Bottoms S F, Paul R H, Iams J D, Mercer B M, Thom E A, Roberts J M, Caritis S N, Moawad A H, Van Dorsten J P, Hauth J C, Thurnau G R, Miodovnik M, Meis P M, McNellis D
National Institute of Child Health and Human Development, Network of Maternal-Fetal Medicine Units, Bethesda, Maryland, USA.
Am J Obstet Gynecol. 1997 May;176(5):960-6. doi: 10.1016/s0002-9378(97)70386-7.
Our purpose was to evaluate the relationship between the approach to obstetric management and survival of extremely low-birth-weight infants.
In this prospective observational study we evaluated 713 singleton births of infants weighing < or = 1000 gm during 1 year at the 11 tertiary perinatal care centers of the National Institutes of Child Health and Human Development network of maternal-fetal medicine units. Major anomalies, extramural delivery, antepartum stillbirth, induced abortion, and gestational age < 21 weeks were excluded. The obstetrician's opinion of viability and willingness to perform cesarean delivery in the event of fetal distress were ascertained from the medical record or interview when documentation was unclear. Grade 3 and 4 intraventricular hemorrhage, grade 3 and 4 retinopathy of prematurity, necrotizing enterocolitis requiring surgery, oxygen dependence at discharge or 120 days, and seizures were considered serious morbidity. Survival without serious morbidity was considered intact survival. Logistic regression was used to evaluate the influence of the approach to obstetric management, adjusted for birth weight, growth, gender, presentation, and ethnicity.
Willingness to perform cesarean delivery was associated with increased likelihood of both survival (adjusted odds ratio 3.7, 95% confidence interval 2.3 to 6.0) and intact survival (adjusted odds ratio 1.8, 95% confidence interval 1.0 to 3.3). Willingness to intervene for fetal indications appeared to virtually eliminate intrapartum stillbirth and to reduce neonatal mortality. Below 800 gm or 26 weeks, however, willingness to perform cesarean delivery was linked to an increased chance of survival with serious morbidity. Although obstetricians were willing to intervene for fetal indications in most cases by 24 weeks, willingness to perform cesarean delivery was associated with twice the risk for serious morbidity at that gestational age.
The approach to obstetric management significantly influences the outcome of extremely low-birth-weight infants. Above 800 gm or 26 weeks the obstetrician should usually be willing to perform cesarean delivery for fetal indications. Between 22 and 25 weeks willingness to intervene results in greater likelihood of both intact survival and survival with serious morbidity. In these cases patients and physicians should be aware of the impact of the approach to obstetric management and consider the likelihood of serious morbidity and mortality when formulating plans for delivery.
我们的目的是评估产科管理方式与极低出生体重儿存活率之间的关系。
在这项前瞻性观察性研究中，我们评估了美国国立儿童健康与人类发展研究所母婴医学单位网络的11家三级围产期护理中心在1年期间出生的713例单胎、体重≤1000克的婴儿。排除严重畸形、院外分娩、产前死产、人工流产以及孕周＜21周的情况。当记录不明确时，从病历或访谈中确定产科医生对胎儿存活性的看法以及在胎儿窘迫时进行剖宫产的意愿。3级和4级脑室内出血、3级和4级早产儿视网膜病变、需要手术的坏死性小肠结肠炎、出院时或120天时对氧气的依赖以及惊厥被视为严重并发症。无严重并发症的存活被视为完整存活。采用逻辑回归分析评估产科管理方式的影响，并对出生体重、生长情况、性别、胎位和种族进行校正。
进行剖宫产的意愿与存活可能性增加（校正比值比3.7，95%置信区间2.3至6.0）以及完整存活可能性增加（校正比值比1.8，95%置信区间1.从0至3.3）均相关。针对胎儿指征进行干预的意愿似乎几乎消除了产时死产并降低了新生儿死亡率。然而，在体重低于800克或孕周＜26周时，进行剖宫产的意愿与伴有严重并发症存活的几率增加相关。尽管大多数产科医生在24周时愿意针对胎儿指征进行干预，但在该孕周进行剖宫产的意愿与严重并发症风险增加两倍相关。
产科管理方式显著影响极低出生体重儿的结局。体重高于800克或孕周≥26周时，产科医生通常应愿意针对胎儿指征进行剖宫产。在22至25周之间，进行干预的意愿会使完整存活和伴有严重并发症存活的可能性均增加。在这些情况下，患者和医生应了解产科管理方式的影响，并在制定分娩计划时考虑严重并发症和死亡率的可能性。
