监测胎儿血流速度波形对估计高危妊娠胎儿预后的价值

目的：通过大样本临床监测结果，分析血流速度波形对估计胎儿宫内状况的价值。方法：检测718例高危妊娠胎儿的脐动脉（UA）、大脑中动脉（MCA）血流波形，以胎儿出生时脐动脉血PH＜7．19、1分钟Apgar评分≤7分、出生体重低于同孕周标体重第10百分位数以下为胎儿窘迫的诊断标准，分析血流速度波形指数异常诊断胎儿窘迫的敏感度和特异性。结果：各项指标诊断胎儿窘迫的敏感度和特异性分别为：UA－RI为49．8％、96．6％；UA－PI为49．3％、95．6％；MCA－RI为34．0％、96．5％；MCA－PI为21．5％、97．3％。结论：胎儿UA、MCA血流速度波形对诊断胎儿窘迫特异性较高，但敏感度仍然有限，临床应结合其它指标综合分析。     

Maternal steroid therapy for fetuses with immune-mediated complete atrioventricular block: a systematic review and meta-analysis

Introduction: To explore the effect of maternal fluorinated steroid therapy on fetuses affected by immune-mediated complete atrio-ventricular block (CAVB) in utero.

Material and methods: Pubmed, Embase, Cinahl, and ClinicalTrials.gov databases were searched. Only studies reporting the outcome of fetuses with immune CAVB diagnosed on prenatal ultrasound without any cardiac malformations and treated with fluorinated steroids compared to those not treated were included. The primary outcome observed was the regression of CAVB; secondary outcomes were need for pacemaker insertion, overall mortality, defined as the occurrence of either intrauterine (IUD) or neonatal (NND) death, IUD, NND, termination of pregnancy (TOP). Furthermore, we assessed the occurrence of all these outcomes in hydropic fetuses compared to those without hydrops at diagnosis. Meta-analyses of proportions using random effect model and meta-analyses using individual data random-effect logistic regression were used to combine data.

Results: Eight studies (162 fetuses) were included. The rate of regression was 3.0% (95%CI 0.2–9.1) in fetuses treated and 4.3% (95%CI 0.4–11.8) in those not treated, with no difference between the two groups (odds ratio (OR): 0.9, 95%CI 0.1–15.1). Pacemaker at birth was required in 71.5% (95%CI 56.0–84.7) of fetuses-treated and 57.8% (95%CI 40.3–74.3) of those not treated (OR: 9, 95%CI 0.4–3.4). There was no difference in the overall mortality rate (OR: 0.5, 95%CI 0.9–2.7) between the two groups; in hydropic fetuses, mortality occurred in 76.2% (95%CI 48.0–95.5) of the treated and in 23.8% (95%CI 1.2–62.3) of the untreated group, while in those without hydrops the corresponding figures were 8.9% (95%CI 2.0–20.3) and 12% (95%CI 8.7–42.2), respectively. Improvement or resolution of hydrops during pregnancy occurred in 76.2% (95%CI 48.0–95.5) of cases treated and in 23.3% (95%CI 1.2–62.3) of those nontreated with fluorinated steroids.

Conclusions: The findings from this systematic review do not suggest a potential positive contribution of antenatal steroid therapy in improving the outcome of fetuses with immune CAVB.     

Intrauterine growth restriction and absent or reverse end-diastolic blood flow in umbilical artery (Doppler class II or III): A retrospective study of short- and long-term fetal morbidity and mortality

OBJECTIVE: Absent or reverse end-diastolic flow (Doppler II/III) in umbilical artery is correlated with poor perinatal outcome, particularly in intrauterine growth restricted (IUGR) fetuses. The optimal timing of delivery is still controversial. We studied the short- and long-term morbidity and mortality among these children associated with our defined management. STUDY DESIGN: Sixty-nine IUGR fetuses with umbilical Doppler II/III were divided into three groups; Group 1, severe early IUGR, no therapeutic intervention (n = 7); Group 2, fetuses with pathological biophysical profile, immediate delivery (n = 35); Group 3, fetuses for which expectant management had been decided (n = 27). RESULTS: In Group 1, stillbirth was observed after a mean delay of 6.3 days. Group 2 delivered at an average of 31.6 weeks and two died in the neonatal period (6%). In Group 3 after a mean delay of 8 days, average gestational age at delivery was 31.7 weeks; two intra uterine and four perinatal deaths were observed (22%). Long-term follow-up revealed no sequelae in 25/31 (81%) and 15/18 (83%), and major handicap occurred in 1 (3%) and 2 patients (11%), respectively, for Groups 2 and 3. CONCLUSION: Fetal mortality was observed in 22% of this high risk group. After a mean period of follow-up of 5 years, 82% of infants showed no sequelae. According to our management, IUGR associated with umbilical Doppler II or III does not show any benefit from an expectant management in term of long-term morbidity.     

Study of fetal tracheal fluid velocities using Doppler ultrasound

Objective

To characterize tracheal fluid flow during fetal breathing movements by Doppler ultrasound.

Study design

To use pulsed Doppler to measure flow velocity during inspiration and expiration in a cross-sectional study of 15 normal fetuses and determine the correlation, if any, between flow velocity and gestational age.

Results

Cyclic respiratory profiles – both regular and irregular – were observed. Intratracheal flow velocity was very elevated during inspiration, ranging from 10 to 80 cm/s and from 5 to 20 cm/s during expiration.

Conclusion

This technique enables the noninvasive semiquantitative evaluation of fetal breathing movements. This Doppler application opens the field for future studies to characterize the extent of pulmonary hypoplasia.     

Effectiveness of cervical cerclage for a sonographically shortened cervix: a systematic review and meta-analysis

OBJECTIVE: The purpose of this study was to determine the effectiveness of cerclage for a shortened cervix on transvaginal ultrasound scanning in terms of the rates of preterm delivery and adverse neonatal and maternal outcomes. STUDY DESIGN: Pre-MEDLINE and MEDLINE, EMBASE, and the Cochrane Library were searched for human studies that compared cerclage placement to no cerclage on the basis of transvaginal ultrasound findings of a short cervix (< or =2.5 cm). Two authors independently determined eligibility and abstracted data. Meta-analyses were conducted when possible. RESULTS: Thirty-five studies were reviewed; 6 studies were eligible and were included in the analysis. There was no statistically significant effect of cerclage on the rates of preterm delivery (<37, <34, <32, and <28 weeks of gestation), preterm labor, neonatal mortality or morbidity, gestational age at delivery, or time to delivery. Birth weight was significantly higher with than without cerclage (P=.004). CONCLUSION: The available evidence does not support cerclage for a sonographically detected short cervix. A randomized controlled trial is needed to determine whether this intervention will reduce adverse neonatal outcomes.     

Placenta chorioangioma: a rare case and systematic review of literature

Abstract

Objectives: Placental chorioangioma is a relatively rare condition that often results in serious prenatal complications and adverse pregnancy outcome. We report a case of a large chorioangioma that was prenatally diagnosed at 23 weeks with polyhydramnios and fetal anemia. With prenatal monitoring, transplacental therapy with a COX-2 inhibitor and intrauterine transfusion, the pregnancy resulted in the live birth at 30 weeks. Due to the paucity of evidence relating to the management protocols in cases of placental chorioangiomas, we have conducted a systematic review of the literature.

Methods: All reported cases in the English language were captured using the electronic databases. Bibliographies of relevant articles were manually searched.

Results: Sixty-four articles were included reporting 112 cases of placental chorioangioma. In 79, there was no prenatal treatment and in 33 there was in-utero treatment. A systematic comparison of antenatal complications and pregnancy outcomes was performed. No strong conclusion could be made due to the low number and quality of the reported cases.

Conclusion: Placenta chorioangioma represents a challenge with its potentially serious complications adversely affecting pregnancy outcome. An international registry of pregnancies with this rare complication and documentation of pregnancy outcomes will improve the evidence base for prospective management.     

Personalized third-trimester fetal growth evaluation: comparisons of individualized growth assessment,percentile line and conditional probability methods

Objective: To compare third-trimester size trajectory prediction errors (average transformed percent deviations) for three individualized fetal growth assessment methods.

Methods: This study utilized longitudinal measurements of nine directly measured size parameters in 118 fetuses with normal neonatal growth outcomes. Expected value (EV) function coefficients and variance components were obtained using two-level random coefficient modeling. Growth models (IGA) or EV coefficients and variance components (PLM and CPM) were used to calculate predicted values at ～400 third-trimester time points. Percent deviations (%Dev) calculated at these time points using all three methods were expressed as percentages of IGA MA-specific reference ranges [transformed percent deviations (T%Dev)]. Third-trimester T%Dev values were averaged (aT%Dev) for each parameter. Mean?±?standard deviation’s for sets of aT%Dev values derived from each method (IGA, PLM and CPM) were calculated and compared.

Results: Mean aT%Dev values for nine parameters were: (i) IGA: ?4.3 to 5.2% (9/9 not different from zero); (ii) PLM: ?32.7 to 25.6% (4/9 not different from zero) and (iii) CPM: ?20.4 to 17.4% (5/9 not different from zero). Seven of nine systematic deviations from zero were statistically significant when IGA values were compared to either PLM or CPM values. Variabilities were smaller for IGA when compared to those for PLM or CPM, with (i) 5/9 being statistically significant (IGA versus PLM), (ii) 2/9 being statistically significant (IGA versus CPM) and (iii) 5/9 being statistically significant (PLM versus CPM).

Conclusions: Significant differences in the agreement between predicted third-trimester size parameters and their measured values were found for the three methods tested. With most parameters, IGA gave smaller mean aT%Dev values and smaller variabilities. The CPM method was better than the PLM approach for most but not all parameters. These results suggest that third-trimester size trajectories are best characterized by IGA in fetuses with normal growth outcomes.     

Systematic review and meta-analysis of the test accuracy of ductus venosus Doppler to predict compromise of fetal/neonatal wellbeing in high risk pregnancies with placental insufficiency

Objective

To evaluate the test accuracy of ductus venosus Doppler for prediction of compromise of fetal/neonatal wellbeing.

Study design

The search strategy employed searching of electronic databases (Medline, Embase, Cochrane library, Medion) from inception to May 2009, hand searching of journal and reference lists, contact with experts. Two reviewers independently selected articles in which the results of ductus venosus Doppler were associated with the occurrence of compromise of fetal/neonatal wellbeing. There were no language restrictions applied. Data were extracted on study characteristics, quality and results to construct 2 × 2 tables. Likelihood ratios for positive and negative test results, sensitivity, specificity and their 95% confidence intervals were generated for the different indices and thresholds.

Results

Eighteen studies, testing 2267 fetuses met the selection criteria, all performed in a high risk population with placental insufficiency in second/third trimester. Meta-analysis showed moderate predictive accuracy. The best result was for the prediction of perinatal mortality, positive likelihood ratio 4.21 (95% CI 1.98-8.96) and negative likelihood ratio 0.43 (95% CI 0.30-0.61). For prediction of adverse perinatal outcome the results were positive likelihood ratio 3.15 (95% CI 2.19-4.54) and negative likelihood ratio 0.49 (95% CI 0.40-0.59).

Conclusion

Abnormal ductus venosus Doppler showed moderate predictive accuracy for compromise of fetal/neonatal wellbeing overall and perinatal mortality in high risk pregnancies with placental insufficiency.     

Antenatal treatment of fetal goiter: a therapeutic challenge

Objective. Pre-natal ultrasonography presents an opportunity for in-utero therapy of a fetal goiter. Because of the morbidity associated with a large goiter and the risks of repeated intra-amniotic injections, controversy arose about the precise indications of this mode of treatment. We describe our observations in treating a 22-week-old fetus with a large goiter because of dyshormogenesis, monitored with serial 3D high frequency, high resolution ultrasonography and amniotic hormonal measurements. Fetal hypothyroidism was confirmed by cordocentesis and amniotic hormone levels. After assessment of relevant risk factors and the criteria for in-utero intervention, including goiter volume, amniotic fluid index, polyhydramnios and tracheal compression, we determined that hormonal therapy was warranted. Levothyroxine was injected every 7–10 days, and its efficacy monitored by ultrasound changes and amniotic hormone sampling.

Results. Reduction in goiter volume restored normal neck flexion relieving the pressure on the trachea, polyhydramnios was prevented and amniotic hormone levels were normalised. The infant was euthyroid at birth, however, by age 4 days hypothyroidism was diagnosed, and treatment with l-thyroxine started.

Conclusion. Advances in fetal ultrasonography permit judicious therapy of an enlarging goiter in a hypothyroid fetus, which may contribute to enhancing cognitive development. We discuss the value of amniotic hormone sampling, the objectives and risks of in-utero intervention in the light of recent literature and our own observations.     

Noninvasive techniques to detect fetal anemia due to red blood cell alloimmunization: a systematic review

OBJECTIVE: To estimate, in maternal red blood cell alloimmunization, the diagnostic value of fetal ultrasonography and Doppler blood flow velocity in the evaluation and prediction of fetal anemia. METHODS: Literature from 1970 to 2000 was identified using general bibliographic databases (MEDLINE and EMBASE), the Cochrane Library and relevant specialist register of the Cochrane Collaboration, and by checking reference lists of known primary and review articles. Studies were selected if the accuracy of the fetal ultrasound parameters or Doppler studies of blood flow in the fetal vessels was estimated compared with a reference standard (fetal hemoglobin). The diagnostic tests evaluated were ultrasound measurement of the fetal spleen perimeter and Doppler studies of blood velocity estimates in the umbilical vein, ductus venosus, middle cerebral artery, thoracic aorta, and umbilical vessel combined with the thoracic aorta. Study selection, quality assessment, and data abstraction were performed independently and in duplicate. Data from the selected studies were abstracted as 2 x 2 tables comparing the diagnostic test result with the reference standard. Diagnostic accuracy was expressed as likelihood ratios. RESULTS: The review included eight primary studies with 362 pregnancies affected by red cell alloimmunization. Prospective patient recruitment and complete population details were reported in half of the selected studies (four of eight). Only one study reported masking the diagnostic test results to clinicians. The diagnostic test performance varied widely according to the type of the test evaluated and the cutoff level used to define fetal anemia, which varied from study to study. The diagnostic test study of highest methodological quality reported a positive likelihood ratio of 8.45 (95% confidence interval 4.69, 15.56) and negative likelihood ratio of 0.02 (95% confidence interval 0.001, 0.25) for maximum middle cerebral artery Doppler velocity. CONCLUSION: The literature reporting noninvasive techniques to predict fetal anemia is methodologically poor and a standard approach to the evaluation of these techniques is lacking. A recommendation for practice cannot be generated without further rigorous research.     

检测胎儿脑动脉阻力指数对评价脑生长发育的意义

以２８例健康妊娠妇女的胎儿为观察对象，从孕龄１２周起，应用彩色多普勒超声技术连续监测胎儿大脑中动脉阻力指数的变化幅度。结果表明，在胎儿脑发育过程中，脑血管有两个低血管阻力期，一个在妊娠１２～２０周，另一个在妊娠３６～４０周，胎儿脑生长发育曲线呈弧线型，在妊娠早期和晚期胎儿有两个较大的脑细胞增殖期，这一发现有助于对脑正常代谢的认识，为采取措施保护和促进脑发育提供了理论根据。     

Effects of maternal smoking on human placental vascularization: A systematic review

The abnormal development of placental vascularization leads to placental insufficiency, which further reduces the nutrient and trace exchange between maternal circulation and fetal circulation. These changes cause maternal and fetal complications. The objective of our systematic review was to explore the effects of maternal smoking on placental vascularization. The eligibility criteria were: articles with experimental, quasi-experimental or observational design, performed on human subjects, that study the association, correlation or causation between maternal smoking and changes in placental vascular network. A total of 33 full-text papers were assessed for eligibility, resulting in 12 original articles that were included in the systematic review. Doppler studies confirm reductions in blood flow velocity waveforms and increase in RI in the uterine, umbilical and fetal middle cerebral arteries. These findings are confirmed by morphometric measurements of fetal capillaries in villi that were shown to be smaller in smoke exposure groups.     

Prediction of fetal outcome without intrauterine intervention using a cardiovascular profile score: a systematic review and meta-analysis

Objective: With the help of fetal echocardiography, cardiovascular profile score (CVPS) can be evaluated. However, no general agreement has been recognized on the prediction value of CVPS on fetal adverse outcome.

Methods: Literature review has identified up to Nov 2012 in the databases. Meta-analysis was performed in a fixed/random-effect model using Revman 5.1.1 and Meta-disc 1.4. The differences among different cut-offs were measured by STATA 11.0.

Results: Result from seven studies reported an outcome in favor of significant lower CVPS in fetus of adverse outcome with std. mean difference of ?1.17 (95% CI?=??1.78, ?0.55). The overall performance of CVPS ≤6 prediction adverse outcome evaluated as area under the summary receiver operating characteristic curves (AUC) was 0.8777. The AUC of CVPS ≤7 was 0.8728 and the AUC of CVPS ≤8 was 0.7207. However, the result indicated the performance of CVPS ≤6 prediction adverse outcome had a statistical significance comparing to other two cut-offs.

Conclusion: Analysis has proven the CVPS is a credible index for predicting fetal adverse outcome. And once CVPS decreased at eight, the patient should be observed carefully. With the CVPS dropped at seven, treatment is demanded immediately while some cases suffer irreversible cardiac dysfunction.     

The MCA Doppler and its role in the evaluation of fetal anemia and fetal growth restriction

Doppler velocimetry of the middle cerebral artery (MCA) has played a major role in fetal medicine for the last 23 years, both in intrauterine growth-restricted (IUGR) and anemic fetuses. Its utility in the diagnosis and management of cases of fetal anemia was initially demonstrated in cases of red cell alloimmunization and later extended to other types of anemia. In addition, MCA Doppler studies are crucial in the evaluation of IUGR fetuses. This article is a review of the role of the MCA in these 2 conditions.