Crombleholme T M, D'Alton M, Cendron M, Alman B, Goldberg M D, Klauber G T, Cohen A, Heilman C, Lewis M, Harris B H
Division of Pediatric Surgery, Tufts University School of Medicine, Boston, MA, USA.
J Pediatr Surg. 1996 Jan;31(1):156-62; discussion 162-3. doi: 10.1016/s0022-3468(96)90340-1.
Pediatric surgeons are increasingly called on by obstetrical colleagues to counsel parents about the implications of a prenatal ultrasound finding. Our understanding of the natural history of many prenatally diagnosed surgical conditions has grown significantly in recent years. Whether prenatal surgical consultation can influence perinatal course had not been investigated.
During an 21-month period, 12,865 prenatal ultrasound studies were performed on a total of 4,551 patients, and 221 prenatal surgical consultations were obtained through a newly established fetal treatment program at a tertiary care prenatal diagnostic center. To evaluate the impact of prenatal pediatric surgical consultation on perinatal course, the authors reviewed changes in management including termination of pregnancy, in utero intervention, and altered site, mode, or timing of delivery.
Two hundred twenty-one fetuses were referred for consultation; their 234 congenital anomalies included genitourinary (36%), thoracic (16%), intraabdominal (14.5%), abdominal wall (10.6%), neurological (9%), skeletal (6%), and head and neck (2.5%) defects; 2.5% had tumors and 2.5% were twin pregnancies. Pregnancy was terminated in 9.5% of cases, because of patient request, chromosomal abnormality, or dismal prognosis. In 3.6%, the decision to terminate was changed as a result of consultation. Site of delivery was changed as a result of consultation in 37% to facilitate postnatal evaluation and initiate immediate treatment. Mode of delivery was changed in 6.8% to prevent dystocia, hemorrhage into a tumor, as in sacrococcygeal teratoma, or to provide an emergency airway, as in cervical teratoma. The timing of delivery was changed in 4.5% to avoid further damage to fetal organs in cases of obstructive uropathy, gastroschisis, sacrococcygeal teratoma with high-output failure, and hydrocephalus. Five percent (11) underwent treatment in utero for fetal hydrothorax, obstructive uropathy, twin-twin transfusion syndrome, or lymphangioma. The overall perinatal mortality rate was 2.5%.
Prenatal pediatric surgical consultation may have a significant impact on the perinatal management of the fetus with a surgically correctable congenital anomaly. Providing obstetric colleagues and families with valuable insight into the surgical management of anomalies allows fetal intervention when appropriate, and delivery in an appropriate setting, by the safest mode of delivery, and at the gestational age appropriate to minimize effects of the anomaly.
产科同事越来越多地要求小儿外科医生就产前超声检查结果的影响向家长提供咨询。近年来，我们对许多产前诊断的外科疾病自然史的认识有了显著提高。产前外科会诊是否能影响围产期病程尚未得到研究。
在21个月的时间里，对总共4551名患者进行了12865次产前超声检查，并通过一家三级医疗产前诊断中心新设立的胎儿治疗项目进行了221次产前外科会诊。为了评估产前小儿外科会诊对围产期病程的影响，作者回顾了管理方面的变化，包括终止妊娠、宫内干预以及分娩地点、方式或时间的改变。
221例胎儿被转诊进行会诊；他们的234例先天性异常包括泌尿生殖系统（36%）、胸部（16%）、腹腔内（14.5%）、腹壁（10.6%）、神经系统（9%）、骨骼（6%）以及头颈部（2.5%）缺陷；2.5%患有肿瘤，2.5%为双胎妊娠。9.5%的病例因患者要求、染色体异常或预后不佳而终止妊娠。3.6%的病例因会诊而改变了终止妊娠的决定。37%的病例因会诊而改变了分娩地点，以利于产后评估并立即开始治疗。6.8%的病例改变了分娩方式，以预防难产、如骶尾部畸胎瘤那样的肿瘤内出血，或如颈部畸胎瘤那样提供紧急气道。4.5%的病例改变了分娩时间，以避免在梗阻性尿路病、腹裂、伴有高输出量衰竭的骶尾部畸胎瘤和脑积水病例中对胎儿器官造成进一步损害。5%（11例）因胎儿胸腔积液、梗阻性尿路病、双胎输血综合征或淋巴管瘤而在宫内接受了治疗。围产期总死亡率为2.5%。
产前小儿外科会诊可能对患有可手术矫正先天性异常的胎儿的围产期管理产生重大影响。向产科同事和家庭提供有关异常外科管理的宝贵见解，可在适当的时候进行胎儿干预，并在适当的环境中，以最安全的分娩方式，在合适的胎龄进行分娩，以尽量减少异常的影响。
