超声估测胎儿体重和多普勒参数评价晚发型胎儿生长受限的临床价值

Prediction study of late-onset fetal growth restriction with estimated fetal weight and Doppler parameters

目的探讨INTERGROWTH和Hadlock胎儿体重估测（estimated fetal weight，EFW）标准以及多普勒参数预测晚发型胎儿生长受限（fetal growth restriction，FGR）的准确性。方法本研究为前瞻性队列研究。收集2015年3月至2016年3月在复旦大学附属妇产科医院建卡并分娩的32～41周单胎妊娠孕妇。每2周监测超声指标（包括胎儿生长测量、脐动脉和大脑中动脉），采用分娩前7d内最后一次超声测量值，分别按照INTERGR0WTH和Hadlock标准计算胎儿体重，同时采用Logistic回归方程建立EFW、脐动脉、大脑中动脉单参数模型和多参数联合模型预测晚发型FGR。根据新生儿出生体重是否低于同胎龄应有体重第10百分位数（〈10^th％），分为FGR组（晚发型FGR，出生体重〈10^th％）和对照组（非FGR，出生体重≥10^th％）。并对两种标准预测FGR行ROC曲线分析。结果820例孕妇符合人组条件，排除144例失访病例。最终获得有效数据676例，分为FGR组116例，对照组560例。ROC曲线分析显示，Hadlock—EFWc预测晚发型FGR的截断值为22．6^th％，对应的敏感性、特异性和曲线下面积（AUC）分别为87．3％、82．8％和0．930（0．908—0．953），均高于INTERGROWTH—EFWc的预测价值[截断值为27．5^th％，对应的敏感性、特异性和AUC分别为71．4％、83．7％和0．847（0．807—0．888）]。多普勒参数单独预测晚发型FGR的价值较低（均AUC〈0．7），多参数联合模型（combined model—Ⅰ和Ⅱ）预测FGR的价值较高（AUC分别为0．865和0．936），与其对应的胎儿体重预测模型的准确性相似。结论Hadlock和INTERGROWTH的EFW标准预测本地区晚发型FGR的临床价值均较高，但是Hadlock标准的预测准确性更优。多普勒参数（脐动脉、大脑中动脉）预测晚发型FGR的准确性较低，建议高危孕妇选择性监测。

Objective To explore the predictive accuracy of two estimated fetal weight （EFW） standards （INTERGROWTH and Hadlock） and Doppler parameters for late-onset fetal growth restriction （FGR）. Methods A prospective cohort of women with singleton pregnancies who attended research scans and had a livebirth at the obstetrics and gynecology hospitat of Fudan University during 32 - 41 weeks of gestation was involved. The markers of ultrasound examinations （including growth measurements, umbilical artery and middle cerebral artery parameters） were obtained every two weeks. The INTERGROWTHEFWc and Hadlock-EFWc data were obtained from the last ultrasonography （within 7 days before delivery） and were used to predict later-onset FGR in a single model or in combined models with other Doppler parameters by logistic regression analyses, respectively. According to delivery gestation of age and Chinese birth weight （BW） standards, all cases were divided into a control group （non-FGR, BW≥ 10^th%） and a FGR group （Late-onset FGR, BW〈10^th%）, ROC curve analyses were performed to compare the predictive accuracy for the late-onset FGR between the Hadlock-EFWc and INTERGROWTH-EFWc. Results A total of 820 eligible women were identified and 676 had finished the follow-up and were enrolled in this prospective cohort study. Among them, 116 neonates were assigned to the late-onset FGR group, and 560 as control group （non-FGR）. The cut-off value of the INTERGROWTH-EFWc was percentile 27.5, at which had a sensitivity and specificity of 71.4% and 83.7%. The corresponding sensitivity and specificity were 87.3% and 82.8% at a cut-off value of percentile 22.6 of the Hadlock-EFWc. The Hadlock-EFWc had a higher predictive accuracy for the late-onset FGR than the INTERGROWTH-EFWc, their AUC were 0. 930 （0.908- 0.953） and 0.847 （0.807 - 0.888）, respectively. The accuracy of Doppler single-parameter （umbilical artery and middle cerebral artery） for late-onset FGR were low （AUC%0.7）, but the accuracy of combined model- Ⅰ and Ⅱ were high （AUC 0. 865 and 0.936, respectively）, similar to their corresponding EFWc models, respectively. Conclusions The INTERGROWTH-EFWc could predict effectively for lateonset FGR, however, its predictive accuracy is lower than that of the Hadlock-EFWc. The predictive accuracy of Doppler parameters for late-onset FGR are poor, routine monitoring of non-selected populations is not recommended.