特殊胎心监护图形及胎心率细变异的临床意义

在解读胎心率 (fetalheartrate ,FHR)监护图形时 ,尽管各典型图形的临床意义早已明确 ,但经过近 2 0多年的临床实践及各国产科专家的研究 ,不断发现并描述了诸多特殊监护图形 ,而且这些特殊图形在临床诊断中具有特别重要的作用。本文择其主要者进行讨论。1　特殊胎心监护图形的临床意义1 1　复合减速图形　产科条件不一 ,且产程中的变化迅速而复杂 ,故往往并非单一因素致某单一图形。如有两种以上的因素同时起作用 (见图 1) ,就可能有若干图形重合为一的减速 ,即谓复合减速 ,也有称重合减速者。目前 ,公认早发减速 (earlydeceleration ,ED…     

76例异常胎心监护图形临床分析

７６例异常胎心监护图形临床分析徐慧，方世兰，田洪兰（山东省沂水中心医院）胎心监护能连续监护胎心率的变化，了解其与子宫收缩的关系，及早发现胎儿宫内缺氧状态，以减少缺氧对胎儿的损伤及降低围产儿的死亡率。出现异常的监护图形，预示胎儿预后不良，而频发迟发减速...     

第一产程异常胎心监护图形的分析

目的:探讨第一产程异常胎心监护图形的临床意义。方法:选自第一产程胎心监护图形异常的患者348例为观察组,367例第一产程胎心监护正常者为对照组。观察并比较两组间孕妇并发症及胎儿合并症的情况。结果:①电子胎心监护显示早期减速(ED)所占比例最高,为55.2%,然后依次为变异减速(VD)、晚期减速(LD)、心动过速、心动过缓、基线变异减弱及延长减速(PD)。②观察组中,伴有脐带绕颈及羊水量异常的患者分别占28.4%和10.3%,其比例均明显高于对照组,两组之间均有统计学差异(P<0.05)。③观察组中羊水粪染(Ⅱ-Ⅲ度),Apgar评分≤7分(出生1min),胎儿窘迫及剖宫产的比例均明显高于对照组,两组之间均有统计学差异(P<0.05)。结论:不同电子胎心监护异常图形有不同的临床意义,应该结合临床资料综合分析。     

胎心中央监护及远程监护的评价

胎心中央监护及远程监护是胎儿电子监护和计算机网络技术相结合的结晶,通过网络将医院监护仪与家庭监护仪连接到产科中央监护站,经电脑处理后进行信息贮存和分析,以便更方便、更完善地评价胎儿状况,有效改善胎儿预后。     

胎心监护不良图形与胎儿不良预后的关系

20世纪 70年代 ,胎儿心电监护广泛应用于临床 ,将死产率从 3‰降至 0 .5‰ [1 ] ,但 80年代经大宗调查后发现 ,胎心监护在未明显改善胎儿预后的同时却又大大提高了剖宫产率。随着胎心监护临床研究的进一步深入 ,对其应用 30多年以来的统计分析表明高达 1/ 3的胎儿在产程中表现出胎心变异 ,比例远高于严重酸中毒、新生儿抽搐或脑瘫的发生率 [1 ] ,遂认识到由于医务工作者对监护图形认识不够充分、深入 ,出现了许多“假阳性”,导致上述结果 [2 ,3 ] 。怎样从胎心监护中获得关于胎儿窘迫较为可靠的诊断依据 ,同时又较为准确预测胎儿及新生儿预…     

跳跃型胎心监护图临床意义的探讨

1989年4月至1991年4月施行胎心监护共503例,发现跳跃型胎心监护图20例(孕期18例,产时2例).根据图型情况分为Ⅰ型(完全跳跃型),Ⅱ型(频发跳跃型),Ⅲ型(间发跳跃型).该类图型提示特殊类型的脐带因素存在,由于脐带缠绕胎儿肢体或在羊水过少时脐带被挤在胎儿肢体与躯干之间,胎儿肢体的运动干扰脐带血流可能是导致基线变异增加的原因,然而此种对脐带血流的干扰常不致完全阻断,故胎儿预后好.本文根据图型类别及胎龄情况提出了处理原则.     

第一产程异常胎心监护图形与新生儿结局的关系

目的　探讨第一产程异常胎心监护图形与新生儿结局的关系。方法　回顾分析 2 0 0 2年 8月至 2 0 0 3年 6月在我院足月单胎头位分娩产妇 ,第一产程中胎心率 (FHR)异常图形 2 1 7例 (观察组 )和FHR正常图形的2 6 9例 (对照组 )的临床资料。结果　第一产程异常FHR图形的发生率为 4 4 7% ,常见类型为轻度变异减速(6 4 5 % )、基线变异减弱 (2 1 6 % )和轻度心动过速 (1 2 0 % )。晚期减速、基线变异减弱和重度变异减速是导致新生儿窒息的危险因素。观察组羊水过少 (5 1 % )、脐带缠绕 (2 2 6 % )、羊水粪染 (1 0 6 % )、新生儿窒息 (6 5 % )、新生儿转入NICU(1 0 1 % )的发生率和剖宫产率 (31 8% )明显高于对照组 (P <0 0 5 )。结论　第一产程异常FHR图形的发生率较高 ,其中晚期减速、基线变异减弱、重度变异减速与新生儿窒息的发生相关 ,其他图形可在严密监护下继续试产     

产时Ⅱ类胎心监护图形宫内复苏方法的评价

产时电子胎心监护是一种评估胎儿宫内状态的手段,Ⅱ类监护图形是可疑胎心监护图形,在临床常见,表现形式多样,且不典型,提示胎儿在宫内可疑窘迫,对于该类图形,需正确识别和解读,进行必要的临床干预(如宫内复苏)及后续的再评估。本文重点介绍各种宫内复苏方法及对各种复苏方法的评价。     

Fetal heart rate pattern reflecting the severity of placental abruption

Objective To identify fetal heart rate (FHR) patterns reflecting the severity of placental abruption, and to determine the incidence of normal FHR pattern in cases of placental abruption. Materials and methods We analyzed FHR tracings from 40 pregnant Japanese women with placental abruption. We analyzed which FHR patterns appeared more frequently in cases of low 5-min Apgar score, low cord arterial pH, and large separation. Results Eight out of 40 cases showed a normal FHR pattern, while 32 cases did not show a normal FHR pattern. Undetectable variability and bradycardia appeared more frequently in cases with 5-min Apgar < 7, with cord blood pH < 7.1, and with larger placental separation than in cases without these features. The normal FHR pattern was associated with 5-min Apgar ≥ 7, cord blood pH ≥ 7.1, and separation of <25%. Conclusion Fetal heart rate pattern reflected the severity of placental abruption. Undetectable variability and bradycardia occurred significantly more frequently in cases of severe placental abruption, and thus may reflect the severity of placental abruption.     

Fetal heart rate patterns in pregnancies complicated by maternal diabetes

Objective: To compare the fetal heart rate (FHR) pattern between fetuses of well controlled diabetic and non diabetic mothers using a computerized analysis of FHR. Study design: Weekly fetal surveillance was performed in 99 fetuses of mothers with diabetes class A, 21 fetuses of mothers with diabetes class B-R, and 55 fetuses of non-diabetic women, starting at 30 weeks' gestation. All diabetic patients were well controlled. Fetal surveillance included a computerized analysis of the FHR, umbilical and uterine Doppler velocimetry, and a biophysical profile. Changes of FHR variation, frequency of FHR accelerations, and umbilical and uterine Doppler velocimetry were calculated using a regression analysis for each patient. The average slopes and the intercept at 30, 34, and 38 weeks' gestation of these variables were compared among the three groups. Results: The slope of FHR variation and the frequency of accelerations had a lower rate of increase during the third trimester in fetuses of mothers with diabetes class A (0.84 ± 0.25 ms/week and 0.06 ± 0.02/20 min/week, respectively) compared with fetuses of non-diabetic mothers (1.34 ± 0.55 ms/week and 0.5 ± 0.1/20 min/week, respectively). In fetuses of mothers with diabetes class B-R, FHR variation did not change with gestation (−0.011 ± 0.2 ms/week) with a small increase in the frequency of accelerations (0.02 ± 0.004/20 min/week. While no differences were observed at 30 weeks' gestation, FHR variation and the frequency of accelerations were significantly reduced at 34 weeks' gestation in fetuses of mothers with diabetes class B-R compared with fetuses of non-diabetic mothers (P < 0.01). At 38 weeks' gestation, fetuses of mothers with diabetes class B-R and diabetes class A had both significantly reduced FHR variation as well as frequency of accelerations compared with fetuses of non-diabetic mothers (P < 0.01). The rate of decrease of the umbilical and uterine artery S/D ratios were similar among the three groups. Conclusions: The FHR pattern appears to be different in fetuses of well controlled diabetic mothers when related to fetuses of non-diabetic mothers. Disease specific standards should be considered for interpretation of FHR patterns in diabetic pregnancies.     

Placental abruption and placenta praevia

Antepartum haemorrhage is defined as bleeding from the genital tract from 24 weeks of gestation onwards. The incidence is around 2–5% of all pregnancies progressing beyond 24 weeks. Placenta praevia and placental abruption are of great clinical importance as causes of antepartum haemorrhage. Placenta praevia occurs when the placenta is totally or partly inserted in the lower uterine segment. The aetiology of placenta praevia may merely represent an accident of nature but is associated with advanced maternal age, multiparity and previous uterine damage such as in a previous caesarean section. Usually, the initial bleed is painless and mild, but it may be severe. Screening and diagnosis are normally by ultrasound. A dilemma exists as to whether hospitalisation should be offered to women with an asymptomatic placenta praevia. Caesarean section is the recommended mode of delivery for major placenta praevia. Haemorrhage arising from premature separation of a normally situated placenta is known as abruptio placentae. Risk factors include placental abruption in a previous pregnancy, pre-eclampsia, cigarette smoking, and trauma. The patient typically develops pain over the uterus, and this may not be associated with apparent bleeding at first. The diagnosis is mainly clinical and confirmed by the demonstration of a retroplacental clot after delivery. In the obvious case of abruption, early delivery is of crucial importance. If the baby is still alive and the gestation compatible with survival upon delivery, it is recommended that urgent caesarean section should be performed. However, if the fetus is dead, one should expedite vaginal delivery. Complications of antepartum haemorrhage include maternal shock, especially due to the increased risk of postpartum bleeding. There is a greater risk of premature delivery, fetal hypoxia and sudden fetal death.     

The association between maternal smoking and placenta abruption: a meta-analysis

Background: Several epidemiological studies have determined that maternal smoking can increase the risk of placenta abruption. To date, only a meta-analysis has been performed for assessing the relationship between smoking and placenta abruption. This meta-analysis was conducted to estimate the association between smoking and the risk of placenta abruption.

Methods: A literature search was conducted in major databases such as PubMed, Web of Science, and Scopus from the earliest possible year to April 2016. The heterogeneity across studies was explored by Q-test and I² statistic. The publication bias was assessed using Begg’s and Egger’s tests. The results were reported using odds ratio (OR) estimate with its 95% confidence intervals (CI) using a random effects model.

Results: The literature search yielded 1167 publications until April 2016 with 4?309?610 participants. Based on OR estimates obtained from case–control and cohort studies, there was a significant association between smoking and placenta abruption (1.80; 95% CI: 1.75, 1.85). Based on the results of cohort studies, smoking and placenta abruption had a significant association (relative risk ratio: 1.65; 95% CI: 1.51, 1.80).

Conclusions: Based on reports in epidemiological studies, we showed that smoking is a risk factor for placenta abruption.     

Fetal hiccups; characteristics and relation to fetal heart rate

In 35 two-hour recordings of fetal heart rate and fetal movements, 14 periods of fetal hiccups were present (1.2% of the recording time) with a median duration of 3.5 min (range 1 to 8 min). No specific relation to behavioural states or movement patterns could be identified. The hiccupping frequency varied from 10 to 21 per min. Within a hiccupping spell, the mean frequency decreased from 20 ± 11 to 12 ± 6.2 per min. A small but evident increase in baseline frequency was present during the hiccupping spells, independent from other movements performed by the fetus.     

The association between uterine leiomyoma and placenta abruption: A meta-analysis

Background: Some epidemiological studies have found that uterine leiomyoma can increase the risk of placenta abruption. To date, the meta-analysis has not been performed for assessing the relationship between uterine leiomyoma and placenta abruption. This meta-analysis was conducted to estimate the association between uterine leiomyoma and the risk of placenta abruption.

Methods: A literature search was conducted out in major databases PubMed, Web of Science, and Scopus from the earliest possible year to October 2016. The heterogeneity across studies was explored by Q-test and I² statistic. The publication bias was assessed by Begg's and Egger's tests. The results were showed using odds ratio (OR) estimate with its 95% confidence intervals (CI) using a random-effects model.

Results: The literature search included 953 articles until October 2016 with 232,024 participants. Based on OR estimates obtained from case–control and cohort studies, there was significant association between uterine leiomyoma and placenta abruption (2.63; 95% CI: 1.38, 3.88).

Conclusions: We showed based on reports in observational studies that uterine leiomyoma is a risk factor for placenta abruption.     

Fetal heart rate patterns and sudden infant death syndrome

OBJECTIVE: To determine differences in electronic fetal monitoring patterns between infants who died of sudden infant death syndrome and controls. DESIGN: Case-control study (N = 127). SETTING: A tertiary-level women's hospital in Providence, Rhode Island. PARTICIPANTS: Infants born between 1990 and 1998 who subsequently died of sudden infant death syndrome and controls. Demographic and clinical data included medical maternal charts and fetal monitoring records. RESULTS: Compared with controls (n = 98), the mothers whose infants subsequently died of sudden infant death syndrome (n = 29) had lower birthweight babies (sudden infant death syndrome 2,840 vs. controls 3,385 g; p < .01), were younger (22 vs. 28 years; p < .01), were more likely to receive Medicaid health insurance (odds ratio 4.6; confidence interval 1.9-11.2), were more likely to be unmarried (odds ratio 5.2; confidence interval 2.1-12.8), had less intention to breastfeed (26% vs. 57%), and were more likely to smoke (odds ratio 4.6; confidence interval 9-11.2). MAIN OUTCOME MEASURES: There were no statistical differences in fetal heart rate variability or sleep/wake cycles detected between groups. CONCLUSION: Statistical differences were found in demographic characteristics between sudden infant death syndrome mother-infant couples and their controls. However, no differences were detected in the intrapartum electronic fetal monitoring records, specifically in variability and sleep/wake cycles.     

Fetal heart rate after vibroacoustic stimulation

Objective

To define reference ranges for fetal heart rate (FHR) parameters after vibroacoustic stimulation (VAS) according to gestational age by determining the relationship between FHR and gestational age using a computerized analysis system.

Methods

Data were analyzed from 3453 women using 10-minute observational recordings during nonstress testing (NST) and VAS testing. FHR parameters were analyzed according to gestational age.

Results

All FHR parameters were related to gestational age except for mean baseline FHR, which did not vary significantly with gestational age. All other parameters followed trends similar to the NST results, except for decelerations.

Conclusion

FHR parameters after VAS differed significantly according to gestational age. The results suggest that the gestational age of the fetus should be considered when interpreting FHR patterns after VAS.