静脉导管超声检测在产前检查中的应用价值

本文着重介绍超声检测静脉导管在产前检查中的应用价值,阐述静脉导管的组织解剖结构、静脉导管分流的机制以及静脉导管在诊断胎儿生长受限、先天性心脏病等疾病中的临床意义.     

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。     

11～14孕周正常胎儿静脉导管血流参考范围

目的建立孕早期正常胎儿静脉导管（DV）不同时相血流速和各参数参考范围。方法应用彩色多普勒超声测定800例11~14孕周正常单胎胎儿DV血流参数：心室收缩期峰值流速（S-peak）,心室舒张期峰值流速（D-peak）,心房收缩期最大流速（A-wave）,搏动指数（PI）,阻力指数（R I）和S-peak/A-wave（S/A）。结果 7例出现生理性零及20例反向房收缩（RA）波;S-peak（30.26~36.46 cm/s）,D-peak（24.71~30.62 cm/s）,A-wave（11.13~14.33 cm/s）,与孕龄正相关均有显著性差异（P〈0.01）;PI（0.84~1.66）,R I（0.64~0.67）,S/A（2.71~3.11）,与孕龄相关性差（P〉0.05）。结论 11~14孕周正常胎儿DV频谱中存在着3.3%的生理性零或RA波,流速随着孕龄增加而增加;而R I、PI、S/A变化不明显。     

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。     

正常胎儿静脉导管的多普勒血流波型

本文报告了６０例２３～３６周正常孕妇胎儿的静脉导管血流波型，２Ｄ显像静脉导管为一狭窄喇叭样管道，其管腔连接于脐静脉和下腔静脉。最狭窄处的血管内径小于２ｍｍ，脉冲多普勒频谱图为三相型，心室收缩期波峰、心室舒张期波峰、心房收缩期波谷仍为正向频谱。流速测定：心室收缩期峰值平均５５．１±１２．９２ｃｍ／ｓ，心室舒张期峰值平均４７．４５±１３．８７ｃｍ／ｓ，心房收缩期峰值平均为２９．１４±１０．４９ｃｍ／ｓ，平均最大流速４６．０４±１２．３６ｃｍ／ｓ，静脉导管指数０．４８±０．１２［（心室收缩期最大峰值一心房收缩期最大峰值）／心室收缩期最大峰值］。血流量２７．５３±１２．１７ｍｌ／ｍｉｎ，静脉导管与脐静脉血流量之比（ＤＶ／ＵＶ）０．３２±０．１６，本研究表明应用超声多普勒技术可以测定静脉导管血流速度，高流速的静脉导管血流支持含氧较高脐血主要流入卵圆窝左心的理论，正常人类胎儿大约１／３脐静脉血，流入静脉导管。     

先天性心脏病胎儿静脉导管血流频谱及血流参数

目的 分析先天性心脏病(CHD)胎儿静脉导管的频谱特征及血流参数,探讨其血流参数的变化及特定CHD与参数之间的可能相关性。方法 记录160胎CHD胎儿静脉导管波形及各频谱参数,随访并分组,探寻可能对CHD有提示意义的血流参数。结果 160 胎CHD胎儿中,右心系统发育异常胎儿的静脉导管频谱异常发生率明显高于其他畸形,其中又以三尖瓣闭锁+室间隔缺损及室间隔完整的右心室流出道梗阻畸形者发生率更高;且当搏动指数>1.39、前负荷指数>1.35及静脉峰值流速指数>1.53时,诊断右心系统发育异常的意义较大。结论 静脉导管波形异常可早期提示胎儿CHD,尤其是右心系统发育不良,对临床决策及判断预后有一定指导意义。     

多普勒超声监测心律失常胎儿脐动脉、静脉导管血流频谱的研究

目的 探讨多普勒超声监测心律失常胎儿脐动脉、静脉导管血流频谱的临床价值及其对胎儿预后的影响.方法 对孕16～41周的产科听诊、胎儿电子监护或超声检查发现心律异常的796例胎儿进行多普勒超声检查,监测脐动脉和静脉导管血流频谱,分析其对胎儿预后的影响.所有纳入研究的胎儿出生后尽量进行心电图和超声心动图检查.结果 796例胎儿中检出心律失常136例.136例心律失常胎儿中脐动脉舒张末期血流缺失或反向18例,静脉导管A谷缺失或反向9例.18例血流频谱异常的心律失常胎儿合并先天性心脏病12例(占66.7％).心动过缓胎儿伴发血流频谱异常和先天性心脏病的比例高.结论 脐动脉、静脉导管血流频谱正常的心律失常胎儿预后良好;反之预后较差.监测心律失常胎儿的脐动脉、静脉导管血流频谱,可以为临床明确诊断、早期干预提供依据.     

胎儿静脉导管及颈项透明层厚度的超声检测在先天性心脏畸形筛查中的价值

目的 探讨胎儿静脉导管多普勒血流频谱异常及颈项透明层（NT）增厚在早期胎儿先天性心脏畸形（CHD）筛查中的临床应用价值.方法 对3562例孕11~14周的孕妇行常规产前检查,进行胎儿静脉导管多普勒血流频谱和NT检测,对静脉导管血流频谱异常或NT增厚胎儿于孕18~20周行超声心动图检查以确诊或除外CHD,对静脉导管血流频谱和NT正常的胎儿于20~24周行胎儿常规系统筛查,对可疑胎儿心脏异常者再行胎儿超声心动图检查.所有活产儿于出生后1周内进行超声心动图检查,对引产胎儿进行尸检.结果 ①3562例胎儿中静脉导管多普勒血流频谱异常胎儿CHD的发生率明显高于静脉导管多普勒血流频谱正常的胎儿（P ＜ 0.01）,其敏感性、特异性及阳性预测值分别为55.22%、96.97%和25.87%;②NT增厚的胎儿CHD发生率明显高于NT正常胎儿（P ＜ 0.01）,其敏感性、特异性及阳性预测值分别为49.25%、98.03%及32.35%;③静脉导管多普勒血流频谱异常和NT增厚的胎儿CHD发生率明显高于静脉导管多普勒血流频谱及NT均正常的胎儿（P ＜ 0.01）,其敏感性、特异性及阳性预测值分别为43.28%、99.46%和60.42%.结论 胎儿静脉导管多普勒血流频谱异常和NT增厚可作为CHD的早期筛查指标.     

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。     

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。     

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。     

Longitudinal Reference Values for Ductus Venosus Doppler in Low-Risk Pregnancies

The aim of this study was to establish normal ranges of blood flow velocities and indices in the fetal ductus venosus (DV) during the second half of normal pregnancy. A Doppler study of 60 healthy pregnant women without fetal pathologies was performed during the second half of pregnancy. The peak systolic velocity (PSV), peak diastolic velocity (PDV), maximum velocity during atrial contraction (VAC), peak systolic velocity / maximum velocity during atrial contraction (S/A ratio), pulsatility index for the vein (PIV), preload index (PLI) and velocity index for the vein (VIV) were calculated from the DV at 4-week intervals. A significant increase in PSV, PDV and VAC was observed from the 20–23^6/7 to the 28–31^6/7 weeks, with stabilization of values until the end of the pregnancy. On the other hand, the study showed a significant decrease for the S/A ratio, PIV, PLI and VIV from the 20–23^6/7 to the 28–31^6/7 weeks and remaining stable from then until term. (E-mail: dralemar@uol.com.br)     

Correlation between ductus venosus spectrum and right ventricular diastolic function in isolated single-umbilical-artery foetus and normal foetus in third trimester

BACKGROUNDSingle umbilical artery (SUA) is the most common umbilical cord malformation in prenatal diagnosis. The presence of an SUA can cause blood circulation disorder in the foetus and functional changes of the foetal heart, affecting foetal circulation. The right ventricular diastolic functions in foetuses with isolated SUA and in normal foetuses in the third trimester were evaluated using the spectral Doppler of blood flow in the foetal ductus venosus (DV).AIMTo evaluate the right ventricular diastolic functions in foetuses with isolated SUA and in normal foetuses in the third trimester.METHODSColour Doppler was used to measure the spectrum of foetal DV and tricuspid orifice in 34 foetuses with isolated SUA aged 28-39 wk and in age-matched healthy controls. The DV flow velocities and velocity ratios were measured. The early passive/late active (E/A) ratio at the tricuspid orifice and tissue Doppler Tei index of the foetal right ventricular in the two groups were also measured.RESULTSDuring the third trimester, the isolated SUA group showed a lower ‘a’-wave peak velocity in the DV than the control group (P < 0.05). The correlations between the velocity ratios and E/A ratio at the tricuspid orifice in the two groups were analysed, and the correlation between the ventricular late diastolic velocity/ventricular diastolic peak flow velocity and E/A ratios was the best (R² of the isolated SUA group: 0.520; R² of the control group: 0.358). The correlations between the velocity ratios and tissue Doppler Tei index of foetal right ventricular in the two groups were analysed, and the correlation between the pulsatility index for veins (PIV) and tissue Doppler Tei index ratios was the best (R² of the isolated SUA group: 0.865; R² of the control group: 0.627).CONCLUSIONIn the isolated SUA group, the atrial systolic peak velocity ‘a’ decreased, and this finding might be related to the changes in foetal cardiac functions. The ratio of ventricular late diastolic velocity to ventricular diastolic peak flow velocity was closely related to the E/A ratio at the tricuspid valve and can be used to identify changes in the right ventricular diastolic functions of isolated SUA and healthy foetuses. PIV was closely related to the tissue Doppler Tei index of the foetal right ventricular and can be used to identify the right ventricular overall functions of isolated SUA and healthy foetuses.     

生长受限胎儿静脉导管、脐动脉彩色多普勒血流监测的临床价值

目的探讨彩色多普勒超声(CDFI)监测生长受限(FGR)胎儿静脉导管、脐动脉的血流参数的临床价值。方法 50例FGR组胎儿,80例正常胎儿为对照组,CDFI检测其静脉导管前负荷指数(PLI)、心室收缩期峰值流速/心房收缩谷流速(S/a)、脐动脉心室收缩峰值流速/心舒张末期流速(S/D)及搏动指数(PI)。结果与对照组比较,FGR组脐动脉S/D、PI、静脉导管S/a、PLI均增高(P0.05)。脐动脉S/D正常组与S/D异常组比较、静脉导管S/a正常组与S/D异常组比较,分娩时孕龄、出生时新生儿体质量、5 min Apart评分、剖宫产率及围生期死亡率差异均有统计学意义(P0.05)。采用静脉导管S/a和脐动脉S/D均异常较仅采用脐动脉S/D异常预测妊娠结局的误诊率低,诊断指数高。结论应用CDFI监测FGR胎儿静脉导管及脐动脉血流参数有重要的临床价值。     

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.     

胎羊炎症反应综合征静脉导管血流动力学变化与炎性介质关系的研究

目的 探讨胎羊内注射内毒素(LPS)后的静脉导管血流动力学变化及其与胎羊炎性介质变化的关系.方法 10只中晚孕山羊分为两组(实验组和对照组各5只),实验组于妊娠120～130 d行超声引导下胎羊脐静脉或脐-门静脉窦穿刺术,注射LPS(Escherichia coli O111:B5;L1885)约10μg/kg胎羊质量,对照组注射等量生理盐水.并分别于注射LPS前(0.5 h)、注射LPS后1 h、3 h、6 h应用彩色多普勒血流显像检测静脉导管血流频谱变化.同时抽取脐静脉血,用ELISA方法检测TNF-α、IL-6含量,并评价TNF-α、IL-6与静脉导管血流参数之间的相关性.结果 实验组给药后静脉导管搏动指数(DVPI)、心室收缩期峰值速度(S)、心室舒张期峰值流速(D)、血流量(DVQ)、静脉导管指数(DVI)、心室收缩期峰值速度/心房收缩期峰值流速(S/A)、(S-A)/D随给药时间升高,并且高于对照组(均P＜0.05);心房收缩期峰值流速(A波)下降,并且低于对照组(P＜0.05);静脉导管峡部的内径(DVD)无明显变化.实验组DVPI与血清IL-6、TNF-α呈正相关(P均＜0.05);实验组A波值与血清IL-6、TNF-α呈负相关(均P＜0.05);S波、DVI、D波、DVQ、S/A、(S-A)/D与血清IL-6呈正相关(均P＜0.05),与TNF-α无明显相关(均P＞0.05);静脉导管峡部内径与血清IL-6、TNF-α均无明显相关.结论 DVPI、A值可能成为预测胎儿全身炎症反应综合征简便而有效的指标.     

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.     

运用彩色多普勒流速剖面图测定血流量的实验研究

运用实验血流模型，检测新近开发的彩色多普勒血流速度部面图（velocityprofile，VP）对血流量测定的准确性，并与脉冲型多普勒（PulsedwaveDoppler，PWD）测定法比较。结果显示在不同流速下两种方法的流量测值与实际流量间均有高度相关性，相关系数r分别为0．999（P＜0．001）和0．988（P<0．02）。但测得流量与实际流量之间的误差程度，VP法为-7.64～2．79％，PWD法为17.82～27.97％。表明VP法较PWD法更接近实际情况。     

Effect of microbubble contrast on intracranial blood flow velocity assessed by transcranial Doppler

Purpose

Ultrasound contrast agents (UCA) salvage a considerable number of transcranial Doppler (TCD) exams which would have failed because of poor bone window. UCA bolus injection causes an undesirable increase in measured blood flow velocity (BFV). The effect of UCA continuous infusion on measured BFV has not been investigated, and some in vitro experiments suggest that gain reduction during UCA administration may also influence measured BFV. This study aimed to investigate the effect of UCA continuous infusion on BFV measured by TCD and the influence of gain reduction on these measurements in a clinical setting.

Methods

The right middle cerebral artery of ten patients with optimal bone window was insonated using a 2 MHz probe. UCA were administered using an infusion pump. BFV was measured (1) at baseline, (2) during UCA infusion, (3) during UCA infusion with gain reduction, and (4) after UCA wash-out phase. Gain reduction was based on the agreement between two neurosonographers on the degree of gain reduction necessary to restore baseline Doppler signal intensity (DSI). Actual DSI was estimated offline by analysis of raw data.

Results

BFV measured during UCA infusion with no gain adjustment was significantly higher than baseline BFV [peak systolic velocity (PSV): 85.1 ± 19.7 vs. 74.4 ± 19.7 cm/s, p < 0.0001; Mean velocity (MV): 56.5 ± 11.8 vs. 50.2 ± 12.3 cm/s, p < 0.0001]. BFV measured during UCA infusion with gain reduction was not significantly higher than baseline BFV (PSV: 74.3 ± 18.9 vs. 74.4 ± 19.4 cm/s, p = 0.8; MV: 49.4 ± 11.0 vs. 50.2 ± 12.3 cm/s, p = 0.8). Actual DSI during UCA infusion with gain reduction was not significantly higher than baseline DSI (13 ± 1 vs. 13 ± 1 dB).

Conclusion

This study shows that UCA continuous infusion leads to an increase in measured BFV which may be counteracted by reducing Doppler gain thus restoring pre-contrast DSI.