McCurdy C M, Seeds J W
Department of Obstetrics and Gynecology, University of Arizona Health Sciences Center, Tucson.
Clin Perinatol. 1993 Mar;20(1):81-106.
Obstetric delivery may be accomplished by only two methods, vaginally or abdominally. In the management of the pregnancy complicated by a fetal malformation, the choice of delivery method may be made on obstetrical grounds or in belief that one method offers the fetus benefit over the other. That choice must be based on knowledge of the nature of the individual malformation in question, the presence or absence of associated fetal malformations, the presence or absence of fetal karyotype abnormalities, fetal maturity, and fetal presentation. Clear evidence of benefit from cesarean delivery is not available in the case of many malformations that are often considered for abdominal delivery. The infrequency of many of these anomalies typically precludes the accumulation of sufficient experience in any one center or successful completion of randomized trials to evaluate treatment modalities. Most studies therefore are retrospective or flawed by small numbers of patients. Logic dictates that certain malformations that produce sufficient enlargement of fetal structures are at probable risk for dystocia of labor (e.g., severe hydrops, severe hydrocephalus, large sacrococcygeal teratoma) and may benefit from abdominal delivery. Other malformations may predispose the affected fetus to trauma or decompensation during labor and vaginal delivery. It is these anomalies that have the most controversy surrounding the "best" mode of delivery and of which we have attempted to address. Table 4 includes proposed criteria for choosing abdominal versus vaginal delivery in the gestation complicated by congenital anomaly. The birth method in the context of a fetal malformation is a choice optimally made after careful discussions with the patient, pediatrician, and pediatric surgeons. Such discussion should include a careful review of the nature of the anomaly, the optimal prognosis, and the evidence of benefit for a specific birth method. Once the pregnancy in question has been evaluated, appropriate consultations obtained, and the available data reviewed with the patient, the obstetrician again assumes a role of patient advocate. The obstetrician is the counselor, the educator, and the friend the patient needs during such a difficult time. The discussion of birth method in the case of a fetal malformation creates a conflict of interest for the patient, but typically a paradoxic result of this conflict occurs. The patient's welfare, which is usually best served by vaginal delivery, may be in conflict with the fetal concerns, which might benefit from abdominal delivery. The data might be clear but more often the data are less than convincing.(ABSTRACT TRUNCATED AT 400 WORDS)
产科分娩仅可通过两种方式完成，即经阴道或经腹。在处理合并胎儿畸形的妊娠时，分娩方式的选择可基于产科理由，或基于认为一种方式比另一种方式对胎儿更有益的信念。这种选择必须基于对所讨论的个体畸形性质的了解、是否存在相关胎儿畸形、是否存在胎儿核型异常、胎儿成熟度以及胎儿先露情况。对于许多常考虑经腹分娩的畸形，尚无剖宫产有益的确切证据。这些异常情况大多不常见，这通常使得在任何一个中心都难以积累足够的经验，也难以成功完成随机试验来评估治疗方式。因此，大多数研究是回顾性的，或者因患者数量少而存在缺陷。从逻辑上讲，某些导致胎儿结构充分增大的畸形可能存在难产风险（例如，严重水肿、严重脑积水、巨大骶尾部畸胎瘤），经腹分娩可能有益。其他畸形可能使受影响的胎儿在分娩和阴道分娩过程中易受创伤或失代偿。正是这些畸形在“最佳”分娩方式上存在最多争议，而我们试图解决这些争议。表4列出了在合并先天性畸形的妊娠中选择经腹分娩与经阴道分娩的建议标准。在胎儿畸形情况下的分娩方式选择，最好在与患者、儿科医生和小儿外科医生仔细讨论后做出。这种讨论应包括对畸形性质、最佳预后以及特定分娩方式益处的仔细审查。一旦对相关妊娠进行了评估、获得了适当的会诊意见并与患者一起审查了现有数据，产科医生再次承担起患者代言人的角色。在这样困难的时刻，产科医生是患者需要的顾问、教育者和朋友。胎儿畸形情况下分娩方式的讨论会给患者带来利益冲突，但这种冲突通常会产生矛盾的结果。通常经阴道分娩最有利于患者的福祉，但这可能与胎儿的情况相冲突，而经腹分娩可能对胎儿有益。数据可能很明确，但更多时候数据并不那么有说服力。（摘要截选至400字）
