Society for Maternal-Fetal Medicine Publications Committee, Washington, DC; the Division of Maternal-Fetal Medicine, University of California, San Francisco, San Francisco, CA.
Department of Obstetrics, Gynecology and Reproductive Sciences, The University of Texas Health Science Center at Houston, Houston, TX.
Am J Obstet Gynecol. 2015 Feb;212(2):127-39. doi: 10.1016/j.ajog.2014.12.018. Epub 2014 Dec 31.
Nonimmune hydrops is the presence of ≥2 abnormal fetal fluid collections in the absence of red cell alloimmunization. The most common etiologies include cardiovascular, chromosomal, and hematologic abnormalities, followed by structural fetal anomalies, complications of monochorionic twinning, infection, and placental abnormalities. We sought to provide evidence-based guidelines for the evaluation and management of nonimmune hydrops fetalis.
A systematic literature review was performed using MEDLINE, PubMed, EMBASE, and Cochrane Library. The search was restricted to English-language articles published from 1966 through June 2014. Priority was given to articles reporting original research, although review articles and commentaries also were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion in this document. Evidence reports and guidelines published by organizations or institutions such as the National Institutes of Health, Agency for Health Research and Quality, American Congress of Obstetricians and Gynecologists, and Society for Maternal-Fetal Medicine were also reviewed, and additional studies were located by reviewing bibliographies of identified articles. Grading of Recommendations Assessment, Development, and Evaluation methodology was employed for defining strength of recommendations and rating quality of evidence. Consistent with US Preventive Task Force guidelines, references were evaluated for quality based on the highest level of evidence.
Evaluation of hydrops begins with an antibody screen (indirect Coombs test) to determine if it is nonimmune, detailed sonography of the fetus(es) and placenta, including echocardiography and assessment for fetal arrhythmia, and middle cerebral artery Doppler evaluation for anemia, as well as fetal karyotype and/or chromosomal microarray analysis, regardless of whether a structural fetal anomaly is identified. Recommended treatment depends on the underlying etiology and gestational age; preterm delivery is recommended only for obstetric indications including development of mirror syndrome. Candidates for corticosteroids and antepartum surveillance include those with an idiopathic etiology, an etiology amenable to prenatal or postnatal treatment, and those in whom intervention is planned if fetal deterioration occurs. Such pregnancies should be delivered at a facility with the capability to stabilize and treat critically ill newborns. The prognosis depends on etiology, response to therapy if treatable, and the gestational age at detection and delivery. Aneuploidy confers a poor prognosis, and even in the absence of aneuploidy, neonatal survival is often <50%. Mirror syndrome is a form of severe preeclampsia that may develop in association with fetal hydrops and in most cases necessitates delivery.
非免疫性胎儿水肿是指在不存在红细胞同种免疫的情况下，存在≥2 种异常胎儿液体积聚。最常见的病因包括心血管、染色体和血液学异常，其次是结构胎儿异常、单绒毛膜双胞胎并发症、感染和胎盘异常。我们旨在为非免疫性胎儿水肿的评估和管理提供循证指南。
采用 MEDLINE、PubMed、EMBASE 和 Cochrane 图书馆进行系统文献回顾。搜索范围仅限于 1966 年至 2014 年 6 月期间发表的英文文章。优先考虑报告原始研究的文章，尽管也查阅了综述文章和评论文章。专题研讨会和科学会议上报告的研究摘要不被认为足以纳入本文件。还审查了美国国立卫生研究院、医疗保健研究与质量局、美国妇产科医师学会和母胎医学学会等组织或机构发布的证据报告和指南，并通过查阅已确定文章的参考文献来查找其他研究。采用推荐评估、制定和评估方法对建议的强度和证据质量进行分级。与美国预防服务工作组指南一致，根据最高证据水平评估参考文献的质量。
水肿的评估始于抗体筛查（间接 Coombs 试验）以确定是否为非免疫性，对胎儿和胎盘进行详细超声检查，包括超声心动图和胎儿心律失常评估，以及大脑中动脉多普勒评估以评估贫血，以及胎儿核型和/或染色体微阵列分析，无论是否发现结构胎儿异常。推荐的治疗取决于潜在病因和胎龄；仅建议对有镜像综合征发展等产科指征的孕妇进行早产。皮质类固醇和产前监测的候选者包括那些病因不明、病因可通过产前或产后治疗的患者，以及如果胎儿恶化则计划干预的患者。此类妊娠应在具有稳定和治疗重症新生儿能力的机构中分娩。预后取决于病因、治疗反应（如果可治疗）以及检测和分娩时的胎龄。非整倍体预后不良，即使没有非整倍体，新生儿存活率通常也<50%。镜像综合征是一种严重的子痫前期形式，可能与胎儿水肿相关，在大多数情况下需要分娩。
