胎儿持续性心动过缓15例临床分析

Objective?To find out the common causes and prognosis of fetal persistent bradycardia. Methods?Retrospective analysis was performed on 15 cases of fetal bradycardia diagnosed by fetal echocardiography in Peking University First Hospital from January 2013 to January 2020. Results?① There were 3 cases of fetal bradycardia complicated with fetal heart malformation, All of them chose to terminate pregnancy.② There were 8 patients with atrioventricular block, the main cause of which was positive maternal serum autoantibody anti-Ro (SS-A) combined with anti-La (SS-B) in 5 cases. 4 cases delivery at term, permanent pacemakers were placed in 2 neonates. ③ There were 4 cases of fetal bradycardia with atrioventricular 1:1 conduction, all of which were delivered at term. Only one case was diagnosed as sick sinus syndrome after birth. Conclusion?Fetal heart malformation should be ruled out in fetal bradycardia, and atrioventricular block mainly caused by abnormal maternal autoantibodies. The long-term prognosis of fetal bradycardia is closely related to the etiology.     

Autoimmune-mediated congenital heart block

Autoimmune-mediated congenital heart block (CHB) is a severe manifestation of neonatal lupus in which conduction tissues of the fetal heart are damaged. This occurs due to passive transference of maternal anti-SSA/Ro and anti-SSB/La autoantibodies and subsequent inflammation and fibrosis of the atrioventricular (AV) node. Notably, the disease manifests after the fetal heart has structurally developed, ruling out other anatomical abnormalities that could otherwise contribute to the block of conduction. Complete AV block is irreversible and the most common manifestation of CHB, although other cardiac complications such as endocardial fibroelastosis (EFE), dilated cardiomyopathy, and valvular insufficiency have been observed. In this review, we detail the classification, prevalence, pathogenesis, and clinical management recommendations for autoimmune CHB.     

Recurrent miscarriage, congenital heart block and systemic lupus erythematosus

We report the obstetric history of a woman, who between 15 spontaneous abortions, gave birth to a child with congenital heart block. She later developed systemic lupus erythematosus, had antibodies to SS-A/Ro and SS-B/La but was repeatedly negative for antiphospholipid antibodies.     

Systemic lupus erythematosus and pregnancy

PURPOSE OF REVIEW: Pregnancy in patients with systemic lupus erythematosus is associated with a high risk of maternal disease exacerbation and adverse fetal outcome. This review summarizes recent published findings on lupus pregnancy. RECENT FINDINGS: The literature is in agreement that for most women with inactive and stable systemic lupus erythematosus, pregnancy is safe for both mother and fetus. The main risk factors for adverse pregnancy course and outcome are active disease, nephritis with proteinuria, hypertension, and maternal serum antibodies to SS-A/Ro, SS-B/La, cardiolipin, beta2-glycoprotein I, and lupus anticoagulant. Recent studies have broadened our understanding of the immunological mechanism underlying congenital heart block induced by anti-Ro/La antibodies. In addition, the approach to oral contraceptives has been modified on the basis of two well controlled studies suggesting that they do not cause exacerbation of inactive or mild disease. SUMMARY: Pregnancy in patients with systemic lupus erythematosus is safe and manageable provided the disease is stable. Patients should be evaluated before pregnancy for pregestational risk factors and be closely followed during pregnancy. In most cases of lupus flare during pregnancy, the disease can be safely managed.     

Successful prenatal treatment of congenital heart block with ritodrine administered transplacentally

Congenital heart block (CHB) is rather rare, and a poorer prognosis has been documented in fetuses with a ventricular rate <55 beats per minutes (bpm), in which therapeutic interventions during pregnancy have been warranted. We present a case of CHB associated with maternal anti-SSA/Ro antibody, diagnosed at 28 weeks’ gestation. Fetal echocardiography revealed atrioventricular dissociation, with an atrial rate of 170 bpm and a ventricular rate of 54 bpm. To increase the fetal heart rate, maternal intravenous ritodrine infusion was undertaken, fetal ventricular rate was rapidly increased to 65 bpm. The pregnancy successfully continued until term, and a female infant weighing 2919 g was delivered by cesarean section with Apgar scores of 8 and 8 and 1 and 5 min. The infant is now 12 months of age and growing normally on oral terbutaline without pacing. In a case of fetal heart block, maternal administration of ritodrine may be a therapeutic intervention to improve the fetal and neonatal prognosis. Received: 27 May 2001 / Accepted: 20 August 2001 Correspondence to H. Matsushita     

Fetal congenital complete heart block: prophylaxis with intravenous gammaglobulin and treatment with dexamethasone

We report a case of complete fetal heart block in a 35-year-old Chinese woman known to be positive for anti-SSA/Ro and anti-SSB/La antibodies. She had fetal hydrops leading to intrauterine death in her first pregnancy Prophylactic intravenous immunoglobulin, given at 14 and 18 weeks' gestation, as well as oral dexamethasone, commenced at 24 weeks' gestation, allowed continuation of the pregnancy until 34 completed weeks of gestation. An external pacemaker was inserted in the baby on the first day of life. Two-and-a-half months later, a permanent pacemaker was inserted.     

Isolated congenital atrioventricular block diagnosed in utero: Natural history and outcome

Background. Isolated congenital atrioventricular block (CAVB) diagnosed in utero is associated with a high morbidity and mortality. Prognosis is especially poor when heart rate drops below 55 beats per minute (bpm) and when fetal hydrops develops. We describe the natural history and outcome of 24 infants with isolated CAVB diagnosed in utero, review the literature, and assess the risk factors that could predict outcome.

Methods. This was a retrospective multicenter study of 24 patients with isolated CAVB diagnosed in utero.

Results. CAVB was detected at a mean gestational age (GA) of 24.7 ± 5.1 weeks. Ten fetuses initially presented with complete heart block. Low heart rate or incomplete heart block was the first documentation of bradyarrhythmia in the other 14 fetuses. In 11 of them, CAVB developed during pregnancy after a median time of 3 (range 1–16) weeks. Fetal hydrops developed in 10 of 24 (42%) fetuses at a mean GA of 27.6 ± 5.1 weeks. Hydropic fetuses showed lower heart rates during pregnancy (47 ± 10 bpm) than non-hydropic fetuses (57 ± 10 bpm). There were three intrauterine deaths; all were hydropic and female. Nine viable females and 12 males were born at a mean GA of 37.1 ± 6.1 weeks with an average birth weight of 3097 ± 852 g. Fifteen CAVB patients required pacemaker (PM) intervention, 10 of them immediately after birth. Dilated cardiomyopathy (DCM) developed in three infants of whom two died of congestive heart failure, shortly after the diagnosis was made; one is still alive. Mortality before or after birth was 21%, and was associated with heart rates below 50 bpm and development of fetal hydrops. Poor outcome, defined as death, PM implantation, or development of DCM, occurred in 83% of cases and was associated with heart rates below 60 bpm during pregnancy.

Conclusions. Isolated CAVB diagnosed in utero is associated with high morbidity and mortality. Patients who develop fetal hydrops show lower heart rates during pregnancy than patients who do not. A fetal heart rate below 50 bpm and development of fetal hydrops is associated with increased mortality. Rates below 60 bpm are associated with PM requirement and/or DCM.     

Longitudinal measurements of fetal breathing, body movements, heart rate, and heart rate accelerations and decelerations at 24 to 32 weeks of gestation

Fetal breathing, fetal body movements, fetal heart rate, and fetal heart rate accelerations and decelerations were studied longitudinally in healthy fetuses between 24 and 32 weeks' gestation in the second and third hour following an 800 kcal maternal meal. The expected increase in fetal breathing following a maternal meal was not seen until fetuses were at 30 to 32 weeks' gestation. The number of body movements decreased and the interaction between body movements and fetal heart rate accelerations became more evident as fetuses became older. Fetal heart rate decelerations increased with gestational age, and the relative proportion of total decelerations that were either associated with body movements or were part of a deceleration/acceleration/deceleration complex increased from 24 to 32 weeks' gestation. The data support the hypothesis that gestational age is an important variable to consider when interpreting biophysical measurements in the human fetus at 24 to 32 weeks' gestation. Fetal body movements may be the single most important measurement of fetal health at these gestational ages.     

Extremely low ventricular rate in a fetus with an isolated non-autoimmune complete congenital heart block. Case report

Congenital complete heart block (CCHB) is an uncommon disorder with an incidence of about 1/20,000 in liveborn infants. It can occur in the setting of structurally normal heart or with structural disease; it is associated with high mortality and morbidity and requires a high index of suspicion for early diagnosis and therapy. Isolated CCHB in a fetus is usually associated with the presence of autoantibodies to SSA (Ro) and SSB (La) antigens in the maternal circulation. Such antibodies cross into the fetal circulation and cause inflammation of the conduction tissues; the causal mechanism is not known. Although the prognosis for the majority of fetuses is good, it is less favourable in fetuses with a ventricular rate <55 bpm in early pregnancy or with a decrease in the ventricular rate by >5 bpm during pregnancy. It is not known if the same prognostic criteria apply for fetuses with isolated non-autoimmune CCHB. This article reports authors' experience in managing a pregnancy with an extremely low fetal heart rate (47 bpm) in a single fetus with an isolated non-autoimmune CCHB in which the outcome was favorable.     

Analysis of outcome in hydrops fetalis in relation to gestational age at diagnosis, cause and treatment

OBJECTIVE: To examine fetal outcome in hydrops fetalis in relation to gestational age at diagnosis and following investigation and treatment. METHODS: All cases of hydrops fetalis presenting to the Fetal Medicine Unit during the last seven years, between 1993 and 1999, were identified from the Fetal Medicine Database. During this time 87 of 13,980 patients who attended the Fetal Medicine Unit had hydrops fetalis. The cases were examined for gestational age at presentation according to etiology and fetal survival following investigation and treatment. The fetal survival rates for non-immune cases of hydrops before and after 24 weeks were compared. RESULTS: The cause of hydrops was determined antenatally in 71 of the 87 (82%) cases. Of the 51 cases presenting before 24 weeks' gestation, 23 (45%) were due to chromosomal abnormality. After 24 weeks, fetal tachyarrhythmias and hydrothorax were the most common causes and accounted for 14 (38%) of the 36 cases. Thirty-four cases (39%) of hydrops received intrauterine treatment. The survival rates excluding chromosomal abnormalities in the non-immune cases before and after 24 weeks' gestation were 31% and 48%, respectively, and were not significantly different. CONCLUSIONS: The survival rate in cases of hydrops fetalis may be improved with appropriate prenatal investigation and therapy. The etiology of hydrops is different before and after 24 weeks, and even when cases of chromosomal abnormality are excluded the survival rate is similar before and after 24 weeks.     

Fetal Echocardiography: An 8-Year Experience

Over 8 years, 680 fetuses in 521 gestations underwent echocardiography. Indications included genetic or teratogenic risk, arrhythmias, diabetes, collagen vascular disease, hypertension, growth retardation, and hydrops. Most studies were normal. Eight fetuses had structural heart disease, 31 had benign atrial or ventricular premature beats, five had benign unsustained arrhythmias, three had heart block associated with maternal autoantibodies, and one had sustained supraventricular tachycardia with hydrops. Eight had suspected hydrops, fetal demise, or molar pregnancy. There were 19 cases of abnormal umbilical artery Doppler waveforms and three with pathologic cerebral artery waveforms.

Fetal echocardiography is a valuable noninvasive diagnostic tool in selected cases with a high sensitivity and specificity for serious hemodynamic problems.     

Effect of maternal exercise with graded treadmill on fetal heart rate]

The effect of maternal exercise on the fetal and maternal heart rate was studied in 10 normal pregnant women in their third trimester. They participated in 15 minute graded treadmill exercise. Fetal heart rate (FHR), uterine contraction, maternal blood pressure, electrocardiogram, and oxygen consumption were monitored, before, during, and after exercise. FHR could be monitored in 7 women. Maternal maximal heart rate ranged from 143 to 168 bpm which approximated 61% to 84% training intensity. FHR showed a significant rise in 4 women during exercise. Of four cases which showed more than 70% training intensity, 3 demonstrated fetal tachycardia over 160 bpm and one demonstrated fetal bradycardia under 120 bpm. The baseline fetal heart rate remained from 120 bpm to 160 bpm in cases under 70% training intensity. There was no pathological deceleration and the variability was preserved in all cases. It is suggested that maternal exercise intensity should be less than 70% of the patient's maximal capacity, which approximates maternal heart rate of about 150 bpm.     

A surprising case of sustained antenatal fetal bradycardia

Persistent fetal bradycardia noted in the antenatal period can occur secondary to maternal conditions, fetal cardiac structural defects, or from congenital heart block. Fetal bradycardia can be mistaken for maternal pulse and should be confirmed with ultrasound whenever possible. Prompt evaluation of the fetus with bradycardia can lead to early interventions designed to prevent cardiac damage and/or hydrops.     

Fetal heart rate response to cordocentesis and pregnancy outcome: a prospective cohort.

OBJECTIVE: To evaluate fetal cardiac response to cordocentesis and whether such changes may affect pregnancy outcome. METHODS: 117 singleton pregnant women requiring percutaneous trans-abdominal cordocentesis were prospectively included. Fetal heart rate was continuously evaluated by ultrasound for 1 min after completion of cordocentesis and intermittently for 20 min more. Fetal and pregnancy outcomes were analyzed by grouping fetal cardiac response to cordocentesis into bradycardia, normal heart rate and tachycardia groups. RESULTS: Women included in the study were 30.5+/-4.0 years old and had a gestational age of 23.7+/-2.0 weeks. Fetal blood sample obtained by cordocentesis was 3.1+/-0.8 ml. Fetal heart rate before cordocentesis was 149+/-8 beats per minute (bpm), ranging from 130 to 169 bpm. Fetal heart rate post-cordocentesis was 145+/-30 bpm (from 32 to 175 bpm). The incidence of bradycardia and tachycardia was 10.3% (n=12) and 6.0% (n=7), respectively. Fetal heart rate returned to normal levels in all cases at 相似文献   

Steroid therapy for hydrops associated with antibody-mediated congenital heart block

Evaluation of fetal bradycardia noted during a routine prenatal visit at 24 weeks' gestation in a mother without symptoms showed an antibody-mediated heart block with anti-La (SSB) antibody present. The fetus had a pericardial effusion and ascites. After maternal steroid therapy, the ascites resolved and the pericardial effusion was substantially diminished. Steroid therapy may be a helpful adjunct for treatment of a premature infant with hydrops as a result of antibody-mediated heart block.     

In utero treatment of fetal complete heart block with terbutaline. A case report.

BACKGROUND: Isolated fetal complete heart block is an uncommon finding, with a mortality rate of 20-30%. Various treatment modalities have been reported, with no consistent success. CASE: Fetal complete heart bock was diagnosed in a 30-year-old woman at 29 weeks' gestation. She had an elevated antinuclear antibody and anti-SSA antibody titer. Fetal cardiac decompensation was detected at 32 weeks. After a trial of intravenous isoproterenol without significant side effects, she was treated with oral terbutaline. An increase in the fetal ventricular rate and complete resolution of hydrops fetalis occurred. A male infant was delivered by cesarean section, at term, and underwent cardiac pacemaker implantation at 4 days of age. CONCLUSION: The treatment of fetal complete heart block is controversial. Premature delivery with cardiac pacing is associated with high morbidity and mortality. We report prenatal treatment with oral sympathomimetic medication, which allowed delivery to be delayed until term, with a successful outcome.     

Fetal dysrhythmias

Fetal cardiac dysrhythmias are potentially life-threatening conditions. However, intermittent extrasystoles, which are frequently encountered in clinical practice, do not require treatment. Sustained forms of brady- and tachyarrhythmias might require fetal intervention. Fetal echocardiography is essential not only to establish the diagnosis but also to monitor fetal response to therapy. In the last decade, improvements in ultrasound methodology and new diagnostic tools have contributed to better diagnostic accuracy and to a greater understanding of the electrophysiological mechanisms involved in fetal cardiac dysrhythmias. The most common form of supraventricular tachycardia - that caused by an atrioventricular re-entry circuit - should be differentiated from other forms of tachyarrhythmias, such as atrial flutter and atrial ectopic tachycardia. Ventricular tachycardia is rare in the fetus. Sustained tachycardias, intermittent or not, might be associated with the development of congestive heart failure and hydrops fetalis. Prompt treatment with either anti-arrhythmic drugs or delivery must be considered. Persistent fetal bradycardias associated with complete heart block are also potentially dangerous, whereas bradyarrhythmia due to blocked ectopy is well tolerated in pregnancy. Heart block can be associated with maternal anti-Ro/La autoantibodies or develop in fetuses with left atrial isomerism or with malformations involving the atrioventricular junction. The treatment of fetuses with immune-mediated heart block remains debatable. The use of antenatal steroid therapy is not widely accepted and there is concern over the risks and benefits of its use in the fetus. Direct fetal cardiac pacing has rarely been attempted.     

Reversal of Ballantyne syndrome by selective second-trimester fetal termination. A case report

BACKGROUND: Ballantyne syndrome (mirror syndrome, triple edema) describes the unusual association of fetal and placental hydrops with maternal preeclampsia. In most cases, the poor fetal prognosis and associated maternal risks warrant delivery regardless of gestational age. We used novel therapy for Ballantyne syndrome in a twin pregnancy. CASE: Ballantyne syndrome occurred at 16 weeks' gestation due to severe, unexplained hydrops in one of dichorionic twins. Selective termination of the affected fetal twin resulted in reversal of the preeclamptic findings in the mother, and the surviving twin was born uneventfully at term. CONCLUSION: This case strengthens the association of fetal and placental hydrops with preeclampsia and suggests selective fetal termination for Ballantyne syndrome due to hydrops in one of multichorionic fetuses.     

Congenital chylothorax in neonatal thyrotoxicosis.

We report a patient with congenital chylothorax who also had neonatal thyrotoxicosis secondary to maternal Graves' disease. Fetal tachycardia with hydrops was detected at 28 weeks' gestational age. The fetus responded to antithyroid medication in utero but had persistent bilateral pleural effusion. At birth, he had respiratory distress due to massive pleural effusion. Cytologic studies of pleural fluid were consistent with chylothorax. To the best of our knowledge, the association of congenital chylothorax with fetal (neonatal) thyrotoxicosis, has not been reported previously.     

Neonatal lupus erythematosus: results of maternal corticosteroid therapy.

OBJECTIVE: To assess the possibility of preventing cardiac or cutaneous manifestations of neonatal lupus erythematosus or treating the fetus with congenital heart block by administering corticosteroid therapy to the mother. METHODS: Eighty-seven offspring of 40 anti-Ro/SSA-positive mothers, followed up from 1979 to 1996, were evaluated. Autoantibodies against Ro/SSA and La/SSB antigens were detected by immunodiffusion and enzyme-linked immunosorbent assay. RESULTS: None of 26 neonates whose mothers received corticosteroid maintenance therapy initiated before 16 weeks' gestation demonstrated congenital heart block, whereas 15 of 61 neonates whose mothers received no corticosteroids during pregnancy or began receiving steroid therapy after 16 weeks' gestation had congenital heart block. Complete congenital heart block, once developed, did not respond to corticosteroid treatment in utero. Four infants whose mothers received steroid treatment before 16 weeks' gestation had skin lesions of neonatal lupus erythematosus. CONCLUSION: Once established, complete congenital heart block was irreversible and maternal corticosteroid therapy did not effectively prevent cutaneous lupus erythematosus. However, prenatal maintenance therapy with prednisolone or betamethasone given to the mother starting early in pregnancy (before 16 weeks' gestation) might reduce the risk of developing antibody-mediated congenital heart block in the offspring.