脐静脉穿刺用于产前诊断230例分析

目的：探讨B超引导下游离脐带穿刺术成功率和安全性。方法：对230例因各种原因行产前诊断的孕妇进行B超引导下游离脐静脉穿刺术。结果：102例18－21周孕妇穿刺成功率为90．5％，72例22－28周孕妇成功率97．8％，56例28周以上的成功率为100．0％，总成功率96．1％；169例穿刺经过胎盘，胎盘渗血29．2％（49／168），脐带穿刺后渗血17．8％（41／230）。胎心过缓者占5．2％（12／230）。术后未出现早产、宫内感染等并发症。结论：B超引导下脐带穿刺术用于产前诊断是一项成功率高且安全的方法。     

脐带正常附着的胎膜前置血管破裂1例

一、病例摘要 患者，25岁，因停经9个月余，见红2h入院待产。入院后B超检查提示：宫内妊娠39^＋4周，单活胎，左枕前，胎盘3级，胎盘位置：后壁。羊水指数：74mm。入院时查胎心及骨盆外测量均正常，宫颈评分5分。入院后观察1d余，胎心监护NST9分，患者未临产，无宫缩。肛查：宫颈管消退90％，质地中等，宫口未开，先露位于S^0。     

米非司酮配伍米索前列醇足月妊娠引产对胎盘及母婴血生化的影响

目的 :了解小剂量米非司酮配伍小剂量米索前列醇用于足月妊娠引产时胎盘形态、功能及母婴血生化的变化。方法 :将 80例妊娠期无明显并发症及合并症 ,因孕期延长而引产的初产妇随机分成两组 ,A组 36例 ,口服米非司酮 10 0mg ,36h后将米索前列醇 50 μg置于阴道后穹窿 ,间隔 3h如无宫缩再置 ,2 4h内使用米索前列醇不超过 3次 ;B组4 4例单用米索前列醇引产 ,用法同上 ;C组配对 4 0例自然临产者。 3组临产后均取母血检测胎盘功能 ;分娩后取母血及脐血测定肝、肾功能及皮质醇 ;取胎盘行形态学检查并进行定量分析。结果 :A组需用米索前列醇的次数较B组明显减少。 3组产妇肝、肾功能及胎盘功能均正常 ,皮质醇组间无明显差异 ,脐血T -BI增高但组间无明显差异。胎盘绒毛合体细胞结节、纤维素样坏死、血管合体细胞膜形成的发生率 ,3组间无明显差异。结论 :未发现足月孕妇口服米非司酮 10 0mg配伍小剂量米索前列醇引产对胎盘形态及功能产生影响 ,亦未发现母婴血生化指标因此而改变     

风心病换瓣术后8月,妊娠36周,宫内死胎

1病历摘要患者,33岁,孕3产1。末次月经2003年11月1日,因妊娠36周,胎动消失2天,风心病二尖瓣瓣膜(机械瓣)置换术后8月,于2004年7月8日收入院。孕妇因患风心病二尖瓣狭窄于2003年10月26日行二尖瓣换瓣手术(机械瓣),术后一直服用华法林2.5mg/d。停经后无恶心、呕吐等早孕反应,孕5+月到我院行产前检查,准备分娩。B超检查:宫内单活胎,胎儿双顶径3.8cm,胎动、胎心好,头环完整,脊柱无畸形。劝其终止妊娠,并叮嘱到心内科就诊。入院前2天,胎动消失,B超检查提示无胎动及胎心,双顶径8.1cm,胎儿侧脑室有3cm×4cm×4cm积液,胎儿股骨长5.7cm,胎盘附着于前…     

双子宫同时足月妊娠1例

孕妇 2 6岁 ,住院号 0 0 12 40 8,孕 2产 0 ,于 1998年 9月2 1日孕 37周时来院检查。查体 :血压正常 ,腹部呈横置哑铃状 ,两侧腹均触及一胎儿 ,胎心率分别为 140 /ｍｉｎ、144 /ｍｉｎ。临床诊断 :宫内孕双胎活胎。Ｂ超检查 :腹腔内探及双子宫 ,两宫内均探及一胎儿及其附属物。左宫内胎儿 :胎位ＬＯＰ ,胎心胎动可及 ,双顶径 8 5ｃｍ ,股骨长6 8ｃｍ ,后壁胎盘 ,羊水指数 14ｃｍ ;右宫内胎儿 :胎位ＲＳＡ ,胎心胎动可及 ,双顶径 9 0ｃｍ ,股骨长 7 1ｃｍ ,后壁胎盘 ,羊水指数 15ｃｍ。Ｂ超诊断 :双子宫同时妊娠。当天住院待产 ,经检查发现…     

彩色和能量多普勒超声对高危妊娠胎盘绒毛动脉的血流监测及与妊娠结局的关系

目的　研究高危妊娠胎盘循环的病理生理变化及与其妊娠结局的关系。方法　将研究对象根据脐血流S/D值和临床症状将 1 0 2例研究对象分为三组 :脐血流S/D≥ 95 th%者 37例为胎儿 -胎盘供血不足组 ;脐血流S/D <95 th%者同时有妊娠合并症及并发症者 4 2例为妊娠合并症和并发症组 ;无任何妊娠合并症和并发症2 3例作为正常妊娠对照组。经彩色和能量多普勒超声检测三组脐动脉、胎盘内绒毛动脉的阻力及计数胎盘内绒毛血管的条数并与妊娠结局相比较。结果　脐血流S/D≥ 95 th%的孕妇胎盘内绒毛血管的数量明显低于正常妊娠组和妊娠合并症、并发症组 ,胎盘内绒毛动脉的S/D值均显著高于其他两组。虽然正常组和妊娠合并症及并发症组脐动脉血流S/D值均小于 95 th% ,但妊娠合并症和并发症组胎盘内绒毛血管的数量显著低于正常组 ,胎盘内绒毛动脉S/D值显著高于正常组。三组中胎儿 -胎盘供血不足组妊娠结局最差 ;妊娠合并症和并发症组胎儿体重和胎盘重量居中 ;正常妊娠无不良围产儿结局。结论　彩色和能量多普勒超声可监测胎盘内绒毛血管数量及绒毛动脉的阻力 ,其血流动力学的变化为进一步洞察高危妊娠胎盘循环提供了直接依据     

微小病毒B19感染与妊娠晚期胎死宫内的关系

成人中微小病毒B19感染率高达50％～70％。该病毒易侵袭骨髓或胎肝内未成熟红细胞,抑制红细胞形成,导致贫血。有报道微小病毒B19感染引起妊娠中晚期胎儿水肿、自然流产和胎死宫内。但微小病毒B19感染导致的非水肿性妊娠晚期胎儿死亡尚未引起足够的重视。 1992～1998年,经超声确诊的妊娠晚期胎死宫内共93例,于36h内发动分娩。产后收集胎盘组织及母血,于24h内储存于-20℃。另取胎盘组织用甲醛固定并用石蜡包埋。部分死胎作尸解并取组织活检。以荧光免疫法检测母血清中抗微小病毒B19IgG和IgM。以PCR法检测胎盘组织、母血清及胎     

妊娠13+5周子宫破裂误诊宫外孕破裂1例

患者 31岁 ,住院号 6 2 770。孕 3产 1 ,因停经 1 3 5周 ,突发下腹剧痛 1 0h ,于 2 0 0 4年 1月 2日急诊入院。 6年前足月顺娩一女婴 ,近两年人工流产 2次。末次月经 2 0 0 3年9月 2 0日 ,停经后有早孕反应 ,未行B超等检查。入院前1 0h性交后突然出现下腹剧烈持续性疼痛 ,伴恶心、呕吐。B超提示 :宫内胎儿双顶径 3 0cm ,胎心正常 ,胎盘位于宫底后壁 ,腹腔内大片液性暗区。腹穿抽出不凝血 6mL。门诊以“宫内孕 1 3 5周 ,腹腔积血待查 ?”收住院。查体 :BP1 4 1 / 1 0 7kPa(1 0 5 / 80mmHg) ,贫血貌 ,全腹压痛 ,反跳痛 ( ) ,肌紧张不明…     

临床多选题

〔A型题〕 向4了孕42周孕妇自觉胎动减少,宫缩时下列胎心监护出现哪项胎心改变可考虑胎儿宫内窘迫? A.早发性胎心改变B.迟发性胎心变慢 C.散发性胎心变慢D.心动过速E.心动过缓 问48妊娠晚期孕妇数胎动以监护胎儿安危,以下哪项表示胎儿有危险? A.胎动每小时大于5次B.胎动每小时小于弓次C.胎动侮12小时小于10次D.胎动每12小时小于20次E.胎动每24小时小于50次 问49胎儿宫内窘迫需立即结束妊娠的指标是: A.胎心小于120次/分B.胎动小于3次/小时C.羊水混有胎粪D.胎心监护出现迟发性胎心变慢E.胎儿头皮血pH<7.20 向50胎儿宫内窘迫的处理哪项…     

双胎栓塞综合征一例

患者女 ,2 3岁 ,初产妇 ,停经 35 + 1 周 ,双胎妊娠 ,B超检查发现一胎胎死宫内入院。平素月经规律 ,核对孕周无误。孕 5 + 月时 B超检查提示双胎 ,胎儿大体未见异常 ,符合孕周。不定期外院产前检查 ,停经 2 8周出现双下肢水肿 ,休息后可缓解。停经 31周 B超提示胎儿双顶径分别为 8.1cm和7.4cm,股骨长 5 .8cm和 4.9cm,第二胎儿小于第一胎儿。停经 34+ 2 周出现血压升高 ,达 130 / 90 m m Hg(1mm Hg=0 .133 k Pa) ,尿蛋白 (+) ,浮肿 (+)。 2 d后入当地县医院治疗 ,B超检查提示双头位 ,第一胎儿双顶径 9.3 cm ,股骨长6 .4cm,可见胎心胎动 ;…     

Pure fetal blood samples obtained by cordocentesis: technical aspects of 322 cases

Three hundred and twenty-two percutaneous umbilical blood samplings were performed over 4 years in our prenatal diagnostic centre. A 3.5 MHz sector ultrasound transducer was used to guide a 22.5-gauge needle under local anaesthesia. Sampling was performed for rapid fetal karyotyping (within 72 h) in 120 cases, for diagnosis of fetal toxoplasmosis in 133 cases, for determination of the severity of Rh immunization in 15 cases, and for diagnosis of congenital rubella in 4 cases. Pure fetal blood was obtained in 98.7 per cent of the cases after two attempts. The approach to the cord was either transamniotic or transplacental. Puncturing was preferentially done at the placental insertion of the cord (72.2 per cent of the cases) and the mean blood sample volume was 3.5 ml. The rate of fetal death in utero was 1.9 per cent, including two cases of amnionitis, one trisomy 18, and one severe bradycardia. The failures were due to sampling at an early stage of pregnancy (before gestation week 18), to maternal obesity, oligohydramnios, and the inexperience of the operator.     

Effects of uterine contraction and a beta-stimulant on placental and fetal brain blood flow in correlation with fetal heart rate changes

The effects of uterine contraction on placental and fetal brain blood flow in correlation with fetal heart rate change and also beta-stimulant on placental and fetal brain blood flow during late deceleration were studied in late pregnant rabbits. We determined the fetal heart rate (FHR) and placental and fetal brain blood flow by a thermocouple method under urethane anesthesia. Fetuses exposed to a more than 30% decrease in placental blood flow by uterine contraction developed more than 20% bradycardia and also a significant decrease in fetal brain blood flow. There are a significant relationship between the decrease in FHR and fetal brain blood flow. beta-stimulant administered to the mother suffering from already severely hypoxic fetal bradycardia increased FHR in accordance with the increase in the placental blood flow and moreover there was recovery from decreased fetal brain blood flow.     

Direct chromosome analysis in the second and third trimesters by placental biopsy in 30 pregnancies

Direct chromosome analysis was performed on placental villi obtained by ultrasound-guided transabdominal needle aspiration in 30 women at between 23 and 37 weeks gestation. Placental biopsy is simple in the presence of severe oligohydramnios where fetal blood sampling is usually more difficult. Direct karyotyping of placental villi is more rapid than chromosomal analysis from fetal blood and from amniotic fluid. Two chromosomal anomalies were discovered: one trisomy 18 and one 6p+. Villus sampling failed in one woman and two samples obtained at 36 and 37 weeks gestation could not be karyotyped. The procedure did not affect the outcome of the pregnancy.     

Fetal blood sampling by liver puncture

Fetal blood sampling has been performed in several ways; placentacentesis, fetoscopy, or umbilical code puncture. The problems with these methods are technical difficulties and contamination of maternal blood or amniotic fluid. To solve these problems, we have tried fetal blood sampling by fetal liver puncture with a 21 approximately 23 gauge needle through the maternal abdomen under real time scan guidance. 10 patients underwent this procedure. They ranged from 18 weeks to 22 weeks of gestation at the time of sampling. The sampling procedures were done easily and the samples taken were shown to be pure fetal blood by red blood cell sizing. All the patients continued pregnancy after the examination and none of the pregnancies was influenced by the puncture. 7 patients have been delivered with neither sampling scars nor damage to liver function. This method provides pure fetal blood, the procedure is simple and, in our experience, no complications have occurred.     

Placental compliance--inferences from Doppler studies of umbilical blood flow during cardiac arrhythmia

Pulsed Doppler ultrasound was used to investigate human umbilical artery blood flow patterns in three fetuses where cardiac arrhythmias were present, viz., congenital bradycardia, multiple extrasystoles and 'dropped beats'. The impedance to blood flow along these arteries was assessed by the pulsatility index. The results suggest that the placental vascular bed on the fetal side has a high compliance.     

Cordocentesis for diagnostic indications: two years' experience

Cordocentesis was performed 96 times over a two-year interval, for a variety of diagnostic indications, in 55 completed pregnancies of 16-40 weeks' duration. There were four unsuccessful procedures, two associated with severe hydramnios and posterior placentas in which the available needles were too short. Sixty-three percent of procedures were successful on the first try; 95% succeeded within three attempts. Sixty-four percent of the samples were obtained from the placental cord origin, 27% from a free-floating loop, and 9% from the fetal cord origin. There were no maternal or significant fetal complications, and bleeding from the puncture site was not a problem. The present series confirms previous reports suggesting that in the proper hands, cordocentesis for diagnosis is a safe, rapid, and efficient means of obtaining access to the fetal circulation.     

Diagnostic mid trimester amniocentesis: how safe?

OBJECTIVE: Genetic mid-trimester amniocentesis is a common invasive procedure. The origin of the commonly quoted 0.5% rate of procedure-related pregnancy loss after amniocentesis is obscure and is in conflict with the only randomized prospective study that reported a procedure-related rate of loss of 1.0%. This review was performed to establish an estimate of procedure-related pregnancy loss after mid-trimester amniocentesis. The impact of placental puncture on the rate of loss and the risk of direct needle injury to the fetus were also examined. STUDY DESIGN: The National Library of Medicine database was used to identify English language reports of >1000 amniocenteses with sufficient detail and follow up data to allow the calculation of the rate of spontaneous pregnancy loss after amniocentesis but before 28 completed weeks. These reports were divided into 2 groups to assess the impact of the ultrasound technique. Group I described only preamniocentesis ultrasound evaluation; group II described primarily concurrent ultrasound needle guidance. Pregnancy loss between the 2 groups was compared. The impact of placental puncture and reported direct fetal trauma were examined. The significance of differences was tested using chi-square analysis, with significance at a probability value of < or =.05. RESULTS: Twenty-nine reports that totaled 68,119 amniocenteses were examined. In a comparison of all studies in group I with all studies in group II, there was a lower rate of loss after amniocenteses with the use of concurrent guidance (1.4%) compared with the use of preamniocentesis ultrasound evaluation (2.1%) that was significant ( P <.001). Among only the 5 controlled studies that used preamniocentesis ultrasound evaluation, the difference in rate of loss between amniocentesis patients and control subjects was 0.6% ( P =.0042; 95% CI, 0.19, 1.03), which was identical to the difference in the rate of loss of 0.6% between amniocentesis patients and control subjects from the 5 controlled studies that used concurrent ultrasound needle guidance ( P <.0001; 95% CI, 0.31, 0.90). Multiple case reports and small series of presumed fetal needle trauma were reviewed, but most of these attributed causation to the amniocentesis needle based only on circumstantial association. Two cases with direct evidence of fetal needle trauma are discussed. Finally, the rate of loss after placental puncture from among 9 reports that provided this detail was 1.4% and not different from the overall rate of loss that was noted in group II. CONCLUSION: This examination of experience with 68,119 amniocenteses from both controlled and uncontrolled studies provides a substantive basis for several conclusions: (1) Contemporary amniocentesis with concurrent ultrasound guidance in controlled studies appears to be associated with a procedure-related rate of excess pregnancy loss of 0.6% (95% CI, 0.31, 0.90). To determine the total rate of loss, this must be added to the reported natural rate of loss without amniocentesis among control patients of 1.08%. (2) The use of concurrent ultrasound guidance appears to reduce the number of punctures and the incidence of bloody fluid. Concurrent ultrasound guidance was associated with a reduced rate of loss when all studies were compared, but not among controlled studies. (3) Direct fetal needle trauma is rare, and rarely proved, but may occur more frequently than is reported because of a failure to diagnose and a failure of the consistent production of sequelae. (4) This experience does not substantiate an increased rate of pregnancy loss if placental puncture is required.     

Rapid karyotyping for prenatal diagnosis in the second and third trimesters of pregnancy

Direct chromosome preparations were performed on placental villi obtained by ultrasound-guided needle aspiration between 18 and 37 weeks of pregnancy in 53 patients. The sampling yielded a sufficient amount of tissue with a maximum of two, and in most cases one, insertions. Placental biopsy is easily performed in cases of severe oligohydrammnios, where fetal blood sampling is usually more difficult. Direct karyotyping of placental villi is faster than chromosome analysis from fetal blood or application of the pipette method on amniotic fluid cells, and currently represents the most rapid approach to prenatal diagnosis of chromosomal abnormalities from the first to the third trimester of pregnancy.     

Elevated maternal serum alpha-fetoprotein: association with placental sonolucencies, fetomaternal hemorrhage, vaginal bleeding, and pregnancy outcome in the absence of fetal anomalies.

Elevated maternal serum alpha-fetoprotein (MSAFP) levels have been associated with an increased incidence of both placental sonolucencies and pregnancy complications. We designed a prospective study to test the hypothesis that the presence of these sonolucencies or a positive maternal Kleihauer-Betke stain would be associated with an elevated risk of obstetric complications. We enrolled 95 women with singleton pregnancies, elevated MSAFP, and no evidence of fetal anomalies on second-trimester ultrasound evaluation. Placental sonolucencies were documented at the time of ultrasound examination, and a maternal Kleihauer-Betke stain for fetal cells was obtained on the same day. Complications of pregnancy included fetal growth retardation, preterm delivery, late vaginal bleeding (at or after the 20th week of gestation), and fetal death. Women with elevated MSAFP had an increased incidence of placental sonolucencies, positive maternal Kleihauer-Betke stains, first-trimester vaginal bleeding, late vaginal bleeding, preterm delivery, fetal growth retardation, and fetal death compared with controls. Thirty-nine of 95 women with elevated MSAFP (41.1%) had at least one complication. In women with elevated levels, neither the presence of placental sonolucencies nor a positive Kleihauer-Betke stain correlated with first-trimester vaginal bleeding, the MSAFP level, or an increased risk of pregnancy complications. First-trimester vaginal bleeding was associated with an increased risk of preterm delivery in subjects with elevated MSAFP.     

Fetal blood sampling from the intrahepatic vein: analysis of safety and clinical experience with 214 procedures

Transabdominal fetal blood sampling under ultrasonic guidance was performed at the intrahepatic vein on 214 occasions in 177 fetuses. In 72 cases, an intravascular transfusion was also attempted at the same site. In 91.1% of the samplings, more than 1 mL of pure fetal blood was obtained, and in 89.9% of transfusions, fetal hematocrit or platelet concentration was raised to a satisfactory level. Fetal bradycardia and intraperitoneal bleeding occurred in 2.3% of the cases. Among fetuses at low risk, there was only one intrauterine death, which occurred 3 weeks after the procedure, and one spontaneous abortion in a patient with twin pregnancy. In fetuses with Rh/Kell alloimmunization or perinatal alloimmune thrombocytopenia, the survival rate was 86%. Four liver enzymes were assayed in the blood of 13 fetuses that underwent transfusions at the intrahepatic vein and 13 controls in whom the site of sampling was the umbilical vein at the placental cord insertion. No differences were found between the groups at the subsequent transfusion 2-5 weeks later. The intrahepatic vein is an alternate site of sampling/transfusion when access is difficult or failure occurs at the placental cord insertion. This approach minimizes the risks of fetal blood loss, fetomaternal hemorrhage, arterial vasospasm, and cord tamponade.