产前保健指南解读

孕前和孕期保健指南（第1版）,中华医学会妇产科学分会产科学组,产前保健存在的问题,缺乏产前检查的规范化方案盲目开出一些无关紧要的检查项目 又常漏掉重要的检查项目 不合理补充营养素不重视孕期健康教育及指导,本指南制订的意义,传统产前检查模式缺乏循证医学证据的支持 全国各地产前检查的方案差异较大许多国家早已发布了自己的产前保健指南并不断更新孕期保健指南将规范产前检查的时间和内容,指南说明,强化循证医学的理念本指南包括：孕前保健和孕期保健每次检查的内容均包含： 1. 健康教育及指导 2. 常规保健 3. 辅助检查（必查项目和备查项目） 本次发布：文字版+表格版,孕前保健（孕前3月）,参照国家计生委国家免费孕前优生健康检查项目试点工作技术服务规范(2010) ，卫生部孕前保健服务工作规范（2007年）将辅助检查分为必查项目和备查项目，减少必查项目，增加备查项目。,健康教育及指导,1. 有计划的妊娠2. 合理营养,控制体重3. 遗传病、慢性病、传染病的评估4. 合理用药5. 避免接触有毒有害物质和宠物6. 改变不良生活方式;避免高强度的工作、高噪音环境和家庭暴力7. 保持心理健康8. 合理运动方式9. 补充叶酸,特别说明,叶酸补充 ：0.4mg0.8mg/d，或含叶酸的复合维生素 The U.S. Preventive Services Task Force (USPSTF) and Centers for Disease Prevention and Control (CDC) recommend that all women of childbearing age take a daily vitamin supplement containing 400 to 800 micrograms of folic acid. Ann Intern Med 2009;150:632-39. 既往发生过NTD的孕妇，则需每天补充叶酸4mg Vincenzo Berghella. Obstetric Evidence Based Guidelines. London:Informa; 2007 Clinical Practice Guideline for Pregnancy Management. Version 2.0. Washington, DC: Pregnancy Management Working Group; 2009,必查项目,（1）血常规（2）尿常规（3）血型（ABO和Rh） （4）肝功能（5）肾功能（6）空腹血糖 （7）HBsAg（8）梅毒筛查（9）HIV筛查 （10）宫颈细胞学检查 ( 1年内未查者）,备查项目,(1) TORCH筛查(2) 宫颈阴道分泌物检查(白带常规、淋球菌、沙眼衣原体) (3) 甲状腺功能检测(4) 地中海贫血筛查（广东、广西、海南、湖南、湖北、四川、重庆等地）(5) 75g OGTT (高危妇女) (6) 血脂检查(7) 妇科超声(8) 心电图(9) 胸部线,孕期保健,孕期保健的日程安排要根据产前检查的目的来决定 本指南推荐的产前检查的孕周分别是：,Health Care Guideline: Routine Prenatal Care. 14th Edition. Minnesota: ICSI;2010,首次（妊娠 6-13+6 周）产前检查,健康教育及指导,1. 流产的认识和预防2. 生活方式的指导3. 避免接触有毒有害物质和宠物4. 慎用药物5. 孕期疫苗的接种6. 改变不良生活方式;避免高强度的工作、高噪音环境和家庭暴力7. 保持心理健康8. 继续补充叶酸0.4mg0.8mg/d至3个月, 有条件继续服用含叶酸的复合维生素,必查项目,1. 血常规2. 尿常规3. 血型（ABO和Rh）4.肝功和肾功5.空腹血糖6. HBsAg 7. 梅毒筛查8. HIV筛查,备查项目,1. HCV筛查 Health Care Guideline: Routine Prenatal Care. 13th Edition. Minnesota: ICSI;2009 Antenatal care routine care for the healthy pregnant woman. NICE clinical guideline 62. 20082. 抗D滴度(Rh阴性者) Health Care Guideline: Routine Prenatal Care. 13th Edition. Minnesota: ICSI;2009 Obstetric Evidence Based Guidelines. London:Informa; 2007 3. 75g OGTT (高危孕妇) Health Care Guideline: Routine Prenatal Care. 13th Edition. Minnesota: ICSI;20094. 地中海贫血筛查5. 甲状腺功能筛查Clinical Practice Guideline for Pregnancy Management. Version 2.0. Washington, DC: Pregnancy Management Working Group; 20095. 甲状腺功能筛查Clinical Practice Guideline for Pregnancy Management. Version 2.0. Washington, DC: Pregnancy Management Working Group; 2009,备查项目,6. 血清铁蛋白(Hb105g/L者）Clinical Practice Guideline for Pregnancy Management. Version 2.0. Washington, DC: Pregnancy Management Working Group; 20097. 结核菌素(PPD)试验（高危孕妇） Health Care Guideline: Routine Prenatal Care. 13th Edition. Minnesota: ICSI;2009 Clinical Practice Guideline for Pregnancy Management. Version 2.0. Washington, DC: Pregnancy Management Working Group; 2009 Obstetric Evidence Based Guidelines. London:Informa; 2007 8. 宫颈细胞学检查（孕前12月未查者） Clinical Practice Guideline for Pregnancy Management. Version 2.0. Washington, DC: Pregnancy Management Working Group; 2009 Obstetric Evidence Based Guidelines. London:Informa; 2007 裘佳敏, 刘铭, 段涛. 产前检查.中华全科医师杂志, 2007, 6(6):334-336,备查项目,9.宫颈分泌物检测淋球菌和沙眼衣原体(高危孕妇或有症状者) Clinical Practice Guideline for Pregnancy Management. Version 2.0. Washington, DC: Pregnancy Management Working Group;2009 Health Care Guideline: Routine Prenatal Care. 13th Edition. Minnesota: ICSI;2009 Obstetric Evidence Based Guidelines. London:Informa; 2007 董悦. 对围产期TORCH感染筛查的重新评价.中华妇产科杂志，2004, 39（11）:725-72810. 细菌性阴道病的检测（早产史者） Clinical Practice Guideline for Pregnancy Management. Version 2.0. Washington, DC: Pregnancy Management Working Group;2009 Obstetric Evidence Based Guidelines. London:Informa; 200711.心电图检查,备查项目,12. 超声检查早孕期：确定宫内妊娠、孕周、双胎绒毛膜性 妊娠11-13+6周：测量胎儿NT厚度并核定孕周 NT测量按照英国胎儿医学基金会标准进行（）,支持文献,1. Health Care Guideline: Routine Prenatal Care. 13th Edition. Minnesota: ICSI;20092. Clinical Practice Guideline for Pregnancy Management. Version 2.0. Washington, DC: Pregnancy Management Working Group; 20093. Obstetric Evidence Based Guidelines. London:Informa; 20074. 严英榴. 胎儿结构异常的早孕期超声筛查.中国实用妇科与产科杂志, 2008, 24（2）：102-1065. Nicolaides KHIncreased nuchal translucency with normal karyotype / Nicolaides KH .The 11-13+6 weeks scanLondon: Fetal Medicine Foundation，2004，71-946. American Institute of Ultrasound in MedicineAIUM Practice Guideline for the Performance of an Antepartum Obstetric Ultrasound ExaminationEB/OL /publications,备查项目,13. 早孕期母体血清学筛查(PAPP-A 和游离-hCG) (妊娠1013+6周) 注意事项：空腹；超声确定孕周；确定抽血当天的体重。 高危者，可考虑绒毛活检或联合中孕期血清学筛查结果再决定羊膜腔穿刺检查1. 李之朋, 杨春艳, 陈敏. 唐氏综合征的早期筛查.中国实用妇科与产科杂志, 2008, 24（2）：87-902. ACOG Practice Bulletin No. 77: Screening for fetal chromosomal abnormalities. American College of Obstetricians and Gynecologists. Obstet Gynecol ,2007,109(1):217-227.3. Wald NJ, Rodeck C, Hackshaw AK, et al. First and second trimester antenatal screening for Down syndrome: the results of the serum, urine and ultrasound screening study (SURUSS). Health Technol Assess, 2003,7:1-77. 4. Malone FD, Canick JA, Ball RH, et al. First trimester or second trimester screening, or both, for Downs syndrome（FASTER）. N Engl J Med 2005;353:2001-2011. 5. Wald NJ, Nuttly WJ, Hackshaw AK. Antenatal screening for Down syndrome with the quadruple test. Lancet , 2003 ,361:835-836,备查项目,14. 妊娠 10-12周行绒毛活检（高危孕妇） Health Care Guideline: Routine Prenatal Care. 13th Edition. Minnesota: ICSI;2009 Antenal screening and diagnostic testing for singleton pregnancies. Obstetric guideline17.Vancouver: BCRCP; 2003,妊娠 14-19+6周 产前检查,健康教育及指导,1. 流产的认识和预防2. 妊娠生理知识3. 孕期营养和生活方式的指导4. 中孕期胎儿非整倍体筛查的意义5. Hb105g/L, 补充元素铁60-100mg/d6.开始补充钙剂, 600mg/d,特别说明,Hb105g/L, 补充元素铁60-100mg/d Antenatal care routine care for the healthy pregnant woman. NICE clinical guideline 62. 2008. Clinical Practice Guideline for Pregnancy Management. Version 2.0. Washington, DC: Pregnancy Management Working Group; 2009补充钙剂, 600mg/d Health Care Guideline: Routine Prenatal Care. 13th Edition. Minnesota: ICSI;2009 Obstetric Evidence Based Guidelines. London:Informa; 2007,必查项目,无,备查项目,胎儿非整倍体中孕期血清学筛查（AFP, hCG and uE3） (妊娠1520+0周，最佳孕周16-18周),支持文献,1. Health Care Guideline: Routine Prenatal Care. 13th Edition. Minnesota: ICSI;20092. Clinical Practice Guideline for Pregnancy Management. Version 2.0. Washington, DC: Pregnancy Management Working Group; 20093. Antenatal care routine care for the healthy pregnant woman. NICE clinical guideline 62. 2008.4. Antenal screening and diagnostic testing for singleton pregnancies. Obstetric guideline17.Vancouver: BCRCP; 20035. ACOG Practice Bulletin No. 77: Screening for fetal chromosomal abnormalities. American College of Obstetricians and Gynecologists. Obstet Gynecol ,2007,109(1):217-227.6. Wald NJ, Rodeck C, Hackshaw AK, et al. First and second trimester antenatal screening for Down syndrome: the results of the serum, urine and ultrasound screening study (SURUSS). Health Technol Assess, 2003,7:1-77. 7. Malone FD, Canick JA, Ball RH, et al. First trimester or second trimester screening, or both, for Downs syndrome（FASTER）. N Engl J Med 2005;353:2001-2011. 8. Wald NJ, Nuttly WJ, Hackshaw AK. Antenatal screening for Down syndrome with the quadruple test. Lancet ,361:835-36, 2003. 9. 周建军, 胡娅莉. 唐氏综合征的中孕期筛查. 中国实用妇科与产科杂志, 2008, 24: 90-93,备查项目,羊膜腔穿刺检查胎儿染色体（妊娠16-21周） (预产期时孕妇年龄35岁或高危人群） 卫生部.产前诊断技术管理办法(2002年),妊娠 20-24周 产前检查,健康教育及指导,1. 早产的认识和预防2. 营养和生活方式的指导 3. 胎儿系统超声筛查的意义,必查项目,1. 胎儿系统超声筛查（妊娠18-24周） ：筛查胎儿的严重畸形2. 血常规3. 尿常规,支持文献,18-22周 Obstetric Evidence Based Guidelines. London:Informa; 2007 18-21周 Antenatal care routine care for the healthy pregnant woman. NICE clinical guideline 62. 2008.18-20周 Clinical Practice Guideline for Pregnancy Management. Version 2.0. Washington, DC: Pregnancy Management Working Group; 2009 Obstetric Evidence Based Guidelines. London:Informa; 200718-23周 陈敏. 胎儿结构异常的中孕期超声筛查.中国实用妇科与产科杂志, 2008, 24(2): 106-110 严英榴. 先天性心脏病的产前筛查及诊断.中华临床医师杂志, 2010, 4(6):706-710 Stansard views for examination of the fetus/Pilu G Nicolaides KH, Ximenes R, et al. The 18-23 weeks scan.London:ISUOGFetal Medicine Foundation，2002. 18-24周 段涛. 产前检查.中华全科医师杂志, 2007, 6(6):334-336 16-24周 卫生部.产前诊断技术管理办法(2003年),备查项目,宫颈评估（超声测量宫颈长度和内口宽度） 中华医学会妇产科分会产科学组. 早产的临床诊断与治疗推荐指南(草案). 中华妇产科杂志, 2007, 42(7):498-500 Health Care Guideline: Routine Prenatal Care. 13th Edition. Minnesota: ICSI;2009 Clinical Practice Guideline for Pregnancy Management. Version 2.0. Washington, DC: Pregnancy Management Working Group;2009,妊娠 24-28周 产前检查,健康教育及指导,1. 早产的认识和预防2. GDM筛查的意义,必查项目,1. GDM筛查 50g GCT：7.2mmol/L, 11.1 mmol/L, 则进行75g OGTT 11.1mmol/L, 即测空腹血糖 直接行75g OGTT (空腹5.1mmol/L,1小时10.0mmol/L, 2小时8.5mmol/L) International association of diabetes and pregnancy study groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy Diabetes Care, 2010, 33: 676-682. 2. 尿常规,备查项目,1. 抗 D 滴度复查( Rh 阴性者)2. 宫颈阴道分泌物 fFN 检测(早产高危者)Clinical Practice Guideline for Pregnancy Management. Version 2.0. Washington, DC: Pregnancy Management Working Group;2009中华医学会妇产科分会产科学组. 早产的临床诊断与治疗推荐指南(草案). 中华妇产科杂志, 2007, 42(7): 498-500时春艳. 胎儿纤维连接蛋白对先兆早产孕妇发生早产的预测价值中华围产医学杂志, 2006,9(1) : 2-5,妊娠 30-32周 产前检查,健康教育及指导,1. 分娩方式指导2. 注意胎动 Health Care Guideline: Routine Prenatal Care. 13th Edition. Minnesota: ICSI; 2009 Antenatal care routine care for the healthy pregnant woman. NICE clinical guideline 62. 2008 不主张胎动计数3. 母乳喂养指导4. 新生儿护理指导,必查项目,1. 血常规2. 尿常规 3. 超声检查：胎儿生长、羊水量、胎位、胎盘 Obstetric Evidence Based Guidelines. London:Informa; 2007 Antenatal care routine care for the healthy pregnant woman. NICE clinical guideline 62. 2008,备查项目,1. 超声测量宫颈长度 （早产高危者） 2. 宫颈阴道分泌物检测 fFN （早产高危者）,妊娠 32-36周 产前检查,健康教育及指导,1. 分娩前生活方式的指导2. 分娩相关知识 3. 新生儿疾病筛查 4. 抑郁症的预防,必查项目,尿常规,备查项目,1. 妊娠35-37周 GBS筛查：具有高危因素的孕妇（如合并糖尿病、前次新生儿有GBS感染等），取肛周与阴道下1/3分泌物培养 Health Care Guideline: Routine Prenatal Care. 13th Edition. Minnesota: ICSI;2009 （常规筛查） Clinical Practice Guideline for Pregnancy Management. Version 2.0. Washington, DC: Pregnancy Management Working Group;2009 （常规筛查） Obstetric Evidence Based Guidelines. London:Informa; 2007 （常规筛查） Antenatal care routine care for the healthy pregnant woman. NICE clinical guideline 62. 2008 （不主张常规筛查） 2. 妊娠3234周肝功、血清胆汁酸检测（高发病率地区疑似ICP的孕妇）3. NST检查 (妊娠34周开始，高危孕妇) Antenatal care routine care for the healthy pregnant woman. NICE clinical guideline 62. 20084. 心电图复查（高危孕妇）,妊娠37-41周产前检查（7-11次）,健康教育及指导,1. 分娩相关知识（临产的症状、分娩方式、分娩镇痛） 2. 新生儿免疫接种指导3. 产褥期指导4. 胎儿宫内情况的监护5. 41周, 住院并引产 Clinical Practice Guideline for Pregnancy Management. Version 2.0. Washington, DC: Pregnancy Management Working Group;2009 Antenatal care routine care for the healthy pregnant woman. NICE clinical guideline 62. 2008 中华医学会妇产科学分会产科学组. 妊娠晚期促宫颈成熟与引产指南(草案). 中华妇产科杂志, 2008, 43(1):75-76,必查项目,1. 宫颈检查，Bishop评分2. 超声检查（评估胎儿大小、羊水量、胎盘成熟度、胎位和脐血流S/D值等）Clinical Practice Guideline for Pregnancy Management. Version 2.0. Washington, DC: Pregnancy Management Working Group;2009Antenatal care routine care for the healthy pregnant woman. NICE clinical guideline 62. 20083. NST检查（每周一次）,备查项目,无,常规保健内容（每次）,1. 询问胎动、阴道出血、宫缩、饮食、运动等情况2. 体格检查 血压 孕妇体重，评估体重增长是否合理 宫底高度和腹围，评估胎儿体重增长是否合理 胎心率 胎位,孕期不推荐常规检查的内容,孕期不推荐常规检查的内容,1. 骨盆外测量 Health Care Guideline: Routine Prenatal Care. 13th Edition. Minnesota: ICSI;2009 Clinical Practice Guideline for Pregnancy Management. Version 2.0. Washington, DC: Pregnancy Management Working Group;2009 不能预测产时头盆不称,孕期不推荐常规检查的内容,2. 弓形虫（TOX）、巨细胞病毒（CMV）和单纯疱疹病毒（HSV）血清学筛查 Health Care Guideline: Routine Prenatal Care. 13th Edition. Minnesota: ICSI;2009 Clinical Practice Guideline for Pregnancy Management.Version 2.0.Washington, DC: Pregnancy Management