胎内発育障害児の胎内保育限界

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Recent advances in perinatal medicine contributed to the survival of extremely premature infants. Nonetheless, prognosis of the fetus with intrauterine growth retardation (IUGR) especially of preterm IUGR is not satisfactory with respect to both neonatal and long term neurodevelopmental outcome. As in utero pathophysiology of the IUGR has been revealed by noninvasive fetal monitoring technique along with invasive cordocentesis to determine fetal blood gas parameters, most of the neonatal morbidity of IUGR is thought to be originated prior to birth. Excluding the IUGR due to chromosomal abnormalities, fetal anomalies and multiple gestation, severe preeclampsia contributes nearly 60 to 80% of the etiology of IUGR in our series. In IUGR with severe preeclampsia, it is noteworthy that the incidence of symmetrical IUGR is approximately 50%, suggesting disturbance in head growth is responsible for symmetrical growth. We have shown that the disturbance in head growth is particularly important not only for neurodevelopmental but also for short term neonatal mortality and morbidity. It is suggested that the reasonable timing of delivery of preterm IUGR should be before onset of fetal acidosis and/or cessation of fetal head growth for the following reasons. 1. There is a relationship between fetal acidemia at cordocentesis and subsequent neurodevelopment. 2. The incidence of neonatal morbidity including hypoglycemia, hemoconcentration and thrombocytopenia increased with the degree of disturbance in head circumference at birth. We propose that the IUGR fetus should be monitored weekly for its growth by ultrasound fetometry and noninvasive fetal monitoring methods including nonstress test, Biophysical profile scoring and Doppler velocimetry. The fetus should be delivered when the cessation of fetal head growth has been observed for more than 7 days even though NST and other noninvasive tests are still reassuring. Among the noninvasive fetal monitoring methods, pulsatility index of the umbilical artery seemed to be correlated with the extent of fetal acidemia. Therefore, in the absence of cessation of the head growth, short term surveillance with Doppler velocimetry might be helpful for demonstrating fetal acidemia. Since neonatal morbidity presumably related to prematurity such as RDS is not serious for unknown reason in IUGR, one should not overweigh the risk of prematurity when determining the timing of delivery in comparison to the hypoxic organ damages such as necrotising enterocolitis, renal failure, pulmonary hemorrhage and cardiac failure in neonatal period. To evaluate this proposal, prospective studies should be employed.
社団法人日本産科婦人科学会の論文
1993-08-01

胎内発育障害児の胎内保育限界

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