Dall'Asta Andrea, Frusca Tiziana, Rizzo Giuseppe, Ramirez Zegarra Ruben, Lees Christoph, Figueras Francesc, Ghi Tullio
Department of Medicine and Surgery, Obstetrics and Gynaecology Unit, University of Parma, Parma, Italy; Department of Metabolism, Digestion and Reproduction, Institute of Reproductive and Developmental Biology, Imperial College London, United Kingdom.
Department of Medicine and Surgery, Obstetrics and Gynaecology Unit, University of Parma, Parma, Italy.
Eur J Obstet Gynecol Reprod Biol. 2024 Apr;295:18-24. doi: 10.1016/j.ejogrb.2024.02.002. Epub 2024 Feb 5.
The evidence-based management of human labor includes the antepartum identification of patients at risk for intrapartum hypoxia. However, available evidence has shown that most of the hypoxic-related complications occur among pregnancies classified at low-risk for intrapartum hypoxia, thus suggesting that the current strategy to identify the pregnancies at risk for intrapartum fetal hypoxia has limited accuracy.
To evaluate the role of the combined assessment of the cerebroplacental ratio (CPR) and uterine arteries (UtA) Doppler in the prediction of obstetric intervention (OI) for suspected intrapartum fetal compromise (IFC) within a cohort of low-risk singleton term pregnancies in early labor.
Prospective multicentre observational study conducted across four tertiary Maternity Units between January 2016 and September 2019. Low-risk term pregnancies with spontaneous onset of labor were included. A two-step multivariable model was developed to assess the risk of OI for suspected IFC. The baseline model included antenatal and intrapartum characteristics, while the combined model included antenatal and intrapartum characteristics plus Doppler anomalies such as CPR MoM < 10th percentile and mean UtA Doppler PI MoM ≥ 95th percentile. Predictive performance was determined by receiver-operating characteristics curve analysis.
804 women were included. At logistic regression analysis, CPR MoM < 10th percentile (aOR 1.269, 95 % CI 1.188-1.356, P < 0.001), mean UtA PI MoM ≥ 95th percentile (aOR 1.012, 95 % CI 1.001-1.022, P = 0.04) were independently associated with OI for suspected IFC. At ROC curve analysis, the combined model including antenatal characteristics plus abnormal CPR and mean UtA PI yielded an AUC of 0.78, 95 %CI(0.71-0.85), p < 0.001, which was significantly higher than the baseline model (AUC 0.61, 95 %CI(0.54-0.69), p = 0.007) (p < 0.001). The combined model was associated with a 0.78 (95 % CI 0.67-0.89) sensitivity, 0.68 (95 % CI 0.65-0.72) specificity, 0.15 (95 % CI 0.11-0.19) PPV, and 0.98 (0.96-0.99) NPV, 2.48 (95 % CI 2.07-2.97) LR + and 0.32 (95 % CI 0.19-0.53) LR- for OI due to suspected IFC.
A predictive model including antenatal and intrapartum characteristics combined with abnormal CPR and mean UtA PI has a good capacity to rule out and a moderate capacity to rule in OI due to IFC, albeit with poor predictive value.
基于证据的人工分娩管理包括在产前识别有产时缺氧风险的患者。然而，现有证据表明，大多数与缺氧相关的并发症发生在被归类为产时缺氧低风险的妊娠中，这表明目前识别产时胎儿缺氧风险妊娠的策略准确性有限。
评估脑胎盘比率（CPR）和子宫动脉（UtA）多普勒联合评估在预测低风险单胎足月妊娠早期产程中疑似产时胎儿窘迫（IFC）的产科干预（OI）中的作用。
2016年1月至2019年9月在四个三级产科单位进行的前瞻性多中心观察性研究。纳入自然发动分娩的低风险足月妊娠。建立了一个两步多变量模型来评估疑似IFC的OI风险。基线模型包括产前和产时特征，而联合模型包括产前和产时特征以及多普勒异常，如CPR MoM＜第10百分位数和平均UtA多普勒PI MoM≥第95百分位数。通过受试者操作特征曲线分析确定预测性能。
纳入804名女性。在逻辑回归分析中，CPR MoM＜第10百分位数（调整后比值比1.269，95%可信区间1.188-1.356，P＜0.001）、平均UtA PI MoM≥第95百分位数（调整后比值比1.012，95%可信区间1.001-1.022，P = 0.04）与疑似IFC的OI独立相关。在ROC曲线分析中，包括产前特征加上异常CPR和平均UtA PI的联合模型的曲线下面积为0.78，95%可信区间（0.71-0.85），P＜0.001，显著高于基线模型（曲线下面积0.61，95%可信区间（0.54-0.69），P = 0.007）（P＜0.001）。联合模型与0.78（95%可信区间0.67-0.89）的灵敏度、0.68（95%可信区间0.65-0.72）的特异度、0.15（95%可信区间0.11-0.19）的阳性预测值、0.98（0.96-0.99）的阴性预测值、2.48（95%可信区间2.07-2.97）的阳性似然比和0.32（95%可信区间0.19-0.53）的阴性似然比相关，用于疑似IFC导致的OI。
一个包括产前和产时特征以及异常CPR和平均UtA PI的预测模型有良好的排除OI的能力和中等的纳入OI的能力，尽管预测价值较差。
