超声预测晚发型胎儿宫内生长受限的临床价值

目的 探讨超声对晚发型胎儿宫内生长受限的预测价值。方法 选取在我院行产前超声检查的孕妇99例,依据不同妊娠结局分为正常组66例（胎儿宫内发育正常）和迟发组33例（晚发型胎儿宫内生长受限）,获取两组心肌做功指数（MPI）、脑胎盘率（CPR）、肝静脉血流阻力指数（HVI）、静脉脉搏传递时间（VPTT）及心输出量（CO）,比较两组上述参数的差异。相关性分析采用Spearman相关分析法;绘制受试者工作特征（ROC）曲线分析各参数预测晚发型胎儿宫内生长受限的效能。结果 正常组CPR、VPTT、CO均高于迟发组,MPI、HVI均低于迟发组,差异均有统计学意义（均P<0.05）。CO与VPTT呈正相关（r=0.783,P<0.001）,CPR与HVI呈负相关（r=-0.374,P=0.037）,MPI与HVI呈正相关（r=0.639,P<0.001）。ROC曲线分析显示,MPI、CPR、HVI、VPTT、CO预测晚发型胎儿宫内生长受限的曲线下面积分别为0.809、0.836、0.987、0.897、0.989,敏感性分别为0.886、0.545、0.894、0.894、0.924...     

Tei指数在胎儿心功能评价中的应用

目的测量胎儿心脏Tei指数,建立不同孕周组胎儿心脏Tei指数正常参考值范围,评估Tei指数在临床应用中的价值.方法超声检查16～40孕周正常胎儿299例,测得胎儿心脏Tei指数291例.结果 299例正常胎儿Tei指数的检测成功率为97.3%;3个不同孕周组胎儿之间Tei指数无统计学差异(P＞0.05);Tei指数95%正常参考值范围为0.445±0.101.结论胎儿心脏Tei指数测量方法简便;Tei指数在16～40周正常胎儿中稳定性好;95%正常参考值范围为0.445±0.101.     

彩色多普勒超声在宫内胎儿生长受限诊断中的应用价值分析

目的:探讨应用彩色多普勒超声诊断宫内胎儿生长受限(FGR)的价值。方法:选取本院2018年1月—2020年6月收治的42例FGR孕妇为观察组,40例胎儿宫内发育正常的孕妇为对照组,均采取彩色多普勒超声检查,观察两组胎儿脐动脉(UA)、大脑中动脉(MCA)及静脉导管(DV)的血流参数指标。结果:在UA血流参数上,观察组胎儿在搏动指数(PI)、阻力指数(RI)、收缩期与舒张期最大血流速度的比值(S/D)上均高于对照组,收缩期最大血流速度(PSV)低于对照组,差异均有统计学意义(P<0.05);胎儿MCA参数上,观察组PI、RI、S/D、PSV均低于对照组(P<0.05);胎儿DV血流参数上,观察组心室收缩峰S流速、心房收缩谷a流速均低于对照组,S/a高于对照组,差异均有统计学意义(P<0.05)。结论:采取彩色多普勒超声诊断FGR的价值显著,值得推广。     

超声指标及母血中血清蛋白指标与胎儿宫内生长受限的关系

目的研究并探讨超声指标、母血中血清蛋白指标与胎儿宫内生长受限（FGR）的关系。方法于2015年1月~2015年12月,选取在佛山市顺德区妇幼保健院产科门诊建卡的900例孕妇作为研究对象,于28~32w对孕妇进行彩色多普勒超声筛查和血清学检查,记录超声筛查中的胎儿小脑横径（TCD）、胎儿主动脉峡部（AOI）血流指标与血清学检查中的视黄醇结合蛋白（RBP）、血清前白蛋白（PA）,并分别对胎儿生长受限作出诊断。对受检孕妇进行追踪随访,待孕妇分娩后,对胎儿宫内生长受限的病例数进行统计,计算超声检查、血清学检查对胎儿宫内生长受限的敏感度、特异度、阳性预测值、阴性预测值,采用Kappa一致性检验对其诊断准确性进行判断。根据胎儿宫内生长是否受限将孕妇分为FGR组和对照组,对比两组的TCD、AOI、RBP、PA,并计算其相关性。结果超声检查对胎儿宫内生长受限的敏感度、特异度、阳性预测值、阴性预测值分别为97.62%、99.35%、96.09%、99.61%,血清学对胎儿宫内生长受限的敏感度、特异度、阳性预测值、阴性预测值分别为96.83%、99.48%、96.83%、99.48%,与妊娠结果之间均具有良好的一致性。与对照组孕妇相比,FGR组的TCD、AOI均明显更小（P〈0.05）,RBP、PA明显更低（P〈0.05）。经计算得出,TCD、AOI、RBP、PA与胎儿宫内生长受限均密切相关。结论产前超声筛查、母血中血清学检查对胎儿宫内生长受限的诊断准确性较高,超声指标和母血中的血清学蛋白指标可对胎儿宫内生长受限予以敏感的反映。     

超声心动图新技术评价胎儿心功能研究进展

胎儿心功能对判断胎儿宫内情况、监测病情及预测预后具有重要意义。超声心动图是产前常用评价胎儿心功能的非侵入性影像学方法之一,组织多普勒、速度向量成像、空间-时间相关成像等超声心动图新技术可为临床评价胎儿心功能提供客观、准确的信息。本文就超声心动图新技术评价胎儿心功能的研究进展进行综述。     

孕中期超声与甲状腺激素联合检查对诊断非匀称型胎儿宫内生长受限的价值

目的探讨孕中期超声与甲状腺激素联合检查对诊断非匀称型胎儿宫内生长受限（IUGR）的价值。 方法选取2016年6月至2019年6月在南京医科大学第二附属医院建立围产期保健卡的自然受孕单胎孕中期母胎6010例，其中胎儿为非匀称型IUGR者97例为观察组，同孕期胎儿生长均衡的孕母30例为对照组。分别采用Mann-Whitney U检验和独立样本t检验对比评价孕（18±1）周、（22±1）周，观察组与对照组母体血清促甲状腺激素（TSH）和游离甲状腺素（FT₄）水平的差异。采用受试者操作特征（ROC）曲线分析孕（18±1）周和（22±1）周母体TSH和FT₄预测胎儿生长迟缓的价值。 结果观察组母体（18±1）周和（22±1）周时FT₄水平低于对照组[（10.74±2.87）pmol/L vs（14.83±1.91）pmol/L；（11.96±2.87）pmol/L vs（15.28±2.14）pmol/L]，差异均具有统计学意义（t=-6.978、-6.793，P均<0.001）；观察组母体（22±1）周时TSH水平高于对照组[2.52（1.74~3.21）mlU/ml vs 1.96（1.54~2.76）mlU/ml]，差异有统计学意义（Z=-2.191，P=0.028）；（18±1）周时2组母体TSH水平比较，差异无统计学意义（P>0.05）。孕（18±1）周、（22±1）周时母体FT₄预测胎儿生长迟缓的敏感度均大于95%，分别为96.7%和100%，显著高于TSH（32.4%和55.2%）；但母体TSH预测胎儿生长迟缓的特异度（90.0%和73.3%）却高于FT₄（75.7%和56.2%）。 结论孕中期超声与甲状腺激素联合检查对非匀称型IUGR具有一定的预测价值。     

超声心动图评价胎儿心功能的现状与进展

胎儿期有多种疾病可以影响胎儿的心功能,而心功能状态对预测患病胎儿预后有着重要意义.超声心动图是产前判断胎儿心功能不可缺少的无创影像学方法.随着计算机和超声心动图技术的进步,一些更新更准确的心功能测定方法被逐渐应用于临床.在许多疾病的发展过程中,一些测量指标的变化规律都与心功能有着密切联系.准确评估心功能对胎儿的优生优育具有重要意义.     

胎儿静脉导管超声检查在预测宫内生长受限胎儿出生结局中的应用价值

目的探讨胎儿静脉导管超声检查在预测宫内生长受限胎儿不良出生结局中的应用价值。方法选取我院确诊存在宫内生长受限胎儿的孕妇53例,依据新生儿出生不同结局分为正常组23例、轻微异常组15例和明显异常组15例。检测比较各组胎儿静脉导管多普勒血流参数变化情况。结果胎儿静脉导管的心室收缩期峰值流速/最大心房期回流速度(DVS/A)、静脉导管的阻力指数(DVRI)及静脉导管血流量/脐静脉血流量(QDV/QUV)均可以对FGR胎儿的明显异常出生结局作出预测,其中DVS/A曲线下面积最大,为91%,其次为DVRI,曲线下面积为90%,QDV/QUV曲线下面积为74%。结论 DVS/A、DVRI及QDV/QUV均可以作为预测宫内生长受限胎儿明显异常出生结局的指标,其中DVS/A、DVRI预测价值较高。     

11~14周正常胎儿心脏超声检查

目的对妊娠11^＋0～14^＋6周正常胎儿心脏结构进行观察，获得该孕周内正常胎儿心脏的生理参数。方法对100位孕妇在妊娠11^＋0～14^＋6周进行常规经腹超声检查，同时观察胎儿心脏各切面结构并进行测量。结果胎儿心脏各切面显示率不同，四腔心显示率最高，其次是动脉交叉，而动脉导管的显示率最低。妊娠13周以后胎儿心脏结构超声可清晰显示。胎儿心脏周长、面积及各心室内径的增加与孕周有相关性，而心脏周长与胸廓周长比值，心脏面积与胸廓面积比值，左右心房比值以及房室率均相对衡定，与孕周之间无明显相关性。结论由于在妊娠13周以后胎儿心脏结构能够清晰显示，因此，可以将胎儿超声心动图检查时间提前至妊娠中期的早期。主要筛查与四腔心切面相关的严重的胎儿先天性心脏畸形，有利于胎儿严重先天性心脏畸形的早期诊断。     

产前超声诊断胎儿卵圆孔血流受限或提前关闭的研究进展

近年来,有关胎儿卵圆孔血流受限或提前关闭的研究逐渐增多,产前超声在胎儿卵圆孔血流受限或提前关闭的诊断及预后评价方面具有重要应用价值。本文就近年来产前超声诊断胎儿卵圆孔血流受限或提前关闭的研究进展进行综述。     

宫内生长受限胎儿主动脉峡部血流动力学研究进展

宫内生长受限（IUGR）可致胎儿死亡以及围生期发病率和新生儿死亡率升高,临床常通过观察胎儿血流动力学变化监测IUGR。主动脉峡部（AoI）连接左右心室,其血流方向可因左右心室系统和外周血管压力差的改变而变化。监测AoI血流动力学变化可有效了解IUGR胎儿的情况。本文对IUGR胎儿AoI血流动力学的研究进展进行综述。     

Monitoring of fetuses with intrauterine growth restriction: a longitudinal study.

OBJECTIVE: To describe the time sequence of changes in fetal monitoring variables in intrauterine growth restriction and to correlate these findings with fetal outcome at delivery. METHODS: This was a prospective longitudinal observational multicenter study on 110 singleton pregnancies with growth-restricted fetuses after 24 weeks of gestation. Short-term variation of fetal heart rate, pulsatility indices of fetal arterial and venous Doppler waveforms and amniotic fluid index were assessed at each monitoring session. The study population was divided into two groups: Group 1 comprised pregnancies with severely premature fetuses, which were delivered < or =32 weeks and Group 2 included pregnancies delivered after 32 completed weeks. Logistic regression was used for modeling the probability for abnormality of a variable in relation to the time interval before delivery. Trends over time were analyzed for all variables by multilevel analysis. RESULTS: Ninety-three (60 in Group 1 and 33 in Group 2) fetuses had at least three data sets (median, 4; range, 3-27) and had the last measurements taken within 24 h of delivery or intrauterine death. The percentage of abnormal test results and the degree of abnormality were higher in Group 1 compared to Group 2. Amniotic fluid index and umbilical artery pulsatility index were the first variables to become abnormal, followed by the middle cerebral artery, aorta, short-term variation, ductus venosus and inferior vena cava. In Group 1, short-term variation and ductus venosus pulsatility index showed mirror images of each other in their trend over time. Perinatal mortality was significantly higher if both variables were abnormal compared to only one or neither being abnormal (13/33 (39%) vs. 4/60 (7%); P = 0.0002; Fisher's exact test). CONCLUSION: Ductus venosus pulsatility index and short-term variation of fetal heart rate are important indicators for the optimal timing of delivery before 32 weeks of gestation. Delivery should be considered if one of these parameters becomes persistently abnormal.     

Physiologic restriction versus genetic weight potential: study in normal fetuses and in fetuses with intrauterine growth retardation.

Physiologic weight restriction is defined as the difference between the genetic and real weight in a normal fetus. The aims of this study were (1) to obtain, in normal pregnancies, reference values of mean weight restriction between 32 and 42 weeks for both male and female fetuses, and (2) to observe how weight restriction may influence intrauterine growth retardation. In the first part of the study, 1004 ultrasonograms of 389 different women were studied and the estimated fetal weights with their regression curves were calculated and drawn for all fetuses by sex. Differences between the 50th percentile of the genetic curves in normal population and the estimated fetal weight values for each of the 1004 examinations were calculated and weight restriction 50th and 90th percentiles were described. In the second part of the study, genetic curves were constructed retrospectively for 20 fetuses with intrauterine weight restriction whose examinations were performed before week 28 and were compared with curves for the normal population. Finally, for the 20 patients with intrauterine weight restriction, differences between genetic and real weight at delivery were plotted and compared with weight restriction 50th and 90th percentiles. Also, fetuses with intrauterine weight restriction were compared according to differing degrees of restriction. Weight restriction began between 31 and 33 weeks of gestation and was earlier and marked in female fetuses. Genetic percentiles were higher in normal fetuses than in fetuses with intrauterine weight restriction. In addition, pregnancies of intrauterine growth restricted fetuses with greater degrees of weight restriction were more abnormal than those of fetuses with a lesser degree of weight restriction. Both facts imply that some of the fetuses included in the classic diagnosis of intrauterine weight restriction may be genetically small fetuses. Concepts of weight restriction and physiologic weight restriction might be applied to discriminate between normal, genetically small fetuses and fetuses affected with intrauterine growth retardation.     

Abnormal maternal cardiac function and morphology in pregnancies complicated by intrauterine fetal growth restriction.

OBJECTIVE: To explore maternal cardiac function through an echocardiographic evaluation, in a group of nulliparous patients with intrauterine fetal growth restriction during the third trimester of pregnancy. METHODS: Twenty-one consecutive nulliparous pregnant women who had fetuses with intrauterine growth restriction (IUGR) and abnormal umbilical artery Doppler pulsatility index (PI) underwent maternal echocardiographic examination during the third trimester of gestation. The data were then compared with those obtained from 21 normal nulliparous women who had fetuses with an estimated fetal weight > 10th percentile and a normal umbilical artery Doppler PI who were considered as the control group. RESULTS: Heart rate was slightly lower in the IUGR group, whereas blood pressure and total vascular resistance were higher compared with the control subjects. End-diastolic volume, stroke volume and cardiac output were lower in the IUGR patients compared with normal patients. The IUGR group had smaller left atrial maximal dimensions and greater left atrial minimal areas compared with the control subjects. Left atrial function was depressed in the IUGR group. A smaller left ventricular mass was present in the IUGR patients compared with the control subjects. Isovolumetric relaxation time (IVRT) was prolonged in the IUGR patients compared with the controls. CONCLUSIONS: The absence of a 'correct' maternal cardiovascular compensatory response to abnormal trophoblastic invasion, might be one of the factors that slowly determine the conditions of reduced placental perfusion and eventually of the development of fetal growth restriction.     

Maternal cardiovascular function in pregnancies complicated by intrauterine growth restriction.

OBJECTIVE: To investigate maternal cardiovascular function in pregnancies complicated by intrauterine growth restriction (IUGR). METHODS: Maternal echocardiography and ambulatory blood pressure monitoring were performed in pregnancies complicated by IUGR (n = 12) and controls (n = 12), all of whom were normotensive at enrollment. RESULTS: Compared to controls, maternal blood pressure (P = 0.016) and total vascular resistance (P = 0.008) were higher in IUGR pregnancies. Heart rate was lower (P = 0.003), as was systolic function expressed by midwall fractional shortening (P = 0.04). No significant differences between the two groups were observed for left atrial or left ventricular dimensions, nor for left ventricular geometry. Assessment of diastolic function by means of transmitral Doppler flow measurements revealed a significantly longer isovolumetric relaxation time in pregnancies with IUGR (P = 0.006). CONCLUSIONS: In normotensive pregnancies complicated by IUGR, as compared to controls, there is decreased diastolic and systolic maternal cardiac function, and a higher blood pressure.     

Doppler assessment of the aortic isthmus and perinatal outcome in preterm fetuses with severe intrauterine growth restriction.

OBJECTIVES: To evaluate the characteristics and association with perinatal outcome of the aortic isthmus (AoI) circulation as assessed by Doppler imaging in preterm growth-restricted fetuses with placental insufficiency. METHODS: This was a prospective cross-sectional study. Fifty-one fetuses with intrauterine growth restriction (IUGR) and either an umbilical artery (UA) pulsatility index (PI) > 95(th) centile or a cerebroplacental ratio < 5(th) centile were examined at 24-36 weeks' gestation. AoI impedance indices (PI and resistance index) and absolute velocities (peak systolic (PSV), end-diastolic and time-averaged maximum (TAMXV) velocities), were measured in all cases and compared with reference ranges by gestational age. Furthermore, fetuses were stratified into two groups according to the direction of the diastolic blood flow in the AoI: those with antegrade flow (n = 41) and those with retrograde flow (n = 10). Clinical surveillance was based on gestational age and Doppler assessment of the UA, middle cerebral artery and ductus venosus (DV). Adverse perinatal outcome was defined as stillbirth, neonatal death and severe morbidity (respiratory distress syndrome, bronchopulmonary dysplasia, Grade III/IV intraventricular hemorrhage, necrotizing enterocolitis and a neonatal intensive care unit stay > 14 days). RESULTS: Adverse perinatal outcome was significantly associated with an increased AoI-PI (area under the curve 0.77; 95% CI, 0.63-0.92; P < 0.005). A significant correlation (P < 0.001) was found between retrograde blood flow in the AoI and adverse perinatal outcome, the overall perinatal mortality being higher in the retrograde group (70% vs. 4.8%, P < 0.001). In 4/5 (80%) fetuses the reversal of flow in the AoI preceded that in the DV by 24-48 h. AoI-PSV and AoI-TAMXV were < 5(th) centile in 40/51 (78%) and 48/51 (94%) cases, respectively, whereas AoI-PI was > 95(th) centile in 21/51 (41%) cases. CONCLUSIONS: Retrograde flow in the AoI in growth-restricted fetuses correlates strongly with adverse perinatal outcome. Absolute velocities in the AoI are decreased in growth-restricted fetuses. The data suggest a potential role for Doppler imaging of the AoI in the clinical surveillance of fetuses with severe IUGR, which should be confirmed in larger prospective studies.     

Current concepts in intrauterine growth restriction

Regulation of fetal growth is multifactorial and complex. Diverse factors, including intrinsic fetal conditions as well as maternal and environmental factors, can lead to intrauterine growth restriction (IUGR). The interaction of these factors governs the partitioning of nutrients and rate of fetal cellular proliferation and maturation. Although IUGR is probably a physiologic adaptive response to various stimuli, it is associated with distinct short- and long-term morbidities. Immediate morbidities include those associated with prematurity and inadequate nutrient reserve, while childhood morbidities relate to impaired maturation and disrupted organ development. Potential long-term effects of IUGR are debated and explained by the fetal programming hypothesis. In formulating a comprehensive approach to the management and follow-up of the growth-restricted fetus and infant, physicians should take into consideration the etiology, timing, and severity of IUGR. In addition, they should be cognizant of the immediate perinatal response of the growth-restricted infant as well as the childhood and long-term associated morbidities. A multi disciplinary approach is imperative, including early recognition and obstetrical management of IUGR, assessment of the growth-restricted newborn in the delivery room, possible monitoring in the neonatal intensive care unit, and appropriate pediatric follow-up. Future research is necessary to establish effective preventive, diagnostic, and therapeutic strategies for IUGR, perhaps affecting the health of future generations.     

二维斑点追踪技术评价牛磺酸对宫内发育迟缓大鼠心功能的影响

目的 探讨二维斑点追踪技术（STI）评价牛磺酸对宫内发育迟缓（IUGR）大鼠心功能的影响。方法 采用限制蛋白饮食方式建立IUGR大鼠模型，IUGR大鼠出生后随机分为IUGR组、IUGR+低剂量牛磺酸组（低剂量组）及IUGR+高剂量牛磺酸组（高剂量组），每组9只，以出生后正常饮食大鼠为正常对照组。出生4周后，以STI检测各组大鼠左心室心肌应变，HE染色检测大鼠心肌细胞数量及体积，免疫组织化学检测大鼠心肌Ⅰ型及Ⅲ型胶原。结果 ①出生时，与正常对照组相比，IUGR组、低剂量组、高剂量组体质量均明显减低（P均<0.05）。出生4周后，与正常对照组相比，IUGR组体质量均无明显改变（P>0.05）；与IUGR组相比，低剂量组、高剂量组体质量均无明显改变（P均>0.05）。②出生4周后，与正常对照组相比，IUGR组左心室局部周向峰值应变显著降低（P<0.05）；与IUGR组相比，低剂量组和I高剂量组左心室局部周向峰值应变均显著增高（P均<0.05）；与低剂量组相比，高剂量组左心室局部周向峰值应变显著增高（P<0.05）。③与正常对照组相比，IUGR组大鼠心肌细胞数量减少、体积增大，Ⅰ型、Ⅲ型胶原表达增高；与IUGR组相比，低剂量组及高剂量组心肌细胞体积减少，Ⅰ型及Ⅲ型胶原表达减低，以高剂量组为著。结论 牛磺酸能提高IUGR大鼠左心室局部周向峰值应变，抑制Ⅰ型及Ⅲ型胶原表达，发挥抗心肌纤维化、改善IUGR大鼠心功能作用，尤以高剂量牛磺酸效果更好。     

Abnormal fetal cerebral and umbilical Doppler measurements in fetuses with intrauterine growth restriction predicts the severity of perinatal morbidity

PURPOSE: This prospective study was performed to determine if the ratio of the middle cerebral artery (MCA) S/D ratio (ratio of peak systolic blood flow velocity to diastolic velocity) to the umbilical artery (UA) S/D ratio (MCA/UA S/D ratio) predicts the degree of neonatal morbidity in fetuses suspected of having intrauterine growth restriction (IUGR). METHODS: Sixty-one fetuses were identified prospectively by sonography as having an estimated fetal weight below the 10th percentile for gestational age. The 61 fetuses underwent Doppler sonography in the third trimester and then were stratified into 3 groups based on the MCA/UA S/D ratio: group A, MCA/UA S/D ratio > 1.0 (controls; n = 37); group B, MCA/UA S/D ratio < or = 1.0 (intracerebral blood flow redistribution; n = 16); and group C, reversed or absent UA diastolic flow (n = 8). Outcome variables assessed included gestational age at delivery, birth weight, UA pH, mode of delivery, respiratory distress syndrome requiring intubation, and intracranial hemorrhage. RESULTS: The mean MCA/UA S/D ratios in groups A and B were 1.69 + /- 0.61 and 0.59 + /- 0.24, respectively (p < 0.01). The mean gestational ages at delivery for groups A, B, and C were 34.7, 33.2, and 29.0 weeks, respectively. The mean birth weights were below the fifth percentile for age for groups B and C and significantly related to the severity of abnormal Doppler findings (p < 0.01) after correction for age. Mean UA pHs were 7.25 + /- 0.01, 7.19 + /- 0.01, and 7.14 + /- 0.13 for groups A, B, and C, respectively, with significant differences between groups A and B (p < 0.05) and groups A and C (p < 0.05). Respiratory distress syndrome and intracranial hemorrhage were not associated with abnormal Doppler findings after correction for gestational age. The interval between the abnormal Doppler examination and delivery (p < 0.001) and the occurrence of fetal distress requiring cesarean section (p < 0.001) were significantly related to the severity of Doppler findings. CONCLUSIONS: In fetuses with suspected IUGR, abnormal MCA/UA S/D ratios are strongly associated with low gestational age at delivery, low birth weight, and low UA pH. Abnormal MCA/UA S/D ratios are also significantly associated with shorter interval to delivery and the need for emergent delivery.