胎儿先天性心脏病的高危因素及产前超声诊断

目的　探讨胎儿先天性心脏病 (CHD)的高危因素及彩色超声诊断胎儿先天性心脏病的适应证。方法　彩色超声仪检查 2 780例孕妇 ,回顾分析胎儿CHD发病的高危因素 ;比较高危、低危孕妇组胎儿先天性心脏病的发病率。结果　孕妇孕期上呼吸道感染、高龄、先兆流产、早孕期接触X线等是胎儿CHD发病的高危因素。高危组胎儿先天性心脏病发病率为 6 81% ,低危组发病率为 1 5 4 % ,两组胎儿CHD发病率间差别有显著性意义 (P <0 0 1)。结论　胎儿先天性心脏病存在高危因素 ,对高危孕妇常规及适时地进行胎儿心脏超声产前诊断 ,及早发现复杂性胎儿先天性心脏病 ,可减少出生缺陷。     

产前超声监测对双胎妊娠并发症的诊断及治疗选择的价值

目的：探讨双胎妊娠的产前超声监测方法对双胎并发症的诊断及治疗选择的价值。方法回顾性分析81例双胎妊娠孕妇的临床资料和超声监测方法,综合评估是否出现双胎输血综合征（TTTS）、选择性胎儿生长受限（sIUGR）等单绒毛膜双胎（MC双胎）特有的并发症,进行相应分期、分型和监测;随访至妊娠终止。结果81例双胎妊娠中双绒毛膜双羊膜囊双胎（DCDA ）40例出现双胎之一宫内死亡1例,双胎生长不一致1例;38例单绒毛膜双羊膜囊双胎（MCDA）出现TTTS 4例,sIUGR 2例,双胎之一唇腭裂畸形1例,双胎之一宫内死亡1例;3例单绒毛膜单羊膜囊双胎（MCMA）并发双胎之一无心畸形1例,联体双胎1例。DCDA并发症明显小于MC双胎并发症（P＜0．05）。DCDA双胎丢失率1/80（胎）,MC双胎丢失率11/82（胎）。DCDA胎儿丢失率明显低于MC双胎胎儿丢失率（ P＜0．05）。产前超声监测与终止妊娠结果100％符合。结论早孕期诊断双胎妊娠的绒毛膜性具有重要的临床意义;对＜26孕周的 MC双胎每2周监测1次,可早期诊断并发症;对≥26孕周的 TTTS及sIUGR在超声严密监测下选择分娩时机,可提高MC双胎围生儿生存率。     

复杂性双胎的研究进展

随着促排卵药及辅助生殖技术的广泛开展,双胎妊娠的发生率逐渐升高。复杂性双胎是最新提出的一个概念,指双胎的胚胎分化、胎儿发育相互间的影响,出现双胎之一死胎、畸形、双胎发育不一致等复杂情况。早期发现、诊断及干预复杂性双胎的发生越来越受到社会重视。多普勒彩超的应用及胎儿镜的开展对复杂性双胎的诊断及处理具有重要的临床意义。     

妊娠中期胎儿心轴角度与胎儿先天性心脏病的关系

目的 通过测量胎儿心脏角度,探讨妊娠中期胎儿心轴角度与胎儿先天性心脏病（congenital heart defects,CHD）之间的关系。方法 选择2017年12月至2019年5月在首都医科大学附属北京妇产医院建档并进行规范化产前超声筛查的胎儿为研究对象,其中病例组52例,对照组104例。按照国际妇产超声学会（International Society of Ultrasound in Obstetrics and Gynecology,ISUOG）指南标准,在胎儿四腔心切面测量胎儿心轴角度。结果 病例组与对照组间孕妇年龄及胎儿胎龄差异无统计学意义（t=1.825、－0.928,P>0.05）。病例组心轴角度为50.03°±24.02°,对照组心轴角度为42.64°±6.30°,差异具有统计学意义（P<0.05）。病例组心轴异常所占比例为30.77%（16/52）,对照组心轴异常所占比例为0.96%（1/104）,差异具有统计学意义（P<0.05）,心轴角度异常的胎儿发生先天性心脏病的风险增加了近45倍,表明胎儿心轴角度异常与胎儿先天性心脏病的关系十分密切。结论 胎儿心轴异常与胎儿先天性心脏病密切相关,当超声筛查发现心轴异常时,应更加注意胎儿心脏的检查。     

超声引导下经阴道多胎妊娠减胎术后妊娠结局分析

目的 分析行多胎妊娠减胎术患者的妊娠结局情况。方法 回顾性分析2009年1月至2019年9月期间63例多胎妊娠孕妇在我院经阴道减胎术的临床资料,根据患者减胎类型不同将患者分为四组:四胎减为双胎组、三胎减为双胎组、三胎减为单胎组、双胎减为单胎组,分析各组患者减胎术后妊娠结局情况。结果 实行减胎术的63例患者中,有50例成功分娩,早期流产3例(4.67%),晚期流产9例(14.29%),因胎儿唇裂行引产术1例(1.59%),足月产37例(58.73),早产13例(20.63%),低体质量儿率43.53%。多胎减为双胎的两组间以及多胎减为单胎的两组间早期流产、早产、新生儿体重、低体质量儿率等差异无统计学意义。与多胎减为单胎组相比,多胎减为双胎组新生儿体质量低,P＜0.05,而两组间早期流产率、晚期流产率、早产率、低体质量儿率等均无统计学差异。结论 多胎妊娠减胎术后妊娠结局可能与最终妊娠数相关,而与最初妊囊数关系不大,多胎减至双胎组较多胎减为单胎组有较高的并发症发生,因此建议接受多胎妊娠减胎术的患者减至单胎妊娠。     

胎儿先天性心脏病与染色体异常的临床分析

目的通过分析产前超声心动图筛查出的胎儿先天性心脏病其染色体异常情况,提高胎儿先天性心脏病(congenital heart disease,CHD)的产前诊断率。方法 2006年1月至2010年12月在本院产科门诊行超声心动图检查(孕11～14周和孕22～26周)的孕妇28 056例[年龄19～43(27.48±4.35)岁,孕(28.65±5.12)周],发现心脏结构异常的胎儿再行染色体检查后终止妊娠,结合胎儿大体解剖、染色体异常情况进行综合分析。结果近5年本院胎儿超声心动图检查提示CHD 592例,引产后尸解证实的胎儿先天性心脏病79例,其中38例行染色体检查,发现染色体异常17例,其中21-三体3例,18-三体7例,克氏综合征1例,三倍体1例,46,XX性反转1例,45,X/46,46,X,r(X)1例,小Y 5例。结论复杂型先天性心脏病或先天性心脏病合并其他心外畸形的胎儿应进行核型分析,避免染色体异常综合征患儿的出生。     

双胎妊娠早产177例临床分析

目的 探讨双胎妊娠早产的病因、终止妊娠的方式和时机.方法 对2000年1月-2009年12月双胎妊娠病例资料进行回顾性分析.双胎早产共177例,其中早期早产组(A组)72例,晚期早产组(B组)105例;选择双胎足月产208例为对照组(C组).结果 双胎早产发生原因以自发性早产为首位,晚期早产中医源性早产比率高于早期早产...     

Identification of congenital cardiac malformation and in utero arrhythmia by fetal echocardiography

M-mode, 2D and Pulsed Doppler Echocardiography were performed on 111 fetuses of high-risk pregnancies. Fetal gestation ages ranged 16-41 weeks. Six congenital cardiac diseases were detected in utero and confirmed at autopsy in 4 cases, and one by Pulsed Doppler Echocardiography after delivery. These included a rhabdomyoma, an endocardial fibroelastosis with hydrops, a pulmonary stenosis with tricuspid regurgitation, a VSD, a VSD with descending aortic stenosis, an AV canal defect with single atrium and single AV valve with regurgitation. Arrhythmia was diagnosed in 23 fetuses, 9 had transient sinus bradycardia, 8 had premature atrial contraction, 2 had premature ventricular contraction which disappeared after birth, 4 had sustained sinus bradycardia, one of them combined PVC occurring in bigeminy and trigeminy, which continued after birth. These 4 fetuses had congenital heart disease. Conclusion: (1) 2 DE and PDE are the most valuable non-invasive technique for detection of fetal structural cardiac abnormalities. (2) M-mode and PDE make correct rhythm diagnosis in fetus. (3) The fetus with transient sinus bradycardia or PAC usually has a favorable prognosis. Sustained bradycardia has a more ominous prognosis, particularly if associated with heart abnormalities. (4) Fetal hydrops may associate with congestive cardiac failure in uterus. The incidence of cardiac disease is high in hydrops.     

双胎输血综和征的产前超声诊断分析

目的 探讨彩色多普勒超声产前诊断双胎输血综和征的临床价值. 方法 二维重点观察两胎儿之一有无贴附现象,两胎儿性别是否相同,两胎儿胎盘个数,两胎儿间有无丝线样的分隔,胎盘与隔膜连续处有无双胎峰,两胎儿之间有无不平衡性生长,羊水的多少,两脐带的走行及脐带有无异常,最后注意有无合并其它畸形.应用多普勒超声分别测量脐动脉收缩/舒张血流速度的比值(S/D比值)、阻力指数(RI)、波动指数(PI),并观察供血儿脐动脉舒张末期血流. 结果产前超声共筛查诊断双胎输血综和征41例,合并其它畸形6例. 结论 彩色多普勒超声能对双胎输血综和征做出产前诊断,对进一步诊断及治疗方案的选择有重要的临床价值.     

Development of fetal growth charts in twins stratified by chorionicity and mode of conception: a retrospective cohort study in China

Background:Twin pregnancies continue to increase worldwide; however, the current clinical prenatal evaluation for the intrauterine growth of twins still relies on the growth standards of singletons. We attempted to establish a set of fetal biometric references for Chinese twin pregnancies, stratified by chorionicity and conception mode as spontaneously conceived monochorionic diamniotic (SC-MCDA), spontaneously conceived dichorionic diamniotic (SC-DCDA), and assisted reproductive technology dichorionic diamniotic (ART-DCDA) twins.Methods:From 2016 to 2019, the ultrasonographic fetal biometric measurements were longitudinally collected in pregnant women, including fetal weight, biparietal diameter, head circumference, abdominal circumference, femur length, and humerus length. The linear mixed models were used to test the difference of growth patterns between groups, and the growth curve of each biometric parameter was modeled by a generalized additive model for location scale and shape.Results:A total of 929 twin pregnant women and 2019 singleton pregnant women, met the inclusion criteria. Among twin pregnancies, 148 were SC-MCDA, 215 were SC-DCDA, and 566 were ART-DCDA twins. Overall, SC-DCDA twins grew faster than SC-MCDA twins, while slower than ART-DCDA twins (all P < 0.05), and all of the three groups showed significant differences comparing with singletons, especially during the third trimester. Hence, the customized fetal growth charts of each fetal biometric parameter were, respectively, constructed for SC-MCDA, SC-DCDA, and ART-DCDA twins.Conclusions:The fetal biometric trajectories demonstrated characteristic patterns according to chorionicity and conception mode. To fill the gap, we modeled fetal biometric parameters for Chinese SC-MCDA, SC-DCDA, and ART-DCDA twin pregnancies, hoping to provide a reference for the further establishment of fetal growth reference values for Chinese twin fetuses.     

顺序分段法在胎儿心脏超声诊断中的应用

目的　探讨“顺序分段法”提高胎儿心脏超声的宫内先天性心脏病 (先心病 )诊断的准确率。　方法　首先确定心脏位置及心胸比例 ,将胎儿心脏分为 4个节段 (心房、心室、大血管及血管交叉、主动脉弓和动脉导管弓 )筛查及诊断先心病 ,同时对每例胎儿进行外周动、静脉多普勒血流检测 ,评价先心病对外周血流动力学及胎儿生长发育的影响。　结果　 1470例胎儿中检出先心病 45例 ,其中复杂性心血管畸形 19例、心功能降低 13例、6例胎儿水肿及大量心包积液 ,合并心律失常 7例 ,外周血流搏动指数 (PI)与正常组差异有显著性 (P<0 .0 1)。　结论　胎儿心脏超声“顺序分段法”可明显提高先心病的检出率及诊断准确率 ,特别有利于在产前低危人群中的筛查。     

彩色多普勒超声在非高危胎儿产前心脏筛查中的临床价值

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诊断价值,以便尽可能地降低先天性心脏病患儿的出生率及围生儿死亡率。方法回颐性分析2009年6月～2011年12月解放军第四二一医院联合应用左、右室流出道切面和四腔心切面法对孕18～24周的非高危胎儿进行心脏筛查的3780例临床资料。结果经引产尸解及产后随访证实,本组共检出先天性心脏病胎儿26例（其中严重先天性脏病12例）,心脏畸形的总发生率为6．9‰。24例经产前多普勒超声筛查检出,漏诊2例（法洛四联症1例、室间隔缺损1例）,产前超声检出率为92．3％。结论彩色多普勒超声能获得较满意的胎儿心脏声像,胎心结构清楚,能检出大多数胎儿心脏畸形．是产前筛查胎儿先天性心脏病的首选方法,在非高危胎儿产前心脏筛查中有重要的临床价值。     

Some aspects of twin-gestation in the mare

A study has been made of 44 cases of twin pregnancy in mares. The fetuses, foals, fetal membranes and blood groups of parents and foals were examined in order to determine the incidence of chorio-vascular anastomosis, blood chimaerism and freemartinism.All of the twins proved to be dizygotic and 33 of the 34 pregnancies were bicornual. Fusion of the chorion was seen in 14 of 22 placentas and macroscopic choriovascular bridges were observed in five of these, although blood chimaerism was diagnosed in 11 of 25 cases (44 per cent) examined. This would indicate a high incidence of microchoriovascular anastomosis. The fetal female genital organs of four heterosexual twins were found to be anatomically and histologically normal at autopsy despite the existence of blood chimaerism. Five other sexvalley mature mares born as heterosexual twins with chimaerism all had normal genital organs and estrus cycles and one of these has since become pregnant. The important interspecies differences with respect to the incidence and degree of choriovascular anastomosis and freemartinism are stressed and suggestions for a plausible explanation were advanced.     

单脐动脉胎儿心脏畸形超声筛查的意义

目的探讨单脐动脉（SUA）与心脏畸形的关系及对SUA胎儿常规进行超声心动描记术检查的必要性。方法2009年9月-2012年9月因存在胎儿先天性心脏病高危因素接受胎儿超声心动描记术检查的孕妇666名,采用节段性分析法扫查心脏切面,对胎儿的心脏位置、主要结构及连接进行分析和评价,根据胎儿是否存在SUA分为单纯SUA组（A组,n=63）、SUA合并其他先天性心脏病高危因素组（B组,n=15）和非SUA但存在其他先天性心脏病高危因素组（c组,n=588）,所有胎儿出生后1个月内接受超声心动描记术检查,对三组胎儿心脏畸形的发生情况进行分析和比较。结果A、B、C组心脏畸形的发生率分别为9．5％（6／63）、40．0％（6／15）和3．9％（23／588）。统计学分析结果显示：B组心脏畸形发生率显著高于其他两组,A组心脏畸形发生率显著高于C组,差异均有统计学意义（P〈0．05）。结论SUA胎儿先天性心脏病的发生率较高,因此对SUA胎儿尤其是合并先天性心脏病高危因素者,有必要常规进行超声心动描记术检查。     

Use of the lambda sign in fetal reduction of dizygotic triplets after intracytoplasmic sperm injection

With the increased use of artificial reproductive technologies, there are ever greater numbers of multifetal pregnancies. The increased incidences of monozygotic twins and triplet gestations can be attributed to several factors. It is important to differentiate the chorionicity in the management of multifetal pregnancies because monochorionic gestations lead to an increased risk of prematurity, twin-to-twin transfusion, morbidity, and mortality. In a dizygotic triplet pregnancy, increased risks of obstetric complications result from the monozygotic twins, such as twin-to-twin transfusion, as well as from the presence of triplets. Fetal reduction can lower these risks. During the first trimester, a "lambda sign" on ultrasound can differentiate between monozygotic twins and a separate fetus. In this paper, we present selective fetal reduction of 1 of the monozygotic twins in order to reduce the risks resulting from either monozygotic twins or from triplets. By sacrificing 1 monozygotic twin, we believe the quality of life of the remaining babies in this case were improved.     

阴道B超引导下多胎妊娠早期减胎术的护理

目的:探讨多胎妊娠阴道B超引导下选择性减胎术的护理经验。方法:对2007年9月至2010年8月在我院生殖中心进行早期B超引导下经阴道选择性减胎术的20例多胎妊娠患者的手术结局及其心理护理、术前护理、术中护理、术后护理和出院指导进行总结分析。结果:20例减胎成功,术后无感染及流产;其中1例经病人要求减灭一胎保留单卵双胎的孕妇,术后7日B超显示停止发育。结论:多胎患者妊娠早期阴超引导下选择性减胎术是一种操作简单、安全有效的补救性方法,良好的护理措施可提高减胎手术成功率;包含单卵双胎的多胎妊娠减胎患者,原则上应减灭单卵双胎,保留单胎。     

产前超声检查对胎儿先天性心脏病的诊断价值分析

目的考察产前超声检查对胎儿先天性心脏病的诊断价值。方法选取2009年1月-2013年1月采用产前超声进行胎儿先心病筛查的孕妇238例作为研究对象,所有孕妇均经过胎儿超声心动图检查并进行诊断。结果 238例孕妇总共娩出240名胎儿,经过临床证实共有先天性心脏病38例(15.8%),其中超声诊断先天性心脏病32例,确诊率为84.2%。结论产前超声检查胎儿先天性心脏病是一种安全、有效、经济的诊断方法,对于提高先天性心脏病的产前确诊率、优生优育等方面都有十分重大的意义,因此超声检查是检查胎儿CHD的首选诊断技术。     

Selective termination in multiple pregnancy

Women new have a new option regarding selective termination in multiple pregnancies. New technology, researched in Australia, makes it possible to selectively terminate an abnormal fetus during first trimester, without interfering with the continuation of pregnancy. The growth and development of the normal fetus is insured. This technique can also be employed in those multiple pregnancies where parents opt, for instance, for one child as opposed to twins or triplets. Selective termination appeals principally to those located somewhere in the middle of the abortion issue. The procedure does, however, carry some small risks. When successful, it avoids the tragedy of complete termination of the pregnancy, or permanent damage to the surviving fetus. As a result, the procedure, on ethical grounds, has a small place in the arena of family planning. Selective termination is still a new procedure, and while it encourages reports on its success, it is still too early to label the success rates as confirmed. For instance, in situations where multiple pregnancies result from attempts at treatment for infertility, with all fetuses being normal, it is problematic which fetuses should be terminated. This applies in cases of fetuses selected for termination with some unexpected abnormality present. Another problem is monozygotic twin pregnancies with an anastomosis between two fetal circulations in the placenta. Both the National Bioethics Consultative Committee and the Federal and State Law Reform Commissions would be useful forums to discuss the ethical and legal issues as they apply to the procedure of selective termination. Practice of this procedure should be sued judiciously be physicians until more medical facts support a widespread acceptance of the practice.     

辅助生殖技术治疗后单卵双胎妊娠的临床分析

目的探讨经辅助生殖技术（ART）治疗后单卵双胎（MZT）的发生、处理及妊娠结局。方法回顾性分析2010年1月~2015年 6月在南方医科大学南方医院生殖医学中心行体外受精-胚胎移植（IVF-ET）、单精子卵胞浆内显微注射－胚胎移植（ICSI-ET）治 疗后临床妊娠患者的基本资料,统计MZT的发生情况,按单纯性MZT、伴MZT多胎妊娠及异位妊娠分类分析94例MZT的处 理及妊娠结局,同时分别对比单纯MZT与同期非MZT双胎妊娠、伴MZT三胎妊娠减灭单胎和减灭双胎后、以及伴MZT三胎妊 娠与非MZT三胎妊娠减为双胎后的流产率、活产率、早产率和足月产率等指标。结果获得临床妊娠的6257个胚胎移植周期 中,94例为MZT妊娠（1.5%,94/6257）,其发生率在IVF（1.8%,47/2649）与ICSI（1.2%,10/822)间比较无统计学差异（P=0.272）; 在新鲜胚胎移植周期（1.6%,57/3471）与冻融胚胎移植周期（1.3%,37/2786）间比较也无统计学差异（P=0.310）。94例MZT中, 45例为单纯MZT,43例为伴MZT的三胎妊娠,3例为伴MZT的四胎妊娠,3例为异位妊娠（含复合妊娠）。与同期非MZT双胎 妊娠相比,单纯MZT妊娠的足月产率、活产率较低,流产率及新生儿畸形发生率较前者高,且差异均具有统计学意义（P<0.05）; 比较减灭单胎和减灭双胎的伴MZT三胎妊娠,减灭双胎妊娠组的足月产率、活产率均高于减灭单胎妊娠组,且流产率和早产率 也低于后者,但经统计学处理,显示无统计学意义（P>0.05）;与同期减为双胎的非MZT三胎妊娠者相比,伴MZT三胎妊娠减为双胎后 的足月产率、早产率、活产率均低于前者,流产率较前者高,但均无统计学意义（P>0.05）。结论经ART治疗后MZT妊娠的发生率显著 高于自然妊娠;单纯MZT的妊娠结局较异卵双胎差;对于伴MZT的多胎妊娠,减灭MZT孕囊者可能获得较好的妊娠结局。     

发育不同一性双胎妊娠的妊娠结局临床分析

目的探讨发育不同一性双胎妊娠的临床诊断、处理与妊娠结局。方法以双胎胎儿体重差〉20%为发育不同一性双胎妊娠诊断标准,回顾性分析比较1997年1月-2009年8月间中山三院分娩的66例发育不同一性双胎妊娠（观察组）与同期312例发育一致双胎妊娠（对照组）的临床资料,比较两组在妊娠并发症、合并症、分娩情况和围产儿预后等的差异。结果观察组晚期流产、早产、羊水过多、双胎输血综合征、双胎之一胎死宫内和胎盘早剥的发生率分别为18.2%（12/66）、63.6%（42/66）、30.0%（20/66）、34.8%（23/66）、13.6%（9/66）和4.5%（3/66）,对照组为8.0%（25/312）、35.9%（112/312）、14.7%（46/312）、1.3%（4/312）、3.8%（12/312）、0.96%（3/312）,两组间比较差异有统计学意义（P〈0.01）;观察组剖宫产率78.8%（52/66）,阴道分娩率21.2%（14/66）,对照组剖宫产率为75.0%（234/312）,阴道分娩率25.0%（78/312）,两组间差异无统计学意义（P〉0.01）;观察组围产儿病死率18.1%（24/132）,新生儿窒息率44.7%（59/132）,对照组围产儿病死率为2.9%（18/624）,新生儿窒息率15.7%（98/624）,两组间比较差异有统计学意义（P〈0.01）;观察组胎儿畸形的发生率为3.7%（5/132）,显著高于对照组0.6%（4/624）。结论发育不同一性双胎妊娠主要的并发症（晚期流产、早产、羊水过多、双胎输血综合征、胎盘早剥、围产儿死亡、新生儿窒息和胎儿畸形）发生率明显高于发育一致双胎妊娠,临床上应给予重视,及时发现,及时诊断,适时终止妊娠以提高围产质量。