Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Columbia University Irving Medical Center, New York, NY, USA.
Department of Biology, College of Arts and Sciences, University of Pennsylvania, Philadelphia, PA, USA.
J Matern Fetal Neonatal Med. 2021 Jun;34(12):1978-1982. doi: 10.1080/14767058.2019.1651838. Epub 2019 Aug 12.
Shoulder dystocia complicates up to 3% of vaginal births. The clinical ability to predict shoulder dystocia is limited, especially among diabetic women. We sought to evaluate if fetal growth trajectory measured from ultrasonographic (US) estimated fetal weight (EFW) percentiles was associated with increased risk for shoulder dystocia.
We performed a case-control study among women diagnosed with diabetes at a single institution between 2005 and 2015. Two diabetic controls without shoulder dystocia based on the year of delivery were included for each woman with a shoulder dystocia. Women with a single EFW measurement, delivery by cesarean, or multiple gestation were excluded. Demographic and US data were collected. Fetal growth trajectory was calculated from EFW measurements in the last two growth ultrasound scans performed closest to delivery. We compared the odds of EFW percentile change per week above specific thresholds for shoulder dystocia cases versus controls. The following cutoffs were generated: a mean percentile per week increase of > 0%, ≥ 0.5%, ≥ 1%, and ≥ 2%. Among those with EFW percentile changes that decreased (<0%), we evaluated whether odds of an abdominal circumference (AC) > 75th percentile or an EFW > 75th percentile was higher for women with shoulder dystocia. The primary exposure was increased growth trajectory. Secondary outcomes included analysis of the following adverse neonatal outcomes: (i) low 5 minutes Apgar score, (ii) rates of NICU admission, and (iii) neonatal demise.
Of 3954 diabetics, we identified 68 cases with shoulder dystocia and 136 controls who did not have shoulder dystocia. Women who experienced a shoulder dystocia were more likely to be of advanced maternal age as compared to those without a shoulder dystocia (41.9% versus 23.5, = .01); all other demographic characteristics were similar between groups. At growth trajectory cutoffs of > 0%, ≥ 0.5%, ≥ 1%, and ≥ 2% per week, odds ratios were increased among shoulder dystocia cases versus controls (OR = 1.8, 95% confidence interval (CI) = 0.9-3.3; OR = 1.6, 95% CI = 0.8-3.2; OR = 1.7, 95% CI = 0.7-3.9; and OR = 1.8, 95% CI = 0.6-5.3; respectively); however, this was not statistically significant. For women with fetal growth trajectories that decreased (< 0%), shoulder dystocia was associated with increased odds of fetal AC > 75th percentile and overall growth > 75th percentile (OR = 3.3, 95% CI = 1.5-7.1, OR = 4.8, 95% CI = 1.3-17.4, respectively). There was no difference in neonatal outcomes between shoulder dystocia cases and controls.
Future research is required to determine if fetal growth velocity proves to be a useful tool in identifying women at increased risk for shoulder dystocia. Larger studies are required for precise estimates of risk, and associated neonatal outcomes.
肩难产在阴道分娩中占比高达 3%。临床预测肩难产的能力有限，尤其是在糖尿病女性中。我们试图评估从超声估计胎儿体重（EFW）百分位测量得出的胎儿生长轨迹是否与肩难产的风险增加有关。
我们在 2005 年至 2015 年间在一家机构对患有糖尿病的妇女进行了病例对照研究。为每例肩难产患者选取 2 例在分娩年份没有肩难产的糖尿病对照患者。排除单胎 EFWS 测量值、剖宫产分娩或多胎妊娠的患者。收集人口统计学和超声数据。胎儿生长轨迹是从最后两次生长超声扫描中最接近分娩的 EFW 测量值计算得出的。我们比较了肩难产病例与对照组之间每周 EFW 百分位变化超过特定阈值的比值。生成以下截止值：每周平均百分位增加 > 0%、≥ 0.5%、≥ 1%和≥ 2%。对于 EFW 百分位降低（<0%）的患者，我们评估了肩难产患者的腹围（AC）>75 百分位或 EFW>75 百分位的可能性是否更高。主要暴露因素为生长轨迹增加。次要结局包括分析以下不良新生儿结局：（i）5 分钟 Apgar 评分低，（ii）NICU 入院率，和（iii）新生儿死亡。
在 3954 名糖尿病患者中，我们发现 68 例肩难产和 136 例无肩难产的对照组。与无肩难产的患者相比，经历肩难产的患者更有可能为高龄产妇（41.9%比 23.5%，P=0.01）；两组的其他人口统计学特征相似。在每周增长>0%、≥0.5%、≥1%和≥2%的生长轨迹截止值时，肩难产病例与对照组的比值比均升高（比值比=1.8，95%置信区间[CI]：0.9-3.3；比值比=1.6，95%CI：0.8-3.2；比值比=1.7，95%CI：0.7-3.9；比值比=1.8，95%CI：0.6-5.3；分别）；然而，这并不具有统计学意义。对于胎儿生长轨迹下降（<0%）的患者，肩难产与胎儿 AC>75 百分位和总体生长>75 百分位的可能性增加有关（比值比=3.3，95%CI：1.5-7.1，比值比=4.8，95%CI：1.3-17.4，分别）。肩难产病例与对照组的新生儿结局无差异。
需要进一步研究以确定胎儿生长速度是否能成为识别肩难产风险增加的女性的有用工具。需要更大的研究来精确估计风险和相关的新生儿结局。
