Luthy D A, Wardinsky T, Shurtleff D B, Hollenbach K A, Hickok D E, Nyberg D A, Benedetti T J
Division of Perinatal Medicine, Swedish Hospital Medical Center, Seattle, WA 98104.
N Engl J Med. 1991 Mar 7;324(10):662-6. doi: 10.1056/NEJM199103073241004.
Background. Meningomyelocele can now be detected before birth. Few data are available on its natural history, however, and optimal management at the time of delivery is controversial, although it has been suggested that labor and vaginal delivery may cause pressure on exposed nerve roots, resulting in additional loss of neural function. Methods. To assess the effect of labor and the type of delivery on the level of motor function in fetuses with uncomplicated meningomyelocele, we identified 200 cases of this disorder, accounting for 95 percent of the cases that occurred in the state of Washington during our 10-year study period. We compared the outcomes of 47 infants delivered by cesarean section before labor began, 35 delivered by cesarean section after a period of labor, and 78 who were delivered vaginally (another 40 were ineligible for the study). In cases of meningomyelocele detected prenatally, cesarean section was performed before the onset of labor if isolated meningomyelocele without severe hydrocephalus was present. The infants delivered in this manner were compared with those who were delivered either vaginally or by cesarean section after labor began. Results. At two years of age, the infants who had been exposed to labor were 2.2 times more likely to have severe paralysis than those delivered by cesarean section without labor (95 percent confidence interval, 1.7 to 2.8). Infants delivered by cesarean section before the beginning of labor had a mean (+/- SD) level of paralysis 3.3 +/- 3.0 segments below the anatomical level of the spinal lesion at two years of age, as compared with 1.1 +/- 2.3 for infants delivered vaginally and 0.9 +/- 4.1 for infants delivered by cesarean section after the beginning of labor (P less than 0.001 for both comparisons). Exposure to labor did not affect the frequency of neonatal complications or later intellectual performance. Conclusions. For the fetus with uncomplicated meningomyelocele, delivery by cesarean section before the onset of labor may result in better subsequent motor function than vaginal delivery or delivery by cesarean section after a period of labor.
背景。脊髓脊膜膨出现在可在出生前检测到。然而，关于其自然病史的数据很少，而且分娩时的最佳处理方法存在争议，尽管有人提出分娩和阴道分娩可能会对暴露的神经根造成压力，导致神经功能进一步丧失。方法。为了评估分娩和分娩方式对单纯性脊髓脊膜膨出胎儿运动功能水平的影响，我们确定了200例该疾病病例，占我们10年研究期间华盛顿州发生病例的95%。我们比较了47例在分娩开始前剖宫产的婴儿、35例在分娩一段时间后剖宫产的婴儿和78例经阴道分娩的婴儿的结局（另外40例不符合研究条件）。对于产前检测到的脊髓脊膜膨出病例，如果存在单纯性脊髓脊膜膨出且无严重脑积水，则在分娩开始前进行剖宫产。将以这种方式分娩的婴儿与那些在分娩开始后经阴道或剖宫产分娩的婴儿进行比较。结果。在两岁时，经历过分娩的婴儿出现严重瘫痪的可能性是未经历分娩的剖宫产婴儿的2.2倍（95%置信区间，1.7至2.8）。在分娩开始前剖宫产的婴儿在两岁时的平均（±标准差）瘫痪水平比脊髓病变解剖水平低3.3±3.0节段，相比之下，经阴道分娩的婴儿为1.1±2.3节段，分娩开始后剖宫产的婴儿为0.9±4.1节段（两项比较P均小于0.001）。经历过分娩不影响新生儿并发症的发生率或后期智力表现。结论。对于单纯性脊髓脊膜膨出胎儿，在分娩开始前剖宫产可能比阴道分娩或分娩一段时间后剖宫产产生更好的后续运动功能。
