Wolf H, Arabin B, Lees C C, Oepkes D, Prefumo F, Thilaganathan B, Todros T, Visser G H A, Bilardo C M, Derks J B, Diemert A, Duvekot J J, Ferrazzi E, Frusca T, Hecher K, Marlow N, Martinelli P, Ostermayer E, Papageorghiou A T, Scheepers H C J, Schlembach D, Schneider K T M, Valcamonico A, van Wassenaer-Leemhuis A, Ganzevoort W
Department of Obstetrics and Gynecology, Academic Medical Centre, Amsterdam, The Netherlands.
Center for Mother and Child of the Phillips University, Marburg, Germany.
Ultrasound Obstet Gynecol. 2017 Jul;50(1):71-78. doi: 10.1002/uog.17215.
To explore whether, in early fetal growth restriction (FGR), the longitudinal pattern of fetal heart rate (FHR) short-term variation (STV) can be used to identify imminent fetal distress and whether abnormalities of FHR recordings are associated with 2-year infant outcome.
The original TRUFFLE study assessed whether, in early FGR, delivery based on ductus venosus (DV) Doppler pulsatility index (PI), in combination with safety-net criteria of very low STV on cardiotocography (CTG) and/or recurrent FHR decelerations, could improve 2-year infant survival without neurological impairment in comparison with delivery based on CTG monitoring only. This was a secondary analysis of women who delivered before 32 weeks and had consecutive STV data recorded > 3 days before delivery and known infant outcome at 2 years of age. Women who received corticosteroids within 3 days of delivery were excluded. Individual regression line algorithms of all STV values, except the last one before delivery, were calculated. Life tables and Cox regression analysis were used to calculate the daily risk for low STV or very low STV and/or FHR decelerations (below DV group safety-net criteria) and to assess which parameters were associated with this risk. Furthermore, it was assessed whether STV pattern, last STV value or recurrent FHR decelerations were associated with 2-year infant outcome.
One hundred and forty-nine women from the original TRUFFLE study met the inclusion criteria. Using the individual STV regression lines, prediction of a last STV below the cut-off used by the CTG monitoring group had sensitivity of 42% and specificity of 91%. For each day after study inclusion, the median risk for low STV (CTG group cut-off) was 4% (interquartile range (IQR), 2-7%) and for very low STV and/or recurrent FHR decelerations (below DV group safety-net criteria) was 5% (IQR, 4-7%). Measures of STV pattern, fetal Doppler (arterial or venous), birth-weight multiples of the median and gestational age did not usefully improve daily risk prediction. There was no association of STV regression coefficients, a low last STV and/or recurrent FHR decelerations with short- or long-term infant outcomes.
The TRUFFLE study showed that a strategy of DV monitoring with safety-net criteria of very low STV and/or recurrent FHR decelerations for delivery indication could increase 2-year infant survival without neurological impairment. This post-hoc analysis demonstrates that, in early FGR, the daily risk of abnormal CTG, as defined by the DV group safety-net criteria, is 5%, and that prediction is not possible. This supports the rationale for CTG monitoring more often than daily in these high-risk fetuses. Low STV and/or recurrent FHR decelerations were not associated with adverse infant outcome and it appears safe to delay intervention until such abnormalities occur, as long as DV-PI is within normal range. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
探讨在早期胎儿生长受限（FGR）中，胎儿心率（FHR）短期变异（STV）的纵向模式是否可用于识别即将发生的胎儿窘迫，以及FHR记录异常是否与2岁婴儿结局相关。
最初的TRUFFLE研究评估了在早期FGR中，基于静脉导管（DV）多普勒搏动指数（PI）并结合产时监护（CTG）上极低STV和/或反复出现的FHR减速的安全网标准进行分娩，与仅基于CTG监测进行分娩相比，是否能提高2岁时无神经功能障碍的婴儿存活率。这是对在32周前分娩、分娩前>3天有连续STV数据记录且已知2岁时婴儿结局的女性进行的二次分析。排除在分娩前3天内接受过皮质类固醇治疗的女性。计算除分娩前最后一个STV值外所有STV值的个体回归线算法。使用生命表和Cox回归分析计算低STV或极低STV和/或FHR减速（低于DV组安全网标准）的每日风险，并评估哪些参数与该风险相关。此外，评估STV模式、最后一个STV值或反复出现的FHR减速是否与2岁婴儿结局相关。
来自最初TRUFFLE研究的149名女性符合纳入标准。使用个体STV回归线，预测最后一个STV低于CTG监测组使用的临界值时，敏感性为42%，特异性为91%。在纳入研究后的每一天，低STV（CTG组临界值）的中位风险为4%（四分位间距（IQR），2 - 7%），极低STV和/或反复出现的FHR减速（低于DV组安全网标准）的中位风险为5%（IQR，4 - 7%）。STV模式、胎儿多普勒（动脉或静脉）、出生体重相对于中位数的倍数以及胎龄等指标并不能有效改善每日风险预测。STV回归系数、低的最后一个STV和/或反复出现的FHR减速与婴儿短期或长期结局均无关联。
TRUFFLE研究表明，采用DV监测并结合极低STV和/或反复出现的FHR减速作为分娩指征的安全网标准的策略，可以提高2岁时无神经功能障碍的婴儿存活率。这项事后分析表明，在早期FGR中，按照DV组安全网标准定义的CTG异常的每日风险为5%，且无法进行预测。这支持了在这些高危胎儿中比每日更频繁地进行CTG监测的理论依据。低STV和/或反复出现的FHR减速与不良婴儿结局无关，只要DV - PI在正常范围内，似乎可以安全地延迟干预，直到出现此类异常情况。版权所有© 2016国际妇产科超声学会。由约翰·威利父子有限公司出版。
