Meise C, Germer U, Gembruch U
Division of Prenatal Medicine, Department of Obstetrics and Gynaecology, Medical University of Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany.
Ultrasound Obstet Gynecol. 2001 May;17(5):398-402. doi: 10.1046/j.1469-0705.2001.00397.x.
To assess the influence of isolated congenital heart disease (CHD) on fetal arterial Doppler blood flow velocity waveforms.
Doppler flow velocimetry was performed in the umbilical artery and middle cerebral artery in 115 consecutive fetuses with antenatally diagnosed CHD. Gestational age ranged between 19 and 41 weeks. Fetuses with isolated CHD were defined as group A (n = 55), showing cardiogenic hydrops fetalis in six cases; group B included 60 cases complicated by chromosomal or non-chromosomal extracardiac malformation, uteroplacental dysfunction or non-cardiogenic non-immune hydrops fetalis. The control group comprised 100 healthy fetuses of uncomplicated pregnancies. Individual pulsatility index measurements were converted into their Z-scores (delta values) for statistical analysis.
In regard to the umbilical artery pulsatility index, 115 fetuses with CHD showed a significantly greater (P < 0.001) difference from the normal mean for gestation (delta values) than the control group. However, 29 of the 33 cases with indices above the 95% reference interval were additionally associated with extracardiac malformations, uteroplacental dysfunction or non-cardiogenic non-immune hydrops fetalis. While fetuses with isolated CHD still showed significantly higher values than healthy fetuses (P < 0.01), only in 4 of 55 (7%) fetuses did the measured umbilical artery pulsatility index exceed the 95% reference interval. There was no significant difference from the control group, in which 4 of 100 cases showed an umbilical artery pulsatility index above the 95% reference interval. Elevated umbilical artery pulsatility indices were seen in only four cases of severe obstruction of the outflow tracts leading to reverse perfusion of the affected great artery and in one case of Ebstein's anomaly with pulmonary insufficiency. Although all four fetuses with isolated CHD and elevated umbilical artery pulsatility index died, 14 of 18 fetuses with lethal outcome had normal pulsatility index values in the umbilical artery. Investigations of the middle cerebral artery blood flow revealed no significant difference between fetuses with and without CHD or any subgroups.
This study shows that arterial blood flow velocity waveforms in fetuses with isolated CHD do not show sufficient alterations to be of diagnostic value. Only in severe outflow tract obstructions due to a 'steal effect' or in significant insufficiencies of semilunar valves leading to an impaired 'wind-kessel function' may the special hemodynamic changes induced by CHD result in a significant increase of pulsatility index in the umbilical artery. In the majority of cases with CHD the increase of pulsatility index of umbilical arterial blood flow velocity waveforms, however, results from extracardiac anomalies, especially uteroplacental dysfunction and chromosomal abnormalities. Furthermore, umbilical artery Doppler sonography is not clinically helpful in predicting fetal outcome.
评估孤立性先天性心脏病（CHD）对胎儿动脉多普勒血流速度波形的影响。
对115例产前诊断为CHD的连续胎儿进行脐动脉和大脑中动脉的多普勒血流测速。孕周在19至41周之间。孤立性CHD胎儿定义为A组（n = 55），其中6例出现心源性胎儿水肿；B组包括60例合并染色体或非染色体心脏外畸形、子宫胎盘功能障碍或非心源性非免疫性胎儿水肿的病例。对照组包括100例正常妊娠的健康胎儿。将个体搏动指数测量值转换为Z值（差值）进行统计分析。
关于脐动脉搏动指数，115例CHD胎儿与正常孕周均值（差值）的差异显著大于对照组（P < 0.001）。然而，33例指数高于95%参考区间的病例中，有29例还合并心脏外畸形、子宫胎盘功能障碍或非心源性非免疫性胎儿水肿。虽然孤立性CHD胎儿的值仍显著高于健康胎儿（P < 0.01），但55例中只有4例（7%）测量的脐动脉搏动指数超过95%参考区间。与对照组无显著差异，对照组100例中有4例脐动脉搏动指数高于95%参考区间。仅在4例严重流出道梗阻导致受累大动脉逆向灌注的病例以及1例合并肺功能不全的埃布斯坦畸形病例中观察到脐动脉搏动指数升高。虽然4例孤立性CHD且脐动脉搏动指数升高的胎儿均死亡，但18例致死结局的胎儿中有14例脐动脉搏动指数值正常。大脑中动脉血流检查显示，有CHD和无CHD的胎儿或任何亚组之间无显著差异。
本研究表明，孤立性CHD胎儿的动脉血流速度波形没有足够的改变以具有诊断价值。只有在因“盗血效应”导致的严重流出道梗阻或半月瓣显著功能不全导致“风箱功能”受损时，CHD引起的特殊血流动力学变化才可能导致脐动脉搏动指数显著增加。然而，在大多数CHD病例中，脐动脉血流速度波形搏动指数的增加是由心脏外异常引起的，尤其是子宫胎盘功能障碍和染色体异常。此外，脐动脉多普勒超声检查在预测胎儿结局方面对临床没有帮助。
