jiān)護(hù)和胎心率短期變異有何改變,?

答:反應(yīng)型胎心監(jiān)護(hù)圖實(shí)際上可排除胎兒低氧血癥,。胎心率短期變異是通過電腦化的胎心監(jiān)護(hù)圖獲得的反映胎兒自主神經(jīng)系統(tǒng)功能的生物物理參數(shù),。在胎兒生長(zhǎng)受限伴隨嚴(yán)重低氧血癥或缺氧的情況下,,胎兒交感神經(jīng)和副交感神經(jīng)活動(dòng)的改變導(dǎo)致胎兒心率變異減少,從而降低了短期變異,。

問:有沒有測(cè)量胎兒心率的客觀方法,?

答:電腦化的胎心監(jiān)護(hù)圖和胎心率短期變異評(píng)估的有效性已在胎兒低氧血癥和酸血癥的侵入性檢測(cè)方法中得到驗(yàn)證,是唯一客觀的胎兒心率測(cè)量方法〔29〕,。常規(guī)胎心監(jiān)護(hù)圖的目視檢查提供不了電腦化的胎心監(jiān)護(hù)圖相同的信息,,因?yàn)閭鹘y(tǒng)的胎心監(jiān)護(hù)圖在很大程度上是一種主觀評(píng)估,觀察者本人和不同觀察者間的可重復(fù)性較低,。

生物學(xué)指標(biāo)

問:有用于篩查,、診斷和管理小于胎齡兒和胎兒生長(zhǎng)受限的生物學(xué)指標(biāo)嗎?

答:胎盤生物標(biāo)志物在與胎盤疾病相關(guān)的妊娠高血壓疾病和/或胎兒生長(zhǎng)受限的篩查,、診斷和治療方面具有潛在作用〔30〕,。已經(jīng)研究了幾種胎盤因子,包括胎盤蛋白以及微小RNA和mRNA,。一些胎盤蛋白,,如妊娠相關(guān)血漿蛋白-A,是妊娠早期胎盤功能的生物標(biāo)志物,,然而其預(yù)測(cè)能力有限〔31,32〕,。

可溶性fms樣酪氨酸激酶-1與胎盤生長(zhǎng)因子的比值被提議作為短期預(yù)測(cè)因子,以排除臨床上懷疑患有子癇前期的女性〔33〕,。雖然一些報(bào)告表明,,使用可溶性fms樣酪氨酸激酶-1/胎盤生長(zhǎng)因子比值可能有助于小于胎齡兒和胎兒生長(zhǎng)受限的管理和鑒別〔34-38〕,但由于缺乏進(jìn)行臨床干預(yù)后的試驗(yàn)數(shù)據(jù),,無法推薦這些試驗(yàn)作為超聲檢查的輔助手段,。關(guān)于在小于胎齡兒和胎兒生長(zhǎng)受限篩查中,使用生物標(biāo)志物的快速發(fā)展的研究討論,,超出了本指南的范圍,。

推薦

  • 僅憑胎兒大小不足以識(shí)別胎兒生長(zhǎng)受限,除非腹圍或估計(jì)胎兒體重低于第3百分位數(shù)(推薦等級(jí):C),。

  • 胎兒生長(zhǎng)速度的下降,,即腹圍或估計(jì)胎兒體重下降>2個(gè)四分位數(shù)或>第50百分位數(shù)(例如從第70個(gè)百分位數(shù)下降到或低于第20個(gè)百分位數(shù)),應(yīng)警醒醫(yī)生可能為胎兒生長(zhǎng)受限(推薦等級(jí):C)。

  • 子宮胎盤和胎兒胎盤循環(huán)的多普勒檢查可用于鑒別小于胎齡兒和胎兒生長(zhǎng)受限(良好實(shí)踐要點(diǎn)),。

  • 建議對(duì)疑似胎兒生長(zhǎng)受限的妊娠進(jìn)行多模式評(píng)估,。電腦化的胎心監(jiān)護(hù)圖或生物物理評(píng)分應(yīng)與多普勒檢查聯(lián)合使用(推薦等級(jí):A)。

早發(fā)型和晚發(fā)型胎兒生長(zhǎng)受限的定義

問:胎兒生長(zhǎng)受限有幾種主要表型,?

答:胎兒生長(zhǎng)受限有兩種主要表型,,在許多方面存在顯著差異,如發(fā)病率,、早期妊娠超聲預(yù)測(cè)性,、發(fā)病胎齡、胎盤組織病理學(xué)表現(xiàn),、多普勒血流頻譜,、母體相關(guān)疾病、嚴(yán)重程度和圍產(chǎn)期結(jié)局,。表1列出了這兩種表型的主要特征,。根據(jù)觀察,一種表型常發(fā)生在妊娠早期,,而另一種常發(fā)生于近足月,,這兩種表型分別被定義為早發(fā)型和晚發(fā)型胎兒生長(zhǎng)受限〔39-42〕

表1 早發(fā)型和晚發(fā)型胎兒生長(zhǎng)受限的主要臨床特征

臨床特征

早發(fā)型

胎兒生長(zhǎng)受限

晚發(fā)型

胎兒生長(zhǎng)受限

主要臨床挑戰(zhàn)

處理

發(fā)現(xiàn)

發(fā)生率

30%

70%

有臨床表現(xiàn)時(shí)胎齡

< 32周

≥ 32 周

胎兒超聲發(fā)現(xiàn)

胎兒可能很小

胎兒不一定很小

多普勒檢查

包括臍動(dòng)脈,、大腦中動(dòng)脈和靜脈導(dǎo)管的多普勒頻譜改變

大腦血流重新分布

生物物理評(píng)分

可能異常

可能異常

妊娠期高血壓疾病

經(jīng)常

不經(jīng)常

胎盤組織病理學(xué)發(fā)現(xiàn)

胎盤植入不良,、螺旋動(dòng)脈異常、母體血管灌注不良

不太特異的胎盤發(fā)現(xiàn),,主要改變了物質(zhì)擴(kuò)散

圍產(chǎn)兒死亡率

母體心血管血流動(dòng)力學(xué)狀態(tài)

低心輸出量,,高外周血管阻力

不太明顯的母體心血管發(fā)現(xiàn)

問:區(qū)別早發(fā)型和晚發(fā)型胎兒生長(zhǎng)受限的主要標(biāo)準(zhǔn)是什么?

答:早發(fā)型和晚發(fā)型胎兒生長(zhǎng)受限的區(qū)別通?;谠谌焉?2~34周之前還是之后做出的診斷,。雖然臍動(dòng)脈多普勒評(píng)估似乎比胎齡能更好地區(qū)別胎兒生長(zhǎng)受限兩種表型與子癇前期和不良圍產(chǎn)期結(jié)局的關(guān)系〔39,40〕,但妊娠32周似乎是診斷時(shí)的最佳胎齡截?cái)嘀?,并為兩種胎兒生長(zhǎng)受限表型提供了合理的分類〔40〕,。因此,胎齡閾值在很大程度上被認(rèn)為是區(qū)別早發(fā)型和晚發(fā)型胎兒生長(zhǎng)受限的主要標(biāo)準(zhǔn)〔16〕,,在本指南中也被用于區(qū)別早發(fā)型和晚發(fā)型胎兒生長(zhǎng)受限,。

問:目前最受認(rèn)可的胎兒生長(zhǎng)受限定義是哪個(gè)?

答:胎兒生長(zhǎng)受限的定義因不同指南和作者群體而異〔43〕,。國際Delphi共識(shí)提出的標(biāo)準(zhǔn)代表了最受認(rèn)可的胎兒生長(zhǎng)受限定義(表2)〔16〕,。在最近的一項(xiàng)驗(yàn)證研究中,使用Hadlock生長(zhǎng)標(biāo)準(zhǔn)EFW<第10百分位數(shù)定義胎兒生長(zhǎng)受限來預(yù)測(cè)不良新生兒結(jié)局〔44〕,。盡管Delphi標(biāo)準(zhǔn)與對(duì)新生兒不良結(jié)局的預(yù)測(cè)改善相關(guān),,然而該隊(duì)列研究擴(kuò)大了孕齡區(qū)間,兩種定義不相上下,。

表2 根據(jù)國際Delphi共識(shí)對(duì)無先天性異常的早發(fā)型和晚發(fā)型胎兒生長(zhǎng)受限的定義

早發(fā)型胎兒生長(zhǎng)受限:

GA< 32周,,無先天性異常

晚發(fā)型胎兒生長(zhǎng)受限:

GA ≥ 32周,無先天性異常

AC/EFW <第3百分位數(shù)或UA-AEDF

AC/EFW <第3百分位數(shù)

或  下述3項(xiàng)中至少2項(xiàng)

  1. AC/EFW <第10百分位數(shù)聯(lián)合

  2. UtA-PI >第95百分位數(shù)和/或

  3. UA-PI >第95百分位數(shù)

  1. AC/EFW < 第10百分位數(shù)

  2. AC/EFW 交叉百分位數(shù) > 生長(zhǎng)百分?jǐn)?shù)中的2個(gè)四分位數(shù)*

  3. CPR <第5百分位數(shù)或UA-PI >第95百分位數(shù)

*生長(zhǎng)百分位數(shù)是非定制的百分位數(shù),。AC,胎兒腹圍,;AEDF,,舒張末期血流缺失,;CPR,,腦胎盤比率,;EFW,,估計(jì)胎兒體重;GA,,胎齡,;PI,搏動(dòng)指數(shù),;UA,,臍動(dòng)脈,;UtA,,子宮動(dòng)脈。出自Gordijn等人〔16〕,。

推薦

  • 胎兒生長(zhǎng)受限兩種主要表型,,早發(fā)型和晚發(fā)型,具有不同的臨床,、超聲和病理學(xué)特征(推薦等級(jí):D),。

  • 國際婦產(chǎn)科超聲學(xué)會(huì)指南的作者們推薦采用Delphi共識(shí)標(biāo)準(zhǔn)定義的胎兒生長(zhǎng)受限〔16〕(良好實(shí)踐要點(diǎn))。

多普勒檢查

問:對(duì)于多普勒測(cè)速技術(shù)有普遍的共識(shí)嗎,?

答:盡管多普勒測(cè)速技術(shù)在產(chǎn)科實(shí)踐中已經(jīng)使用了近40年,,但對(duì)于使用哪些指標(biāo)、閾值和/或參考范圍,,還沒有達(dá)成普遍的共識(shí),。當(dāng)進(jìn)行定性評(píng)估時(shí),不需要考慮這些,例如評(píng)估靜脈導(dǎo)管a波缺失/反向或臍動(dòng)脈的舒張末期血流缺失/反向,,但它們影響多普勒檢查的定量評(píng)估,。國際婦產(chǎn)科超聲學(xué)會(huì)提供了關(guān)于如何進(jìn)行子宮胎盤和胎兒多普勒檢查的國際指南〔45〕。

問:為什么胎兒大腦中動(dòng)脈和臍動(dòng)脈多普勒指數(shù)報(bào)告存在參考范圍的差異,?

答:在報(bào)告大腦中動(dòng)脈和臍動(dòng)脈多普勒指數(shù)參考范圍及其比值的研究中,,存在相當(dāng)大的方法學(xué)異質(zhì)性,這至少可以部分解釋報(bào)告參考范圍的差異〔46〕,。即使在方法學(xué)質(zhì)量得分較高的研究中,,“正常”和正常態(tài)范圍的定義也存在顯著差異〔46〕,。最近的一項(xiàng)研究評(píng)估了提供大腦中動(dòng)脈搏動(dòng)指數(shù),、臍動(dòng)脈搏動(dòng)指數(shù)和腦胎盤血流比參考范圍的10篇被引用最多的文章,發(fā)現(xiàn)多普勒參考范圍存在很大差異,,導(dǎo)致足月時(shí)大腦中動(dòng)脈搏動(dòng)指數(shù)第5百分位數(shù)截?cái)嘀档淖儺愋愿哌_(dá)50%,。同樣,研究發(fā)現(xiàn),,臍動(dòng)脈搏動(dòng)指數(shù)高于第95百分位數(shù)(20–40%)和腦胎盤血流比低于第5百分位數(shù)(15–35%)的截?cái)嘀荡嬖陲@著差異〔47〕,。據(jù)報(bào)道,用于生物測(cè)量,、多普勒參數(shù)和出生體重的參考范圍存在很大差異,,即使在胎兒生長(zhǎng)受限管理方面具有高度專業(yè)水平的、國家級(jí)的醫(yī)療中心也是如此,,這可能會(huì)對(duì)胎兒生長(zhǎng)受限的診斷和管理產(chǎn)生很大影響〔48〕,。

定量多普勒檢查缺乏標(biāo)準(zhǔn)化的另一個(gè)原因是,所使用的多普勒指數(shù)不一致,,尤其是在研究中,。例如,腦血流重新分布可以定義為大腦中動(dòng)脈搏動(dòng)指數(shù)低于不同的百分位數(shù)閾值(第5或第10個(gè)百分位數(shù)),、Z值或中位數(shù)的倍數(shù),,也可以分別定義為臍腦血流比或腦胎盤血流比高于或低于不同的百分位數(shù)閾值、Z值或中位數(shù)的倍數(shù)〔49〕,。

問:定義胎兒生長(zhǎng)受限的多普勒標(biāo)準(zhǔn)是什么,?

答:Delphi共識(shí)規(guī)范將腦胎盤血流比低于第5個(gè)百分位數(shù)和臍動(dòng)脈搏動(dòng)指數(shù)高于第95個(gè)百分位數(shù)確定為定義胎兒生長(zhǎng)受限的多普勒標(biāo)準(zhǔn)〔16〕。應(yīng)用大腦中動(dòng)脈搏動(dòng)指數(shù)和臍動(dòng)脈搏動(dòng)指數(shù)比值(腦胎盤血流比和臍腦血流比)而不是單個(gè)指標(biāo)的基本原理是,,它們對(duì)胎兒低氧更敏感[50],,并且與不良圍產(chǎn)兒結(jié)局的相關(guān)性更強(qiáng)〔49,51〕。研究中報(bào)告腦胎盤血流比的頻率高于臍腦血流比,。最近的一項(xiàng)研究表明,,相比腦胎盤血流比,,臍腦血流比可以更好地區(qū)分出早發(fā)型胎兒生長(zhǎng)受限中處于異常范圍的病例〔52〕。然而,,應(yīng)該強(qiáng)調(diào)的是,,沒有強(qiáng)有力的證據(jù)支持這兩個(gè)比值中的哪一個(gè)更好。

問:應(yīng)該如何認(rèn)識(shí)這些差異的存在,?

答:所用多普勒參考范圍和指數(shù)的高度變異性對(duì)產(chǎn)前診斷,、監(jiān)測(cè)、分娩時(shí)機(jī)的決策,、研究結(jié)果的可重復(fù)性和比較,、臨床決策、規(guī)范的有效性,,及許多其他方面都具有很大的影響〔46〕,。關(guān)于胎兒生長(zhǎng)受限的診斷和管理應(yīng)選用哪個(gè)參考范圍的討論,超出了本指南的范圍,。然而,,應(yīng)認(rèn)識(shí)到這些差異的存在,需要采取行動(dòng)去統(tǒng)一臨床實(shí)踐和研究中采用的多普勒指數(shù),、閾值和參考范圍,。表S1總結(jié)了最為相關(guān)的研究中所報(bào)告的大腦中動(dòng)脈及其比值參考值。

圖片
圖片

表S1,  Most relevant studies reporting reference ranges for fetal middle cerebral artery (MCA), cerebroplacental ratio (CPR) and umbilical–cerebral ratio (UCR). Adapted from Ruiz-Martinez et al〔47〕,。

早發(fā)型胎兒生長(zhǎng)受限

問:早發(fā)型胎兒生長(zhǎng)受限的病因?

答:早發(fā)型胎兒生長(zhǎng)受限尤其與母體胎盤血管灌注不良有關(guān),,其特征為螺旋動(dòng)脈重塑異常,、胎盤絨毛和多灶性梗死的病理特征;這些病理狀況導(dǎo)致所謂的“胎盤功能不全”,,并形成胎盤介導(dǎo)的胎兒生長(zhǎng)受限的最常見基礎(chǔ)〔53,54〕,。胎盤絨毛的慢性缺血損害胎盤生長(zhǎng)因子的分泌,并導(dǎo)致合胞體結(jié)過度釋放可溶性fms樣酪氨酸激酶-1,,從而導(dǎo)致可溶性fms樣酪氨酸激酶-1/胎盤生長(zhǎng)因子比值升高,,這是早發(fā)型胎兒生長(zhǎng)受限和妊娠期高血壓疾病的典型特征〔34-38〕。

問:早發(fā)型胎兒生長(zhǎng)受限早期改變時(shí)哪項(xiàng)指標(biāo)最先出現(xiàn)異常,?

答:多普勒臍動(dòng)脈搏動(dòng)指數(shù)升高通常先于一系列多普勒頻譜的改變,、胎心率的改變、生物物理評(píng)分的改變及嚴(yán)重低氧血癥伴隨酸中毒引起的終末期心血管惡化〔55-57〕,。子宮動(dòng)脈,、臍動(dòng)脈和大腦中動(dòng)脈多普勒異常代表早發(fā)型胎兒生長(zhǎng)受限的早期改變,并可能在嚴(yán)重心血管和代謝惡化發(fā)生前數(shù)周出現(xiàn),。

問:早發(fā)型胎兒生長(zhǎng)受限的晚期表現(xiàn),?

答:雖然臍動(dòng)脈舒張末期血流缺失代表子宮胎盤功能的進(jìn)行性惡化,,但它仍然先于嚴(yán)重的胎兒惡化,并且進(jìn)展到反向臍動(dòng)脈舒張末期血流可能很慢,。然而,,臍動(dòng)脈多普勒改變的程度和速度,從血流阻力增加到舒張末期血流缺失,,決定了胎兒惡化的速度〔56,58〕,。以嚴(yán)重胎盤功能不全為特征的早發(fā)型胎兒生長(zhǎng)受限的晚期惡化表現(xiàn)為反向臍動(dòng)脈舒張末期血流,而靜脈導(dǎo)管的改變(a波缺失或反向)則反映為全身性心血管的惡化和代謝失代償〔57,59〕,。這種心血管惡化可能先于胎心短期變異改變或與胎心短期變異改變伴隨發(fā)生,,最終表現(xiàn)為生物物理評(píng)分異常、胎心監(jiān)護(hù)圖自發(fā)性重復(fù)減速和死胎〔39,60〕,。

問:胎兒生長(zhǎng)受限有沒有有效的治療方法,?

答:目前,盡管對(duì)重度子癇前期的有效識(shí)別和管理可能會(huì)延長(zhǎng)一些早發(fā)型胎兒生長(zhǎng)受限的妊娠,,但對(duì)于早發(fā)型胎兒生長(zhǎng)受限尚無有效的治療方法,。

問:早發(fā)型胎兒生長(zhǎng)受限臨床管理的關(guān)鍵點(diǎn)是什么?

答:及時(shí)糖皮質(zhì)激素的應(yīng)用,、硫酸鎂的應(yīng)用,、轉(zhuǎn)診到三級(jí)醫(yī)療中心并慎重選擇最安全的分娩方式,是早發(fā)型胎兒生長(zhǎng)受限管理的關(guān)鍵理念〔61〕,。最終,,為了防止缺氧和酸中毒導(dǎo)致圍產(chǎn)兒并發(fā)癥率和死亡率的嚴(yán)重后果,終止妊娠是早發(fā)型胎兒生長(zhǎng)受限的唯一治療方法,。另一方面,,終止妊娠的決策必須與早產(chǎn)可能帶來的傷害進(jìn)行權(quán)衡〔62,63〕胎兒生長(zhǎng)受限是導(dǎo)致早產(chǎn)不良結(jié)局的獨(dú)立風(fēng)險(xiǎn)因素,,這一事實(shí)使情況更加復(fù)雜,,從而使結(jié)局更加不利〔64,65〕。這一點(diǎn)突出表現(xiàn)在,,在早發(fā)型胎兒生長(zhǎng)受限的胎兒中,,妊娠26周后新生兒存活率才首次超過50%,相較發(fā)育正常的適于胎齡兒晚2周〔55〕,。因此,,在管理早發(fā)型胎兒生長(zhǎng)受限時(shí),最佳監(jiān)測(cè)和分娩時(shí)機(jī)至關(guān)重要,。

如何監(jiān)測(cè)

問:早發(fā)型胎兒生長(zhǎng)受限應(yīng)如何監(jiān)測(cè),?

答:一旦懷疑/診斷出早發(fā)型胎兒生長(zhǎng)受限,應(yīng)根據(jù)統(tǒng)一的管理方案,,在三級(jí)胎兒醫(yī)學(xué)和新生兒醫(yī)療機(jī)構(gòu)對(duì)妊娠進(jìn)行監(jiān)測(cè)和管理〔66〕,。新生兒和母胎醫(yī)學(xué)專家的多學(xué)科會(huì)診咨詢很重要,。一項(xiàng)隨機(jī)試驗(yàn)(歐洲隨機(jī)臍帶和胎兒血流試驗(yàn)數(shù)據(jù))表明,根據(jù)包括靜脈導(dǎo)管多普勒和電腦化胎心監(jiān)護(hù)圖在內(nèi)的特定方案進(jìn)行監(jiān)測(cè)和決定分娩時(shí)機(jī),,可獲得比期待更好的結(jié)局〔66〕,。應(yīng)該考慮到電腦化的胎心監(jiān)護(hù)圖不可得或不普遍使用的情況。在這種情況下,,除了多普勒評(píng)估外,,如果可以,還可進(jìn)行傳統(tǒng)的胎心監(jiān)護(hù)圖評(píng)估和生物物理評(píng)分〔27〕,。胎動(dòng)的缺失與靜脈導(dǎo)管多普勒指數(shù)的改變相關(guān),,可預(yù)測(cè)胎兒臍帶血pH<7.20,而胎兒肌張力的缺失與pH<7.00或堿剩余<?12 mEq/L相關(guān)〔27〕,。

問:應(yīng)多久監(jiān)測(cè)一次胎兒臍動(dòng)脈多普勒檢查,?

答:監(jiān)測(cè)頻率應(yīng)基于胎兒生長(zhǎng)受限和臍動(dòng)脈異常的嚴(yán)重程度。當(dāng)臍動(dòng)脈多普勒檢查結(jié)果逐漸惡化,,存在臍動(dòng)脈舒張末期血流缺失或反向時(shí),,需要更密集監(jiān)測(cè),每2~3天進(jìn)行一次,。對(duì)于監(jiān)測(cè)頻率沒有達(dá)成共識(shí),,但是,推薦的管理策略在其他地方描述〔29,42,67〕,。

問:可以根據(jù)大腦中動(dòng)脈多普勒結(jié)果確定分娩時(shí)機(jī)嗎,?

答:早發(fā)型胎兒生長(zhǎng)受限中,大腦中動(dòng)脈多普勒是最早出現(xiàn)異常的參數(shù)之一,。低大腦中動(dòng)脈搏動(dòng)指數(shù)與不良的短期新生兒不良結(jié)局以及低大腦中動(dòng)脈搏動(dòng)指數(shù)和高臍腦血流比與新生兒2歲時(shí)神經(jīng)系統(tǒng)發(fā)育不良結(jié)局之間的相關(guān)性似乎較弱〔52〕,。然而,分娩時(shí)的胎齡和出生體重對(duì)這些結(jié)局有最顯著的影響〔52〕,。因此,大腦中動(dòng)脈多普勒似乎可以指導(dǎo)妊娠32周前的監(jiān)測(cè),,但沒有證據(jù)顯示應(yīng)根據(jù)它來確定分娩時(shí)機(jī),。

問:母體胎盤生長(zhǎng)因子在胎兒生長(zhǎng)受限診斷和管理中有價(jià)值嗎?

答:約70%的早發(fā)型胎兒生長(zhǎng)受限孕婦會(huì)發(fā)展為妊娠期高血壓疾病,,主要是子癇前期〔68〕,。因此,推薦對(duì)無癥狀的早發(fā)型胎兒生長(zhǎng)受限的孕婦進(jìn)行規(guī)律的血壓評(píng)估,、監(jiān)測(cè)尿蛋白/肌酐的比值和基礎(chǔ)的肝腎功能,。盡管母體胎盤生長(zhǎng)因子檢測(cè)可能有用,但在沒有母體高血壓的情況下,,生物標(biāo)記物在胎兒生長(zhǎng)受限診斷和管理中的價(jià)值仍不明確,。

糖皮質(zhì)激素預(yù)防

問:早發(fā)型胎兒生長(zhǎng)受限患者需要糖皮質(zhì)激素促胎肺成熟治療嗎,?

答:所有關(guān)于早發(fā)型胎兒生長(zhǎng)受限的可用指南都推薦,如果可能在妊娠34+0周之前分娩,,應(yīng)使用糖皮質(zhì)激素預(yù)防新生兒呼吸窘迫綜合征〔43,67.70-74〕,。然而,英國皇家婦產(chǎn)科學(xué)會(huì)( Royal College of Obstetricians and Gynaecologists,RCOG)推薦最大胎齡至妊娠35+6周前進(jìn)行糖皮質(zhì)激素預(yù)防〔67〕,。盡管有此推薦,,但值得注意的是,尚未進(jìn)行隨機(jī)試驗(yàn)以確定糖皮質(zhì)激素對(duì)早產(chǎn)兒的益處是否也適用于生長(zhǎng)受限的早產(chǎn)兒,。在這些胎兒中,,較小的胎盤減少了糖皮質(zhì)激素的代謝,并且內(nèi)源性腎上腺糖皮質(zhì)激素水平已經(jīng)很高,,這可能會(huì)進(jìn)一步損害胎兒腦白質(zhì)和髓鞘形成〔75〕,。在臍動(dòng)脈舒張末期血流缺失或反向的胎兒中,應(yīng)用糖皮質(zhì)激素期間需要加強(qiáng)日常監(jiān)測(cè)〔76〕,。

硫酸鎂預(yù)防

問:胎兒生長(zhǎng)受限患者也需要應(yīng)用硫酸鎂進(jìn)行胎兒神經(jīng)保護(hù)治療嗎,?

答:有很好的證據(jù)表明硫酸鎂對(duì)早產(chǎn)胎兒神經(jīng)保護(hù)的有效性,然而,,其最小的確切有效胎齡閾值仍不清楚〔77〕,。許多指南和研究推薦使用硫酸鎂對(duì)生長(zhǎng)受限胎兒進(jìn)行神經(jīng)保護(hù),盡管推薦的開始胎齡各不相同,,如妊娠<32~33周〔73〕,、<32周〔70,72〕、<30周〔78〕或<29周〔79〕,。由于缺乏強(qiáng)有力的證據(jù)支持可以在各國統(tǒng)一應(yīng)用硫酸鎂預(yù)防的最佳胎齡,,我們建議參考當(dāng)?shù)鼗蚋鱾€(gè)國家的指南。

分娩時(shí)機(jī)和方式

問:對(duì)早發(fā)型胎兒生長(zhǎng)受限的新生兒結(jié)局產(chǎn)生不利影響的主要量化參數(shù)是什么,?

答:一項(xiàng)大型前瞻性國際多中心研究提供了證據(jù),,證明早產(chǎn)胎齡和低出生體重是對(duì)早發(fā)型胎兒生長(zhǎng)受限的新生兒結(jié)局產(chǎn)生不利影響的主要量化參數(shù)〔55〕。事實(shí)上,,對(duì)于極端早產(chǎn)兒(<27周)和極低出生體重兒(<600克),,每延長(zhǎng)妊娠一天可將新生兒存活率提高2%。妊娠27周后,,靜脈導(dǎo)管多普勒參數(shù)成為新生兒預(yù)后的主要預(yù)測(cè)指標(biāo)〔55〕,。

問:早發(fā)型胎兒生長(zhǎng)受限的最佳分娩時(shí)機(jī)是何時(shí)?基于何種證據(jù),?

答:首個(gè)關(guān)于胎兒生長(zhǎng)受限分娩時(shí)機(jī)的隨機(jī)對(duì)照試驗(yàn)是生長(zhǎng)受限干預(yù)試驗(yàn)(GRIT)〔80,81〕,。當(dāng)臨床醫(yī)生不確定受損胎兒的最佳分娩時(shí)機(jī)時(shí),該研究評(píng)估了即刻分娩與期待管理的效果。期待管理組的中位分娩時(shí)間為4.9天,,而即刻分娩組為0.9天,,兩組在2歲或?qū)W齡時(shí)的神經(jīng)發(fā)育結(jié)果沒有顯著差異〔82〕。

TRUFFLE研究是關(guān)于早發(fā)型胎兒生長(zhǎng)受限分娩時(shí)機(jī)的最大型隨機(jī)試驗(yàn),,基于三個(gè)隨機(jī)組:早期靜脈導(dǎo)管多普勒改變(搏動(dòng)指數(shù)>第95百分位數(shù)),、晚期靜脈導(dǎo)管多普勒改變(a波位于或低于基線)和電腦化的胎心監(jiān)護(hù)圖上的胎心率短期變異降低(妊娠29周前<3.5 ms,之后<4.0 ms)〔83〕,。此外,,在所有三組中,安全保障標(biāo)準(zhǔn)被應(yīng)用為分娩的絕對(duì)適應(yīng)證,,在所有三組中表現(xiàn)為自發(fā)反復(fù)的持續(xù)無誘因的胎心減速,,或在靜脈導(dǎo)管組,妊娠26+0~28+6周時(shí)胎心率短期變異<2.6ms,,在妊娠29+0~31+6周時(shí)胎心率短期變異<3.0ms,。如果妊娠30周后發(fā)生臍動(dòng)脈-舒張末期血流反向或妊娠32周后臍動(dòng)脈舒張末期血流缺失,建議終止妊娠,。總的來說,,TRUFFLE研究提供的證據(jù)表明,基于靜脈導(dǎo)管多普勒檢查聯(lián)合電腦化的胎心監(jiān)護(hù)圖安全保障標(biāo)準(zhǔn)的分娩時(shí)機(jī)可以改善存活嬰兒遠(yuǎn)期(2歲)神經(jīng)發(fā)育結(jié)局,。電腦化的胎心監(jiān)護(hù)圖的胎心率短期變異“安全保障” 故意設(shè)置在低于兩個(gè)靜脈導(dǎo)管隨機(jī)組的水平,。圖1顯示了TRUFFLE研究推薦的監(jiān)測(cè)和管理早發(fā)型胎兒生長(zhǎng)受限妊娠的方案〔66〕。盡管TRUFFLE研究的數(shù)據(jù)顯示,,在無神經(jīng)損傷的嬰兒存活率方面(82%的兒童)優(yōu)于期待值,,但研究開始時(shí)的胎齡、分娩胎齡和出生體重與不良結(jié)局密切相關(guān),。必須強(qiáng)調(diào)的是,,只有聯(lián)合使用靜脈導(dǎo)管多普勒檢查和電腦化的胎心監(jiān)護(hù)圖的監(jiān)測(cè)方案和分娩決策標(biāo)準(zhǔn),才能復(fù)制與TRUFFLE試驗(yàn)相似的結(jié)果,。

如果沒有或不使用電腦化的胎心監(jiān)護(hù)圖,,分娩時(shí)機(jī)應(yīng)基于多普勒測(cè)量指數(shù)(主要是妊娠30周前的靜脈導(dǎo)管)聯(lián)合傳統(tǒng)的胎心監(jiān)護(hù)圖評(píng)估或生物物理評(píng)分。出現(xiàn)復(fù)發(fā)的自發(fā)性無誘因胎心減速是分娩的適應(yīng)證,。然而,,目視分析傳統(tǒng)胎心監(jiān)護(hù)圖的胎心反應(yīng)性時(shí),應(yīng)考慮胎齡和相應(yīng)的胎兒成熟度的影響,。同樣,母體因素(如重度子癇前期,、子癇,、HELLP綜合征)或產(chǎn)科急癥,如胎盤早剝,,是終止妊娠的絕對(duì)適應(yīng)證,。

考慮到嚴(yán)重胎盤功能不全和胎兒低氧血癥/缺氧的強(qiáng)相關(guān)性,,大多數(shù)早發(fā)型胎兒生長(zhǎng)受限病例均建議擇期剖宮產(chǎn)終止妊娠。重要的是,,如果分娩方式是根據(jù)產(chǎn)婦的適應(yīng)證來決定的,,主要是妊娠期高血壓疾病,這可能會(huì)對(duì)圍產(chǎn)兒和產(chǎn)婦的結(jié)局產(chǎn)生不利影響〔68〕,。

圖片

圖1, 解釋了TRUFFLE研究推薦用于監(jiān)測(cè)和處理早期診斷的胎兒生長(zhǎng)受限妊娠方案的流程圖,。

AC,腹圍,;

cCTG,,電腦化胎心監(jiān)護(hù)圖;

DV,,靜脈導(dǎo)管,;

EDF,舒張末期血流,;

PI,,搏動(dòng)指數(shù);

STV,,短變異,;

轉(zhuǎn)載自Bilardo等〔66〕。

推薦

  • 早發(fā)型胎兒生長(zhǎng)受限的妊娠應(yīng)在具有新生兒醫(yī)護(hù)最高水平的三級(jí)醫(yī)療機(jī)構(gòu)進(jìn)行監(jiān)測(cè)和管理(良好實(shí)踐要點(diǎn)),。

  • 推薦由新生兒和母胎醫(yī)學(xué)專家進(jìn)行多學(xué)科管理(良好實(shí)踐要點(diǎn)),。

  • 推薦進(jìn)行多模式評(píng)估,包括胎心監(jiān)護(hù)圖和臍動(dòng)脈,、大腦中動(dòng)脈及靜脈導(dǎo)管多普勒評(píng)估(推薦等級(jí):A),。

  • 當(dāng)電腦化胎心監(jiān)護(hù)圖可用時(shí),胎心率短期變異應(yīng)做為評(píng)估的主要參數(shù)(推薦等級(jí):A),。

  • 應(yīng)根據(jù)胎兒生長(zhǎng)受限的嚴(yán)重程度和臍動(dòng)脈多普勒改變安排監(jiān)測(cè)(良好實(shí)踐要點(diǎn)),。

  • 終止妊娠應(yīng)基于生物物理評(píng)估或母體適應(yīng)證,如下所示:

?  在任何胎齡:存在母體適應(yīng)證(如重度子癇前期,、HELLP綜合征)或產(chǎn)科急癥時(shí)需要終止妊娠(良好實(shí)踐要點(diǎn)),;

?  妊娠24+0~25+6周:個(gè)體化管理(良好實(shí)踐要點(diǎn));

?  ≥ 妊娠26+0周,,如果存在以下任何情況應(yīng)終止妊娠:

- 自發(fā)性反復(fù)持續(xù)性無誘因胎心率減速(推薦等級(jí):A),;

- 生物物理評(píng)分改變(評(píng)分≤ 4)(良好實(shí)踐要點(diǎn));

?  妊娠26+0~28+6周:如果靜脈導(dǎo)管a波等于或低于基線,,或胎心率短期變異<2.6 ms(推薦等級(jí):A),;

?  妊娠29+0~31+6周:如果靜脈導(dǎo)管a波等于或低于基線,或胎心率短期變異<3.0 ms(推薦等級(jí):A);

?  妊娠32+0~33+6周(30+0周后允許):如果UA-EDF反向或胎心率短期變異<3.5 ms(良好實(shí)踐要點(diǎn)),;

?  妊娠≥ 34+0周(32+0周后允許):如果臍動(dòng)脈舒張末期血流缺失或胎心率短期變異<4.5ms(良好實(shí)踐要點(diǎn)),。

  • 如果計(jì)劃在妊娠34+0周前終止妊娠,推薦使用糖皮質(zhì)激素預(yù)防(推薦等級(jí):B),。

  • 如果存在以下一種或多種情況,,推薦擇期剖宮產(chǎn)分娩:電腦化胎心監(jiān)護(hù)圖胎心率短期變異異常、靜脈導(dǎo)管多普勒改變,、臍動(dòng)脈舒張末期血流缺失或反向,、生物物理評(píng)分改變、母體適應(yīng)證(良好實(shí)踐要點(diǎn)),。

未完,,待續(xù)

圖片

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