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1、2023未足月胎膜早破的管理摘要未足月胎膜早破(pretermprematureruptureofmembranes,PPROM)因发病率不低，且与早产、母儿感染、新生儿呼吸疾病等并发症有关，一直是产科临床研究的热点问题。虽然近年来PPROM管理在不断更新和完善,但一些争议和挑战仍然存在。如PPROM诊断后,是否需要卧床休息？是终止妊娠还是期待治疗？如何使用各种治疗药物才能起到最佳的治疗效果？本文将根据近年来的最新证据对目前存在的争议与挑战进行详细阐述。【关键词】胎膜早破；妊娠中期；临床方案未足月胎膜早破(pretermprematureruptureofmembranes,PPROM)是指妊
2、娠不满37周发生的临产前胎膜自然破裂。单胎妊娠PPROM发生率为2%4%,双胎妊娠PPROM发生率为7%20%1IPPROM是导致早产的主要原因之一，占比25%-30%;PPROM也可能导致母婴感染、脐带脱垂、胎儿窘迫、胎儿肺发育不全、胎盘早剥等母儿并发症21PPROM发生率不低，因此一直是产科临床研究的热点，尽管国内外学术组织相继推出并不断更新PPROM指南，但仍然存在一些争议和挑战。一、卧床休息与否PPROM后早产发生率较高2,住院管理可以更快更及时地处理可能发生的严重并发症，如胎盘早剥、绒毛膜羊膜炎、胎死宫内等。目前，美国妇产科医师学会(AmericanCollegeofObstetri
3、ciansandGynecologists,ACOG)、加拿大妇产科医师协会(SocietyofObstetriciansandGynaecologistsofCanada,SOGC)和法国妇产科医师学会(FrenchCollegeofGynaecologistsandObstetricians,CNGOF)等组织均推荐PPROM诊断后立即住院管理，而不支持门诊管理.无论是住院管理还是门诊管理，卧床休息一直被认为是PPROM的规范医嘱。卧床休息分为绝对卧床休息和限制活动(可下床进行如厕、洗澡、室内走动等少量活动工2019年，一项随机对照试验(randomizedcontroltrial,RCT
4、)对24-36周+6PPROM孕妇绝对卧床与限制活动进行上瞰，发现绝对卧床并未延长妊娠潜伏期，也未改善母儿结局30进一步研究发现，与不卧床休息的孕妇相比，绝对卧床休息N3d孕妇发生血栓栓塞事件的风险显著增加(15.6/1000与0.8/1000,P0.05)40因此对于PPROM孕妇不宜推荐绝对卧床休息。PPROM孕妇期待治疗期间，限制活动的目的可能是延长妊娠潜伏期并防止脐带脱垂，虽看似合理，但目前并无确切证据表明限制活动可以改善PPROM的围产结局。2009年的一项调查研究显示，尽管大多数医生认为卧床休息获益很小或没有益处，但有87%的母胎医学专家仍会建议PPROM孕妇卧床休息5该调杳研究中
5、的卧床休息是指限制活动，即每天下床时间不超过1-2h允许如厕、洗澡及室内短暂走动等少量活动。2020年,美国母胎医学会(SocietyforMaternal-FetalMedicine,SMFM)指出限制活动可能与各种不良结局有关，不建议PPROM孕妇常规限制活动6I临床医生应告知PPROM患者卧床休息的利弊，与患者和家属共同抉择。选择卧床休息的孕妇应考虑进行血栓预防、心理支持等干预，尽可能避免或减少卧床休息的副作用。鉴于我国PPROM孕妇通常选择卧床休息所以有必要评估卧床休息对PPROM孕妇围产结局的影响。二、终止妊娠或期待治疗的选择关于PPROM的处理是选择终止妊娠还是期待治疗，需要考虑以
6、下因素：孕周、母儿情况、新生儿救治水平、患者及家庭意愿、治疗成本、潜在的家庭和社会负担、存活早产儿的长期生存质量及潜在的医患矛盾等。近年来，早产儿救治水平取得了巨大进步，如体外人工胎盘、外源性肺表面活性物质等治疗手段可以有效治疗早产儿呼吸衰竭，改善早产儿结局7o因此产科在临床处理PPROM时已较几十年前更加从容。但基本原则仍是在母儿无保胎禁忌证的情况下，尽可能期待治疗至足月。若计划终止妊娠,应尽量在完成促胎肺成熟治疗后进行。胎儿的成熟度与孕周息息相关，而PPROM的孕周跨度非常大，孕周越小则新生儿发病率和死亡率越高。因此，孕周是决定PPROM治疗方式的最重要因素。根据孕周大小可将PPROM分为
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