The World Health Organization Fetal Growth Charts: A Multinational Longitudinal Study of Ultrasound Biometric Measurements and Estimated Fetal Weight.
The World Health Organization Fetal Growth Charts: A Multinational Longitudinal Study of Ultrasound Biometric Measurements and Estimated Fetal Weight.
复制标题
世界卫生组织胎儿生长图：超声生物识别测量和估计胎儿体重的跨国纵向研究。
DOI：
10.1371/journal.pmed.1002220
复制
发表时间：
2017-01
期刊：
影响因子：
15.8
通讯作者：
Platt LD
中科院分区：
文献类型：
--
作者：
Kiserud T;Piaggio G;Carroli G;Widmer M;Carvalho J;Neerup Jensen L;Giordano D;Cecatti JG;Abdel Aleem H;Talegawkar SA;Benachi A;Diemert A;Tshefu Kitoto A;Thinkhamrop J;Lumbiganon P;Tabor A;Kriplani A;Gonzalez Perez R;Hecher K;Hanson MA;Gülmezoglu AM;Platt LD
围产期死亡率和发病率仍然是与早产和胎儿生长减少密切相关的主要全球健康挑战，鉴于越来越多的证据表明，胎儿生长一般与成年后常见非传染性疾病的风险程度有关，这一问题值得进一步关注。在此背景下，世卫组织高度重视提供估计胎儿体重（EFW）的当前胎儿生长图表和旨在供全世界使用的常见超声生物测量。我们进行了一项跨国前瞻性观察性纵向研究，研究了高或中等社会经济地位妇女的低风险单胎妊娠胎儿生长情况，并且没有已知的环境对胎儿生长的限制。十个国家（阿根廷、巴西、刚果民主共和国、丹麦、埃及、法国、德国、印度、挪威和泰国）的研究中心招募了有可靠的最后一次月经和胎龄信息的参与者，这些信息是通过妊娠8-13周测量的冠臀长来确认的。参与者在怀孕期间进行了人体测量和营养评估，并进行了七次预定的超声波检查。52名参与者撤回了同意，1387名参与者参与了这项研究。在研究开始时，产妇年龄中位数为28岁（四分位间距[IQR] 25-31），身高中位数为162厘米（IQR 157-168），体重中位数为61公斤（IQR 55-68）， 58%的妇女未生育，每日热量摄入中位数为1,840卡（IQR 1,487-2,222）。中位妊娠持续时间为39周（IQR 38-40），尽管各国之间存在显著差异，最大差异为12天（95% CI 8-16）。出生体重中位数为3300克（IQR为2980 - 3615）。各国之间的出生体重存在差异，例如，即使在调整胎龄后，印度的新生儿明显小于其他国家。31名妇女流产，3名胎儿宫内死亡。对8203组超声测量结果进行了异常值和杠杆点的仔细检查，并选择了14至40周的测量结果进行分析。采用分位数回归法对7,924组超声测量数据进行分析，建立胎儿头围、双顶径、肱骨长、腹围、股骨长及其与头围、双顶径之比、EFW的纵向参考区间。EFW的生长分布不对称：在妊娠早期，较低百分位数的分布略宽，在妊娠后期，较高百分位数的分布明显扩大。在EFW测量中，男胎比女胎大，但分布的下分位数差距较小（3.5%），上分位数差距较大（4.5%）。母亲年龄和母亲身高对EFW有积极影响，特别是在分布的下尾，母亲年龄每增加10岁，EFW的影响为2%至3%，母亲身高每增加10厘米，EFW的影响为1%至2%。母体体重对EFW有一个小的正向影响，特别是在分布的高尾，母体体重每增加10kg， EFW的影响为1.0%至1.5%。分娩妇女比未分娩妇女的胎儿重，在分布的下分位数中差距较大，约为1%至1.5%，在上分位数中差距减小。各国间EFW的增长也存在显著差异。尽管这项研究具有多国性质，但样本量是图表泛化的一个限制因素。本研究提供了世界卫生组织胎儿生长图，用于EFW和常见的超声生物测量，并显示了世界不同地区之间的差异。利用一项跨国纵向研究的数据，玛丽安娜·威德默和同事们报告了世界卫生组织的胎儿生长图表。出生时体型小与围产期死亡率、儿童发病率和成人健康风险有关，这些都是世界卫生组织优先考虑的主要全球健康挑战。超声胎儿出生前体重的估计今天在临床实践中得到了非常广泛的应用，而且，虽然对高危妊娠的识别和管理至关重要，但目前世界范围内使用的参考范围主要基于来自少数高收入国家的单一人群，因此不确定普遍适用性。因此，世卫组织要求提供基于多个人群的新的胎儿生长图表，以供普遍使用，同时为日益加强的预防非传染性疾病和促进从出生前开始的健康生命历程的倡议奠定基础。总共有1387名来自非洲、亚洲、欧洲和南美洲十个国家的低风险怀孕、无营养和社会背景的健康妇女参与了一项关于胎儿生长的纵向研究。在怀孕期间，反复使用超声测量来建立国际胎儿生长图表，包括头和腹部围、大腿骨长度和胎儿体重，使用这三种测量的组合来估计。胎儿生长表现出相当大的自然差异，在不同国家之间差异显著。生长受母亲年龄、身高、体重、胎次和胎儿性别的影响较小。同样，即使在调整了怀孕时间长短的差异后，各国的出生体重也存在显著差异。我们认为，这些世卫组织估计胎儿体重增长图表比目前普遍使用的图表更适合国际使用。然而，各国之间的差异、产妇因素和胎儿性别的差异意味着这些生长图表可能需要根据当地临床使用进行调整，以提高其诊断和预测性能。即使在最佳条件下，胎儿生长和出生体重也会发生相当大的变化，而且无法用母亲和人口因素来解释，这可能表明，首先，这种后代大小的自然变化是一种集体适应策略，从进化的角度来看，这种策略已被证明是非常成功的；其次，人类出生前发育变化的主要决定因素仍有待确定。虽然目前的研究包括十个国家，但如果考虑到大陆内部存在的大量人体测量差异，它仍然只是一个很小的选择。
Perinatal mortality and morbidity continue to be major global health challenges strongly associated with prematurity and reduced fetal growth, an issue of further interest given the mounting evidence that fetal growth in general is linked to degrees of risk of common noncommunicable diseases in adulthood. Against this background, WHO made it a high priority to provide the present fetal growth charts for estimated fetal weight (EFW) and common ultrasound biometric measurements intended for worldwide use. We conducted a multinational prospective observational longitudinal study of fetal growth in low-risk singleton pregnancies of women of high or middle socioeconomic status and without known environmental constraints on fetal growth. Centers in ten countries (Argentina, Brazil, Democratic Republic of the Congo, Denmark, Egypt, France, Germany, India, Norway, and Thailand) recruited participants who had reliable information on last menstrual period and gestational age confirmed by crown–rump length measured at 8–13 wk of gestation. Participants had anthropometric and nutritional assessments and seven scheduled ultrasound examinations during pregnancy. Fifty-two participants withdrew consent, and 1,387 participated in the study. At study entry, median maternal age was 28 y (interquartile range [IQR] 25–31), median height was 162 cm (IQR 157–168), median weight was 61 kg (IQR 55–68), 58% of the women were nulliparous, and median daily caloric intake was 1,840 cal (IQR 1,487–2,222). The median pregnancy duration was 39 wk (IQR 38–40) although there were significant differences between countries, the largest difference being 12 d (95% CI 8–16). The median birthweight was 3,300 g (IQR 2,980–3,615). There were differences in birthweight between countries, e.g., India had significantly smaller neonates than the other countries, even after adjusting for gestational age. Thirty-one women had a miscarriage, and three fetuses had intrauterine death. The 8,203 sets of ultrasound measurements were scrutinized for outliers and leverage points, and those measurements taken at 14 to 40 wk were selected for analysis. A total of 7,924 sets of ultrasound measurements were analyzed by quantile regression to establish longitudinal reference intervals for fetal head circumference, biparietal diameter, humerus length, abdominal circumference, femur length and its ratio with head circumference and with biparietal diameter, and EFW. There was asymmetric distribution of growth of EFW: a slightly wider distribution among the lower percentiles during early weeks shifted to a notably expanded distribution of the higher percentiles in late pregnancy. Male fetuses were larger than female fetuses as measured by EFW, but the disparity was smaller in the lower quantiles of the distribution (3.5%) and larger in the upper quantiles (4.5%). Maternal age and maternal height were associated with a positive effect on EFW, particularly in the lower tail of the distribution, of the order of 2% to 3% for each additional 10 y of age of the mother and 1% to 2% for each additional 10 cm of height. Maternal weight was associated with a small positive effect on EFW, especially in the higher tail of the distribution, of the order of 1.0% to 1.5% for each additional 10 kg of bodyweight of the mother. Parous women had heavier fetuses than nulliparous women, with the disparity being greater in the lower quantiles of the distribution, of the order of 1% to 1.5%, and diminishing in the upper quantiles. There were also significant differences in growth of EFW between countries. In spite of the multinational nature of the study, sample size is a limiting factor for generalization of the charts. This study provides WHO fetal growth charts for EFW and common ultrasound biometric measurements, and shows variation between different parts of the world. Using data from a multinational longitudinal study, Mariana Widmer and colleagues report The World Health Organization fetal growth charts. Small size at birth is associated with perinatal mortality, child morbidity, and adult health risks, all major global health challenges prioritized by the World Health Organization. Ultrasound estimation of fetal weight before birth is today very widely used in clinical practice, and, while essential for the identification and management of high-risk pregnancies, the current reference ranges used worldwide are largely based on single populations from a few high-income countries and are therefore of uncertain general applicability. WHO therefore requested new fetal growth charts based on multiple populations to be made available for general use and at the same time provide a foundation for the growing initiative to prevent noncommunicable diseases and promote a healthy life course starting before birth. In all, 1,387 healthy women with low-risk pregnancies and unconstrained nutritional and social background from ten countries in Africa, Asia, Europe, and South America were included in a longitudinal study of fetal growth. During pregnancy, repeated ultrasound measurements were used to establish international fetal growth charts for head and abdominal circumference, length of the thigh bone, and fetal weight, estimated using a combination of the three measurements. Fetal growth showed considerable natural variation, differing significantly between countries. Growth was to a small extent influenced by maternal age, height, weight, and parity, and by fetal sex. Similarly, birthweight varied significantly between countries, even after adjustment for differences in the length of pregnancy. We suggest that these WHO charts for growth in estimated fetal weight are more suitable for international use than those commonly applied today. However, the differences between countries, with maternal factors, and with fetal sex mean that these growth charts may need to be adjusted for local clinical use to increase their diagnostic and predictive performance. The considerable variation in fetal growth and birthweight which occurs even under optimal conditions, and which is not explicable in terms of maternal and population factors, may suggest, first, that such natural variation in offspring size is a collective adaptive strategy that has proved extremely successful from an evolutionary point of view and, second, that major determinants of variation in human development before birth are still to be determined. Although the present study encompasses ten countries, it still represents only a small selection when the substantial anthropometric variations existing even within continents are taken into account.