Magnetic resonance Imaging of mother and fetus in late gestation to inform and optimise BIRTH management: the MIBIRTH study

2020年，英国有464,437名新生儿，其中三分之一是通过紧急剖腹产(EMCS)或辅助分娩(产钳或真空抽出)分娩的。这些干预措施通常是在长时间的精疲力竭的劳动之后，在正常工作时间以外的麻醉下进行的。这种复杂的分娩在年龄较大的母亲、肥胖的母亲以及婴儿较小或较大的母亲中更为常见。它们与婴儿进入新生儿病房的增加有关，并伴有婴儿大脑的感染和损伤，如缺氧缺血性脑病(HIE)。母亲可能会出血过多，盆底受伤，随后出现尿失禁和/或大便失禁/渗漏，性交痛苦和创伤后应激障碍，对身体和精神健康造成终生影响。大约17%的女性有选择性剖腹产(ELCs)，在英国只有50%的女性在没有辅助的情况下进行阴道分娩。EMCS或助产的主要原因是担心婴儿在分娩时的健康状况，与功能不良的胎盘有关，以及婴儿难以通过产道(头盆比例失调，CPD)。在分娩开始之前，目前很难准确预测哪些婴儿会遇到困难，也很难确定有慢性阻塞性肺疾病风险的怀孕。母亲的年龄和体重等其他因素也很重要。在怀孕结束时为子宫内膜癌或助产创造个性化的风险，将极大地改善患者/临床医生的联合决策，从而有可能避免难产，并改善孕产妇和新生儿的结局。我们计划在妊娠36周后的晚期使用一种名为磁共振成像(MRI)的技术，以识别有更高难产风险的母亲。这种成像不使用辐射，对母亲和婴儿都是安全的。目前广泛应用于临床诊断胎儿畸形，且耐受性良好。我们将对500名有较高不良分娩风险的女性进行扫描，并结合对产妇骨盆、胎头和胎位的测量，以及对胎儿能量储备、心脏功能和胎盘功能的评估。我们将在出生后20周左右就这项研究与母亲们联系。这将使他们有时间阅读患者信息表，观看关于产前磁共振扫描的视频，并与他们的伴侣、亲属和医生讨论这项研究。核磁共振扫描将在KCL的圣托马斯医院进行，扫描过程大约一个小时，中途休息一下。将注意确保母亲在扫描过程中感到舒适，并可以在整个扫描过程中与成像团队交谈。我们将在同一次访问期间进行超声波扫描。将向父母展示他们婴儿的照片，并提供复印件。如果在成像上有任何已知的影响分娩或分娩管理的偶然发现，如低位胎盘，将与母亲讨论并与产科和助产团队分享。我们将收集作为常规产前护理的一部分而获得的临床数据。从分娩和分娩以及母亲和婴儿的结局中获得信息。出生六周后，我们将联系母亲并询问她们的身心健康、喂养方法和婴儿健康的信息。根据所有可用的个人怀孕信息，我们将使用最新的数据建模工具来确定哪些因素与难产的可能性更高有关。这应该提供产生个体风险评分所需的最有价值的数据，该评分可用于EMCS或助产的高危妇女。我们的最终目标是减少紧急分娩和助产的数量，从而改善母亲和婴儿的短期和长期健康和福祉。

In 2020 there were 464,437 U.K. births, of which one third were delivered by Emergency Caesarean Section ( EmCS) or assisted delivery (forceps or vacuum extraction). These interventions often follow a prolonged exhausting labour with a procedure performed under anaesthetic outside normal working hours. Such complex births are more common in older mothers, mothers who are obese and those with small or large babies. They are associated with an increase in baby's admission to the neonatal unit with infection and injuries to the baby's brain, such as hypoxic -ischaemic encephalopathy (HIE). Mothers may suffer excessive bleeding, pelvic floor injuries with subsequent urinary and/or faecal incontinence/leaking, painful sexual intercourse and post-traumatic stress disorder, with lifelong impacts to physical and emotional health. Approximate 17% of women have an elective section (ElCS), leaving only 50% of women in the U.K. having unassisted vaginal deliveries. The main reasons for EmCS or assisted delivery are concerns about baby's wellbeing in labour with compromise relating to a poorly functioning placenta and difficulties with the baby fitting through the birth canal (cephalopelvic disproportion, CPD). Before labour starts, it is currently difficult to accurately predict which babies will get into difficulty or to identify pregnancies at risk of CPD. Other factors such as the mother's age and weight are also important. Creating an individualised risk for EmCS or assisted delivery for a woman at the end of pregnancy would dramatically improve joint patient/clinician decision-making with the potential to avoid a difficult delivery, and improve maternal and neonatal outcome.We plan to use a technique called magnetic resonance imaging (MRI) in late pregnancy, after 36 weeks of gestation (GA), to identify mothers at increased risk of a difficult delivery. This imaging does not use radiation and is safe for both mother and baby. It is currently widely used in clinical practice to diagnose fetal abnormalities and well tolerated. We will scan 500 women who have a higher risk of an adverse delivery and combine measures of the maternal pelvis, fetal head and fetal position with assessment of fetal energy reserves and heart function, and placental function. We will approach mothers at around 20 weeks GA about the study. This will allow them time to read the patient information sheet, watch a video about antenatal MR scanning, and discuss the study with their partners, relatives and doctors. The MRI scan will be performed at St Thomas' Hospital, KCL, taking about one hour with a comfort break halfway through. Attention will be paid to ensure the mother is comfortable during the scan and can talk with the imaging team throughout. We will perform an ultrasound scan during the same visit. Parents will be shown images of their baby and copies provided. If there are any incidental findings on the imaging that are known to influence the management of the birth or delivery, such as a low lying placenta, these will be discussed with the mother and shared with the obstetric and midwifery team. We will collect clinical data acquired as part of routine antenatal care. with information from the labour and delivery and the mothers and baby's outcome. Six weeks after birth we will contact and ask mothers for information about their physical and mental wellbeing, feeding method and baby's health.With all available information for an individual pregnancy we will use the latest data modelling tools to determine which factors relate to a higher chance of a difficult delivery. This should provide the most valuable data required to produce an individual risk score that can be used prospectively in women at high risk for EmCS or assisted delivery. Our ultimate aim is to reduce the numbers of EmCS and assisted deliveries, thereby improving the short and long-term health and wellbeing of both mothers and babies.