先天性心脏病胎儿推迟分娩获益有限

悉尼——根据国际妇产科超声学会(ISUOG)世界大会上公布的一项研究，对于患有严重先天性心脏病的胎儿，从择期晚期早产转变至早期分娩对重症监护时间、新生儿患病率或死亡率等新生儿结局影响甚微。

2009年发表的一项研究表明，39周后分娩的婴幼儿结局有所改善，此后基于这一结果，产科分娩实践发生了变革。为了评价这种实践做法上的变革所造成的影响，哥伦比亚大学医学中心及摩根斯坦利儿童医院的研究者们进行了本研究。他们对危重先天性心脏病患儿的病历进行了审查，并将878名于2004~2008年间在一家三级医疗中心出生的婴幼儿的结局与124名在2010年（即实施变革之后）出生的婴幼儿进行比较。

结果显示，后一组婴儿出生时的平均胎龄（分别为37.8周vs. 38.4周；P<0.01）及平均体重（2,975 g vs. 3,134 g；P<0.01）显著增加，但在5分钟APGAR评分（8.5 vs. 8.6；P=0.11）、中位住院天数（14天[1~197] vs. 16 天[1~144]；P=0.18）及新生儿死亡率（6% vs. 11%；P=0.07）方面没有显著差异。


Ismee Williams医生

主要研究者、纽约-长老会医院/哥伦比亚大学医学中心的胎儿心脏病专家Ismee Williams医生表示，在2009年的论文发表之后，产科医生中的实践做法确实发生了变革，新生儿专家在这方面也起到了推动作用，大家都尽可能不在39周之前分娩，而且不会给任何一位未达到39周的孕妇安排引产或是剖宫产。结果，从2004~2008年间到2010年这段时期内，择期剖宫产和择期引产明显减少，但紧急引产、紧急剖宫产以及发动产程后的剖宫产显著增加。

鉴于本研究是在先天性心脏病患者群中开展的，产生这种结果的一个可能解释是大多数婴儿在出院前都需要做手术。本研究未观察产妇的住院天数或其他产妇患病率指标，但下一步可能就是更细致地观察这种实践变革对产妇的影响。不过也有种可能情况是，对先天性心脏病人群而言，不管是否在38周或39周分娩，都看不到在新生儿结局方面有很大差异，或是对住院天数等发病率重要指标有很大影响。

研究者们无利益冲突声明。

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By: BIANCA NOGRADY, Cardiology News Digital Network

SYDNEY – A shift in practice away from elective late preterm delivery to early term deliveries has shown little effect on neonatal outcomes such as intensive care length of stay, neonatal morbidity, or mortality in a population with major congenital heart disease, a study has found.

Researchers at Columbia University Medical Center and Morgan Stanley Children’s Hospital, both in New York, sought to evaluate the effect of a change in delivery practice that was introduced following the 2009 publication of a study showing improved outcomes in infants delivered after 39 weeks.

A review of the medical records of infants with critical congenital heart disease compared outcomes in 878 infants born at a single tertiary center during 2004-2008 to outcomes in 124 infants born in 2010, after the change in practice had been implemented.

There was a significant increase in the mean gestational age (37.8 weeks vs. 38.4 weeks, respectively; P less than .01) and in mean birth weight (2,975 grams vs. 3,134 grams; P less than .01).

However there were no significant differences between 2004-2008 and 2010 data in 5-minute APGAR scores (8.5 vs. 8.6; P = .11), median length of stay (14 days [1-197] vs. 16 days [1-144]; P = .18) and neonatal mortality (6% vs. 11%; P = .07), according to data presented at the International Society of Ultrasound in Obstetrics and Gynecology world congress.

"After the 2009 paper came out, there was a real shift in practice among obstetricians – and also pushed by neonatologists – to try to not deliver patients before 39 weeks," said researcher and fetal cardiologist Dr. Ismee Williams, of New York–Presbyterian Hospital/Columbia University Medical Center.

"Then our goal, instead of being 38 weeks, was 39 weeks, and we would not schedule anybody for induction or a cesarean section unless they were 39 weeks and change," Dr. Williams said in an interview.

As a result of the change in practice, there were significant decreases in scheduled cesarean delivery from 2004-2008 to 2010 and in scheduled induction, but significant increases in urgent inductions, urgent cesarean deliveries, and cesarean deliveries after labor.

"We were happy to see that the change did affect a consequent increase in gestational age and birth weight, but we were somewhat surprised that it didn’t affect length of stay," Dr. Williams said.

Given that the study was conducted in a population with congenital heart disease, she said a likely explanation was that most of the infants would require surgery before they were discharged from hospital.

Dr. Williams said that the study didn’t look at maternal length of stay in hospital or other indicators of maternal morbidity, but she noted perhaps the next step would be to examine more closely the effect of the change in practice on mothers.

"However, it’s possible that, in the congenital heart disease population, whether or not you deliver at 38 or 39 weeks, we’re not seeing that big of a difference in terms of the neonatal outcomes or a big impact on big markers of morbidity like length of stay," Dr. Williams said.

There were no conflicts of interest declared.