Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, CA; Fetal Diagnostic Centers, Pasadena, Tarzana, and Lancaster, CA.
Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Denver, CO.
Am J Obstet Gynecol. 2019 Nov;221(5):498.e1-498.e22. doi: 10.1016/j.ajog.2019.05.042. Epub 2019 May 30.
To determine whether abnormal global, transverse, and longitudinal ventricular contractility of the heart in fetuses with an estimated fetal weight <10th centile is present, irrespective of Doppler studies of the umbilical artery and cerebroplacental ratio.
This was a retrospective study of 50 fetuses with an estimated fetal weight <10th centile that were classified based on Doppler results from the pulsatility indices of the umbilical artery and middle cerebral artery, and the calculated cerebroplacental ratio (pulsatility indices of the umbilical artery/middle cerebral artery). Right and left ventricular measurements were categorized into 3 groups: (1) global ventricular contractility (fractional area change), (2) transverse ventricular contractility (24-segment transverse fractional shortening), and (3) basal-apical longitudinal contractility (longitudinal strain, longitudinal displacement fractional shortening, and basal lateral and septal wall annular plane systolic excursion). Z scores for the above measurements were computed for fetuses with an estimated fetal weight <10th centile using the mean and standard deviation derived from normal controls. Ventricular contractility measurements were considered abnormal if their Z score values were <5th centile (z score <-1.65) or >95th centile (Z score >1.65), depending on the specific ventricular measurement.
The average gestational age at the time of the examination was 32 weeks 4 days (standard deviation 3 weeks 4 days). None of the 50 study fetuses demonstrated absent or reverse flow of the umbilical artery Doppler waveform. Eighty-eight percent (44/50) of fetuses had one or more abnormal measurements of cardiac contractility of 1 or both ventricles. Analysis of right ventricular contractility demonstrated 78% (39/50) to have 1 or more abnormal measurements, which were grouped as follows: global contractility 38% (19/50), transverse contractility 66% (33/50); and longitudinal contractility 48% (24/50). Analysis of left ventricular contractility demonstrated 1 or more abnormal measurements in 58% (29/50) that were grouped as follows: global contractility 38% (19/50); transverse contractility 40% (20/50); and longitudinal contractility 40% (20/50). Of the 50 study fetuses, 25 had normal pulsatility index of the umbilical artery and cerebroplacental ratios, 80% of whom had 1 or more abnormalities of right ventricular contractility and 56% of whom had 1 or more abnormalities of left ventricular contractility. Abnormal ventricular contractility for these fetuses was present in all 3 groups of measurements; global, transverse, and longitudinal. Those with an isolated abnormal pulsatility index of the umbilical artery (n=11) had abnormalities of transverse contractility of the right ventricular and global contractility in the left ventricle. When an isolated cerebroplacental ratio abnormality was present, the right ventricle demonstrated abnormal global, transverse, and longitudinal contractility, with the left ventricle only demonstrating abnormalities in transverse contractility. When both the pulsatility index of the umbilical artery and cerebroplacental ratio were abnormal (3/50), transverse and longitudinal contractility measurements were abnormal for both ventricles, as well as abnormal global contractility of the left ventricle.
High rates of abnormal ventricular contractility were present in fetuses with an estimated fetal weight <10th centile, irrespective of the Doppler findings of the pulsatility index of the umbilical artery, and/or cerebroplacental ratio. Abnormalities of ventricular contractility were more prevalent in transverse measurements than global or longitudinal measurements. Abnormal transverse contractility was more common in the right than the left ventricle. Fetuses with estimated fetal weight less than the 10th centile may be considered to undergo assessment of ventricular contractility, even when Doppler measurements of the pulsatility index of the umbilical artery, and cerebroplacental ratio are normal.
确定估计胎儿体重低于第 10 百分位的胎儿是否存在心脏整体、横向和纵向收缩功能异常，而不考虑脐动脉和脑胎盘比的多普勒研究。
这是一项回顾性研究，纳入了 50 名估计胎儿体重低于第 10 百分位的胎儿。根据脐动脉和大脑中动脉搏动指数以及计算出的脑胎盘比（脐动脉/大脑中动脉搏动指数）的多普勒结果对胎儿进行分类。将右心室和左心室的测量结果分为 3 组：（1）整体心室收缩功能（分数面积变化），（2）横向心室收缩功能（24 节段横向分数缩短），（3）基底-顶端纵向收缩功能（纵向应变、纵向位移分数缩短和基底外侧和间隔壁环状平面收缩期位移）。使用正常对照组的平均值和标准差，为估计胎儿体重低于第 10 百分位的胎儿计算上述测量值的 Z 分数。如果其 Z 分数值<第 5 百分位数（z 分数<-1.65）或>第 95 百分位数（Z 分数>1.65），则认为心室收缩力测量值异常，具体取决于特定的心室测量值。
检查时的平均孕龄为 32 周 4 天（标准差 3 周 4 天）。50 例研究胎儿中均未出现脐动脉多普勒波形缺失或反向血流。88%（44/50）的胎儿存在 1 个或多个心脏收缩力测量值异常，单侧或双侧心室均有异常。右心室收缩力分析显示 78%（39/50）存在 1 个或多个异常测量值，分为以下几类：整体收缩力 38%（19/50），横向收缩力 66%（33/50）；纵向收缩力 48%（24/50）。左心室收缩力分析显示 58%（29/50）存在 1 个或多个异常测量值，分为以下几类：整体收缩力 38%（19/50），横向收缩力 40%（20/50）；纵向收缩力 40%（20/50）。在 50 例研究胎儿中，25 例脐动脉搏动指数和脑胎盘比正常，其中 80%存在 1 个或多个右心室收缩力异常，56%存在 1 个或多个左心室收缩力异常。这些胎儿的心室收缩力异常存在于所有 3 组测量中，包括整体、横向和纵向。孤立性脐动脉搏动指数异常（n=11）的胎儿存在右心室横向收缩力和左心室整体收缩力异常。孤立性脑胎盘比异常时，右心室表现为整体、横向和纵向收缩力异常，而左心室仅表现为横向收缩力异常。当脐动脉搏动指数和脑胎盘比均异常时（3/50），双侧心室的横向和纵向收缩力以及左心室的整体收缩力均异常。
估计胎儿体重低于第 10 百分位的胎儿存在较高的心室收缩功能异常发生率，而不考虑脐动脉搏动指数和脑胎盘比的多普勒发现。心室收缩力异常以横向测量值更为常见，而不是整体或纵向测量值。右心室的横向收缩力异常比左心室更为常见。即使脐动脉搏动指数和脑胎盘比的多普勒测量值正常，估计胎儿体重低于第 10 百分位的胎儿也可能需要进行心室收缩力评估。
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