【摘要】 目的采用三维超声技术测量复杂先天性心脏病(CHD)胎儿额叶容积与丘脑容积,以评价CHD胎儿脑发育。方法选择2013年4月至2014年12月于中南大学湘雅二医院产检的孕妇241名。所有孕妇均为单胎妊娠。其中CHD组胎儿73例,均经胎儿超声心动图诊断,其中10例胎儿引产后经尸体解剖证实,其余63例胎儿产后经手术确诊;健康对照组胎儿168名。健康对照组胎儿<30周者105名,≥30周者63名。CHD组胎儿<30周者50例,≥30周者23例。首先对孕妇进行常规产科超声检查,测量胎儿双顶径(BPD)、头围(HC);然后应用三维超声容积自动测量(VOCAL)技术测量胎儿额叶容积、丘脑容积、大脑中动脉(MCA)及脐动脉(UA)搏动指数(PI)及脑/脐血流比值(CPR)。采用Pearson相关分析法分析健康对照组胎儿颅脑三维容积与孕周、BPD及HC的相关性。采用独立样本t检验比较健康对照组与CHD组胎儿颅脑三维容积、脑血流参数差异。采用Pearson相关分析法分析胎儿颅脑三维容积与脑血流参数的相关性。结果 (1)健康对照组胎儿额叶容积与孕周、BPD及HC均显著相关(r=0.982、0.930、0.945,P均<0.01),丘脑容积与孕周、BPD及HC也均显著相关(r=0.989、0.973、0.976,P值均<0.01)。(2)≥30周CHD组胎儿额叶容积、丘脑容积均较健康对照组胎儿减小,且差异均有统计学意义[(61.6±8.9)cm3vs(77.6±9.2)cm3,(3.9±0.6)cm3vs(4.2±0.6)cm3,t=7.205、2.122,P值均<0.05],≥30周CHD组胎儿额叶容积经HC标准化后仍小于健康对照组胎儿,且差异仍有统计学意义[(2.6±0.2)cm3/cm vs(2.1±0.2)cm3/cm,t=8.193,P<0.05]。(3)CHD组胎儿MCA-PI、CPR均较健康对照组胎儿降低,且差异均有统计学意义(1.8±0.4 vs 1.7±0.4,1.8±0.5 vs1.6±0.5,t=2.028、3.331,P值均<0.05),胎儿额叶容积、丘脑容积与CPR均呈显著正相关(r=0.618、0.634,P<0.01),说明CPR的减小与胎儿额叶容积、丘脑容积的减小关系密切。结论 CHD在子宫内即影响胎儿脑发育,导致晚孕期胎儿额叶容积及丘脑容积相对减小,其原因可能与CHD胎儿脑血流动力学的改变有关。更多还原

【Abstract】 Objective To evaluate the development of fetal brain in complex congenital heart disease(CHD) by three-dimensional ultrasound technique measuring fetal brain volume. Methods The study was conducted at the Second Xiangya Hospital of Central South University in China between April 2013 and December 2014, enrolled 241 women with single baby. The 73 fetus with CHD were diagnosed by echocardiographic examination; 10 of the fetus were confirmed by autopsy after induction of labour; the other 63 fetus confirmed by cardiac surgery after birth. Volumes were satisfactorily obtained in 168 normal fetus, including 105 fetus gestational age < 30 weeks and 63 fetus gestational age ≥ 30 weeks; and 73 fetus with CHD, including 50 fetus gestational age < 30 weeks and 23 fetus gestational age ≥ 30 weeks. Ultrasound examinations were performed in all fetuses. Fetal biometry, including biparietal diameter(BPD), head circumference(HC) was performed. Volume of frontal lobe and thalamus were measured using 3D ultrasound imaging in normal fetuses and fetus with complex CHD, and blood flow in middle cerebral artery(MCA) and umbilical artery(UA), pulsatility index(PI) and cerebroplacental Doppler ratio(CPR), were obtained. The correlation between fetal brain volumes and gestational age(GA), BPD, HC was analyzed by Pearson?s correlation. Fetal HC, volumes of brain and Doppler parameters were compared between cases and controls using Student?s t-test. The correlation between brain volumes of normal fetuses and fetus with complex CHD and blood flow Doppler parameter is respectively analyzed by Pearson?s correlation. Results(1) The normal fetal volume of frontal lobe were highly correlated with GA, BPD and HC(r=0.982, 0.930, 0.945, all P < 0.01); and the normal fetal volume of thalamus were also highly correlated with GA, BPD and HC(r=0.989, 0.973, 0.976, all P < 0.01).(2) During the third trimester( ≥ 30 weeks), frontal and thalamic volume were significantly smaller in CHD fetuses [(61.6±8.9) cm3 vs(77.6±9.2) cm3,(3.9±0.6) cm3 vs(4.2±0.6) cm3, t=7.205, 2.122, both P < 0.05]. After adjusting the volumes for HC the frontal volume was still significantly smaller in CHD fetus than in normal fetuses [(2.6±0.2) cm3/cmvs(2.1±0.2) cm3/cm, t=8.193, P < 0.05].(3) MCA-PI and CPR were found to be significantly lower in the CHD group compared with controls(1.8±0.4 vs 1.7±0.4, 1.8±0.5 vs 1.6±0.5, t=2.028, 3.331, both P < 0.05). Furthermore, low CPR was significantly associated with decreased frontal lobe and thalamic volume(r=0.618, 0.634, both P < 0.01). Conclusions Congenital heart disease affected fetal brain development in utero, caused smaller volume of frontal lobe and thalamus during the third trimester. Hemodynamic factors may play an important role in this abnormal development.更多还原