高危妊娠中孕11～16周应用超声筛查胎儿心脏畸形的价值

目的:探讨高危妊娠中孕11~16周应用超声筛查胎儿心脏畸形的意义。方法:回顾性分析天津市中心妇产科医院与美国费城儿童医院胎儿心脏中心就诊的高危妊娠孕妇668例,于孕11~16周胎儿心脏超声筛查,其中404例采用四腔心切面筛查法,264例采用心脏节段性扫查法。结果:在所有高危妊娠孕妇中,应用四腔心切面筛查法,严重复杂性先心病的检出率为5.7%(23/404),应用心脏节段性扫查法严重复杂性先心病检出率为9.5%(25/264),两者比较差异无统计学意义(P0.05)。胎儿颈部透明层(nuchal translucency,NT)增高与淋巴水囊瘤患者中,应用四腔心切面筛查法,严重复杂性先心病的检出率为2.5%(9/362),心脏节段性扫查法检出率为10.0%(7/70),两者比较差异有统计学意义(P0.05)。同一孕期(孕12~14周前)比较,四腔心切面筛查法与心脏节段性扫查法对于严重复杂性先心病的检出率分别为5.9%(21/358)、10.4%(8/77),两者比较差异无统计学意义(P0.05)。结论:随着心脏畸形的高危因素如NT值增高、淋巴水囊瘤、胎儿心外畸形等在早期得以越来越多地检出,在同一时间段内应用超声筛查胎儿心脏畸形尤为必要。四腔心切面作为胎儿超声心动图中最重要、最易获得的切面,尤其在早期胎儿心脏体积较小的情况下,对于严重复杂性先心病的检出具有较高的临床应用价值。先心病的早期检出能最大限度减轻对孕妇本身的损害。     

三个心脏超声切面在常见先天性心脏病产前诊断中的作用

目的 探讨三个胎儿超声心动图标准切面：四腔心切面、五腔心切面、三血管平面在发现和诊断胎儿常见先天性心脏病中的作用及对于先天性心脏病产前筛查的意义。方法 回顾2003年5月至2004年7月胎儿心脏畸形各病例的心脏超声图像，记录每一病例三个超声切面（四腔心切面、五腔心切面、三血管平面）的彩色多普勒超声图像表现，分析并总结各切面异常表现的特点。结果 （1）研究共包括胎儿心脏畸形病例26例，疾病类型包括房室间隔缺损、单纯性室间隔缺损、单心室、单心房、左心发育不良综合征、法洛四联症、右心室双出口、纠正性／完全性大动脉转位、动脉单干、主动脉瓣狭窄、肥厚性心肌病（梗阻型）、心脏肿瘤。（2）各心脏畸形病例在这三个心脏超声切面的扫查中至少有1个切面显示异常。每一类心脏畸形在这三个切面图像上均有特征性表现。（3）所有病例中二维四腔心切面（常规产科筛查切面）显示异常的比例为73％，四腔心切面未显示异常的病例包括：完全性大血管转位3例、法洛四联症1例、右心室双出口1例、动脉单干1例、主动脉骑跨伴室间隔缺损1例。（4）各标准切面获得率分别为：96．2％、88．5％、84．6％。结论 （1）四腔心切面、五腔心切面、三血管平面这三个胎儿彩色多普勒心脏超声切面探查在各类胎儿常见的先天性心脏病超声产前检查与诊断中起重要的作用。（2）与运用单个二维四腔心切面探查比较，三个切面的探查方法可提高常见先天性心脏病，尤其是胎儿心脏锥干畸形的检出率。（3）三个切面探查操作较为简便，有望成为一项胎儿先天性心脏病的筛查方法。     

超声心动图的四腔心切面产前诊断胎儿先天性心脏病的价值

目的 探讨超声心动图的四腔心切面（四腔心切面）产前诊断胎儿先天性心脏病（先心病）的价值。方法 回顾性分析780例妊娠16-36周通过四腔心切面进行产前诊断是的孕妇及其新生儿的临床资料。结果 780例胎儿中,94.6%,(738/780)的胎儿可以获取满意的四腔心切面,其中3例胎儿异常,1例为三尖瓣下移畸形（Ebstein综合征）,1例为严重的室间隔缺损,1例为单心房单心室和主动脉狭窄,例1和例3分别于出生后行尸体解剖和新生儿超声心动图检查,均符合产前诊断,例2出生后超声心动图检查证实为单心房和单心室,其余777例新生儿中,出生后身体检查并追踪至产后6周,发现3例先心病,其中1例室间隔缺损,1例房间隔缺损,1例房间隔缺伴肺动脉狭窄,四腔心切面诊断胎儿先心病的敏感性为50%,特异性为100%。结论 四腔心切面可以显示胎儿心脏的大部分结构,探测成功率高,对先心病的宫内诊断有较高的敏感性和极高的特性,可将胎儿四腔心切面作为常规的产检查项目。     

"胎儿心脏筛查指南"在产前超声筛查胎儿先天性心脏病中的应用价值

目的 探讨2006年国际妇产科超声协会公布的"胎儿心脏筛查指南"在产前超声筛查胎儿先天性心脏病中的应用价值.方法 2006年9月-2007年7月在南京大学医学院附属鼓楼医院母胎医学中心接受胎儿超声筛查的单胎孕妇5000例.平均年龄28岁(18～48岁),平均孕周27周(妊娠18～40周).以"胎儿心脏筛查指南"为标准对胎儿四腔心和左、右心事流出道及三血管切面进行扫查,对疑有心脏异常者进一步行胎儿超声心动图枪查,对确诊先天性心脏病胎儿建议羊水或脐血穿刺行染色体核型分析,终止妊娠者行胎儿尸体心脏解剖;继续妊娠者,于胎儿出生后2～6个月行超声心动图随访.结果 (1)超声筛查各切面获取率:5000例单胎孕妇中,四腔心切面获取率为97.64%(4882/5000),其中左、右心室流出道及三血管切面的获取率分别为87.69%(4281/4882)、82.51%(4028/4882)和96.29%(4701/4882).5000例孕妇中,孕中期筛查2750例,孕晚期筛查2250例,孕晚期各标准切面的获取率明显低于孕中期(P<0.05).(2)胎儿先天性心脏病发病率:4882例胎儿中最终诊断先大性心脏病73例,发病率为1.50%(73/4882),其中产前超声确诊50例(孕中期24例、孕晚期26例).超声漏诊23例,误诊1例,合并其他器官畸形18例.(3)随访结局:产前诊断为先天性心脏病的胎儿中接受尸体心脏解剖19例,均与产前超声诊断结果一致;继续妊娠者胎儿出生后接受超声心动图检查12例,其中与产前诊断符合11例,另1例产前诊断三尖瓣关闭不全,产后超声检查正常.接受染色体检查23例,染色体核型异常7例.(4)产前超声筛查的敏感性与特异性:四腔心切面确诊先天性心脏病胎儿28例,同时加入左、右心室流出道及三血管切面共诊断先天性心脏病50例,诊断的敏感性为69%(50/73)、特异性为99.98%(4808/4809),假阴性率为0.48%(23/4831),假阳性率为2%(1/51).结论 国际妇产科超声协会2006年公布的"胎儿心脏筛查指南"临床实用、易于遵循、便于操作.就最佳超声切面获得来说,孕中期(18～27周)是最佳筛查时间.胎儿四腔心和左、右心窒流出道及三血管切面同时筛查,可产前诊断69%的先天性心脏病胎儿.     

心脏轴测定在胎儿先天性心脏病产前超声诊断中的临床意义

目的探讨超声心动图测定心脏轴变化在胎儿先天性心脏病（先心病）产前诊断中的临床意义。方法应用Ａｃｕｓｏｎ１２８×Ｐ／１０彩色多普勒超声诊断仪检查５１８例胎龄１８～４０周的先心病高危胎儿和９０例正常胎儿,在心脏超声四腔观基础上测定胎儿心脏轴,并从多切面观察胎儿心内结构,以确定胎儿有无先心病。结果正常胎儿心脏轴为（４４．８±１０．３）度,先心病胎儿心脏轴为（５８．１±１５．７）度,两者比较,差异有显著性（Ｐ＜０．０１）。单纯四腔观检测胎儿先心病的敏感性为６８．５％,应用心脏超声四腔观加心脏轴测定检测胎儿先心病的敏感性为９１．４％,两者比较,差异有显著性（Ｐ＜０．０５）;５１８例先心病高危胎儿中,产前超声正确诊断先心病３４例,假阳性１例,假阴性１例。结论正常胎儿心脏轴范围２０～７５度,如心脏轴＞７５度,应高度怀疑胎儿先心病;心脏轴测定在胎儿先心病筛查中具有重要作用,可作为一种常规测量指标。     

七切面联合筛查法在孕中晚期胎儿先天性心脏病检查中的应用价值

目的 探讨七切面联合筛查法在孕中晚期胎儿先天性心脏病检查中的可行性和临床价值.方法 2006年9月至2007年2月,在南京医科大学鼓楼临床学院母胎医学中心对妊娠18周以上的2000例单胎孕妇进行胎儿系统结构筛查的同时进行胎儿心脏七切面联合扫查,对先天性心脏病胎儿终止妊娠者进行胎儿尸体心脏解剖;继续妊娠者,于婴儿出生后6个月内进行超声心动图随访.结果 2000例单胎妊娠胎儿中,最终四腔心切面获取率为99.0%,其中左心室流出道、右心室流出道、三血管、主动脉弓、动脉导管弓和上下腔静脉切面的获取率分别为92.5%、90.9%、98.5%、86.8%、84.6%和91.6%.心脏筛查中,脊后位时心脏七切面的获取率均在80%以上.2000例单胎妊娠胎儿中,发现先天性心脏病19例,发生率为0.95%.产前诊断13例(其中误诊1例),漏诊7例,误诊1例,诊断敏感性63.2%、特异性99.9%.结论 七切面联合筛查法在孕中晚期胎儿先天性心脏病检查中切实可行,能在产前诊断出大部分心脏畸形,尤其是心脏复杂畸形.     

胎儿先天性心脏病产前超声筛查诊断模式的评价

目的 评价胎儿先天性心脏病产前超声筛查诊断模式.方法 收集2004年2月-2007年5月复旦大学附属妇产科医院产科在孕24周前行产前诊断的11 410例孕妇,应用超声筛查其11 544例胎儿的先天性心脏病发生情况.超声筛查切面包括四腔心切面、流出道切面(包括左室流出道+三血管切面),计算不同切面诊断先天性心脏病的敏感性及特异性,并随访胎儿预后.结果 (1)11 544例胎儿中,筛查出先天性心脏病48例,漏诊6例,先天性心脏病发生率为0.47%(54/11 544).(2)四腔心切面发现胎儿先天性心脏病33例,主要为室间隔缺损18例(其中9例合并锥干异常)、房室瓣膜异常6例及左、右心不对称9例.四腔心切面诊断先天性心脏病的敏感性为61.11%(33/54),特异性为99.98%(11 488/11 490).流出道切面诊断胎儿先天性心脏病15例,包括肺动脉闭锁1例,肺动脉瓣狭窄3例,大血管错位2例,肺动脉狭窄及大血管错位1例,法洛四联症6例,肺动脉狭窄2例.四腔心切面+流出道切面诊断胎儿先天性心脏病的敏感性为B8.89%(48/54),特异性99.98%(11 488/11 490).(3)48例先天性心脏病胎儿中,有11例合并其他器官系统异常,另有11例行羊膜腔穿刺检查胎儿染色体,其中5例为21三体.结论 四腔心切面+流出道切面对胎儿先天性心脏病的产前超声筛查有较高的检出率,此产前超声筛查诊断模式在临床上诊断胎儿先天性心脏病切实可行.     

彩色多普勒超声在非高危胎儿产前心脏筛查中的临床意义

目的：探讨彩色多普勒超声在非高危胎儿产前心脏筛查中的临床意义。方法：选用我院1125例产前孕检的孕妇，通过多普勒超声的多切面检查，获得较为清晰的二维和彩色多普勒声像图，检查心脏畸形。结果：检查出9例先天性心脏病患者，其中通过产前超声筛查出7例，漏诊2例（室间隔缺损、法洛四联症），经伦理委员会和家属的同意，对引产后患儿进行尸解证实主要原因是由于母体的羊水少、胎儿体位异常、母体腹壁厚。多普勒超声对非高危胎儿的检出率0．6％，对心脏畸形的检查率是78％，诊断准确率是100％。结论：多普勒超声对非高危胎儿进行产前心脏超声筛查，检查率比较高，能够及时发现心脏畸形和做出相应的干预处理。     

超声检测胎儿严重先天性心脏畸形9例分析

目的 探讨二维超声心动图和彩色多普勒超声产前诊断胎儿先天性心脏畸形的可行性。方法 应用二维超声图像对胎儿心脏进行四腔切面,左室流出道,右室流出道切面等心脏解剖结构检查,加以彩色多普勒血液图对胎儿心脏进行血流方向及流速的观察。结果 １３５３９例被检孕妇中９例胎儿存在严重的先天性畸形,其中４例左心发育不良,２例肺动脉瓣狭窄,２例大血管转位,１例内脏反位,右心发育不全,均由病理尸解或新生儿心脏超声证实。     

先天性心脏畸形的产前诊断及临床分析

目的探讨先天性心脏畸形的产前诊断及临床意义。方法本研究应用Yagel5个心脏横面和心脏长轴切面进行胎儿心脏扫描，并有效多普勒血流技术、彩色血流、M型超声等超声仪器各项功能技术，对2002至2004年982例先天心脏畸形高危患者进行胎儿心脏全方位检查，并对引产胎儿进行尸体解剖核对产前诊断的正确性，并进行胎儿染色体分析；对产前诊断未发现明显异常的胎儿进行临床随访，胎儿出生后进行新生儿或要儿心脏超声检查，判定产前诊断的正确性。结果（1）982例先天心脏畸形高危患者中，检查发现胎儿心脏结构异常为46例（4．7％）。其中应用单纯四腔心即能诊断的先天性胎儿心脏结构异常为32例，其余14例需同时结合其他心脏检测平面诊断。（2）41例引产胎儿中，32例进行尸体解剖，病理结果与产前超声检查符合率为93．8％（30／32），其中1例患者病理诊断为永存动脉干畸形，产前诊断为法洛四联症；另1例为右心室双流出道畸形，产前诊断为大动脉转位。（3）46例患者中，32例进行胎儿染色体检测，合并染色体异常8例（25．0％）。（4）5例为产前诊断右心系统略大胎儿，分娩后新生儿或要儿心脏超声检查，结果与产前基本相同，表现为单纯右心系统略大，但新生儿和要儿无任何临床症状。（5）936例产前诊断为正常胎儿心脏患者，新生儿或要儿心脏超声检查发现室间隔缺损1例，动脉导管未闭2例，房间隔缺损1例。结论（1）应用本研究方法，以先天心脏畸形高危患者为筛查对象，产前诊断先天性心脏畸形阳性率为4．7％，产前诊断与尸体解剖符合率为93．8％。（2）应用本研究方法可使高危人群产前诊断胎儿先天性心脏畸形的敏感性达92．0％，特异性达99．6％。（3）单纯左右心比例轻中度失调胎儿可能有较好的临床预后。     

Fetal echocardiographic screening for congenital heart disease: the importance of the four-chamber view

The four-chamber view of the heart has been proposed as a screening method for obstetrical sonographers to assess the fetus for the presence of congenital heart disease. We examined the fetuses in 1022 pregnancies and found 74 structurally abnormal hearts. Seventy-one of these (96%) were found to have an abnormality as seen in the four-chamber view. The four-chamber view of the heart had 92% sensitivity and 99.7% specificity in the detection of congenital heart disease. The positive predictive value was 95.8%, and the negative predictive value was 99.4%. We conclude that the four-chamber view may be a useful screen for the presence of congenital heart disease and should be included as a part of all routine obstetric ultrasound examinations.     

Early prenatal diagnosis of major cardiac anomalies in a high-risk population

OBJECTIVE: To examine the accuracy of early fetal echocardiography performed in a high-risk population combining transvaginal and transabdominal routes. METHODS: A series of 330 high-risk pregnancies were screened by transvaginal and transabdominal scan at 12-17 weeks' gestation in a prospective multicentre trial in Spain between September 1999 and May 2001. A total of 334 fetal heart examinations were performed, including four twin pregnancies. Maternal age ranged from 17 to 46 years (mean 33 years with 36% of women over 34 years). The median gestational age at scan was 14.2 weeks (range 12-17 weeks). For each fetus, visualization of the four-chamber view, the origin of the great arteries, aortic and ductal arches and systemic venous return was attempted in a segmental approach. B-mode and colour/pulsed Doppler flow imaging were used in all cases. The duration of complete heart examination was less than 30 minutes. The examinations were performed by three experienced operators. Reliability was assessed by conventional transabdominal echocardiography at 20-22 weeks, by postnatal follow-up in the first three months of life, and/or by autopsy in cases of termination of pregnancy. RESULTS: The rate of successful visualization of the fetal heart was 94.6% (316/334). In 48 out of 334 (14.4%) fetuses the final diagnosis was abnormal. In 38 out of 48 (79.2%) cases with heart defects the diagnosis was suspected at early echocardiography. In the group with congenital heart defects, 27 cases had an abnormal karyotype (56.3%) and 31 cases showed extracardiac anomalies (64.6%). There were 10 false-negative cases at early scan. There were no false-positive diagnoses. CONCLUSIONS: This experience stresses the usefulness of early fetal echocardiography when performed by expert operators on fetuses specifically at risk for cardiac disease. The high rate of successful visualization of the fetal heart provides a reliable diagnosis of major cardiac defects at this early stage of pregnancy.     

Scan the fetal heart by real-time three-dimensional echocardiography with live xPlane imaging

Objective.?To describe the methodology of live xPlane imaging in the visualization of the fetal heart in detail.

Methods.?Fifty-one consecutive pregnant women with singleton pregnancies were imaged to display four screening sections of the fetal heart, the four-chamber view, the left outflow tract view (LVOT), the right outflow tract view (RVOT), and the three-vessel and trachea view (3VT), using live xPlane imaging. The methodology of how to visualize the screening planes was described in detail. We used two methods to image the fetal heart with live xPlane imaging: one uses the four-chamber view as the starting plane and the other uses the longitudinal view of fetal upper thorax as the starting plane.

Results.?When using the four-chamber view as the starting plane, the visualization rate of LVOT, RVOT, and 3VT was 94.1% (48/51), 100% (51/51), and 98.0% (50/51), respectively. When using the longitudinal view as the starting plane, the visualization rate of four-chamber view, LVOT, RVOT, and 3VT was 100% (51/51), 100% (51/51), 41.2% (21/51), and 100% (51/51), respectively.

Conclusions.?Live xPlane imaging can be used to visualize the screening views of the fetal heart, and potentially may be a useful tool for the assessment and diagnosis of fetal congenital heart diseases.     

Screening performance of first trimester nuchal translucency, ductus venosus blood flow and tricuspid regurgitation for cardiac defects

The present article summarises current knowledge on the risk of fetal cardiac malformations in fetuses with increased nuchal translucency (NT), abnormal ductus venosus blood flow pattern and tricuspid regurgitation. The risk of congenital heart disease (CHD) increases with increasing NT. However, nuchal translucency screening is only modestly efficient in the detection of congenital heart disease in low-risk pregnancies. If the nuchal translucency is normal, abnormal ductus venosus blood flow and tricuspid regurgitation show low sensitivities as single screening parameters. The combination of all 3 markers might increase the detection rates. Fetal echocardiography at 20 weeks of gestation is recommended in foetuses with an NT ≥95th percentile, as the incidence of CHD increases 2.5-fold. When the NT measurement is ≥99th percentile, the risk of CHD increases 10-fold. In this high-risk group and in fetuses with tricuspid regurgitation and/or an abnormal DV flow pattern along with an increased NT, first or early second trimester echocardiography performed by experts is warranted. The early examination of the fetal heart should be completed by a detailed echocardiogram at around 20 weeks of gestation.     

Real-time 3-D echocardiographic evaluation of the fetal heart using instantaneous volume-rendered display

AIM: Using new real-time 3-D fetal echocardiography with instantaneous volume-rendered display, we evaluated the heart anatomy of a number of normal fetuses during pregnancy. METHODS: Eighteen normal fetuses in 17 pregnancies (16 singletons and one twin) at 18-38 weeks' gestation were studied using a transabdominal real-time 3-D ultrasound machine. This machine proved capable of providing continuous 3-D sonographic images every 0.05 and 0.035 s without the need for an external workstation or other additional, costly equipment. For each patient, the fetal heart was first monitored using conventional 2-D echocardiography and was monitored again within 10 min using real-time 3-D echocardiography. RESULTS: Consecutive real-time 3-D images showing a four-chamber view, long-axis view, short-axis view, and right ventricular outflow tract view were obtained in 100%, 66.6%, 38.8%, and 22.2% of fetuses in the study, respectively. Morphological changes to each atrium or ventricle could be observed clearly and in detail throughout the cardiac cycle. The opening and closing of each valve were clearly visible. Moreover, these observations could be made from any direction. CONCLUSIONS: Real-time 3-D echocardiography provides a novel means for evaluation of the fetal heart in 3-D in real time in the second and third trimester of pregnancy. Real-time 3-D echocardiography may be an important modality in future fetal cardiac research and in evaluation of congenital heart disease in the fetus.     

Routine ultrasound examination at 12 or 18 gestational weeks for prenatal detection of major congenital heart malformations? A randomised controlled trial comprising 36,299 fetuses

OBJECTIVE: To compare the rate of prenatal diagnosis of heart malformations between two policies of screening for heart malformations. DESIGN: Randomised controlled trial. SETTING: Six university hospitals, two district general hospitals. SAMPLE: A total of 39 572 unselected pregnancies randomised to either policy. METHODS: The 12-week policy implied one routine scan at 12 weeks including measurement of nuchal translucency (NT), and the 18-week policy implied one routine scan at 18 weeks. Fetal anatomy was scrutinised using the same check-list in both groups, and in both groups, indications for fetal echocardiography were ultrasound findings of any fetal anomaly, including abnormal four-chamber view, or other risk factors for heart malformation. In the 12-week scan group, NT >or=3.5 mm was also an indication for fetal echocardiography. MAIN OUTCOME MEASURE: Prenatal diagnosis of major congenital heart malformation. RESULTS: In the 12-week scan group, 7 (11%) of 61 major heart malformations were prenatally diagnosed versus 9 (15%) of 60 in the 18-week scan group (P= 0.60). In four (6.6%) women in the 12-week scan group, the routine scan was the starting point for investigations resulting in a prenatal diagnosis versus in 9 (15%) women in the 18-week scan group (P=0.15). The diagnosis was made 相似文献   

Detection of congenital heart defects throughout pregnancy; impact of first trimester ultrasound screening for cardiac abnormalities

Objective: To evaluate prospectively the efficacy to screen for congenital heart defects (CHD) during the first trimester nuchal translucency (NT) ultrasound examination by assessing the four chambers’ view of fetal heart. Methods: Pregnancies that were examined prospectively by ultrasound in the first trimester (11th–14th week), the second (19th–24th week) and third trimester were included in the study. 3774 fetuses were examined and fetal heart was assessed during the NT scan by examining the four chambers view. Detailed echocardiography was performed during the anomaly and growth scans. Diagnosis of congenital heart defects (CHD) was further confirmed by a fetal cardiologist. Results: The four chambers view was obtained in 99.52% of the cases. CHD were diagnosed in 29 fetuses (0.77%). Thirteen cases (44.8%) were detected during the 11–13 weeks’ scan, 14 cases (48.3%) during the anomaly scan, 1 CHD (3.5%) during the third trimester scan and 1 case (3.5%) postpartum. Conclusion: Assessment of the four chambers of fetal heart early in pregnancy was feasible and allowed the detection of 45% of CHD. Additional parameters of fetal cardiac anatomy during the NT scan may further improve the detection rate providing pregnancy management information early in the first trimester.