四维超声在胎儿先天性心脏病诊断中的应用与进展

四维超声在胎儿心脏中的应用具有多种模式，可以为临床提供更多的先天性心脏病形态结构的信息，本文就四维超声在胎儿先心病中的应用与进展作一综述。     

超声评价胎儿胃泡发育的研究进展

消化道异常是一种较常见的胎儿畸形,严重者可影响胎儿正常生长发育,甚至导致死亡。准确评价胃泡发育有助于发现和确定胎儿消化道先天发育异常,且在评价胎儿胃肠道动力方面也有一定作用。本文就国内外近年来评价胃泡发育的各种指标和方法予以综述。     

Fetal cardiac interventions: an update of therapeutic options

Objective

This article aims to present updated therapeutic options for fetal congenital heart diseases.

Methods

Data source for the present study was based on comprehensive literature retrieval on fetal cardiac interventions in terms of indications, technical approaches and clinical outcomes.

Results

About 5% of fetal congenital heart diseases are critical and timely intrauterine intervention may alleviate heart function. Candidates for fetal cardiac interventions are limited. These candidates may include critical aortic valve stenosis with evolving hypoplastic left heart syndrome, pulmonary atresia with an intact ventricular septum and evolving hypoplastic right heart syndrome, and hypoplastic left heart syndrome with an intact or highly restrictive atrial septum as well as fetal heart block. The advocated option are prenatal aortic valvuloplasty, pulmonary valvuloplasty, creation of atrial communication and fetal cardiac pacing.

Conclusion

Fetal cardiac interventions are feasible at midgestation with gradually improved technical success and fetal/postnatal survival due mainly to a well-trained multidisciplinary team, sophisticated equipment and better postnatal care.     

电子胎心监护在产科麻醉中应用的研究进展

随着健康中国和产科麻醉医疗的发展,产科手术、胎儿外科、妊娠非产科手术麻醉和分娩镇痛对麻醉医疗的需求越来越高,保障母婴安全给产科麻醉医护人员提出了挑战。电子胎心监护具有快速、动态反映胎儿在子宫内的生理状况,临床上通过监测胎心率基线、 胎心变异、加速、减速以及宫缩参数等,判读胎心监护图形,结合孕产妇的生命体征监测,合理地选择分娩镇痛或产科麻醉方式与临床用药,有助于指导决策胎儿紧急情况的救治措施,保障手术、麻醉和相关治疗期间的母婴安全,提高产科麻醉工作者基本的胎心监测能力,具有重要的临床意义。     

Pathophysiologic Patterns Influencing Fetal Surgery

There are a growing number and variety of fetal disorders that may benefit from intervention prior to birth. Despite the diversity, there are common pathophysiologic denominators or patterns that tie together many seemingly disparate disorders. The purpose of this article was not to review disorders presented in other, accompanying articles but, rather, to present pathophysiologic patterns that common influence fetal surgery within a cohesive framework.     

How useful is intrapartum electronic fetal heart rate monitoring?

It is essential for an obstetric anesthesiologist to be aware of the fetal status before undertaking care of the laboring mother. In the last 20 years electronic fetal monitoring has been the most widely used technique of evaluating the fetus in labor. Recently however, the ability to predict or improve fetal outcome using traditional interpretation has been questioned. This review presents a summary of the current technology and interpretation of intrapartum electronic fetal monitoring, as well as a discussion of its limitations and some of the developments in this field which may help improve the accuracy of fetal assessment. The new developments in fetal monitoring discussed in this article are computerized assessment of fetal heart tracings, heart rate variability analysis, fetal electrocardiogram waveform analysis, abdominal detection of fetal ECG, fetal scalp oxygen saturation, fetal pH sampling and transcutaneous oxygen and carbon dioxide measurement.     

Power spectral analysis of the heart rate variability of goat fetuses during extrauterine incubation

Our aim is to determine the relationship between heart rate and behavioral states of a fetal goat using power spectral analysis. Electrocardiograms, electrocortical activity, and fetal breathing movements are recorded from 7 goat fetuses during extrauterine incubation. The heart rate power spectrum is classified into very low, low, and high frequency bands, and behavioral states are classified into low-voltage electrocortical activity with fetal breathing movements (LVB), low-voltage electrocortical activity without fetal breathing movements (LVN), and high-voltage electrocortical activity (HVN). There is a significant difference in total power spectral density in the high frequency band between LVN and HVN, and LVN and LVB. The relationship between each fetal behavioral state is assessed by power spectral analysis.     

Maternal and Fetal Responses to Halothane in Pregnant Monkeys

Maternal cardiac output, blood pressure, heart rate, fetal blood pressure, heart rate and respiratory blood gases, and uterine blood flow were measured in six pregnant monkeys during halothane-nitrous oxide and oxygen anesthesia and compared to theses same parameters observed during nitrous oxide and oxygen anesthesia. Halothane 1.5% was associated with a decrease in maternal arterial pressure (54%), heart rate (10%), cardiac output (17%), total peripheral resistance (40%), and uterine blood flow (38%). Mean fetal heart rate decreased 18% and mean fetal blood pressure 22%. These changes in fetal hemodynamics were probably related to a direct depression of the fetal cardiovascular system and its usual compensatory mechanism as well as the fetal asphyxia secondary to the decrease in uterine blood flow.     

Spiral electrode for continuous fetal heart rate monitoring during in-utero myelomeningocele repair

Continuous fetal hemodynamic monitoring during in-utero surgery is desirable, but it is often not feasible without intermittent interruption. We report the use of a fetal spiral electrode for continuous heart rate monitoring during fetal myelomeningocele repair. Fetal echocardiography and a fetal spiral electrode were used to monitor fetal heart rate during in-utero repair at 25 weeks’ gestation. We observed good agreement between echocardiographic and spiral electrode heart rate measurements. Using the Bland-Altman approach, the mean (SD) difference between measurements was 1.8 (3.5) beats per minute with limits of agreement of −5.3 to 8.8 beats per minute. This case illuminates a potential role for a fetal spiral electrode as a real-time adjunct in fetal interventions.     

Holter监护仪与多普勒胎心监测准确性的比较研究

目的比较Holter监护仪与多普勒行胎心监测的可靠性和准确性。方法随机选取孕34~41周的200例孕妇,同时采用Holter监护仪与多普勒进行胎心监测,计算并比较母儿心率混淆率。结果 Holter监护仪在全程及母体高运动周期时母儿心率混淆率分别为7.5%及4.5%,显著低于多普勒胎心监测(22.5%,19.5%),差异有统计学意义(均P0.01),两种监测的一致性均较弱(Kappa系数分别为0.324、0.236)。在母体低运动周期,两种监测的母儿心率混淆率差异无统计学意义(P0.05),一致性适中(Kappa系数为0.485)。结论 Holter监护仪较多普勒胎心监测能够降低母儿心率混淆率,有更高的可靠性和准确性。     

Cardiac operations during pregnancy: review of factors influencing fetal outcome

Women with underlying rheumatic heart disease, even if well compensated, can easily be affected by acute heart failure caused by out-of-the-ordinary cardiorespiratory requirements during pregnancy. In such cases, medical therapy is not always sufficient to drive a heart, and open heart operation might be necessary. Many factors associated with cardiac operations requiring cardiopulmonary bypass, such as hypothermia, can adversely affect both the mother and the fetus, but the morbidity and mortality rates are higher for the fetus than the mother. Because fetal heart tones were lost during cardiopulmonary bypass and were reheard in the intensive care unit in our case presentation, we have presumed that the loss of fetal heart tones should not always indicate fetal death and have discussed harmful factors in relation with the fetal morbidity and mortality in light of the literature.     

Intrauterine fetal resuscitation

Oxygen transport from the atmosphere to the fetus is dependent on maternal, placental and fetal factors. If any of these are disturbed, progressive fetal hypoxia and acidosis occur. Electronic fetal heart rate (FHR) monitoring is considered the primary method to assess fetal condition. Fetal distress refers to the presence of a non-reassurance heart trace, irrespective of the presence or absence of fetal acidosis. Intrauterine fetal resuscitation (IUFR) is a practice designed to enhance oxygen delivery to the placenta and maintain umbilical blood flow to counteract fetal hypoxia and acidosis, enabling safe delivery. IUFR measures might include: (i) re-positioning of the parturient to left lateral or alternative to relieve aortocaval compression; (ii) reducing uterine contractions by stopping oxytocics and using tocolytics (iii) correcting maternal hypotension and maximizing uterine blood flow via rapid IV crystalloid infusion; and (iv) maternal oxygen administration to reduce fetal hypoxaemia. IUFR measurements are simple to implement, do not need extensive resources and can lead to considerable improvements in fetal health. Anaesthetists play a pivotal role in IUFR and should be familiar with the process as they will be actively involved in the management of parturient during labour and before emergency surgical interventions.     

产前超声判断胎儿心脏位置的方法

产前心脏超声检查难度较大,识别胎儿心脏位置十分关键。本文就产前心脏超声检查中识别胎儿心脏位置的方法进行综述。     

The effect of lumbar epidural analgesia on the fetal heart

Fetal heart rate was monitored by continuous cardiotocography in 67 patients who were subjected to standard epidural block. In 43% of cases a deterioration in the fetal heart rate pattern was observed. The abnormal heart rate usually responded to conservative treatment. In 3 cases caesarean section was necessary. The deterioration of the fetal heart rate was usually associated with maternal hypotension.     

Adenovirus-mediated gene transfer to the peritoneum and hepatic parenchyma of fetal mice in utero.

BACKGROUND: The development of effective gene transfer in utero will provide alternative approaches to the treatment of genetic disorders. For many disorders, the fetal liver and peritoneum are important target tissues. Our goals were to compare the tissue sites and duration of transferred gene expression after intraperitoneal (i.p.) or intrahepatic adenoviral-mediated gene transfer in utero in the developing murine fetus. METHODS: Day 15 CD-1 fetuses were injected intrahepatically or intraperitoneally with recombinant adenoviruses containing the luciferase or beta-galactosidase reporter gene. Tissue levels of luciferase were quantitated, or tissues were examined for X-gal staining. RESULTS: Luciferase expression was observed in multiple fetal tissues (including brain, intestine, liver, and lung) and persisted up to 32 days after intrahepatic delivery. Significant hepatic tropism was demonstrated. CONCLUSIONS: Intrahepatic and intraperitoneal injection in utero results in transduction of multiple tissues in the developing murine fetus. Transuterine injection of fetal mice via intrahepatic and intraperitoneal routes provides a valuable model for assessing the efficacy of gene delivery vectors in the prenatal treatment of genetic disorders. These studies demonstrate that hepatic and intraperitoneal gene transfer to the developing murine fetus is feasible and may provide therapeutic levels of proteins during fetal development.     

Case of general anesthesia for subtotal thyroidectomy in a pregnant woman with 27th week gestation

We report a case of general anesthesia for subtotal thyroidectomy in a pregnant woman with 27th week gestation. A 33-year-old pregnant woman was diagnosed with thyroid carcinoma. We planned subtotal thyroidectomy at 27 weeks of gestation. We gave thiamylal, fentanyl and rocuronium for induction of anesthesia. Tracheal intubation was performed. Anesthesia was maintained with sevoflurane and fentanyl. Because of tachycardia, we tilted the operating table to displace the uterus to the left. We continued monitoring fetal heart rate during the operation. The fetal heart rate remained between 130 and 150 beats x min(-1). The operation was performed with no trouble. She gave birth to a baby at 37th week gestation. We should pay attention to maternal safety, fetal toxicity including teratogenecity, fetal asphyxia and pre-term labor. We could successfully manage her anesthesia using intraoperative fetal heart rate monitoring.     

Diagnosis of an unsuspected maternal hemorrhage via fetal heart rate tracing

Early detection of placental abruption often relies on the observation of vaginal bleeding; however, overt bleeding does not always occur. We report the case of an unsuspected placental abruption diagnosis that was prompted by an internal fetal scalp electrode tracing. The presence of a "normal" fetal heart rate (FHR) of approximately 150 beats per minute with poor variability, which matched the maternal heart rate (MHR), suggested that the tracing was not of fetal origin. An urgent ultrasound examination revealed a fetal demise with a possible concealed abruption, proving that the scalp electrode tracing was actually maternal in origin. Though reports of transmission of MHR via a deceased fetus are not new, it is uncommon for MHR to mimic a normal, reassuring FHR. This report reinforces the need for anesthesiologists to be adept at interpreting and integrating FHR monitors with maternal monitors prior to initiation of epidural analgesia.     

妊娠合并心脏病的麻醉

妊娠合并心脏病患者因心脏病类型不同，其麻醉管理方法不同。此文章首先探讨了妊娠期心血管变化及机制，然后对几种主要类型的心脏病合并妊娠患者的具体的病理生理特点及麻醉管理重点进行了综述。综合上述和疼痛机制的知识，以及考虑可能影响母儿安危的因素，来选择能达到最佳的镇痛和麻醉效果的方法和药物，使母儿预后满意。     

Fetal hyperinsulinemia and protein turnover in fetal rat tissues.

The effects of fetal hyperinsulinemia on protein turnover in various tissues of fetal rats were determined after transuteral injection of insulin to rat fetuses at day 19 of gestation. Tissue protein content was measured on the subsequent days of gestation (days 20-22), and protein synthesis was determined at day 20 of gestation in fetal tissues after intravenous injection of [3H]phenylalanine into the maternal circulation, followed by measurements of tissue free and protein-bound phenylalanine specific radioactivity in fetal diaphragm, brain, heart, and liver. Rates of protein degradation in these fetal tissues were calculated by subtracting protein accretion rates from rates of protein synthesis. The injection of insulin to rat fetuses at day 19 of gestation resulted in relative macrosomia versus saline-injected controls from the same litter (body wt at day 20 of gestation, 3.26 +/- 0.15 g for saline-injected fetuses and 3.60 +/- 0.25 g for insulin-injected fetuses, P less than 0.001) and increased protein and RNA content of brain, heart, and liver. Although fractional rates of protein synthesis were not significantly elevated in tissues from the hyperinsulinemic fetuses, absolute rates of protein synthesis were increased in brain, heart, and liver of hyperinsulinemic fetuses. Hyperinsulinemia did not reduce calculated rates of protein breakdown in fetal brain, heart, or liver but did in fetal diaphragm. We conclude that the major effect of fetal hyperinsulinemia on protein turnover in rats is to increase protein synthesis in selected tissues without simultaneously affecting protein breakdown.