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。     

Longitudinal reference ranges for ductus venosus flow velocities and waveform indices.

OBJECTIVES: Serial Doppler measurements of the ductus venosus are used increasingly for monitoring fetuses at risk of hemodynamic compromise, but existing reference ranges are based on cross-sectional studies and thus are less suitable for comparison with serial measurements. We aimed to establish longitudinal reference ranges for ductus venosus flow velocities and waveform indices and to provide the necessary terms for calculating conditional reference ranges for serial measurements. METHODS: This was a longitudinal study of 160 low-risk pregnancies. Pulsed Doppler ultrasound was used to record ductus venosus blood flow velocities at 4-week intervals from 20-22 weeks of gestation onwards. RESULTS: With a success rate of 93%, 547 measurements (four or five in each fetus) were used to establish reference ranges. The time-averaged maximum velocity was 50 cm/s at 21 weeks of gestation, increased to 60 cm/s at 32 weeks, and remained so until term. Similarly, the peak systolic velocity increased from 59 cm/s at 21 weeks to 71 cm/s at 31 weeks and remained so until term. The end-diastolic velocity showed a continuous increase from 31 cm/s at 21 weeks to 43 cm/s at 40 weeks. The pulsatility index for veins decreased from 0.57 at 21 weeks to 0.44 at 40 weeks. When conditioned by a previous measurement, the reference ranges for the next observation became narrower and commonly shifted compared with those of the entire population. CONCLUSION: The new longitudinal reference ranges presented here reflect the development of the ductus venosus flow velocities and velocity indices and are thus appropriate for serial measurements, particularly if conditional terms are included.     

Effect of fetal gender on first-trimester ductus venosus blood flow.

OBJECTIVES: Recent reports have suggested that nuchal translucency (NT) measurements in the first trimester may be influenced by fetal gender. Since both NT and central venous blood flow are considered to be related to fetal cardiac function, we investigated gender-related differences in first-trimester ductus venosus Doppler indices. METHODS: A total of 73 male and 79 female normal fetuses at 10-14 weeks of gestation were included in the study. The pulsatility index for veins (PIV), peak velocity during ventricular systole (S-wave), time-averaged maximum velocity (TAMV) and A-wave velocity (A-wave) were recorded in each case and converted to the corresponding Z-scores. RESULTS: The mean Z-score values of PIV, S-wave and TAMV were significantly lower in male fetuses compared to female fetuses (P < 0.01 for all three indices). By contrast, A-wave velocities were not different in the two groups. The correlation between S-wave velocity and TAMV was significant in both male (P < 0.001) and female (P < 0.001) fetuses, while PIV did not appear to be related to TAMV either in males (P = 0.90) or in females (P = 0.49). A-wave velocity had a significant negative correlation with PIV in both groups. Finally, PIV was significantly correlated with S-wave velocity in female fetuses (P < 0.01) but not in males (P = 0.14). CONCLUSION: These findings suggest that early cardiovascular development may be different in male and female fetuses.     

Middle cerebral artery peak systolic and ductus venosus velocity waveforms in the hydropic fetus.

OBJECTIVE: The purpose of this study was to assess whether Doppler assessment of the middle cerebral artery (MCA) peak systolic velocity (PSV) and ductus venosus (DV) velocity waveforms during sonography of hydropic fetuses may specify the cause of fetal hydrops. METHODS: A level II sonographic examination was performed in 16 hydropic fetuses, and the MCA PSV and DV velocity waveforms were assessed. The MCA PSV values divided hydropic fetuses into anemic (group 1) and nonanemic (group 2) fetuses. In group 2 fetuses, the DV was defined as normal or abnormal. Sonographic examination and Doppler assessment of these vessels specified the cause of hydrops and indicated the use of specific investigations for diagnosing the etiology of fetal hydrops. RESULTS: Seven of 16 fetuses had MCA PSV values greater than 1.50 multiples of the median (group 1). Nine of 16 fetuses had normal MCA PSV values (group 2); among them, 7 of 9 had either absent or reversed flow in the DV, and 2 had a normal DV. In group 1, the cause of fetal anemia was investigated by maternal serum tests, and 5 cordocentesis procedures were performed. In group 2, 7 of 9 fetuses had reversed flow in the DV, which suggested a cardiac abnormality confirmed by echocardiography. Five cordocentesis procedures were performed for fetal karyotype, and in 2 fetuses, the cause of hydrops was idiopathic. CONCLUSIONS: Our data suggest that assessment of the MCA PSV and DV velocity waveforms in the hydropic fetus may further our knowledge of the etiology of hydrops and may indicate which investigations among the many available should be used for diagnosing the cause of fetal hydrops.     

早孕期胎儿静脉导管频谱波型分析

目的探讨早孕期不同类型胎儿静脉导管频谱波型与胎儿生长发育及预后之间的关系。方法165例头臀长（CRL）在25-80mm之间的高危胎儿接受了经腹壁早孕期超声检查及绒毛活检。根据胎儿静脉导管血流不同波型将频谱形态分为三型：Ⅰ型：在整个心动周期内无反向血流;Ⅱ型：在心房收缩期的起始段出现很短时间内的反向血流信号,随后的大部分心房收缩期内为正向血流信号;Ⅲ型：在整个心房收缩期内为持续反向血流。所有本组胎儿进行了产前染色体核型分析、基因学及酶学检查,并随访至生后。结果在本组病例中,只有2例胎儿静脉导管频谱波型为Ⅲ型,绒毛检查结果证实其中一例为21-三体,另一例为黏多糖储积症。26例胎儿经基因学诊断为遗传性疾病,2例胎儿宫内死亡。在其余135例正常发育胎儿组中,95例（70.4%）胎儿静脉导管频谱为Ⅰ型,40例（29.6%）胎儿频谱为Ⅱ型。按胎儿头臀长分为5组（≤39mm,40-49mm,50-59mm,60-69mm,≥70mm）后,Ⅰ型/Ⅱ型胎儿例数分别为24/16、31/8、15/13、11/2、14/1。应用非参数检验的统计学方法分析,结果显示Ⅰ型及Ⅱ型频谱波型的出现频率与胎儿头臀长分组密切相关（P=0.015）,绝大多数的Ⅱ型静脉导管频谱出现在头臀长小于60mm的胎儿组中。结论通过本组正常胎儿的研究显示,早孕期胎儿静脉导管频谱波型中心房收缩早期出现的很短的反向血流信号应被视为一种“正常变异”现象,而非一种异常的静脉导管频谱类型,特别是在胎儿头臀长小于60mm时。     

Prenatal sonography of extracorporeal ductus venosus in association with large fetal gastroschisis

Liver herniation commonly associated with omphalocele occurs in only approximately 2.3% to 16% of fetuses with gastroschisis. Liver herniation in such cases is associated with considerably decreased survival rates (43% vs 97% with or without liver herniation, respectively). Rarely, abnormally positioned fetal hepatic vasculature has been reported mainly in association with congenital diaphragmatic hernia. In these rare cases, intrathoracic depiction of hepatic venous vasculature has assisted in confirming intrathoracic displacement of the fetal liver. We present a case of a large gastroschisis with complete herniation of the fetal liver in which prenatal sonography depicted an extracorporeal ductus venosus.     

胎儿静脉导管多普勒血流检测在产前诊断中的应用

随着对胎儿血流动力学研究的深入和超声多普勒技术的成熟,分析胎儿静脉系统的血流变化逐渐成为估测宫内胎儿情况的最新手段.其中,胎儿静脉导管(DV)血流的变化更能准确、全面地评价胎儿生长发育状况,预测染色体异常和心脏疾病等的发病风险.本文对DV超声多普勒检测在产前诊断中的应用进行综述.     

胎儿静脉导管异位引流至冠状静脉窦产前超声表现:3例报告及文献复习

目的 结合文献及3例临床所见,观察胎儿静脉导管（DV）异位引流至冠状静脉窦（CS）产前超声表现。方法 回顾性分析3胎DV异位引流至CS胎儿,结合文献复习观察其产前超声特征。结果 产前超声于3胎四腔心后切面均见CS扩张,内径分别为3.6、8.2及4.8 mm;DV异位引流至扩张的CS。于1胎（序号1）见4支肺静脉汇入左心房（LA）,DV经房间隔后方于左心房顶绕行至扩张的CS;1胎（序号2）三血管气管切面肺动脉主干左侧见永存左上腔静脉（PLSVC）,旋转探头追踪观察发现DV与CS相连;1胎（序号3）4支肺静脉均回流入LA,三血管气管切面见主动脉弓位于气管右侧、左锁骨下动脉起自降主动脉起始部。结论 产前超声观察胎儿DV异位引流至CS四腔心后切面可见CS扩张,并可合并其他血管畸形。     

Color Doppler study of the venous circulation in the fetal brain and hemodynamic study of the cerebral transverse sinus.

OBJECTIVES: To describe the venous circulation in the fetal brain; to describe the normal blood flow velocity waveform in the transverse sinus and to establish normal reference ranges for the second half of gestation. POPULATION: A total of 126 pregnant women with uncomplicated pregnancies at 20-42 weeks of gestation. METHODS: A combination of color-coded Doppler and two-dimensional real-time ultrasound was used to identify the main venous systems in the fetal brain. Blood flow velocity waveforms of the transverse sinus were obtained from a transverse plane of the head at the level of the cerebellum. RESULTS: A waveform could be obtained in the cerebral transverse sinus in 98% of the cases. The waveform obtained was triphasic with a forward systolic component, a forward early diastolic component and a lower forward component in late diastole. Reverse flow during atrial contraction was seen before 28 weeks and the diastolic flow increased with gestation thereafter. Pulsatility and resistance indices decreased and flow velocities increased in the transverse sinus throughout gestation. CONCLUSION: The venous circulation of the fetal brain can be identified by color Doppler. The gestational age-related decrease in resistance and increase in flow velocities suggest that hemodynamic studies of the cerebral transverse sinus might have clinical implications in studying compromised fetuses.     

Normal values of fetal ductus venosus blood flow waveforms during the first stage of labor.

OBJECTIVE: To present normal values of fetal ductus venosus blood flow waveforms during the first stage of labor during and between contractions. MATERIALS AND METHODS: Seventy-eight women between the 37th and 41st weeks of gestation were included in the study. At distinct stages of cervical dilation, blood flow velocity waveforms of the fetal ductus venosus during and between contractions were visualized in fetuses with a normal non-stress test. The pulsatility index for veins, peak velocity index for veins and fetal heart rate were calculated off-line. The means +/- standard deviations (SD) during and between contractions were compared using the Wilcoxon test. RESULTS: Ductus venosus blood flow velocity waveforms were visualized during 331 contractions and 375 episodes of uterine quiescence in 74 of 78 fetuses (95%) during normal labor. The mean +/- standard deviation values of pulsatility and peak velocity indices for veins during contractions were 1.66 +/- 0.85 (median: 1.56, range: 0.29-4.69) and 1.46 +/- 0.65 (median: 1.34, range: 0.26-3.13), respectively. Between contractions the values were 0.48 +/- 0.19 (median: 0.46, range: 0.14-1.00) for the pulsatility index and 0.44 +/- 0.18 (median: 0.42, range: 0.14-1.00) for the peak velocity index for veins. These differences during and between contractions were highly significant (P-value < 0.0001), whereas the fetal heart rate showed no significant differences. CONCLUSION: There are significant differences in fetal ductus venosus blood flow waveforms during and between labor contractions. Further studies should evaluate whether these normal values of the fetal ductus venosus are beneficial for risk evaluation in fetuses with an abnormal non-stress test and/or intrauterine growth restriction.     

超声检测水肿胎儿静脉导管血流频谱的变化

目的 分析水肿胎儿的静脉导管(DV)血流参数,观察心源性水肿及重型α-地中海贫血引起的胎儿水肿者DV血流频谱改变。 方法 选取产前超声检查发现的69胎水肿胎儿,根据病因分心源性水肿组(17胎)和重型α-地中海贫血组(52胎),分别测量DV血流频谱并进行参数分析。 结果 心源性水肿组88.24%(15/17)DV出现心室收缩期峰值速度(S)波降低、心房收缩期峰值速度(a)波缺失或反向,静脉峰值流速指数(PVIV)、DV搏动指数(DVPI)及DV阻力指数(DVRI)升高。重型a-地中海贫血组50.00%(26/52)表现为S波增高,59.62%(31/52)a波增高,69.23%(36/52)PVIV减低,80.77%(42/52)DVRI降低,86.53%(45/52)DVPI降低。两组比较,水肿胎儿DV血流频谱与相应孕周正常胎儿DV参考值的差值差异有统计学意义(P<0.01)。 结论 两组水肿胎儿DV血流频谱改变不同。DV血流参数对于鉴别胎儿水肿病因及指导临床诊疗有重要意义。     

Intrauterine growth restriction and fetal body composition.

OBJECTIVE: To assess the differences in fetal body compartments between fetuses with normal growth and those with reduced intrauterine growth, during the third trimester, through ultrasonographic determination of subcutaneous tissue thickness (SCTT). METHODS: Twenty-eight patients were enrolled into this case control study carried out at 30-31 weeks' gestation. Two study groups were matched for maternal age and pregestational body mass index: controls (n = 14) and intrauterine growth-restricted (IUGR) fetuses (n = 14). Routine ultrasound-derived biometric parameters (head circumference, abdominal circumference, femur length and humerus length) were measured. Additionally, the mid-arm fat mass and lean mass (MAFM and MALM), the mid-thigh fat mass and lean mass (MTFM and MTLM), the abdominal fat mass (AFM) and the subscapular fat mass (SSFM) were measured. The Mann-Whitney U-test and Student's t-test were used to compare the two groups. RESULTS: The abdominal circumference and the humerus were significantly smaller in IUGR fetuses than in controls. Most of the SCTT values were different in the two groups. The SSFM (3.6 +/- 1.1 vs. 2.6 +/- 0.7 mm; P = 0.011), the AFM (5.1 +/- 0.7 vs. 4 +/- 1 mm; P = 0.01), the MAFM (3.5 +/- 0.9 vs. 2.2 +/- 0.8 cm2; P < 0.01) and MALM (2.1 +/- 0.4 vs. 1.7 +/- 0.5 cm2; P = 0.029) were all significantly greater in fetuses with normal development compared to those with growth restriction. CONCLUSIONS: During the third trimester, SCTT (with the exception of MTFM and MTLM) is reduced in fetuses with IUGR. Furthermore, MALM is lower in growth-restricted fetuses, confirming that the parameters measured in this study are affected in IUGR fetuses. Our findings indicate that specific changes in fetal body compartments occur as a result of chronic metabolic impairment.     

胎儿静脉导管血流频谱参数在晚孕期妊娠期糖尿病中的研究曹云云 牛建梅 曾敏 孔晓晓 杨田 姚世发 杜硕娟

目的 探讨晚孕期妊娠期糖尿病(GDM)胎儿静脉导管(DV)的频谱参数在临床中的应用价值,并分析胎儿妊娠结局。方法 选择GDM组78例为研究组,正常妊娠组136例作为对照组。应用超声检测胎儿DV频谱参数包括S、D、a、v、Tmax、S/a、PI、PLI及PVIV,将两组间参数进行分析,并对这些胎儿追踪,随访至妊娠结束,比较两组间胎龄、分娩方式、体质量及妊娠结局的关系。结果 1、GDM组胎儿DV频谱参数S、D、v 、a、Tmax测值均小于正常妊娠组,而S/a、PI、PLI及PVIV测值均高于正常妊娠组;其中S、D、v 、a、Tmax、PVIV两组间比较差别有统计学意义(P＜0.05);S/a、PI、PLI两组间比较差别无统计学意义(P＞0.05)。2、GDM组的胎龄及体质量均低于正常组,而剖宫产率及不良妊娠结局均高于正常组;胎龄及剖宫产率在两组间比较差别有统计学意义(P＜0.05),而体质量及不良结局在两组间比较差别无统计学意义(P＞0.05)。结论 应用超声监测晚孕期GDM胎儿DV的频谱参数,可为临床预测胎儿妊娠情况提供依据,在一定程度上尽可能延长妊娠时间,降低剖宫产率及不良妊娠结局的发生。     

Fetal ductus venosus, middle cerebral artery and umbilical artery flow responses to uterine contractions in growth-restricted human pregnancies.

OBJECTIVE: To explore fetal ductus venosus (DV) flow velocity changes relative to umbilical artery (UA) blood flow and brain-sparing flow (BSF) during uterine contractions. METHODS: Forty-five term fetuses suspected of having growth restriction were exposed to an oxytocin challenge test (OCT) with simultaneous Doppler velocimetry in the UA, middle cerebral artery (MCA) and DV. Basal BSF was defined as a MCA-to-UA pulsatility index (PI) ratio of < 1.08, and de novo BSF as a decrease in MCA-PI of > or = 1 SD (equivalent to a value of 0.24 units) during the OCT. RESULTS: Basal DV flow velocities were lower in the BSF group (n = 7) than they were in the non-BSF group (n = 38). During the OCT, DV flow velocity parameters changed in neither group but MCA-PI decreased in the non-BSF group. A crude de novo BSF was not associated with DV flow velocity changes, but when UA-PI changes were considered, a serial relationship was found between decreased UA-PI, increased DV flow velocity, and decreased MCA-PI. When UA-PI increased, the MCA-PI still decreased (though not significantly) but DV flow velocity parameters remained unchanged. CONCLUSIONS: Established fetal BSF is associated with low DV flow velocities, but in an acute sequence there might be two contrasting courses along which BSF develops: one with an increase and one with a decrease in the UA vascular flow resistance. In the former situation the DV flow velocity increases, while in the latter situation the role of the DV in the acute redistribution of fetal blood flow is unclear.     

The sequence of changes in Doppler and biophysical parameters as severe fetal growth restriction worsens.

OBJECTIVE: To test the hypothesis that hemodynamic changes depicted by Doppler precede deteriorating biophysical profile score in severe intrauterine growth restriction. METHODS: Intrauterine growth-restricted fetuses with elevated umbilical artery Doppler pulsatility index (PI) > 2 standard deviations above mean for gestational age and birth weight < 10th centile for gestational age were examined longitudinally. Fetal well-being was assessed serially with five-component biophysical profile scoring (tone, movement, breathing, amniotic fluid volume and non-stress test) and concurrent Doppler examination of the umbilical artery, middle cerebral artery and ductus venosus, inferior vena cava and free umbilical vein. For fetuses with a final biophysical profile score < 6/10, progression of biophysical profile scoring, arterial PI and venous peak velocity indices were analyzed longitudinally. Gestational age effect was removed by converting indices to Z-scores (deviation from gestational age mean, in standard deviations). RESULTS: Forty-four of 236 intrauterine growth-restricted fetuses (18.6%) required delivery for abnormal biophysical profile scoring. The median gestational age at entry was 25 weeks and 1 day and at delivery was 29 weeks and 6 days. The median interval between examinations was 1.5 days and the majority had daily testing in the week prior to delivery. Between first examination and delivery, significant deterioration was observed for Doppler criteria (chi-square, P < 0.001) and biophysical parameters (Fisher's exact, P = 0.02) predominantly confined to the week prior to delivery/stillbirth. Doppler variables changed first. In 42 fetuses (95.5%), one or more vascular beds deteriorated, accelerating especially in the umbilical artery and ductus venosus at a median of 4 days before biophysical profile scoring deteriorated. Two to 3 days before delivery, fetal breathing movement began to decline. The next day, amniotic fluid volume began to drop. Composite biophysical profile score dropped abruptly on the day of delivery, with loss of fetal movement and tone. Three principal patterns of Doppler deterioration were observed: (i) worsening umbilical artery PI, advent of brain sparing and venous deterioration (n = 32, 72.7%); (ii) abnormal precordial venous flows, advent of brain sparing (n = 6, 13.6%); and (iii) abnormal ductus venosus only (n = 4, 9.1%). In the majority (31, 70.5%), Doppler deterioration was complete 24 h before biophysical profile score decline. In the remainder (11, 25%), Doppler deterioration and biophysical profile score < 6/10 were simultaneous. CONCLUSION: In the majority of severely intrauterine growth-restricted fetuses, sequential deterioration of arterial and venous flows precedes biophysical profile score deterioration. Adding serial Doppler evaluation of the umbilical artery, middle cerebral artery and ductus venosus to intrauterine growth restriction surveillance will enhance the performance of the biophysical score in the detection of fetal compromise and therefore optimizing the timing of intervention.     

静脉导管的多普勒血流流速曲线在筛选胎儿先天性心脏病中的临床意义

目的：探讨静脉导管的血流流速曲线在筛选和协助早期诊断胎儿先天性心脏病中的临床意义。方法：应用彩色多普勒超声诊断系统检测240例14－41孕周的正常胎儿和20例先天性心脏病胎儿的静脉导管血流流速曲线，并计算静脉导管血流阻力指数、搏动指数及心室收缩期峰值速度与心房收缩期最大流速比值。结果：①正常胎儿静脉导管的血流流速曲线呈特殊的波形：心室收缩期波峰S、心室舒张期波峰D和心房缩期波谷A，前向血流持续整个心动周期；②20例先天性心脏病胎儿中8例静脉导管的A波出现反转，9例A波降低或缺失，3例无明显变化。先天性心脏病胎儿组静脉导管血流指数较胎龄相匹配的正常胎儿组增高，两组比较差异有显著性意义（P＜0．05）。结论：彩色多普勒超声检测胎儿静脉导管的血流流速曲线可筛选或协助早期诊断胎儿先天性心脏病。     

颈部透明层厚度、心脏三尖瓣反流和静脉导管血流联合Z评分对胎儿先天性心脏病的诊断效能分析

目的研究颈部透明层厚度（NT）、心脏三尖瓣反流（TR）和静脉导管血流（DV）联合胎儿心脏测量参数Z评分对胎儿先天性心脏病的诊断效能。 方法采用2015年1月至2020年2月在内蒙古医学院附属医院进行孕早期新生儿筛查的6 217例孕妇作为研究对象,根据引产与分娩共确证胎儿患有先心病分为观察组和对照组,分别对两组胎儿的NT、TR、DV以及心脏测量参数Z评分进行比较。分析NT、TR、DV与Z评分的联合对胎儿先天性心脏病的诊断效能。 结果观察组胎儿的NT、TR、DV异常率均高于对照组（χ²=1 953.577、1 805.085、1 339.066,均P＜0.001）。在以双顶径的预测中,观察组胎儿的主动脉Z评分低于对照组（0.012±0.001 vs 0.023±0.002,t=84.259,P＜0.001）,肺动脉Z评分高于对照组（0.035±0.002 vs 0.025±0.003,t=38.623,P=0.000）;在以股骨长的预测中,观察组胎儿的主动脉Z评分（0.022±0.003 vs 0.037±0.004,t=38.172,P＜0.001）以及肺动脉Z评分（0.031±0.005 vs 0.039±0.003,t=12.474,P＜0.001）低于对照组;在以实际孕周的预测中,观察组胎儿的主动脉Z评分（0.013±0.001 vs 0.022±0.002,t=68.939,P＜0.001）以及肺动脉Z评分（0.014±0.002 vs 0.019±0.003,t=19.312,P＜0.001）低于对照组。NT、TR、DV与Z评分联合诊断胎儿先天性心脏病的灵敏度为93.44%,显著优于单独诊断;NT、TR、DV与Z评分联合诊断胎儿先天性心脏病的受试者工作特征曲线下面积为0.892,显著高于单独检测（95%CI：0.654~0.912,P＜0.001）。 结论NT、TR、DV联合胎儿心脏测量参数Z评分对胎儿先天性心脏病具有积极的诊断意义。