指南速遞 | SOGC指南：胎兒生長受限-單胎妊娠的篩查,、診斷和管理

新用戶09758046 2023-11-29 發(fā)布于陜西

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胎兒生長受限是一種常見的產(chǎn)科并發(fā)癥，最常見的原因是潛在的胎盤疾病,。胎兒生長的準(zhǔn)確評估是產(chǎn)前保健的核心目標(biāo),。“2023 SOGC臨床實(shí)踐指南：胎兒生長受限-單胎妊娠的篩查,、診斷和管理（No.442）”指南主要針對胎兒生長受限-單胎妊娠的篩查,、診斷和管理提供指導(dǎo)建議。

臨床實(shí)踐變更推薦

1.胎兒生長受限診斷主要用德爾斐（Delphi）共識的基于超聲標(biāo)準(zhǔn),，同時(shí)需要對早發(fā)（＜32周）和晚發(fā)型（≥32周）胎兒生長受限作出區(qū)分,。

2.目前沒有足夠證據(jù)推薦常規(guī)使用阿司匹林來預(yù)防胎兒生長受限（對于缺乏早發(fā)子癇前期高危因素人群）。

3.胎兒生長評估建議通過基于無并發(fā)癥的胎兒超聲生長標(biāo)準(zhǔn),，不建議使用基于出生體重?cái)?shù)據(jù)的生長圖表,。

4.任何時(shí)候的有生機(jī)兒到36周，當(dāng)懷疑胎兒生長受限時(shí),，建議測量PIGF或者sFlt-1/PIGF,，以協(xié)助臨床醫(yī)生區(qū)分胎盤源性的胎兒生長受限、非胎盤因素相關(guān)的胎兒生長受限以及小于胎齡兒,。

5.在晚發(fā)胎兒生長受限監(jiān)測中,，大腦中動脈多普勒測量最好結(jié)合腦胎盤多普勒比值（大腦中動脈PI/臍動脈PI，CPR）,。腦胎盤比值小于第5個(gè)百分位數(shù),，考慮異常、根據(jù)孕周,，這個(gè)發(fā)現(xiàn)可以有助于協(xié)助監(jiān)護(hù)或明確分娩指征,。

總結(jié)

1.對于臨床醫(yī)生來說，了解生長受限胎兒（FGR）和小于胎齡兒（SGA）之間的區(qū)別是很重要的,，因?yàn)镕GR會提高孕婦圍產(chǎn)期并發(fā)癥率和死亡率,，但SGA并不會。（證據(jù)質(zhì)量高）

2.SGA指的是胎兒經(jīng)超聲測得的腹圍（AC）或估測胎兒體重（EFW）低于給定參考范圍的第10百分位數(shù)或指嬰兒出生體重低于第10百分位數(shù),。（證據(jù)質(zhì)量高）

3.FGR指胎兒因潛在的病理而未達(dá)到其遺傳預(yù)期的生長潛能的情況,，多分為妊娠32周前罕見的早發(fā)型FGR（患病率0.5%），或更常見的妊娠32周及以后的晚發(fā)型FGR（患病率5%-10%）,。（證據(jù)質(zhì)量中等）

4.FGR診斷主要采用Delphi共識的基于超聲標(biāo)準(zhǔn),。測量指標(biāo)因胎齡而異，包括胎兒大小,、胎兒生長情況以及臍動脈（UA）,、子宮動脈（UtA）和大腦中動脈（MCA）多普勒異常。（證據(jù)質(zhì)量中等）

5.早發(fā)型FGR應(yīng)在妊娠32周前診斷出，同時(shí),，其依據(jù)應(yīng)至少滿足以下三個(gè)標(biāo)準(zhǔn)中的其中一個(gè)：

（1）AC或EFW低于第3百分位數(shù),；

（2）UA多普勒評估中存在晚期不良變化（如臍動脈舒張末期血流缺失，AEDF或反向,，REDF等）,；

（3）AC或EFW低于第10百分位數(shù)，并伴有子宮動脈多普勒異常（UtA-PI＞第95百分位數(shù)）或UA多普勒異常（UA-PI＞第95百分位數(shù)）,。（證據(jù)質(zhì)量中等）

6.晚發(fā)型FGR應(yīng)在妊娠32周或之后診斷出,，其依據(jù)是AC或EFW低于第3百分位數(shù)或滿足以下3個(gè)標(biāo)準(zhǔn)中的至少2個(gè)標(biāo)準(zhǔn)：

（1）AC或EFW低于第10百分位數(shù)；

（2）AC或EFW超過2個(gè)四分位數(shù),；

（3）多普勒異常（UA-PI＞第95百分位數(shù)或CPR＜第5百分位數(shù)）。（證據(jù)質(zhì)量中等）

7.在妊娠早期,，對于FGR的多模式評估比基于臨床危險(xiǎn)因素的更有效,。但由于加拿大在實(shí)行時(shí)發(fā)現(xiàn)流程過于復(fù)雜，故目前不推薦該法,。（證據(jù)質(zhì)量中等）

8.在妊娠中期,，超聲觀察組合（在胎兒解剖學(xué)超聲掃描中進(jìn)行）可能有助于早發(fā)型FGR的診斷。這些經(jīng)超聲檢測出的病理特征有：胎兒的生物測量評估值低于其胎齡標(biāo)準(zhǔn)值一周以上,、短股骨,、腸回聲、單臍動脈,、臍帶邊緣插入或帆狀附著,。（證據(jù)質(zhì)量中等）

9.在妊娠中期和晚期，UtA和UA多普勒評估都不能有效預(yù)測低危妊娠情況下的FGR,。（證據(jù)質(zhì)量高）

10.在妊娠中期或晚期對PIGF的測量不能有效預(yù)測低危妊娠情況下的FGR,。（證據(jù)質(zhì)量中等）

11.常規(guī)的恥骨聯(lián)合-宮體高度測量對FGR敏感且特異性較高，這對于體重指數(shù)正常的臨床低?；颊邅碚f是一種可接受的方法,。考慮產(chǎn)婦的身高,、體重,、年齡等和既往妊娠結(jié)局等，可提高評估的準(zhǔn)確性,。超聲檢查會比常規(guī)的恥骨聯(lián)合-宮體高度測量更精確（對于體重指數(shù)＞35kg/m²,，羊水過多或巨大子宮肌瘤患者）。（證據(jù)質(zhì)量中等）

12.UA多普勒波形在胎盤源性的早發(fā)型FGR中通常異常,，而在胎盤源性的晚發(fā)型FGR中通常正常,。當(dāng)FGR是由于染色體數(shù)量變異（如18三體綜合征、21三體綜合征或三倍體綜合征等）或胎兒自身其他的疾病時(shí)，UA多普勒檢查結(jié)果可能異常,。（證據(jù)質(zhì)量高）

推薦

預(yù)測FGR

1.對于在妊娠早期或中期母體血清篩查分析結(jié)果異常的孕婦,，可能存在FGR和其他胎盤源性的并發(fā)癥的風(fēng)險(xiǎn)。醫(yī)務(wù)人員應(yīng)使用UtA多普勒評估（如有）來判斷其出現(xiàn)FGR的最大風(fēng)險(xiǎn),。（強(qiáng)推薦,，證據(jù)質(zhì)量中等）

2.在發(fā)現(xiàn)存在FGR的臨床危險(xiǎn)因素或胎兒解剖學(xué)超聲結(jié)果提示時(shí)，臨床醫(yī)生應(yīng)在孕期第24-26周時(shí)進(jìn)行胎兒生長的基線超聲評估,，并與UtA多普勒評估和/或PIGF測量結(jié)果相結(jié)合,，以告知患者妊娠晚期的胎兒監(jiān)測計(jì)劃。（強(qiáng)推薦,，證據(jù)質(zhì)量中等）

預(yù)防FGR

3.在第一次產(chǎn)前檢查時(shí),，臨床醫(yī)生應(yīng)耐心、包容地與患者討論以下話題：吸煙,、飲酒,、藥物濫用和孕期適當(dāng)?shù)捏w重管理。這將有助于更好地實(shí)施產(chǎn)前預(yù)防措施,。（強(qiáng)推薦,，證據(jù)質(zhì)量高）

4.在妊娠16周前開始服用低劑量阿司匹林（150mg/d-162mg/d），并持續(xù)到＞34周,，僅可預(yù)防有子癇前期風(fēng)險(xiǎn)的患者發(fā)生FGR,。(特定條件下建議，證據(jù)質(zhì)量低)

5.臨床醫(yī)生應(yīng)謹(jǐn)慎聯(lián)合使用低分子肝素和低劑量阿司匹林以預(yù)防FGR（對于少數(shù)易出現(xiàn)嚴(yán)重胎盤病變的子癇前期患者）,。(特定條件下建議,，證據(jù)質(zhì)量低)

發(fā)現(xiàn)FGR

6.醫(yī)務(wù)人員可持續(xù)測量恥骨聯(lián)合-宮底高度來檢測體重指數(shù)＜30kg/m²的臨床低危患者的FGR,。（特定條件下建議,，證據(jù)質(zhì)量中等）

7.對于體重指數(shù)高（特別當(dāng)＞35kg/m²時(shí)）、羊水過多或巨大子宮肌瘤的患者,，醫(yī)護(hù)人員應(yīng)采用超聲檢查（而不是恥骨聯(lián)合-宮底高度測量）,。（強(qiáng)推薦，證據(jù)質(zhì)量中等）

8.超聲醫(yī)師應(yīng)使用Hadlock-3公式（體重=1.326-0.00326*腹圍*股骨長度 0.0107*頭圍 0.0438*腹圍 0.158*股骨長度）計(jì)算胎兒體重,，并應(yīng)用于超聲測量頭圍,、腹圍和股骨長。（強(qiáng)推薦,，證據(jù)質(zhì)量中等）

9.醫(yī)務(wù)人員應(yīng)基于無并發(fā)癥的胎兒超聲生長圖來估測胎兒體重,，以此來解釋胎兒的生長。（強(qiáng)推薦,，證據(jù)質(zhì)量中等）

10.對于低風(fēng)險(xiǎn)孕婦,，應(yīng)使用持續(xù)恥骨聯(lián)合-宮體高度測量和選擇性的超聲檢查，而不推薦常規(guī)的妊娠晚期超聲檢查，因?yàn)檫@種做法不能降低死產(chǎn)或不良圍產(chǎn)期結(jié)局的總體風(fēng)險(xiǎn),。（強(qiáng)推薦,，證據(jù)質(zhì)量中等）

疑似FGR的進(jìn)一步檢查

11.疑似FGR的情況應(yīng)由醫(yī)護(hù)人員進(jìn)行系統(tǒng)地評估，包括詳細(xì)的病史,、相關(guān)先天性感染的母體血清篩查以及詳細(xì)的超聲檢查,，以明確診斷和確定導(dǎo)致相關(guān)結(jié)果的潛在原因；同時(shí)將小于胎齡兒和胎盤源性的FGR或由潛在的遺傳疾病或畸形或感染引起的FGR區(qū)分開來,。（強(qiáng)建議,，證據(jù)質(zhì)量高）

12.任何有生機(jī)兒到36周，當(dāng)懷疑FGR時(shí),，單獨(dú)測量（如可獲?。㏄IGF或測量sFlt1/PIGF比值可以幫助臨床醫(yī)生識別胎盤源性的FGR。（特定條件下建議,，證據(jù)質(zhì)量中等）

13.當(dāng)懷疑經(jīng)胎盤的胎兒感染導(dǎo)致早發(fā)型FGR時(shí),，應(yīng)進(jìn)行母體血清ToRCH（弓形蟲、風(fēng)疹病毒,、巨細(xì)胞病毒和單純皰疹病毒）篩查,，巨細(xì)胞病毒感染是最常見的疾病,。疑似先天性感染的患者應(yīng)轉(zhuǎn)診至指定的地區(qū)母胎醫(yī)學(xué)中心進(jìn)行進(jìn)一步評估,。（強(qiáng)建議，證據(jù)質(zhì)量中等）

14.非整倍體非介入性產(chǎn)前篩查可用于確定FGR的遺傳原因,，但考慮到與FGR相關(guān)遺傳疾病的范圍,，結(jié)果正常時(shí)的參考價(jià)值有限。（強(qiáng)建議,，證據(jù)質(zhì)量高）

15.對于疑似早發(fā)型FGR的患者,，尤其合并結(jié)構(gòu)異常、羊水過多或多個(gè)軟指標(biāo)陽性的情況以及與胎盤因素?zé)o關(guān)時(shí),，建議進(jìn)行遺傳咨詢和羊膜腔穿刺術(shù)（用于胎兒DNA的染色體微陣列和先天性感染的分子分析）,。（強(qiáng)建議，證據(jù)質(zhì)量高）

16.對于疑似早發(fā)型FGR的患者,，尤其合并低PIGF水平或sFlt1/PIGF比值升高時(shí),，發(fā)生子癇前期風(fēng)險(xiǎn)很高，應(yīng)對患者進(jìn)行教育和系列評估,。（強(qiáng)建議,，證據(jù)質(zhì)量中等）

早發(fā)型FGR的管理

17.臨床醫(yī)生應(yīng)主要使用多普勒聯(lián)合檢查（子宮動脈、臍動脈,、大腦中動脈,、腦胎盤血流比和靜脈導(dǎo)管多普勒）來識別并監(jiān)測早發(fā)型（＜32周）FGR。（強(qiáng)建議，證據(jù)質(zhì)量高）

18.醫(yī)護(hù)人員應(yīng)聯(lián)合使用無應(yīng)激試驗(yàn)（NST）,、電腦化的胎心監(jiān)護(hù)（如有）或全面或改良胎兒生物物理評分（BPP/mBPP）來監(jiān)測早發(fā)型FGR,，并應(yīng)在連續(xù)超聲檢查期間和住院期間作為輔助檢查進(jìn)行。（特定情況下的建議,，證據(jù)質(zhì)量中等）

19.當(dāng)早發(fā)型FGR的胎兒出現(xiàn)早期臍動脈多普勒波形異常（阻力升高,，表現(xiàn)為搏動指數(shù)＞第95百分位數(shù)）時(shí)，應(yīng)每周通過大腦中動脈和靜脈導(dǎo)管多普勒檢查進(jìn)行評估,。若臍動脈變化保持穩(wěn)定,，并且靜脈導(dǎo)管多普勒檢查正常，門診評估即可,。（強(qiáng)建議,，證據(jù)質(zhì)量中等）

20.當(dāng)觀察到臍帶多普勒波形高度異常（即舒張末期血流反向）時(shí)，或當(dāng)臍動脈舒張末期血流缺失伴有大腦中動脈或靜脈導(dǎo)管多普勒異常時(shí),，臨床醫(yī)生應(yīng)考慮收院進(jìn)行日常監(jiān)測,。（強(qiáng)建議，證據(jù)質(zhì)量中等）

21.當(dāng)早發(fā)型FGR合并子癇前期或其他嚴(yán)重并發(fā)癥,，例如Ⅰ型糖尿病時(shí),，臨床醫(yī)生應(yīng)考慮收院進(jìn)行日常監(jiān)測。（強(qiáng)建議,，據(jù)質(zhì)量中等）

22.如果出現(xiàn)以下情況,，無論胎齡，均應(yīng)安排緊急分娩：

產(chǎn)婦有分娩指征（例如重度子癇前期合并血壓失控或HELLP[溶血,、肝酶水平升高和血小板水平低]綜合征）,；（強(qiáng)建議，證據(jù)質(zhì)量高）

出現(xiàn)胎盤早剝,；（強(qiáng)建議,，證據(jù)質(zhì)量高）

出現(xiàn)NST監(jiān)護(hù)異常（即變異降低或重復(fù)性遲發(fā)減速）。（強(qiáng)建議,，證據(jù)質(zhì)量高）

23.如果靜脈導(dǎo)管多普勒和NST正常,，出現(xiàn)臍動脈舒張末期血流反向，可將分娩時(shí)間推遲至孕30-32周,；出現(xiàn)臍動脈舒張末期血流缺失,，可將分娩時(shí)間推遲到孕32-34周。（強(qiáng)建議,，證據(jù)質(zhì)量高）

24.當(dāng)準(zhǔn)父母因早發(fā)型FGR面臨早產(chǎn)的可能時(shí),，臨床醫(yī)生應(yīng)安排他們向新生兒兒科醫(yī)生進(jìn)行咨詢。（強(qiáng)建議,，證據(jù)質(zhì)量高）

25.臨床醫(yī)生應(yīng)在計(jì)劃性早產(chǎn)前給予一系列的皮質(zhì)類固醇以促進(jìn)胎兒的肺部發(fā)育成熟,，并在分娩當(dāng)天靜脈注射硫酸鎂以保護(hù)胎兒神經(jīng),。這兩種藥物應(yīng)遵循無FGR妊娠的相同方案進(jìn)行使用。（強(qiáng)建議,，證據(jù)質(zhì)量高）

26.剖宮產(chǎn)通常適用于胎盤源性的早發(fā)型FGR和臍動脈（舒張末期血流缺失或血流反向）或靜脈導(dǎo)管（a波反向或缺失）存在嚴(yán)重多普勒異常的情況,，以避免引產(chǎn)所致胎兒急性損傷。（強(qiáng)建議,，證據(jù)質(zhì)量高）

27.當(dāng)有生機(jī)兒（23-26周）發(fā)生嚴(yán)重早發(fā)型FGR,，在即將發(fā)生死胎和新生兒死亡的高危時(shí)期，臨床醫(yī)生應(yīng)向做出艱難決定的準(zhǔn)父母提供全方位支持,。（強(qiáng)建議,，證據(jù)質(zhì)量中等）

晚發(fā)型FGR的管理

28.臨床醫(yī)生可以通過多種工具監(jiān)測疑似的晚發(fā)型FGR。標(biāo)準(zhǔn)的護(hù)理方法包括胎兒運(yùn)動的母體監(jiān)測,、全面或改良胎兒生物物理評分（BPP/mBPP）和無應(yīng)激試驗(yàn)（NST）,。臍動脈多普勒監(jiān)測不應(yīng)單獨(dú)用于監(jiān)測。（強(qiáng)建議,，證據(jù)質(zhì)量中等）

29.大腦中動脈多普勒檢查可作為一種檢測工具,，但理論上應(yīng)與臍動脈多普勒檢查相結(jié)合，并通過推導(dǎo)腦-胎盤多普勒比值（大腦中動脈搏動指數(shù)/臍動脈搏動指數(shù)）來解釋,。大腦中動脈多普勒檢查應(yīng)在胎兒靜止時(shí)進(jìn)行,，以避免出現(xiàn)結(jié)果假陽性。低于胎齡的第5百分位數(shù)的腦胎盤血流比被視作異常腦胎盤血流比,，并提示需要根據(jù)胎齡加強(qiáng)監(jiān)測或安排分娩,。（特定情況下建議，證據(jù)質(zhì)量低）

30.當(dāng)臍動脈和大腦中動脈多普勒檢查結(jié)果正常，患者感受到正常的胎動，并且EFW和胎兒腹圍在第3-9百分位數(shù)時(shí),，建議每周進(jìn)行BPP/mBPP,。（強(qiáng)建議，證據(jù)質(zhì)量低）

31.當(dāng)EFW或AC低于第3百分位數(shù)時(shí),，或當(dāng)其他觀測指標(biāo)表明胎兒生長確實(shí)受限時(shí),，需要進(jìn)行每周進(jìn)行兩次監(jiān)測或安排分娩。主要表現(xiàn)為：

子宮動脈多普勒異常（UtA-PI＞第95百分位數(shù)）,；

臍動脈多普勒異常（UA-PI＞第95百分位數(shù)）,；

大腦中動脈（MCA）多普勒異常（MCA-PI＜第5百分位數(shù)或CPR＜第5百分位數(shù)）；

羊水不足（最大羊水深度＜2厘米）,；

胎盤形態(tài)高度異常,，表明多區(qū)域組織損傷。（強(qiáng)建議,，證據(jù)質(zhì)量中等）

32.胎兒僅有輕度小于胎齡（EFW或AC在第3-9百分位數(shù),，且多普勒檢查結(jié)果正常,，羊水正常），應(yīng)考慮在孕39周進(jìn)行分娩,。（強(qiáng)建議,，證據(jù)質(zhì)量中等）

33.無并發(fā)癥的晚發(fā)型FGR（EFW或AC低于第3百分位數(shù)，多普勒檢查正常,，羊水正常）時(shí),，應(yīng)考慮孕37周進(jìn)行分娩。（強(qiáng)建議,，證據(jù)質(zhì)量中等）

34.當(dāng)出現(xiàn)下列任何一種情況時(shí),，建議晚發(fā)型FGR的產(chǎn)婦在孕37周前分娩：臍動脈多普勒檢查異常（UA-PI＞第95百分位數(shù)，CPR＜第5百分位數(shù)）,、BPP/mBPP異常,、羊水過少或診斷為子癇前期。（強(qiáng)建議,，證據(jù)質(zhì)量中等）

35.對于頭先露且無剖宮產(chǎn)指征的產(chǎn)婦,，嘗試引產(chǎn)應(yīng)考慮到產(chǎn)婦年齡、胎次,、盆腔檢查結(jié)果,、入院時(shí)的超聲檢查結(jié)果、NST結(jié)果和夫妻意愿,。（特定情況下的建議,，證據(jù)質(zhì)量低）

36.因FGR而實(shí)施的引產(chǎn)術(shù)應(yīng)僅在持續(xù)胎心監(jiān)測的住院環(huán)境中進(jìn)行，而非間歇性聽診,。（強(qiáng)建議,，證據(jù)質(zhì)量中等）

37.當(dāng)因疑似晚發(fā)型FGR而引產(chǎn)時(shí)，應(yīng)盡可能優(yōu)先采用機(jī)械的使宮頸成熟的方法而不是使用前列腺素藥物,。機(jī)械性使宮頸成熟可與低劑量催產(chǎn)素聯(lián)合使用,，作為胎兒健康的“催產(chǎn)素挑戰(zhàn)試驗(yàn)”。如果胎心監(jiān)測在引產(chǎn)過程中或分娩前期出現(xiàn)異常,，應(yīng)實(shí)施剖宮產(chǎn)終止妊娠,。（強(qiáng)建議，證據(jù)質(zhì)量中等）

38.當(dāng)出生時(shí)懷疑FGR,，應(yīng)將送胎盤做病理分析（如果可以的話）,，尤其是B超提示明顯的胎盤異常。（強(qiáng)建議,，證據(jù)質(zhì)量中等）

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魏秋娜南方醫(yī)科大學(xué)第二臨床醫(yī)學(xué)院
羅天宇南方醫(yī)科大學(xué)第二臨床醫(yī)學(xué)院
張景怡南方醫(yī)科大學(xué)第二臨床醫(yī)學(xué)院
黃啟濤佛山市第一人民醫(yī)院婦產(chǎn)科

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