背景:关于胎儿生长受限定义的研究集中在预测不良围产期结局上。该方法的显著限制是感兴趣的个体结果可能与病症和治疗相关。评估反映胎儿生长受限病理生理学的结果可能会克服这一局限性。
目的:比较国际妇产科超声学会和母胎医学学会建立的胎儿生长受限定义的诊断性能,以预测与胎盘功能不全和复合不良新生儿结局相关的胎盘组织病理学发现。
方法:在这项单胎妊娠的回顾性队列研究中,我们使用国际妇产科超声学会和母胎医学学会指南来确定有胎儿生长受限的妊娠和相应的对照组.主要结果是预测与胎盘功能不全相关的胎盘组织病理学结果。定义为与母体血管灌注不良相关的病变。复合不良新生儿结局(即,脐动脉pH≤7.1,5分钟Apgar评分≤4,新生儿重症监护病房入院,低血糖,需要机械通气的呼吸窘迫综合征,需要快速分娩的产时胎儿窘迫,和围产期死亡)作为次要结局进行了调查。灵敏度,特异性,阳性和阴性预测值,并确定每个胎儿生长受限定义的接受者工作特征曲线下的面积.使用Logistic回归模型来评估每个定义与研究结果之间的关联。还对两种定义的诊断性能进行了亚组分析,对早期和晚期胎儿生长受限的人群进行了分层。
结果:两个学会的定义均显示出相似的诊断性能以及与主要(国际妇产科超声学会调整的比值比3.01[95%置信区间2.42,3.75];母胎医学学会调整的比值比2.85[95%置信区间2.31,3.51])和次要结果(国际妇产科超声学会调整的置信区间2.65%2.95)此外,两种胎儿生长受限定义对母体血管灌注不良的胎盘组织病理学发现和复合不良新生儿结局的辨别能力有限(国际妇产科超声学会接受者操作特征曲线下面积0.63[95%置信区间0.61,0.65],0.59[95%置信区间0.56,0.61];母胎医学学会受者工作特性下面积0.63[95%置信区间0.61,0.66],0.60[95%置信区间0.57,0.62])。
结论:国际妇产科超声学会和母胎医学学会胎儿生长受限定义对胎盘组织病理学发现与胎盘功能不全和复合不良新生儿结局相关的辨别能力有限。
BACKGROUND: Research on the definition of fetal growth restriction has focused on predicting adverse perinatal outcomes. A significant limitation of this approach is that the individual outcomes of interest could be related to the condition and the treatment. Evaluation of outcomes that reflect the pathophysiology of fetal growth restriction may overcome this limitation.
OBJECTIVE: To compare the diagnostic performance of the fetal growth restriction definitions established by the International Society for Ultrasound in Obstetrics and Gynecology and the Society for Maternal-Fetal Medicine to predict placental histopathological findings associated with placental insufficiency and a composite adverse neonatal outcome.
METHODS: In this retrospective cohort study of singleton pregnancies, the International Society for Ultrasound in Obstetrics and Gynecology and the Society for Maternal-Fetal Medicine guidelines were used to identify pregnancies with fetal growth restriction and a corresponding control group. The primary outcome was the prediction of placental histopathological findings associated with placental insufficiency, defined as lesions associated with maternal vascular malperfusion. A composite adverse neonatal outcome (i.e., umbilical artery pH≤7.1, Apgar score at 5 minutes ≤4, neonatal intensive care unit admission, hypoglycemia, respiratory distress syndrome requiring mechanical ventilation, intrapartum fetal distress requiring expedited delivery, and perinatal death) was investigated as a secondary outcome. Sensitivity, specificity, positive and negative predictive values, and the areas under the receiver-operating-characteristics curves were determined for each fetal growth restriction definition. Logistic regression models were used to assess the association between each definition and the studied outcomes. A subgroup analysis of the diagnostic performance of both definitions stratifying the population in early and late fetal growth restriction was also performed.
RESULTS: Both societies\' definitions showed a similar diagnostic performance as well as a significant association with the primary (International Society for Ultrasound in Obstetrics and Gynecology adjusted odds ratio 3.01 [95% confidence interval 2.42, 3.75]; Society for Maternal-Fetal Medicine adjusted odds ratio 2.85 [95% confidence interval 2.31, 3.51]) and secondary outcomes (International Society for Ultrasound in Obstetrics and Gynecology adjusted odds ratio 1.95 [95% confidence interval 1.56, 2.43]; Society for Maternal-Fetal Medicine adjusted odds ratio 2.12 [95% confidence interval 1.70, 2.65]). Furthermore, both fetal growth restriction definitions had a limited discriminatory capacity for placental histopathological findings of maternal vascular malperfusion and the composite adverse neonatal outcome (area under the receiver-operating-characteristics curve International Society for Ultrasound in Obstetrics and Gynecology 0.63 [95% confidence interval 0.61, 0.65], 0.59 [95% confidence interval 0.56, 0.61]; area under the receiver-operating-characteristics Society for Maternal-Fetal Medicine 0.63 [95% confidence interval 0.61, 0.66], 0.60 [95% confidence interval 0.57, 0.62]).
CONCLUSIONS: The International Society for Ultrasound in Obstetrics and Gynecology and the Society for Maternal-Fetal Medicine fetal growth restriction definitions have limited discriminatory capacity for placental histopathological findings associated with placental insufficiency and a composite adverse neonatal outcome.