脑-胎盘-子宫比率对预测晚发型胎儿生长受限的作用

目的:探讨超声多普勒测量脑-胎盘-子宫比率(CPUR)在预测晚发型胎儿生长受限(FGR)中的效能。方法:选择2020年5月至2021年5月在香港大学深圳医院接受产前检查的1255例单胎妊娠孕妇，孕35～37+6周进行胎儿生长和超声多普勒测量。新生儿出生体质量<第10百分位数的孕妇为FGR组。分别和联合分析子宫动脉(UtA)、脐动脉(UA)和胎儿大脑中动脉(MCA)的搏动指数(PI),通过ROC曲线分析CPUR、脑-胎盘比率(CPR)、脑-子宫比率(C-UtA)对晚发型胎儿FGR预测价值，评估其预测晚发型FGR的敏感度、阳性和阴性预测值。结果:CPUR、CPR、C-UtA、平均UtA-PI在FGR组的曲线下面积值(AUC)为0.88、0.86、0.84、0.72。在一定的截断值和87%以上特异度下，CPUR、CPR、C-UtA、平均UtA-PI对预测FGR的敏感度分别为43.2%、46.6%、39.8%和23.9%;CPUR、CPR、C-UtA、平均UtA-PI、UA-PI对预测FGR的阳性预测值分别为90.5%、71.9%、83.3%、63.6%、5.2%。结论:CPUR预测晚发型FGR的综合效能较CPR、C-UtA、平均UtA-PI更好，可更有效提高临床FGR的检出率，以降低FGR风险。     

脑-胎盘率检测对反复无应激试验无反应型孕妇的临床意义

目的探讨对反复无应激试验（no-stress test,NST）无反应型孕妇进行脑-胎盘率（PIMCA/PIUA）检测的临床意义。方法运用彩色多普勒超声检测200例孕37~41周反复NST无反应型孕妇的胎儿大脑中动脉（MCA）和脐动脉（UA）的血流阻力指标（包括S/D、RI、PI）、计算各自的脑-胎盘率,并根据胎儿有否不良结局分为两组进行比较分析。结果不良结局组测得的MCA各阻力指标明显低于正常组（P〈0.01）,UA各阻力指标明显高于正常组（P〈0.05）,脑-胎盘率明显低于正常组（P〈0.01）。在PIMCA/PIUA〈1组,胎儿不良结局发生率明显高于PIMCA/PIUA〉1组（P〈0.01）;以PIMCA/PIUA〈1预测胎儿不良结局的敏感性为25.7%,特异性为98.2%。结论脑-胎盘率检测对于胎儿不良结局的预测具有不错的临床价值,当反复NST无反应型孕妇（无其他高危因素）的脑-胎盘率〈1时须警惕胎儿不良结局的发生。     

再次评价中孕期中央性前置胎盘状态引产预防性应用子宫动脉栓塞术的临床效果

目的探讨子宫动脉栓塞术在中孕期中央性前置胎盘状态引产中的预防出血效果及不良反应。 方法采用回顾性研究方法对2011年1月至2014年12月在广州医科大学附属第三医院行中孕期中央性前置胎盘状态引产的79例患者临床资料进行分析。将羊膜腔注射乳酸依沙吖啶注射液联合口服米非司酮,同时使用子宫动脉栓塞术引产的29例患者作为栓塞组(其中孕20～27^＋6周18例,<20周11例);将只采用羊膜腔注射乳酸依沙吖啶注射液联合口服米非司酮的50例患者作为对照组(其中孕20～27^＋6周20例,<20周30例);分别对两组患者的引产时间、出血量、术后发热率、术后疼痛强度和月经恢复时间等进行比较。 结果(1)引产时间：孕20～27^＋6周患者中栓塞组除1例因引产失败转为剖宫取胎外,其余17例为(45.94±5.80)h,对照组为(41.23±7.59)h(t＝1.85,P<0.05);两组<20周患者引产时间分别为(49.36±7.80)h和(41.23±13.85)h(t＝1.83,P<0.05)差异有统计学意义。(2)出血量：20～27^＋6周栓塞组出血量少于对照组,分别为(294±60)ml和(356±81)ml(t＝2.64,P<0.01),差异有统计学意义;两组<20周患者出血量差异无统计学意义。(3)栓塞术后疼痛评分：20～27^＋6周两组患者分别为(8.70±0.90)分和(2.11±0.50)分(t＝13.67,P<0.01)差异有统计学意义;<20孕周两组患者分别为(7.27±1.80)分和(1.65±0.48)分(t＝13.39, P<0.01),差异有统计学意义。(4)术后发热：20～27^＋6周两组患者分别为64.71%和5%(t＝18.26,P<0.01),<20周两组患者分别为63.64%和6.67%(t＝11.25, P<0.01),差异有统计学意义。 结论(1)子宫动脉栓塞术对于孕周20～27^＋6周的胎盘前置状态引产出血有积极的预防作用,但对孕周<20周的前置胎盘状态引产预防出血意义不大。(2)子宫动脉栓塞术可能会延长引产时间,增加产后疼痛强度及发热率,临床应用需谨慎。(3)在中孕期前置胎盘状态引产手术中,娴熟的产科处理技术对术中预防和减少出血可以起到积极的作用。     

孕19～23周+6正常胎儿羊水γ-谷氨酰转移酶水平及其随孕周的变化

目的探讨孕19～23周+6正常胎儿羊水γ-谷氨酰转移酶(γ-glutamyl transferase, GGT)水平及其随孕周的变化。方法回顾性收集2021年1月至2022年9月于山东大学齐鲁医院行羊膜腔穿刺产前诊断但遗传学诊断结果正常的383例(孕19～19⁺⁶、20～20⁺⁶、21～21⁺⁶、22～22⁺⁶、23～23周⁺⁶分别为102、103、82、68和28例)单胎妊娠孕妇的羊水上清液, 测定GGT水平。计算各孕周羊水GGT值的xˉ±s、min～max、M、P₁、P_2.5、P₅、P₉₅、P_97.5和P₉₉。GGT为非正态分布数据, 转换为自然对数(lnGGT), 采用最小二乘线性回归分析lnGGT与孕周的线性关系。结果孕19～19⁺⁶、20～20⁺⁶、21～21⁺⁶、22～2...     

胎儿脐动脉及大脑中动脉阻力参数正常值

目的了解本地区低危人群胎儿脐动脉（umbilical artery，UA）及大脑中动脉（middle cerebral artery，MCA）搏动指数（pulsatility index，PI）、阻力指数（resistance index，RI）、收缩期峰值流速与舒张末期流速比值（S／D）的正常参考值范围。方法随机选取2218例孕20～40周的无合并症单胎孕妇，检测脐动脉（近胎儿侧）及大脑中动脉（中段）血流，记录PI、RI、S／D进行分析。结果脐动脉的血流阻力随着胎龄的增加而降低，大脑中动脉的血流阻力在孕20-26周随孕周的增加而增高，孕26～28周时达高峰，28周以后随着孕周的增加而降低。结论了解胎儿脐动脉及大脑中动脉血流阻力在不同孕周的变化规律，对判断及随访胎儿宫内缺氧状况，协助临床做出正确的产科处理具有重要意义。     

不同年龄和孕期的健康孕妇血浆D-二聚体的临界值差异性比较

目的:比较不同年龄和孕期的健康孕妇血浆D-二聚体的差异。方法:选择2020年5月至2021年1月在重庆医科大学附属第一医院进行产前检查的健康孕妇1846例,按孕期分为3组：早孕组(孕周≤13⁺⁶周)481例;中孕组(孕14⁺⁰～27⁺⁶周)591例;晚孕组(孕28⁺⁰～40⁺⁶周)774例。采用乳胶免疫比浊法对其血浆D-二聚体进行定量检测,统计学分析不同年龄和孕周的健康孕妇血浆D-二聚体的差异。结果:孕早期、孕中期和孕晚期的D-二聚体值分别是正常人群D-二聚体参考值上限的3.26倍、6.16倍和10.06倍,与孕早期的P₉₅值比较,孕中期和孕晚期D-二聚体的P₉₅值逐渐增高,差异有统计学意义(P<0.05)。孕妇血浆D-二聚体水平与孕妇年龄无差异性。不同孕期的D-二聚体的临界值为孕早期≤1.63 mg/L,孕中期≤3.08 mg/L,孕晚期≤5.03 mg/L。结论:目前推荐用于正常人群血浆D-二聚体水平参考范围(≤0.5 mg...     

胎儿宫内发育迟缓伴有异常脐动脉血流波型的孕妇其胎儿胎盘循环中肾上腺髓质素水平增高

作者实施本研究的目的是评估胎盘产生的新的血管活性多肽—肾上腺髓质素 (Adrenomedullin)是否参与胎儿宫内发育迟缓(IUGR)时子宫胎盘血流动力学的变化 ,并研究肾上腺髓质素与胎儿胎盘血流间的关系。故作者对 16例孕 2 8～ 39周并发 IUGR伴有异常脐动脉血流波型的孕妇及 16例正常对照孕妇抽取孕妇及脐血标本 ,肾上腺髓质素水平用特殊的放射免疫分析测定 ,彩色 Doppler超声记录子宫、脐带及胎儿大脑中动脉的血流速度波型。结果 :IUGR患者脐血平均肾上腺髓质素水平显著高于对照组 ,其值分别为 6 3.7± 34.2 pg/ ml与 38.1± 14.8pg/ ml,…     

一胎儿结构畸形双胎孕中期减胎术例临床分析

目的 探讨不同绒毛膜性的一胎儿结构畸形双胎胎儿畸形种类差异及不同孕周减胎术妊娠结局。方法 回顾性分析2002—2020年在山东第一医科大学附属省立医院因一胎儿结构畸形行孕中期减胎术的双胎病例,分析双绒毛膜双胎(双绒双胎组)及单绒毛膜双胎(单绒双胎组)胎儿畸形种类及不同减胎孕周的妊娠结局。结果 双绒双胎组颈部畸形占比高,两组其余胎儿畸形种类顺位基本一致。双绒双胎组A(12～13⁺⁶孕周)、B(14～19⁺⁶孕周)、C(20～27⁺⁶孕周)3个亚组流产率、活产率差异无统计学意义,随减胎孕周的增加早产率增加,出生体重降低,差异均有统计学意义,A组早产率低于C组,A组及B组新生儿出生体重高于C组(A、B、C 3组的早产率分别为3.7%、13.9%和25.6%)。单绒双胎组A(12～19⁺⁶孕周)、B(20～27⁺⁶孕周)2个亚组流产率、早产率、活产率差异无统计学意义,A组新生儿分娩孕周及出生体重高于B组[分别为38⁺²(37⁺⁴,40)vs....     

超声多普勒测定脑-胎盘比在产科的应用

脑-胎盘比（cerebroplacental ratio，CPR）为胎儿大脑中动脉搏动指数（pulsatility index，PI）和脐动脉PI的比值，其是反映胎儿宫内缺氧的一项敏感指标，近年来逐渐引起产科和超声科医师的关注。文章依据目前国内外临床研究，阐述CPR在评估胎儿生长发育状况及预测不良围产结局方面的价值。     

脑胎盘率诊断胎儿宫内缺氧的研究进展

胎儿宫内缺氧是围生儿死亡的重要原因之一,产前有效预测胎儿宫内缺氧,对降低围生儿死亡率具有重大意义。联合检测胎儿各项多普勒血流参数,包括脐动脉、大脑中动脉、肾动脉、静脉导管、腹内脐静脉等,能够反映胎儿各个器官的异常状态,准确地评价胎儿宫内缺氧状况,提高胎儿窘迫的诊断率。脑胎盘率(CPR)利用大脑中动脉与脐动脉搏动指数的比值,消除了共同的干扰因素,排除了基数波动的影响,受血流灌注阻抗变化的影响小,比单一血管更能反映胎儿全身血流分布情况,用于早期评价胎盘胎儿血流循环变化,从而更全面地评价宫内缺氧程度,早期预测妊娠不良结局,及时快速准确地发现异常,及时干预,提高围生儿质量,具有临床应用价值,值得临床推广应用。     

双胎妊娠1530例胎儿丢失临床分析

目的探讨双胎妊娠不同绒毛膜性胎儿在不同孕周发生围产儿丢失的风险及单绒毛膜双羊膜囊双胎(MCDA)胎儿丢失的原因。方法回顾性分析2014年1月至2017年12月中国内地10所三级妇产科专科医院或妇幼保健院中分娩的1530例双胎妊娠,比较MCDA与双绒毛膜双羊膜囊双胎(DCDA)胎儿丢失的风险和发生孕周及原因。结果 407例MCDA和1123例DCDA纳入研究。1239+6周MCDA组丢失率为4.68%,DCDA组丢失率为0.98%,丢失风险OR 4.78(95%CI 2.848.03),χ²=42.45,P<0.001。12~23⁺⁶周MCDA组较DCDA组丢失风险OR6.09(χ²=29.53,P<0.001)。24~39⁺⁶周MCDA组较DCDA组丢失风险OR 5.03(χ²=18.73,P<0.001)。MCDA组胎儿丢失原因的前4位依次为:双胎输血综合征(twin-twin transfusion syndrome,TTTs)(36.36%,8/22)、选择性胎儿生长受限(selective intrauterine growth restriction,sIUGR)(22.73%,5/22)、脐带扭转(22.73%,5/22)、帆状胎盘(13.64%,3/22)。DCDA组胎儿丢失原因的前4位依次为:胎膜早破(21.43%,3/14)、胎儿生长受限(fetal growth restriction,FGR)(14.29%,2/14)、胎儿结构异常(14.29%,2/14)、母体感染(7.14%,1/14)。结论 MCDA胎儿丢失风险明显高于DCDA。单绒毛膜性双胎特有的并发症(TTTs、sIUGR)及脐带扭转等都是造成MCDA胎儿丢失的重要原因。     

Assessment of blood flow in the middle cerebral artery and the umbilical artery in fetuses with umbilical venous pulsations

OBJECTIVES: Umbilical venous pulsation is an important sign of hemodynamic compromise, especially during fetal heart failure and asphyxia. DESIGN: The aim of this study was to determine of the blow flow in the middle cerebral artery and the umbilical artery in fetuses with umbilical venous pulsations. MATERIALS AND METHODS: The investigation included 18 fetuses with signs of the intrauterine growth restriction and umbilical venous pulsations after 28th weeks of gestation. We evaluated cerebral-placental ratio (CPR) and pulsation index (PI) in the middle cerebral artery (MCA) and the umbilical artery (UA). RESULTS: We observed brain sparring effect in all cases of analyzing fetuses. There were 77,8% of abnormal flow pattern in umbilical artery. 13 fetuses had a single pulsation pattern in umbilical vein and another 5 had double pulsation pattern. CONCLUSIONS: The coexistence of umbilical vein pulsation and abnormal flow pattern in umbilical artery is closely related to increased perinatal mortality.     

Fetal blood velocity waveforms in normal pregnancies. A longitudinal study

Blood velocity in the umbilical artery, fetal descending aorta and fetal middle cerebral artery was recorded by means of 3.5 MHz pulsed Doppler ultrasound in 22 normal pregnancies. The measurements were performed longitudinally between 25 and 42 weeks of gestation. The maximum blood velocity curves were analysed for pulsatility index (PI), systolic/diastolic velocity ratio (S/D ratio) and in the middle cerebral artery also for the resistance index according to Pourcelot (RI). In the umbilical artery, all variables decreased significantly with increasing gestational age as an expression of the decreasing placental vascular resistance. PI in the descending aorta remained fairly constant during the examined period of gestation. In the middle cerebral artery, all three variables (PI, S/D ratio, RI) decreased significantly as gestation advanced. With the exception of the umbilical artery at 28-32 weeks, PI and S/D ratio were not influenced by the heart rate in any of the vessels examined. Diagrams of the gestational age-related reference values (means +/- 2 SD) for the variables of the blood velocity waveforms were established. Additionally, a ratio of the PI and S/D was calculated for the umbilical artery and middle cerebral artery.     

Amniotic fluid nitric oxide and uteroplacental blood flow in pregnancy complicated by intrauterine growth retardation

Objective To examine the correlation between placental nitric oxide production and uteroplacental blood flow.
Participants Thirty-one pregnant women with fetuses with intrauterine growth retardation and 27 normal pregnancies as controls.
Design Correlation between amniotic fluid measurements of nitrite metabolite in the third trimester and flow velocimetry waveforms recorded from uterine, umbilical and fetal middle cerebral arteries. Intrauterine growth retarded pregnancies were compared with controls.
Main outcome measures Concentrations of nitric oxide metabolites (NO₂^- and NO₃^-) in amniotic fluid were correlated with flow velocimetry waveforms findings by the determination of correlation coefficient.
Results Overall median nitrite values in amniotic fluid were higher (   P < 0.01  ) in intrauterine growth retarded patients (median 8.6 μmol/mg creatinine) than in controls (5.6 μmol/mg creatinine). Pathologic uterine flow velocimetry waveforms in uterine artery (-2SD) were observed in 12 women of the intrauterine growth retarded group, and the concentration of amniotic fluid nitrite was significantly lower (   P < 0.01  ) in these patients (median 4.45 μmol/mg creatinine) than in those with normal flow velocity waveforms (median 11.43 μmol/mg creatinine). A significant negative correlation was observed between nitrite concentrations and uterine artery resistance index, umbilical artery pulsatility index and umbilical artery pulsatility index:middle cerebral artery pulsatility index ratio.
Conclusions We conclude that placental nitric oxide is significantly associated with uteroplacental blood flow and may be important in maintaining adequate uteroplacental perfusion in intrauterine growth retarded pregnancies.     

Effect of an increase of the hematocrit on middle cerebral artery peak and umbilical vein maximum velocities in anemic fetuses

OBJECTIVE: To measure the effects of acute large increases of the hematocrit on fetal peak arterial and maximum venous blood flow velocities. METHODS: Middle cerebral artery peak flow velocities and umbilical vein maximum flow velocities were measured before, immediately after, and 12-24 h after intrauterine transfusions. All measurements were standardized for gestational age. RESULTS: Complete measurements were obtained at 60 intrauterine transfusions. The mean hematocrit before intrauterine transfusion was 0.19 l/l and after 0.40 l/l. The middle cerebral artery peak flow velocity decreased immediately after transfusion in 59 of the 60 cases. There was a rise in umbilical vein maximum flow velocity immediately after intrauterine transfusion in 37 of the 60 cases. The sensitivity of middle cerebral artery peak flow velocity for severe anemia before intrauterine transfusion was 54% and the specificity 57%. The sensitivity of umbilical vein maximum flow velocity for severe anemia before intrauterine transfusion was 67% and the specificity 57%. CONCLUSIONS: An acute large increase of the fetal hematocrit significantly decreases middle cerebral artery peak flow velocity. The effect on umbilical vein maximum velocity is, however, unpredictable.     

Cerebral-umbilical Doppler ratio as a predictor of adverse perinatal outcome.

Using a 3.5-MHz duplex Doppler system, 45 normal-growth and 45 growth-retarded fetuses were studied between 30-41 weeks' gestation. Velocity recordings were obtained from the middle cerebral artery and umbilical artery to calculate the ratio between the two pulsatility indexes. The cerebral-umbilical Doppler ratio is usually constant during the last 10 weeks of gestation. Therefore, a single cutoff value (1.08) was used, above which velocimetry was considered normal and below which it was considered abnormal. The cerebral-umbilical Doppler ratio provided a better predictor of small for gestational age newborns and adverse perinatal outcome than either the middle cerebral artery or umbilical artery alone. In fact, in predicting those newborns who were small for gestational age, the cerebral-umbilical ratio had a 70% diagnostic accuracy [(true positive + true negative)/total number of cases], compared with 54.4% for the middle cerebral artery and 65.5% for the umbilical artery. The results were more encouraging for prediction of adverse perinatal outcome; diagnostic accuracy for the cerebral-umbilical ratio was 90%, compared with 78.8% for the middle cerebral artery and 83.3% for the umbilical artery.     

Accuracy and reproducibility of ultrasound measurements in obstetric management

OBJECTIVE: The aim of this study was to assess the potential of ultrasonography as a routine diagnostic tool in obstetric management. SUBJECTS AND METHODS: For the investigation on interobserver reproducibility, 2 sonologists independently measured the biparietal diameter (BPD), femur length (FL), amniotic fluid index (AFI), and resistance index (RI) of the umbilical and middle cerebral arteries in 20 healthy pregnant women between 28 and 36 weeks of gestation using color and pulsed Doppler ultrasound. A second group of 10 healthy pregnant women between 30 and 35 weeks of gestation were examined to assess the level of intraobserver reproducibility of the Doppler and ultrasound measurements by 2 sonologists. For each patient in this group, the flow waveform was measured three times in succession. Calculations of the intraclass correlation coefficient (Ri) were used to determine the levels of reproducibility. The agreement was considered acceptable only when the Ri value was > or = 6. RESULTS: The interobserver Ris for BPD, FL, AFI, and RI of the umbilical and middle cerebral arteries were 0.93, 0.8, 0.58, 0.49 and 0.56, respectively. The intraobserver Ris of the 2 sonologists in BPD, FL, and RI of umbilical artery were >0.6, whereas those in AFI and RI of middle cerebral artery were <0.6. CONCLUSIONS Both the interobserver and intraobserver reproducibilities of BPD and FL were clinically acceptable, but not in the AFI and RI of umbilical and middle cerebral arteries.     

Added value of cerebro-placental ratio and uterine artery Doppler at routine third trimester screening as a predictor of SGA and FGR in non-selected pregnancies

Objectives: The objective of this study is to determine the added value of cerebroplacental ratio (CPR) and uterine Doppler velocimetry at third trimester scan in an unselected obstetric population to predict smallness and growth restriction.

Methods: We constructed a prospective cohort study of women with singleton pregnancies attended for routine third trimester screening (32⁺⁰–34⁺⁶ weeks). Fetal biometry and fetal–maternal Doppler ultrasound examinations were performed by certified sonographers. The CPR was calculated as a ratio of the middle cerebral artery to the umbilical artery pulsatility indices. Both attending professionals and patients were blinded to the results, except in cases of estimated fetal weight Results: A total of 1030 pregnancies were included. The mean gestational age at scan was 33 weeks (SD 0.6). The addition of CPR and uterine Doppler to maternal characteristics plus EFW improved the explained uncertainty of the predicting models for SGA (15 versus 10%, p?p?=?.03). However, the addition of CPR and uterine Doppler to maternal characteristics plus EFW only marginally improved the detection rates for SGA (38 versus 34% for a 10% of false positives) and did not change the predictive performance for FGR.

Conclusions: The added value of CPR and uterine Doppler at 33 weeks of gestation for detecting defective growth is poor.     

Doppler sonographic findings for hypertension in pregnancy and HELLP syndrome

Doppler examinations of the umbilical artery, both uterine arteries, and the fetal middle cerebral artery were performed in the third trimester in 18 patients with pregnancy induced hypertension, 52 patients with preeclampsia, and 32 patients with HELLP syndrome and the results were correlated with the parameters fetal outcome. For 74% of the patients this was the first pregnancy, in 93% of the cases a cesarean section was necessary; 66% of the newborn babies were dystrophic and 90% of them were born prematurely. The blood flow in one uterine artery was restricted in 95% of all 102 pregnant women, only 5% did not show any pathological findings. A pathological blood flow was observed on Doppler sonography in the umbilical artery in 70% of the group and 39% showed a pathologically increased perfusion of the fetal middle cerebral artery. The average birth weights and gestational ages in the study group were markedly reduced in comparison with healthy pregnant women (pregnancy induced hypertension: 1620 g/35 weeks; preeclampsia: 1660 g/34 weeks; HELLP syndrome: 1160 g/31 weeks, respectively). The lowest values for average birth weight and gestational age occurred when all four investigated blood vessels showed pathological Doppler findings: 1180 g/31 weeks (0 to 1 pathological vascular findings: 2780 g/38 weeks; 2 pathological vascular findings: 1845 g/34.5 weeks; 3 pathological vascular findings: 1330 g/31 weeks). This Doppler study underlines the importance of examining four blood vessels: the uterine, the umbilical, and the fetal middle cerebral arteries for a complete analysis of the fetoplacental hemodynamics. On account of the severely impaired hemodynamics observed in the placentas of our patients with hypertensive diseases in pregnancy or HELLP syndrome, we believe the early diagnosis of these disorders by Doppler sonography and an early start of therapy to be essential.