今日の臨床サポート

胎児発育不全

著者: 鈴木一有 浜松医科大学 周産母子センター

著者: 伊東宏晃 浜松医科大学 周産母子センター

監修: 金山尚裕 静岡医療科学専門大学校

著者校正/監修レビュー済:2019/05/09
患者向け説明資料

概要・推奨   

疾患のポイント:
  1. 胎児発育不全(fetal growth restriction、FGR)とは、妊娠中の胎児推定体重が、該当週数の一般的な胎児体重と比較して明らかに小さい場合のことである。胎児発育不全には、多岐にわたる病態が含まれ、その原因は、主に母体因子、胎児因子(形態異常や胎児感染、染色体異常など)、胎児附属物因子(胎盤・臍帯異常)に分類される。
  1. 胎児発育不全の多くは無症候であり、妊婦健診でみつかることが多い。
  1. 胎児発育不全の危険因子を有する妊婦には特に注意が必要であり、積極的に超音波による胎児計測を行う。
閲覧にはご契
閲覧に
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となりま
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご
  1. 閲覧にはご契約が必要となります。
  1. 閲覧にはご契約が必要となります。
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧に
閲覧にはご契
閲覧にはご契
閲覧にはご契約が必要となりま
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となりま す。閲覧にはご契約 が必要となります。閲覧にはご契
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります
閲覧にはご契
閲覧にはご契約が必要となりま
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必
  1. 閲覧にはご契約が
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要
  1. 閲覧にはご契約が
  1. 閲覧にはご契約が必要となり
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約
閲覧にはご契
閲覧にはご契約が
  1. 閲覧にはご契約が必要となります。閲
  1. 閲覧にはご契約が必要となりま す。閲覧にはご契約が必要となります。閲覧に はご契約が必要 となります。閲覧
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります
閲覧にはご契
閲覧にはご契約が必要とな
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要
閲覧にはご契
閲覧にはご契約が
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
鈴木一有 : 特に申告事項無し[2021年]
伊東宏晃 : 特に申告事項無し[2021年]
監修:金山尚裕 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 産婦人科診療ガイドライン産科編2017
に基づき改訂を行った。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 胎児発育不全はその定義にもよるが、一般に全妊娠の8~10%前後に合併するといわれている[1]
  1. 周産期死亡例での胎児発育不全児の割合は18%、胎児死亡例では31%にまで上昇するため、その管理は周産期医療の大きな課題である[1]
  1. 胎児発育不全より出生した児の周産期死亡率ならびに有病率は、児が小さくなればなるほど高いと報告されている[2]
  1. 胎児発育不全には、多岐にわたる病態が含まれ、主に母体因子、胎児因子(形態異常や胎児感染、染色体異常など)、胎児附属物因子(胎盤・臍帯異常)に分類される[3]
  1. 胎児発育不全の病態像は多彩であるため、そのスクリーニングの時期ならびに方法についても確立しているとはいえないのが現状である[4]
  1. 胎児発育不全はDevelopmental Origins of Health and Disease(DOHaD)との関連が指摘されており、出生した児がその後生活習慣病を発症しやすいことにも留意すべきである。
問診・診察のポイント  
問診:
  1. 胎児発育不全の母体側危険因子は重要であるため、慎重に問診を行う。

今なら12か月分の料金で14ヶ月利用できます(個人契約、期間限定キャンペーン)

11月30日(火)までにお申込みいただくと、
通常12ヵ月の使用期間が2ヶ月延長となり、14ヵ月ご利用いただけるようになります。

詳しくはクリック
本サイトの知的財産権は全てエルゼビアまたはコンテンツのライセンサーに帰属します。私的利用及び別途規定されている場合を除き、本サイトの利用はいかなる許諾を与えるものでもありません。 本サイト、そのコンテンツ、製品およびサービスのご利用は、お客様ご自身の責任において行ってください。本サイトの利用に基づくいかなる損害についても、エルゼビアは一切の責任及び賠償義務を負いません。 また、本サイトの利用を以て、本サイト利用者は、本サイトの利用に基づき第三者に生じるいかなる損害についても、エルゼビアを免責することに合意したことになります。  本サイトを利用される医学・医療提供者は、独自の臨床的判断を行使するべきです。本サイト利用者の判断においてリスクを正当なものとして受け入れる用意がない限り、コンテンツにおいて提案されている検査または処置がなされるべきではありません。 医学の急速な進歩に鑑み、エルゼビアは、本サイト利用者が診断方法および投与量について、独自に検証を行うことを推奨いたします。

文献 

著者: D D McIntire, S L Bloom, B M Casey, K J Leveno
雑誌名: N Engl J Med. 1999 Apr 22;340(16):1234-8. doi: 10.1056/NEJM199904223401603.
Abstract/Text BACKGROUND: At any given gestational age, infants with low birth weight have relatively high morbidity and mortality. It is not known, however, whether there is a threshold weight below which morbidity and mortality are significantly greater, or whether that threshold varies with gestational age.
METHODS: We analyzed the neonatal outcomes of death, five-minute Apgar score, umbilical-artery blood pH, and morbidity due to prematurity for all singleton infants delivered at Parkland Hospital, Dallas, between January 1, 1988, and August 31, 1996. A distribution of birth weights according to week of gestation at birth was created. Infants in the 26th through 75th percentiles for weight served as the reference group. Data on preterm infants (those born at 24 to 36 weeks of gestation) were analyzed separately from data on infants delivered at term (37 or more weeks of gestation).
RESULTS: A total of 122,754 women and adolescents delivered singleton live infants without malformations between 24 and 43 weeks of gestation. Among the 12,317 preterm infants who were analyzed, there was no specific birth-weight percentile at which morbidity and mortality increased. Among 82,361 infants who were born at term and whose birth weights were at or below the 75th percentile, however, the rate of neonatal death increased from 0.03 percent in the reference group (26th through 75th percentile for weight) to 0.3 percent for those with birth weights at or below the 3rd percentile (P<0.001). The incidence of five-minute Apgar scores of 3 or less and umbilical-artery blood pH values of 7.0 or less was approximately doubled for infants at or below the 3rd birth-weight percentile (P=0.003 and P<0.001, respectively). The incidence of intubation at birth, seizures during the first day of life, and sepsis was also significantly increased among term infants with birth weights at or below the 3rd percentile. These differences persisted after adjustment for the mother's race and parity and the infant's sex.
CONCLUSIONS: Mortality and morbidity are increased among infants born at term whose birth weights are at or below the 3rd percentile for their gestational age.

PMID 10210706  N Engl J Med. 1999 Apr 22;340(16):1234-8. doi: 10.1056/・・・
著者: Radek Bukowski, Gordon C S Smith, Fergal D Malone, Robert H Ball, David A Nyberg, Christine H Comstock, Gary D V Hankins, Richard L Berkowitz, Susan J Gross, Lorraine Dugoff, Sabrina D Craigo, Ilan E Timor-Tritsch, Stephen R Carr, Honor M Wolfe, Mary E D'Alton, FASTER Research Consortium
雑誌名: BMJ. 2007 Apr 21;334(7598):836. doi: 10.1136/bmj.39129.637917.AE. Epub 2007 Mar 13.
Abstract/Text OBJECTIVE: To determine if first trimester fetal growth is associated with birth weight, duration of pregnancy, and the risk of delivering a small for gestational age infant.
DESIGN: Prospective cohort study of 38 033 pregnancies between 1999 and 2003.
SETTING: 15 centres representing major regions of the United States.
PARTICIPANTS: 976 women from the original cohort who conceived as the result of assisted reproductive technology, had a first trimester ultrasound measurement of fetal crown-rump length, and delivered live singleton infants without evidence of chromosomal or congenital abnormalities. First trimester growth was expressed as the difference between the observed and expected size of the fetus, expressed as equivalence to days of gestational age.
MAIN OUTCOME MEASURES: Birth weight, duration of pregnancy, and risk of delivering a small for gestational age infant.
RESULTS: For each one day increase in the observed size of the fetus, birth weight increased by 28.2 (95% confidence interval 14.6 to 41.2) g. The association was substantially attenuated by adjustment for duration of pregnancy (adjusted coefficient 17.1 (6.6 to 27.5) g). Further adjustments for maternal characteristics and complications of pregnancy did not have a significant effect. The risk of delivering a small for gestational age infant decreased with increasing size in the first trimester (odds ratio for a one day increase 0.87, 0.81 to 0.94). The association was not materially affected by adjustment for maternal characteristics or complications of pregnancy.
CONCLUSION: Variation in birth weight may be determined, at least in part, by fetal growth in the first 12 weeks after conception through effects on timing of delivery and fetal growth velocity.

PMID 17355993  BMJ. 2007 Apr 21;334(7598):836. doi: 10.1136/bmj.39129.・・・
著者: T C Chang, S C Robson, R J Boys, J A Spencer
雑誌名: Obstet Gynecol. 1992 Dec;80(6):1030-8.
Abstract/Text OBJECTIVE: To determine the most appropriate ultrasonic measurement for the prediction of a small for gestational age (SGA) infant.
DATA SOURCES: A literature search of all English language journals over the last 15 years was undertaken. One hundred seventeen articles on the use of morphometric and Doppler ultrasonic measurements in the diagnosis of SGA were reviewed.
METHODS OF STUDY SELECTION: Studies were included if antenatal and postnatal criteria for diagnosis were clearly defined and data for SGA and normal fetuses were reported, allowing the construction of a 2 x 2 table.
DATA EXTRACTION AND SYNTHESIS: Studies with the same criteria were grouped according to whether the population was high or low risk. The sensitivity, odds ratio (OR), and false-positive rate were calculated for each study; summary statistics were then calculated for each ultrasonic measurement provided the individual sensitivities, ORs, and false-positive rates were not significantly different (P > .01).
CONCLUSIONS: In high-risk subjects, abdominal circumference below the tenth percentile had the highest common sensitivity, and estimated fetal weight below the tenth percentile had the highest common OR. In studies in which morphometric and Doppler ultrasonic measurements were compared in the same subjects, the Doppler ORs tended to be lower than the ORs for morphometric measurements. In low-risk subjects, much lower ORs were found for all ultrasonic measurements. The heterogeneous nature of the studies reviewed may have contributed to the different results within each group.

PMID 1448248  Obstet Gynecol. 1992 Dec;80(6):1030-8.
著者: William J Ott
雑誌名: Am J Perinatol. 2002 Apr;19(3):133-7. doi: 10.1055/s-2002-25313.
Abstract/Text The objective of this study is an attempt to evaluate the best ultrasonic method of diagnosing intrauterine growth restriction (IUGR); a retrospective study of patients with singleton pregnancies who had been scanned at the author's institution within 2 weeks of their delivery was undertaken. Estimated fetal weight, abdominal circumference, head circumference/abdominal circumference ratio, abdominal circumference/femur length ratio, and umbilical artery S/D ratio were compared for accuracy in prediction IUGR in the neonate using both univariant and multivariant statistical analysis. Five hundred one (501) patients were analyzed. One hundred fourteen (114) neonates were classified as IUGR (22.8%). Doppler evaluation of the umbilical artery showed the best sensitivity while both abdominal circumference alone and estimated fetal weight showed similar specificity, positive and negative predictive value, and lowest false-positive and -negative results. Logistic regression analysis confirmed the univariant results and showed that, when used in combination, abdominal circumference and Doppler, or estimated fetal weight and Doppler resulted in the best predictive values. Either estimated fetal weight or abdominal circumference (alone) are accurate predictors of IUGR. Combined with Doppler studies of the umbilical artery either method will provide accurate evaluation of suspected IUGR.

PMID 12012288  Am J Perinatol. 2002 Apr;19(3):133-7. doi: 10.1055/s-20・・・
著者: K Hecher, R Snijders, S Campbell, K Nicolaides
雑誌名: Am J Obstet Gynecol. 1995 Jul;173(1):10-5.
Abstract/Text OBJECTIVE: Our purpose was to investigate arterial, venous, and intracardiac blood flow in growth-retarded fetuses and to relate the Doppler results to blood gases in umbilical venous blood obtained by cordocentesis.
STUDY DESIGN: A cross-sectional, pulsed-wave color Doppler ultrasonographic study of 23 severely growth-retarded fetuses undergoing cordocentesis and measurement of blood gases was performed. Blood velocity waveforms were recorded from the descending thoracic aorta, middle cerebral artery, inferior vena cava, ductus venosus, and atrioventricular valves.
RESULTS: The Doppler studies demonstrated evidence of redistribution in the arterial system with increased impedance to flow in the aorta and decreased impedance in the cerebral circulation. The velocity of flow in the venous system and across the atrioventricular valves was decreased, whereas pulsatility of waveforms in the inferior vena cava and ductus venosus was increased. The mean umbilical venous blood PO2 and pH were decreased, and there were significant associations between blood gases and Doppler parameters in the thoracic aorta, middle cerebral artery, and ductus venosus.
CONCLUSION: In severe intrauterine growth retardation the degree of fetal acidemia can be estimated from Doppler measurements of pulsatility in both the arterial system and the ductus venosus.

PMID 7631665  Am J Obstet Gynecol. 1995 Jul;173(1):10-5.
著者: GRIT Study Group
雑誌名: BJOG. 2003 Jan;110(1):27-32.
Abstract/Text OBJECTIVES: To compare the effect of delivering early to pre-empt terminal hypoxaemia with delaying for as long as possible to increase maturity.
DESIGN: A randomized controlled trial.
SETTING: 69 hospitals in 13 European countries.
PARTICIPANTS: Pregnant women with fetal compromise between 24 and 36 weeks, an umbilical artery Doppler waveform recorded and clinical uncertainty whether immediate delivery was indicated.
METHODS: The interventions were 'immediate delivery' or 'delay until the obstetrician is no longer uncertain'. The data monitoring and analysis were Bayesian.
MAIN OUTCOME MEASURES: 'Survival to hospital discharge' and 'developmental quotient at two years of age', this latter to be reported later.
RESULTS: Of 548 women (588 babies) recruited, outcomes were available on 547 mothers (587 babies). The median time-to-delivery intervals were 0.9 days in the immediate group and 4.9 days in the delay group. Total deaths prior to discharge were 29 (10%) in the immediate group versus 27 (9%) in the delay group (odds ratio 1.1, 95% CI 0.61-1.8). Total caesarean sections were 249 (91%) in the immediate group versus 217 (79%) in the delay group: (OR 2.7; 95% CI 1.6-4.5). These odds ratios were similar for those randomized at gestational ages above or below 30 weeks.
INTERPRETATION: The lack of difference in overall mortality suggests that clinicians participating in this trial were on average prepared to randomize at about the correct equivocal threshold between delivery and delay. However, there was insufficient evidence to convince enthusiasts for either immediate or delayed delivery that they were wrong.

PMID 12504932  BJOG. 2003 Jan;110(1):27-32.
著者: J G Thornton, J Hornbuckle, A Vail, D J Spiegelhalter, M Levene, GRIT study group
雑誌名: Lancet. 2004 Aug 7-13;364(9433):513-20. doi: 10.1016/S0140-6736(04)16809-8.
Abstract/Text BACKGROUND: Although delivery is widely used for preterm babies failing to thrive in utero, the effect of altering delivery timing has never been assessed in a randomised controlled trial. We aimed to compare the effect of delivering early with delaying birth for as long as possible.
METHODS: 548 pregnant women were recruited by 69 hospitals in 13 European countries. Participants had fetal compromise between 24 and 36 weeks, an umbilical-artery doppler waveform recorded, and clinical uncertainty about whether immediate delivery was indicated. Before birth, 588 babies were randomly assigned to immediate delivery (n=296) or delayed delivery until the obstetrician was no longer uncertain (n=292). The main outcome was death or disability at or beyond 2 years of age. Disability was defined as a Griffiths developmental quotient of 70 or less or the presence of motor or perceptual severe disability. Analysis was by intention-to-treat. This trial has been assigned the International Standard Randomised Controlled Trial Number ISRCTN41358726.
FINDINGS: Primary outcomes were available on 290 (98%) immediate and 283 (97%) deferred deliveries. Overall rate of death or severe disability at 2 years was 55 (19%) of 290 immediate births, and 44 (16%) of 283 delayed births. With adjustment for gestational age and umbilical-artery doppler category, the odds ratio (95% CrI) was 1.1 (0.7-1.8). Most of the observed difference was in disability in babies younger than 31 weeks of gestation at randomisation: 14 (13%) immediate versus five (5%) delayed deliveries. No important differences in the median Griffiths developmental quotient in survivors was seen.
INTERPRETATION: The lack of difference in mortality suggests that obstetricians are delivering sick preterm babies at about the correct moment to minimise mortality. However, they could be delivering too early to minimise brain damage. These results do not lend support to the idea that obstetricians can deliver before terminal hypoxaemia to improve brain development.

PMID 15302194  Lancet. 2004 Aug 7-13;364(9433):513-20. doi: 10.1016/S0・・・
著者: A M Schreuder, M McDonnell, G Gaffney, A Johnson, P L Hope
雑誌名: Arch Dis Child Fetal Neonatal Ed. 2002 Mar;86(2):F108-14.
Abstract/Text AIM: To determine whether fetal compromise, manifested by abnormalities of Doppler recordings of umbilical artery velocity waveforms in utero, is associated with neurodevelopmental or educational abnormalities at school age.
METHODS: A cohort of neonates born following high risk pregnancies had been previously identified for a study of the perinatal sequelae of absent (AEDFV) and reversed (REDFV) end diastolic flow velocities. Seventy six children were assessed at 5-12 years of age by a developmental paediatrician who was blinded to perinatal course and Doppler assessments. Forty children born following pregnancies with forward end diastolic flow velocities (FEDFV), were compared with 27 with AEDFV and nine with REDFV. Tests of cognitive, neurological, and sensory function were performed, and reports of behavioural and educational progress were obtained from parents and teachers.
RESULTS: There were no significant differences between FEDFV and AEDFV groups, but on tests of mental ability and neuromotor function the REDFV group had worse scores than either FEDFV or AEDFV. Comparing REDFV and FEDFV groups, the British Ability Scales general conceptual ability mean scores were 87.7 versus 101, and the Quick Neurological Screening Test mean scores were 32.8 versus 21.5.
CONCLUSIONS: Absence of EDFV is well recognised as a marker of fetal compromise which is associated with acute perinatal sequelae. This study suggests it is not associated with adverse neurodevelopmental outcome. However, we found reversal of EDFV on antenatal assessment to be associated with a wide range of problems at school age, suggesting that REDFV represents intrauterine decompensation which may have adverse effects on the developing brain.

PMID 11882553  Arch Dis Child Fetal Neonatal Ed. 2002 Mar;86(2):F108-1・・・

ページ上部に戻る

戻る

さらなるご利用にはご登録が必要です。

こちらよりご契約または優待日間無料トライアルお申込みをお願いします。

(※トライアルご登録は1名様につき、一度となります)


ご契約の場合はご招待された方だけのご優待特典があります。

以下の優待コードを入力いただくと、

契約期間が通常12ヵ月のところ、14ヵ月ご利用いただけます。

優待コード: (利用期限:まで)

ご契約はこちらから