Sonesson Sven-Erik, Ambrosi Aurelie, Nordenstam Felicia, Eliasson Håkan, Wahren-Herlenius Marie
Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.
Division of Rheumatology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.
Acta Obstet Gynecol Scand. 2024 Dec;103(12):2433-2441. doi: 10.1111/aogs.14988. Epub 2024 Oct 9.
We investigated the effects of timing of detection and transplacental fluorinated steroid treatment on ventricular heart rate (HR) and age at pacemaker implantation in fetal third-degree atrioventricular block (AVB).
Twenty-five of 31 fetuses diagnosed with Ro/SSA autoantibody-positive AVB II-III at our tertiary fetal cardiology center (2000-2020) and AVB III as final feto-neonatal outcome were reviewed.
AVB was detected approximately 5 weeks earlier in pregnancy if followed in a surveillance program compared to cases referred from primary care for bradycardia (20.6 [2.3] [mean (SD)] vs. 25.4 [3.2] weeks, p = 0.001). AVB detected before 24 weeks had higher HR than those detected later in gestation (63.3 [6.9] vs. 57.2 [6.9] bpm, p = 0.042), with a larger proportion having HR >60 bpm (80% vs. 33%, p = 0.041). The 17/25 cases that received treatment with fluorinated steroid were diagnosed earlier in gestation, with higher HR at diagnosis (61.7 [7.1] vs. 54.7 [6.3] bpm, p = 0.026), 1-2 weeks after diagnosis/treatment start, and before birth (65.4 [12.4] vs. 54.9 [5.7] bpm, p = 0.030) than untreated cases. Overall, 11 cases were commenced on betamimetics: three at diagnosis and eight at or after the examination made 1-2 weeks after diagnosis/treatment start, without any HR improvement. Two of 24 surviving babies were born preterm, and 4/24 received a neonatal pacemaker. Age at pacemaker implantation correlated significantly with HR before birth (Spearman R 0.57, p = 0.004), and fetuses with HR >60 bpm had a higher rate of pacemaker-free survival at three (90% vs. 40%, p = 0.018) and 12 months of age (80% vs. 13%, p = 0.002). The same trend was observed in pacemaker-free survival at 3 months of age in fluorinated steroid-treated compared to untreated cases (71% vs. 38%, ns).
Our data confirm that AVB III detected earlier in gestation have a higher HR, and suggest that this higher HR can be successfully maintained to the end of gestation in cases treated with fluorinated steroids. Fetuses with HR >60 bpm before birth had a lower rate of pacemaker implantation at 3 and 12 months of age.
我们研究了检测时机和经胎盘给予氟化类固醇治疗对胎儿三度房室传导阻滞（AVB）时心室心率（HR）及起搏器植入年龄的影响。
回顾了我们三级胎儿心脏病中心（2000 - 2020年）诊断为Ro/SSA自身抗体阳性II - III度AVB且最终胎儿 - 新生儿结局为AVB III度的31例胎儿中的25例。
与因心动过缓从初级保健机构转诊的病例相比，如果在监测项目中进行随访，AVB在妊娠中被检测到的时间约早5周（20.6 [2.3] [均值（标准差）] 周对25.4 [3.2] 周，p = 0.001）。在妊娠24周前检测到的AVB比妊娠后期检测到的HR更高（63.3 [6.9] 对57.2 [6.9] 次/分钟，p = 0.042），HR > 60次/分钟的比例更高（80%对33%，p = 0.041）。接受氟化类固醇治疗的17/25例病例在妊娠早期被诊断出来，诊断时HR更高（61.7 [7.1] 对54.7 [6.3] 次/分钟，p = 0.026），在诊断/治疗开始后1 - 2周以及出生前（65.4 [12.4] 对54.9 [5.7] 次/分钟，p = 0.030）也高于未治疗的病例。总体而言，11例开始使用β - 拟交感神经药物：3例在诊断时使用，8例在诊断/治疗开始后1 - 2周进行检查时或之后使用，HR无任何改善。24例存活婴儿中有2例早产，24例中有4例接受了新生儿起搏器植入。起搏器植入年龄与出生前HR显著相关（Spearman相关系数R 0.57，p = 0.004），出生前HR > 60次/分钟的胎儿在3个月（90%对40%，p = 0.018）和12个月龄（80%对13%，p = 0.002）时无起搏器存活的比例更高。与未治疗的病例相比，氟化类固醇治疗的病例在3个月龄时无起搏器存活情况也观察到相同趋势（71%对38%，无显著性差异）。
我们的数据证实，妊娠早期检测到的AVB III度HR更高，并表明在用氟化类固醇治疗的病例中，这种较高的HR可以成功维持到妊娠末期。出生前HR > 60次/分钟的胎儿在3个月和12个月龄时起搏器植入率较低。
