目的:我们试图为胎儿贫血的诊断和治疗提供循证指南。
方法:使用MEDLINE进行了系统的文献综述,PubMed,EMBASE,还有Cochrane图书馆.搜索仅限于1966年至2014年5月发表的英文文章。优先考虑报告原始研究的文章,特别是随机对照试验,尽管查阅了评论文章和评论。在专题讨论会和科学会议上提出的研究摘要被认为不足以纳入。还审查了证据报告和已发布的指南,通过查阅已确定文章的参考书目来定位其他研究。等级(建议评估的等级,发展,和评估)方法用于定义建议的强度并对证据质量进行评级。符合美国预防工作组的指导方针,根据最高水平的证据对参考文献进行质量评估.
结论:我们建议:(1)通过超声多普勒询问测量的大脑中动脉收缩期峰值速度(MCA-PSV)作为检测胎儿贫血的主要技术;(2)羊水三角洲OD450不用于诊断胎儿贫血;(3)MCA-PSV评估保留给那些有贫血风险的患者(大脑中动脉MCA-PSV评估的正确技术包括评估胎儿理想情况下在零度角度不进行角度校正);(4)如果胎儿被认为有严重胎儿贫血的重大风险(MCA大于中位数或积水的1.5倍),在准备宫内输血的情况下进行胎儿血液采样,除非怀孕时与分娩相关的风险被认为小于与手术相关的风险;(5)如果胎儿被认为有严重胎儿贫血的重大风险,将患者转诊至具有侵入性胎儿治疗专业知识的中心;(6)考虑MCA-PSV以确定贫血胎儿再次输血的时机,and,或者,胎儿血红蛋白的预测下降可用于安排第二次手术的时间;(7)在妊娠37-38周时分娩胎儿有显著胎儿贫血风险的妊娠,除非在此之前出现适应症.
OBJECTIVE: We sought to provide evidence-based
guidelines for the diagnosis and management of fetal anemia.
METHODS: A systematic literature review was performed using MEDLINE, PubMed, EMBASE, and the Cochrane Library. The search was restricted to English-language articles published from 1966 through May 2014. Priority was given to articles reporting original research, in particular randomized controlled trials, although review articles and commentaries were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion. Evidence reports and published
guidelines were also reviewed, and additional studies were located by reviewing bibliographies of identified articles. GRADE (Grading of Recommendations Assessment, Development, and Evaluation) methodology was used for defining the strength of recommendations and rating the quality of evidence. Consistent with US Preventive Task Force
guidelines, references were evaluated for quality based on the highest level of evidence.
CONCLUSIONS: We recommend the following: (1) middle cerebral artery peak systolic velocity (MCA-PSV) measured by ultrasound Doppler interrogation be used as the primary technique to detect fetal anemia; (2) amniotic fluid delta OD450 not be used to diagnosis fetal anemia; (3) MCA-PSV assessment be reserved for those patients who are at risk of having an anemic fetus (proper technique for MCA-PSV evaluation includes assessment of the middle cerebral artery close to its origin, ideally at a zero degree angle without angle correction); (4) if a fetus is deemed at significant risk for severe fetal anemia (MCA greater than 1.5 multiples of the median or hydropic), fetal blood sampling be performed with preparation for an intrauterine transfusion, unless the pregnancy is at a gestational age when the risks associated with delivery are considered to be less than those associated with the procedure; (5) if a fetus is deemed at significant risk for severe fetal anemia, the patient be referred to a center with expertise in invasive fetal therapy; (6) MCA-PSV be considered to determine the timing of a second transfusion in fetuses with anemia, and, alternatively, a predicted decline in fetal hemoglobin may be used for timing the second procedure; and (7) pregnancies with a fetus at significant risk for fetal anemia be delivered at 37-38 weeks of gestation unless indications develop prior to this time.