胎儿脐动脉舒张末期血流缺失及脑-胎盘率降低与妊娠结局及存活儿早期预后

Fetal umbilical artery absent end-diastolic flow and decreased cerebral-placental ratio and pregnancy outcome and prognosis of survival children

目的探讨胎儿脐动脉舒张末期血流缺失(AEDF)和(或)脑-胎盘率降低(CRP<1),对妊娠结局及存活儿早期预后影响。方法选取2015年1月至2019年12月,在南京医科大学附属妇产医院住院治疗的发生胎儿脐动脉AEDF和(或)CRP<1,并且符合本研究纳入与排除标准的103例孕妇为研究对象。根据临床对孕妇的综合评估,将其分为终止妊娠组(n=64)与继续妊娠组(n=39)。收集2组孕妇的年龄、身高、体重,发生胎儿脐动脉AEDF和(或)CRP<1时孕妇孕龄,孕妇及新生儿妊娠结局,以及存活儿早期预后。采用成组t检验或χ~2检验,对上述指标进行统计学比较。2组孕妇年龄、身高、体重等一般临床资料比较,差异均无统计学意义(P>0.05)。本研究遵循的程序符合南京医科大学附属妇产医院伦理委员会审核批准(审批文号:宁妇伦字[2019]KY-046)。结果 (1)终止妊娠组孕妇发生胎儿脐动脉AEDF和(或)CRP<1时,孕妇孕龄为(34.6±3.0)孕周,显著大于继续妊娠组的(29.3±3.5)孕周,并差异有统计学意义(t=8.286,P<0.001)。(2)2组孕妇分娩孕龄比较,差异无统计学意义(P>0.05)。继续妊娠组新生儿的出生体重为(1 527.5±828.3) g,显著低于终止妊娠组的(1 894.3±696.5) g,并且差异有统计学意义(t=2.289,P=0.029)。继续妊娠组新生儿窒息发生率为16.7%(5/30),显著低于终止妊娠组的1.5%(1/65),并且差异亦有统计学意义(χ~2=5.589,P=0.018)。(3)继续妊娠组39例孕妇中,9例(23.1%)发生胎死宫内,发生胎死宫内时间为发生胎儿脐动脉AEDF和(或)CRP<1后第4~33天(平均为第16.6天)。终止妊娠组孕妇无一例发生胎死宫内,继续妊娠组孕妇胎死宫内发生率,显著高于终止妊娠组,并且差异有统计学意义(χ~2=13.420,P<0.001)。(4)终止妊娠组与继续妊娠组存活儿的营养不良、孤独症谱系障碍、运动发育落后、发育迟缓、语言障碍、视力障碍、听力障碍发生率分别比较,差异均无统计学意义(P>0.05)。结论孕妇发生胎儿脐动脉AEDF和(或)CRP<1时,提示宫内缺氧严重,甚至已较长时间,即使采取急诊剖宫产术终止妊娠,部分患儿仍然遗留神经发育异常症状。对此类孕妇采取期待妊娠治疗,延长孕龄的同时,也可能增加胎死宫内及新生儿窒息发生率,在期待妊娠治疗中加强胎心监护,并适时终止妊娠尤为重要。

Objective To explore influences of fetal umbilical artery absent end-diastolic flow(AEDF)and/or decreased cerebral-placental ratio(CRP)<1 on pregnancy outcome and prognosis of survival children.Methods A total of 103 pregnant women who hospitalized in Women′s Hospital of Nanjing Medical University from January 2015 to December 2019,with fetal umbilical artery AEDF or CRP<1 and met inclusion and exclusion criteria of this study were selected as research subjects.According to clinical comprehensive evaluation results of pregnant women,they were divided into two groups:termination group(n=64)and continued pregnancy group(n=39).Data were collected concerning the age,height,weight of two groups of pregnant women,gestational age when fetal umbilical artery AEDF and/or CRP<1 occurred,pregnancy outcome of pregnant women and neonates,as well as early prognosis of surviving children.Using independent-samples t test or chi-square test,the above indicators were statistically compared.There were no statistically significant differences between two groups of pregnant women in terms of their age,height,weight and other general clinical data(P>0.05).The procedure followed in this study was approved by the Ethics Committee of the Women′s Hospital of Nanjing Medical University(Approval No.[2019]KY-046).Results①The gestational age when fetal umbilical artery AEDF or CRP<1 occurred in pregnant women in termination group was(34.6±3.0)gestational weeks,which was significantly greater than(29.3±3.5)gestational weeks of continued pregnancy group,and the difference was statistically significant(t=8.286,P<0.001).②There was no significant difference in gestational age of delivery between two groups(P>0.05).The neonatal birth weight in continued pregnancy group was(1527.5±828.3)g,which was significantly lower than that of termination group(1894.3±696.5)g,and the difference was statistically significant(t=2.289,P=0.029).The incidence of neonatal asphyxia was 16.7%(5/30)in continued pregnancy group,which was significantly lower than 1.5%(1/65)in termination group,and the difference also was statistically significant(χ2=5.589,P=0.018).③Among 39 pregnant women in continued pregnancy group,9 cases(23.1%)had intrauterine fetal death,and the time of intrauterine fetal death was 4 to 33 days after the occurrence of fetal umbilical artery AEDF and/or CRP<1(average 16.6 days).There was no intrauterine fetal death in pregnant women in termination group.Incidence of intrauterine fetal death of pregnant women in continued pregnancy group was significantly higher than that in termination group,and the difference was statistically significant(χ2=13.420,P<0.001).④There were no statistically significant differences in incidence of malnutrition,autism spectrum disorder,motor development retardation,developmental delay,language disorders,visual disorders,and hearing disorders among surviving children in termination group and continued pregnancy group(P>0.05).Conclusions When fetal umbilical artery AEDF and/or CRP<1 occurs in pregnant women,it indicates that intrauterine hypoxia has been quite serious,and has even existed for a long time.Even if the pregnancy is terminated by emergency cesarean section,some children would still have symptoms of abnormal neuro-development.Expectant pregnancy treatment for such pregnant women will not only prolong the gestational age,but also may increase the incidence of intrauterine death and neonatal asphyxia.It is of particular importance to strengthen the antepartum fetal heart surveillance and adopt timely termination of pregnancy in treatment of expectant pregnancy.