胎儿生长受限的规范化诊断和管理

<正>随着对胎儿生长受限(fetal growth restriction, FGR)这一疾病的深入研究,该疾病的预测、筛查、诊断等临床处理也有了越来越多的循证医学证据。各个国家发布的FGR指南使得该疾病的诊疗过程愈加规范。本文将结合2019年中华医学会围产医学分会、2019年美国妇产科医师协会以及2020年美国母胎医学会的FGR指南,对如何规范化诊断、管理FGR进行阐述。1 FGR的诊断超声是临床最常用的筛查FGR的手段。     

《2020版美国母胎医学会专家共识：胎儿生长受限的诊断和管理》解读

正胎儿生长受限(fetal growth restriction,FGR)是母体、胎儿和胎盘多种异常状态的最终表现。现今FGR的发病率高达10%,其新生儿病死率仅次于早产儿,并且其对围产期母儿健康和儿童的远期健康也具有重大影响。然而,国际上FGR的诊断标准仍未统一,并且FGR检出率低、预防和治疗措施有限,因此FGR仍然是较为复杂的产科难题。基于现有的循证医学证据,2020年美国母胎医学会(SMFM)专家针对FGR的诊断和管理方案提出21条最新推荐~([1]),本文将结合美国妇产科医师协会(ACOG)2019版FGR指南~([2])以及我国2019版专家共识~([3])对其进行重点解读。     

胎儿生长受限的诊治

胎儿生长受限(fetal growth restriction,FGR),其新生儿无论足月或早产,死亡率与患病率均显著升高,且远期不良结局如儿童时期的认知障碍、成人时期疾病等发生风险增加。2019年美国妇产科医师学会(ACOG)发布了关于FGR的实践指南,我国发布了《胎儿生长受限专家共识(2019版)》(以下简称专家共识)。本文将结合指南对FGR的诊治做文献复习并对一些临床问题进行探讨。     

胎儿生长受限对其肾脏发育的影响

目的：探究胎儿生长受限（fetal growth restriction,FGR）的宫内环境对胎儿肾脏发育的影响。方法：收集2009年11月—2011年12月于天津市中心妇产科医院产科因胎儿原因要求引产的11例FGR和同期12例非FGR死胎或死产胎儿的肾脏组织标本（所有标本的采集均征得患方的知情同意和院伦理委员会的认可）,测量其质量和体积,应用TUNEL法分析肾脏组织细胞凋亡率,并对Bax和Bcl-2蛋白在凋亡细胞中的阳性表达率进行检测。结果：与非FGR组相比,FGR组胎儿的平均肾脏体积、质量和肾单位数目均明显下降（P＜0.01）,而其细胞凋亡率明显增加（P＜0.01）。进一步检测发现,FGR组细胞内促凋亡蛋白Bax的阳性表达率明显增加（P＜0.01）,伴随有凋亡抑制基因Bcl-2的阳性表达率显著降低（P＜0.01）。结论：生长受限的宫内环境可能通过促进细胞凋亡而影响胎儿肾脏发育,为将来进一步探讨FGR的分子机制和成人期疾病的发病机制提供了新的线索。     

胎儿生长受限对胎儿脑神经发育的影响

胎儿生长受限（fetal growth restriction,FGR）可引起胎儿及新生儿近远期发育异常和成年期的严重神经系统疾病,因此FGR对胎儿及新生儿脑神经发育的影响已成为近年来的研究热点。人类研究和动物实验结果显示,FGR的发病时间、FGR的严重程度和分娩时孕周与胎儿脑神经发育密切相关。大脑中动脉多普勒超声、脑-胎盘率可评估FGR胎儿脑血流动力学,相位对比磁共振成像可监测胎儿脑血流及脑结构。早发型和晚发型FGR对子代脑神经发育的影响不同,FGR还可导致胎儿脑结构和功能异常,脑室内出血发生率增加。综述FGR对胎儿脑神经发育影响的研究进展,以期加强临床对FGR胎儿的管理,改善其近远期结局。     

胎儿生长受限：临床实践中的思考及展望

        低出生体重儿在20世纪初期就开始被产科医务工作者所关注。最初人们将这种出生体重低于2500g的新生儿定义为“不成熟”，随后相关研究认识到描述胎儿的生长潜能更为贴切。妊娠期宫内环境不良可导致胎儿生长达不到其应有的生长潜能，出现胎儿生长受限（fetal growth restriction，FGR）。为了推动FGR临床诊治的规范化，美国、加拿大、英国等妇产科学会相继发布了FGR指南［1］。2019年中华医学会围产医学分会发布了“胎儿生长受限专家共识（2019版）”，该指南对FGR的诊断、筛查、预防、监测及终止妊娠时机和方式等进行了相关推荐。在处理FGR的临床实践中，结合该指南，有一些问题值得我们思考。 浏览更多请关注本刊微信公众号及当期杂志。     

2021年美国妇产科医师协会胎儿生长受限指南解读

胎儿生长受限（fetal growth restriction, FGR）,也称为宫内生长受限（intrauterine growth restriction, IUGR）,是一种常见的妊娠并发症。FGR会明显增加胎儿宫内死亡和新生儿死亡的风险,且生长受限的胎儿远期容易发生认知迟缓和成年期的疾病[1, 2]。2021年美国妇产科医师协会（American College of Obstetricians and Gynecologists, ACOG）发布了《胎儿生长受限指南》,该指南在2019年版指南的基础上进行了更新[3],本文将结合中华医学会围产医学会2019年胎儿生长受限专家共识[4],对2021版ACOG指南中要点进行解读。     

胎儿宫内生长受限管理的研究进展

胎儿生长受限(FGR)严重危害胎儿健康,选择有效的监测手段和适当的干预时机对FGR胎儿的预后非常重要。本文总结了FGR的诊断方法,并基于发病进程的不同将FGR划分成早发型、晚发型和足月型,分别阐述了早发型FGR的监测和分娩时机的选择及晚发型和足月型FGR的识别和监测的研究进展,有利于临床对FGR进行更客观有效地管理。     

胎儿生长受限的病因研究进展

胎儿生长受限（FGR）又称宫内生长受限（IUGR）,是指胎儿在母体、胎儿自身以及环境因素影响下未达到其生长潜能,是产科常见疾病之一,也是我国围生儿死亡的主要原因之一。FGR可以引起多种围生儿不良妊娠结局,包括胎儿窘迫、低出生体质量儿、早产等,且与多种远期或成年疾病相关,如代谢综合征、心血管疾病。预防FGR的发生对于提高人口素质有重要意义,但引起FGR的因素众多,主要包括母体因素、胎儿因素及胎盘、脐带因素,各种因素并不只以单一的形式存在,全面了解其发生因素有助于预防该疾病的发生。对FGR的病因进行综述,以期为该疾病的预防提供理论基础。。     

胎儿生长受限分类与管理研究进展

胎儿的生长受母体疾病、胎盘功能、胎儿遗传等多因素影响。胎儿生长受限(FGR)是临床产科极具挑战的问题,围产期患病和死亡率较高,远期预后不良。回顾国内外FGR最新研究进展、指南及专家共识,重点针对非遗传因素FGR的定义分类、超声监测和分娩时机进行综述,为FGR的临床管理提供一定的科学依据,以期改善FGR胎儿的近、远期结局。     

The Semmelweis University experience

The author has worked in genetic counseling and prenatal genetic diagnosis and screening since 1966. He has been the Head of the Department of Obstetrics and Gynecology at Semmelweis University of Budapest for 10 years where he founded its center of prenatal genetics. This tertiary center aims to treat as many pregnancies with a prenatal diagnosis or suspicion of fetal anomalies as possible for confirmation, further testing and possible termination of pregnancy. The department is equipped with an in-house cytogenetic, molecular genetic, fetopathological and ultrasound laboratory and deals with the methodological, psychological, ethical, and legal aspects of abortions. Their excellent database facilitates the follow-up of maternal and fetal patients, in order to investigate the efficiency of genetic counseling and diagnosis. As the President of the Hungarian College of Obstetricians and Gynecologists and the Hungarian Society of Ultrasound in Obstetrics and Gynecology, Zoltán Papp oversees the prenatal diagnosis system for the whole of Hungary. He has also developed and now supervises the quality assurance system which ensures effective and reliable ultrasound screening for pregnant women.     

FIGO Committee for the Ethical Aspects of Human Reproduction and Women's Health: Committee Statement to be Used When Publishing the Enclosed Ethical Guidelines, 1998

EDITORIAL COMMENT: The following report was submitted to the Australian and New Zealand Journal of Obstetrics and Gynaecology for consideration for publication by the Chairperson of the FIGO Committee for the Ethical Aspects of Human Reproduction and Women's Health. The Editorial Committee which decided to publish this paper wish to make the statement that the opinions expressed in the document do not necessarily reflect their endorsement by either the Editorial Board of the Journal or by the Committees of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. These guidelines were published in the International Journal of Gynecology and Obstetrics, which is the official FIGO journal, in the March, 1999 issue. In publishing this material it is acknowledged that the copyright is held by the International Journal of Gynecology and Obstetrics.     

The next twenty-five years.

The next 25 years have been reviewed from the general standpoint of people and economy and from the specific focus of the health care needs of women. Special problems in patient care which will require our immediate attention have been identified. The strengths and weaknesses of the College have been presented. A proposal for reinforcement of organization within the discipline to help us pull together as a team is the creation of 1) A Coordinating Council For Obstetrics and Gynecology; and 2) A Board of Trustees for the American College. These steps I believe are essential to the health growth of our College and the advancement of quality education and improved patient care.     

Correlation of Antenatal Ultrasound Parameters with the Postnatal Outcome of Bilateral Fetal Hydronephrosis

The Journal of Obstetrics and Gynecology of India - To determine the role of antenatal parameters in predicting the outcome of bilateral fetal hydronephrosis. Total 50 antenatal women with...     

Are there gender-specific differences in pregnancy outcome and placental abnormalities of pregnancies complicated with small for gestational age?

Archives of Gynecology and Obstetrics - Adaptations to pathological intrauterine environment might differ in relation to fetal gender. We aimed to study sex-specific differences in placental...     

Does the Porter formula hold its promise? A weight estimation formula for macrosomic fetuses put to the test

Archives of Gynecology and Obstetrics - Estimating fetal weight using ultrasound measurements is an essential task in obstetrics departments. Most of the commonly used weight estimation formulas...     

BOOK REVIEWS

"Disease in Infancy and Childhood." By RICHARD W. B. ELLIS. 2nd Edition.
"Williams' Obstetrics." By NICHOLSON J. EASTMAN. 11th Edition.
"Before and After Childbirth." By JANE MADDERS, M.C.S.P., Dip. Phys. Ed.
"Gynecological Cancer." By JAMES A. CORSCADEN, M.D. 2nd Edition.
"They Did Not Pass By—The Story of the Early Pioneers of Nursing." By DENIS G. MURPHY.
"Natural Childbirth." By H. B. ATLEE, M.D., F.R.C.S., F.I.C.S.
"Tuberculosis in Obstetrics and Gynaecology." By GEORGE SCHAEFER, M.D., F.A.C.S., F.I.C.S.
"Integrated Gynecology." By I. C. RUBIN, M.D., formerly Clinical Professor of Obstetrics and Gynecology, New York University, and JOSEF NOVAK, M.D., Professor of Obstetrics and Gynecology, University of Vienna, and formerly Clinical Professor of Gynecology, College of Physicians and Surgeons, Columbia University.     

May high oxygen affinity of maternal hemoglobin cause fetal growth retardation?

Archives of Gynecology and Obstetrics - Eleven pregnant women with normal fetal outcome (controls), seven women with small for dates babies and 15 non-pregnant women were studied. Hemoglobin (Hb),...     

Long Curriculum 3.0 in Resident Education: Comprehensive Curriculum in Pediatric and Adolescent Gynecology for Postgraduate Trainees in Obstetrics/Gynecology,Pediatrics, and Adolescent Medicine

In 2015, the Resident Education Committee of the North American Society for Pediatric and Adolescent Gynecology published the Long Curriculum in Resident Education to provide educators with a comprehensive document to be used in postgraduate medical education. The original curriculum was designed to meet the resident learning objectives for the Council on Resident Education in Obstetrics and Gynecology, the American Board of Pediatrics, and the Royal College of Physicians and Surgeons of Canada and to provide a more intensive, broader learning experience. The curriculum was updated in 2018. This Committee Document is the third updated version (3.0) of the Long Curriculum in Resident Education.     

Ultrasound evaluation of fetal lung maturity in imminent preterm labor cases

The development of ultrasound examination lets us perform the biophysical assessment of fetus lungs. From 1986, at the Ivth Clinic of Obstetrics and Gynecology in Tychy, examinations of fetus lung were performed with Siemens and Bruel & Kjaer real-time ultrasonographic equipped. The elasticity of fetal lung (DLS--dynamic lung score) was estimated by taking a transversal section through the fetal chest in a plane at fetal in a plane at fetal heart and presented in 3-grade scale: I-grade--lack of elasticity (immaturity of lungs), II-grade--non complete elasticity, III-grade--normal elasticity (maturity of lungs).