Lee Vanessa R, Pilliod Rachel A, Frias Antonio E, Rasanen Juha P, Shaffer Brian L, Caughey Aaron B
a Department of Obstetrics and Gynecology , Oregon Health and Science University , Portland , OR , USA and.
b Department of Obstetrics and Gynecology , Brigham and Women's Hospital and Massachusetts General Hospital , Boston , MA , USA.
J Matern Fetal Neonatal Med. 2016 Mar;29(5):690-5. doi: 10.3109/14767058.2015.1018170. Epub 2015 Sep 4.
To determine the optimal timing of delivery in late preterm intrauterine growth restriction (IUGR) fetuses with abnormal umbilical artery Doppler (UAD) indices.
A decision-analytic model was built to determine the optimal gestational age (GA) of delivery in a theoretic cohort of 10 000 IUGR fetuses with elevated UAD systolic/diastolic ratios diagnosed at 34 weeks. All inputs were derived from the literature. Strategies involving expectant management accounted for the probabilities of stillbirth, spontaneous delivery and induction of labor for UAD absent or reversed end-diastolic flow (AREDF) at each successive week. Outcomes included short- and long-term neonatal morbidity and mortality with quality-adjusted life years (QALYs) generated based on these outcomes. Base case, sensitivity analyses and a Monte Carlo simulation were performed.
The optimal GA for delivery is 35 weeks, which minimized perinatal deaths and maximized total QALYs. Earlier delivery became optimal once the risk of stillbirth was threefold our baseline assumption; our model was also robust until the risk of AREDF at 35 weeks was half our baseline assumption, after which delivery at 36 weeks was preferred. Delivery at 35 weeks was the optimal strategy in 77% of trials in Monte Carlo multivariable sensitivity analysis.
Weighing the risks of iatrogenic prematurity against the poor outcomes associated with AREDF, the ideal GA to deliver late preterm IUGR fetuses with elevated UAD indices is 35 weeks.
确定脐动脉多普勒（UAD）指标异常的晚期早产宫内生长受限（IUGR）胎儿的最佳分娩时机。
构建一个决策分析模型，以确定在理论上10000例于34周诊断出UAD收缩压/舒张压比值升高的IUGR胎儿队列中的最佳胎龄（GA）。所有输入数据均来自文献。涉及期待管理的策略考虑了每连续一周因UAD舒张末期血流缺失或反向（AREDF）导致的死产、自然分娩和引产的概率。结局包括短期和长期新生儿发病率和死亡率，并根据这些结局生成质量调整生命年（QALYs）。进行了基础病例分析、敏感性分析和蒙特卡洛模拟。
最佳分娩胎龄为35周，这使围产期死亡人数最少，并使总QALYs最大化。一旦死产风险是我们基线假设的三倍，更早分娩就成为最佳选择；在35周时AREDF风险降至我们基线假设的一半之前，我们的模型也很稳健，此后更倾向于在36周分娩。在蒙特卡洛多变量敏感性分析中，35周分娩是77%试验中的最佳策略。
权衡医源性早产风险与AREDF相关的不良结局，对于UAD指标升高的晚期早产IUGR胎儿，理想的分娩胎龄为35周。
