本 日お話しする内容 1. 骨盤位分娩に関する臨臨床試験 2. 骨盤位の分娩管理理 方針決定に関わる要素 3. 骨盤位経腟分娩の管理理
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1 骨盤位分娩の管理理 第 66 回 日本産科婦 人科学会学術講演会専攻医教育プログラム 筑波 大学医学医療療系総合周産期医学 小畠真奈奈 平成 26 年年 4 月 17 日
2 本 日お話しする内容 1. 骨盤位分娩に関する臨臨床試験 2. 骨盤位の分娩管理理 方針決定に関わる要素 3. 骨盤位経腟分娩の管理理
3 1. 骨盤位分娩に関する臨臨床試験 骨盤位経腟分娩は前世紀の遺物か? 2000 年年 2004 年年 2006 年年 予定帝切切率率率 50% 80% 症例例の選択 技術の継承 2009 年年 Term Breech Trial 2years after Term Breech Trial ACOG Committee Opinion No.265 ACOG Committee Opinion No. 340 PREMODA study SOGC Clinical Practice Guideline
4 Term Breech Trial Hannah ME, et al., Lancet, 2000 p 26 カ国 121 施設 2183 人 p 予定帝切切群の児の短期予後が 予定経腟群よりも明らかに良良い 一 方で 母体の短期予後は両群で有意差が認められなかった Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial Mary E Hannah, Walter J Hannah, Sheila A Hewson, Ellen D Hodnett, Saroj Saigal, Andrew R Willan, for the Term Breech Trial Collaborative Group* Summary Background For 3 4% of pregnancies, the fetus will be in the breech presentation at term. For most of these women, the approach to delivery is controversial. We did a randomised trial to compare a policy of planned caesarean section with a policy of planned vaginal birth for selected breech-presentation pregnancies. Methods At 121 centres in 26 countries, 2088 women with a singleton fetus in a frank or complete breech presentation were randomly assigned planned caesarean section or planned vaginal birth. Women having a vaginal breech delivery had an experienced clinician at the birth. Mothers and infants were followed-up to 6 weeks post partum. The primary outcomes were perinatal mortality, neonatal mortality, or serious neonatal morbidity; and maternal mortality or serious maternal morbidity. Analysis was by intention to treat. Findings Data were received for 2083 women. Of the 1041 Introduction women assigned planned caesarean section, 941 (90 4%) About were delivered 3 4% of by all caesarean pregnancies section. reach Of term the 1042 with a women fetus in the assigned breech presentation. planned vaginal 1 Data birth, from 591 previously (56 7%) delivered published cohort vaginally. studies Perinatal mortality, have shown neonatal that, mortality, in or serious general, planned neonatal caesarean morbidity was section significantly is better lower for than the planned vaginal caesarean birth section for the group fetus than that for the presents planned as vaginal a breech birth at term. group 2,3 (17 These of 1039 studies [1 6%] are vspotentially 52 of 1039 biased, [5 0%]; however, relative because risk 0 33 women [95% CI were ]; not allocated p<0 0001). to There the were different no modes differences of delivery between at groups random. in terms Other of maternal concerns mortality are that the or studies serious maternal might have morbidity included (41 of pregnancies 1041 [3 9%] that vs 33 would of 1042 [3 2%]; 1 24 [ ]; p=0 35). not currently be considered for a trial of labour (eg, Interpretation footling breech Planned presentation caesarean section [with the is better feet entering than the planned birth vaginal canal ahead birth for of any the term other fetus part in of the the breech body]), and presentation; that clinicians serious maternal undertaking complications vaginal are similar breech deliveries between the may groups. not have been experienced in the technique. Two randomised controlled trials and a Cochrane Lancet 2000; meta-analysis 356: of these trials have not found planned See Commentary caesarean page 1368 section to be associated with substantial benefits for the fetus, but both trials had very small sample sizes. 4 6
5 Term Breech Trial の 2 年年後 Whyte H, et al., Am J Obstet Gynecol, 2004 p 予定帝切切は 2 歳の時点での児の死亡や神経発達遅延のリスク減少にはつながらなかった Hannah ME, et al., Am J Obstet Gynecol, 2004 p 2 年年後の 母体予後のアンケート調査では 予定帝切切と予定経腟でほぼ同じであった Su M, et al., BJOG, 2004 p 予定帝切切は予定経腟よりも分娩中の問題による周産期予後のリスクを減少させる
6 Term Breech Trial の問題点 Glezerman M., Am J Obstet Gynecol, 2006 p 多施設共同研究 : 国 施設による周産期医療療レベルの差 p RCT: 除外基準と振り分けは適切切であったか p 周産期死亡の原因は分娩様式に関連しているか p 予定帝切切群 1039 例例中 17 例例 p 予定経腟群 1039 例例中 52 例例 p Peer reviewは適切切に 行行われたか
7 ACOG Committee Opinion No. 265, Obstet & Gynecol, 2001 p 満期単胎 骨盤位の予定経腟分娩は もはや妥当とはいえない No. 340, Obstet & Gynecol, 2006 p 満期単胎 骨盤位の分娩様式は 熟練した医師の判断に委ねられるべきである ACOG Committee on Obstetric Practice Committee Opinion Number 340, July 2006 (Replaces No. 265, December 2001) This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an Mode of Term Singleton Breech Delivery ABSTRACT: In light of recent studies that further clarify the long-term risks
8 PREMODA study Goffinet F, et al., Obstet & Gynecol, 2006 p フランスとベルギーにおける観察研究 p 厳密な基準によって症例例を選択することにより 満期の 骨盤位経腟分 American Journal of Obstetrics and Gynecology (2006) 194, 娩は安全な選択肢となる Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium François Goffinet, MD, PhD, a,b Marion Carayol, Midwife, a Jean-Michel Foidart, MD, PhD, c Sophie Alexander, MD, PhD, d Serge Uzan, MD, e Damien Subtil, MD, PhD, f Gérard Bréart, MD, a,e for the PREMODA Study Group INSERM U149, Epidemiological Research Unit on Perinatal Health and Women s Health, Universite Pierre et Marie Curie Paris VI, Hoˆpital Tenon a ; Universite Paris-Descartes Paris 5, Faculte de me decine, Service de gyne cologie et obste trique de Port-Royal, Hoˆpital Cochin Saint-Vincent-de-Paul, Assistance Publique-Hoˆpitaux de Paris, b France; Department of Obstetrics and Gynaecology, La Citadelle Hospital, c Lie`ge, Belgium; School of Public Health School, d Bruxelles, Belgium; Department of Obstetrics and Gynaecology, Tenon Hospital, Assistance Publique-Hoˆpitaux de Paris, Universite Pierre et Marie Curie Paris VI, e France; Department of Obstetrics and Gynaecology, Jeanne de Flandre Hospital, f Lille Cedex, France Received for publication June 30, 2005; revised September 30, 2005; accepted October 27, 2005
9 SOGC のガイドライン 骨盤位経腟分娩は選択的帝切切よりも周産期死亡率率率と新 生児短期予後不不良良のリスクが 高い 2. 近代的な施設において慎重に症例例を選択して管理理すれば 選択的帝切切と同様の安全性が得られる 3. 満期の単胎 骨盤位は 症例例を選べば経腟分娩は妥当な選択である 4. 慎重に症例例を選択して管理理すれば 骨盤位の周産期死亡率率率は 1000 出 生に約 2 人 重篤な新 生児短期予後不不良良は 2% である 5. 新 生児の短期予後が重篤であっても 長期的な神経学的予後は どの分娩様式を予定したかによる差はない International Journal of Gynecology and Obstetrics, 2009
10 2. 分娩管理理 方針決定に関する要素 a. 骨盤位の基礎知識識 b. 分娩管理理 方針 c. 試験 骨盤位経腟分娩の必要条件
11 a. 骨盤位の基礎知識識 骨盤位の頻度度 妊娠 28 週 25% 妊娠 36 週以降降 2-3% 骨盤位の要因 母体 ( 狭 骨盤 子宮奇形 ) 羊 水 胎盤 胎児 ( 先天異異常 ) 骨盤位の種類 単臀位 Frank 複臀位 Complete Incomplete ( 膝位 Keeling 足位 Footling)
12 b. 分娩管理理 方針 外回転 選択的帝王切切開 経腟分娩
13 c. 試験経腟分娩の必要条件 膝位 足位でないこと 2500g 以上であること 37 週以降降であること 母体 骨盤が充分な 大きさがあること Hyperextension of the neckがないこと 文書による妊婦の同意が得られていること
14 3. 骨盤位経腟分娩の管理理 a. 陣痛室 分娩室で b. 骨盤位分娩の三種の神器 c. 骨盤位経腟分娩の分娩 手技
15 a. 陣痛室 分娩室で 骨盤位分娩に習熟した医師が管理理する 分娩進 行行が順調であることを適宜評価する 胎児 心拍数陣痛モニタリングを 行行う 破 水時はすぐに内診し 臍帯脱出がないことを確認する 分娩第 二期は 手術室に近接した部屋で管理理する 分娩時には新 生児蘇 生に習熟した医師が 立立ち会う
16 b. 骨盤位分娩の三種の神器 支脚器 タオル 後続児頭鉗 子
17 c. 骨盤位経腟分娩の分娩 手技 自然経腟分娩 臍輪輪までは 自然娩出を待つ Bracht 手技 部分的な 骨盤位牽出術 肩甲娩出法 : 横 8 字法 古典的上肢解出 後続児頭娩出法 :Veit-Smellie 法 後続児頭鉗 子 骨盤位牽出術 全牽出術は可能な限り回避し 帝王切切開を選択する
18 CQ402 骨盤位の取り扱いは? 産婦 人科診療療ガイドライン産科編 外回転術を施 行行する場合は 以下のすべての条件を満たす症例例とする (C) 1. 緊急帝王切切開が可能である 2. 帝王切切開既往がない 3. 児が成熟している 2. 膝位 足位 低出 生体重児 早産 児頭 骨盤不不均衡のいずれかまたはそれを疑わせる場合には帝王切切開を 行行う (C) 3. 以下 2 点を共に満たす場合には 2 以外の 骨盤位に対して 経腟分娩も ( が ) 選択できる (C) 1. 骨盤位牽出術への充分な技術を有する医療療スタッフが常駐すること 2. 経腟分娩と帝王切切開双 方の危険と利利益とを妊婦に充分説明すること 4. 分娩様式選択に際しては 文書による同意を取る (A)
19 まとめ 慎重に分娩 方針を選択した場合 骨盤位の経腟分娩は 帝王切切開分娩を予定する場合と同等に安全である可能性がある 骨盤位経腟分娩の管理理は 選択肢の 一つとしてその技術を継承するとともに検証していかなくてはならない
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