Dodd Maja, Lindqvist Pelle G
Karolinska Institutet, Stockholm, Sweden.
Clinical Sciences and Education, Karolinska Institutet, Sodersjukhuset, Stockholm, Sweden; Department of Obstetrics and Gynecology, Sodersjukhuset, Stockholm, Sweden.
Eur J Obstet Gynecol Reprod Biol. 2021 Jan;256:314-319. doi: 10.1016/j.ejogrb.2020.11.006. Epub 2020 Nov 11.
There is currently no consensus on the management of large fetuses in order to minimize fetal complications. The aim of this study was to assess whether antenatal recognition of large-for-gestational age (LGA) reduced poor obstetric newborn outcomes in a hospital where expectant management was used.
A retrospective cohort study was made of two delivery units at Karolinska University Hospital, Stockholm, Sweden, using expectant management of LGA. All deliveries > 37 weeks of gestation during an 8-year period (2002-2009) were included. The main outcome was severe adverse outcome, a composite variable including neonatal trauma (brachial plexus birth palsy [BPBP] and fractures) and asphyxic sequelae (severe asphyxia, cerebral damage, and fetal/infant death).
The study population consisted of 63,542 appropriate-for-gestational age (AGA) and 3,343 LGA pregnancies (of which 21 % were identified before delivery). Compared to AGA, LGA pregnancies showed a five-fold increased risk of neonatal trauma (OR 5.1, 95 % CI 4.0 - 6.4), but no differences were seen regarding asphyxic sequelae. LGA fetuses identified antenatally had adverse outcomes in 3.7 % of all cases, compared to 3.5 % where LGA was not identified (OR 1.07 95 % CI 0.7 - 1.7). When adjusted for newborn weight deviation, the OR was 0.96, 95 % CI 0.6 - 1.5. There was a three-fold higher risk (OR 3.0, 95 % CI 1.2 - 7.4) of neonatal trauma among non-identified LGA cases > 41 gestational weeks. A total of 81 % of those with LGA were identified after a week 41 routine ultrasound. Out of 68 cases with planned vaginal delivery and expected birth weight > 5000 g, 7.4 % suffered BPBP, representing a 31-fold increase in risk, compared to 0% BPBP among those delivered by elective caesarean section.
Antenatal awareness of LGA did not lower the risk of severe adverse outcomes in a unit using expectant management, but those identified postdate were at a lower risk of neonatal trauma. For every 14 fetuses with an expected birth weight > 5000 g delivered by cesarean section, one case of BPBP could be avoided.
目前对于巨大胎儿的管理尚无共识，以尽量减少胎儿并发症。本研究的目的是评估在一家采用期待管理的医院中，产前识别大于胎龄儿（LGA）是否能降低不良产科新生儿结局的风险。
对瑞典斯德哥尔摩卡罗林斯卡大学医院的两个分娩单元进行回顾性队列研究，采用对LGA的期待管理。纳入了8年期间（2002 - 2009年）所有孕周>37周的分娩。主要结局是严重不良结局，这是一个综合变量，包括新生儿创伤（臂丛神经产瘫[BPBP]和骨折）以及窒息后遗症（严重窒息、脑损伤和胎儿/婴儿死亡）。
研究人群包括63,542例适于胎龄儿（AGA）和3,343例LGA妊娠（其中21%在分娩前被识别）。与AGA相比，LGA妊娠的新生儿创伤风险增加了五倍（OR 5.1，95% CI 4.0 - 6.4），但在窒息后遗症方面未发现差异。产前识别出的LGA胎儿在所有病例中有3.7%出现不良结局，而未识别出LGA的病例中这一比例为3.5%（OR 1.07，95% CI 0.7 - 1.7）。在对新生儿体重偏差进行调整后，OR为0.96，95% CI 0.6 - 1.5。孕周>41周的未识别LGA病例中，新生儿创伤风险高出三倍（OR 3.0，95% CI 1.2 - 7.4）。共有81%的LGA病例是在孕41周常规超声检查后被识别出的。在68例计划阴道分娩且预期出生体重>5000 g的病例中，7.4%发生了BPBP，与择期剖宫产分娩者中0%的BPBP发生率相比，风险增加了31倍。
在采用期待管理的科室中，产前识别LGA并未降低严重不良结局的风险，但孕周过期后识别出的LGA新生儿创伤风险较低。每14例预期出生体重>5000 g且通过剖宫产分娩的胎儿中，可避免1例BPBP的发生。
