心肌做功指数在评价帆状胎盘孕妇胎儿心功能中的应用

doi:10.3877/cma.j.issn.1672-6448.2019.07.008

目的

应用心肌做功指数（MPI）评价帆状胎盘孕妇胎儿心功能的变化及与不良妊娠结局的关系。

方法

选取2016年1月至2018年12月在北京妇产医院确诊帆状胎盘孕妇70例（帆状胎盘组），孕周28~40周，同时选取同孕周正常孕妇89例（对照组），采用t检验比较两组左心室MPI、二三尖瓣口血流速度（E/A比值）及脐动脉搏动指数（UA-PI）、大脑中动脉搏动指数（MCA-PI）和静脉导管搏动指数（DV-PI）。采用ROC曲线分析MPI预测不良妊娠结局，将不良妊娠结局定为如下任意一个：胎儿窘迫、新生儿转ICU、新生儿窒息、呼吸性酸中毒。

结果

帆状胎盘组左心室MPI显著高于正常组，差异有统计学意义（t=4.593，P<0.001）；帆状胎盘组UA-PI显著高于正常组，差异有统计学意义（t=-4.142，P<0.05）；帆状胎盘组二尖瓣E/A值、三尖瓣E/A值、MCA-PI、DV-PI与正常组比较，差异均无统计学意义（P均>0.05）。ROC曲线分析显示帆状胎盘组胎儿左心室MPI预测不良结局的ROC曲线下的面积为0.690（95%置信区间为0.580~0.799）。最佳截断值为0.45，其敏感度为83.3%，特异度为38.1%。

结论

帆状胎盘孕妇胎儿心功能是降低的，左心室MPI升高在一定程度上与不良妊娠结局显著性相关，从而为监测宫内胎儿安危及改善妊娠结局提供依据。

关键词: 帆状胎盘, 胎儿心功能, 心肌做功指数

Objective

To determine whether there are any changes in fetal cardiac function in pregnant women with velamentous cord insertion by using the myocardial performance index and whether there are any influence on perinatal outcome.

Methods

Seventy singleton pregnant women diagnosed with velamentous cord insertion at 28-40 weeks of gestation were recruited to the study from January 2016 to December 2018. They were matched with 89 healthy women with normal pregnancies. Using Doppler echocardiography, the modified myocardial performance index (Mod-MPI) and ratios of E wave/A wave peak velocities (E/A) were determined. The Doppler indices of ductus venosus and umbilical and middle cerebral arteries were also determined in both groups. Adverse perinatal outcome was defined as fetal distress, admission to neonatal intensive care unit, neonatal asphyxia, and respiratory acidosis.

Results

The Mod-MPI (t=4.593, P<0.001) and umbilical artery PI were increased (t=-4.142, P<0.05) in fetuses of pregnant women with velamentous cord insertion compared with controls. The two groups had no significant differences in MV E/A ratio, TV E/A ratio, MCA-PI, or DV-PI (P>0.05 for all). Receiver operating characteristic analysis revealed>0.45 as the optimal cut-off level for MPI in perinatal adverse outcome prediction (sensitivity: 83.3%; specificity: 38.1%; area under the curve: 0.690; 95% confidence interval: 0.580-0.799).

Conclusions

Fetuses of pregnant women with velamentous cord insertion have significantly impaired cardiac function. There is an association between the MPI elevation and adverse perinatal outcome. The Mod-MPI has the potential to provide a theoretical basis for monitoring intrauterine environment.

Key words: Velamentous cord insertion, Fetal cardiac function, Myocardial performance index

图2 对照组胎儿左心室心肌做功指数频谱图（LV-MPI）

图4 对照组胎儿二尖瓣口血流频谱（MV-E/A值）

图6 对照组胎儿三尖瓣口血流频谱（TV-E/A值）

图8 对照组胎儿脐动脉血流频谱（UA-PI）

图10 对照组胎儿大脑中动脉血流频谱（MCA-PI）

图12 对照组胎儿静脉导管血流频谱（DV-PI）

表1 帆状胎盘组与对照组孕妇及胎儿一般资料比较（±s）

组别	例数	孕妇年龄（岁）	体质量指数	孕周（周）	BPD（cm）	HC（cm）	AC（cm）	FL（cm）	EFW（g）
帆状胎盘组	70	29.50±3.20	26.37±2.95	31.89±7.38	8.44±0.74	30.47±2.19	29.88±4.93	6.42±0.60	2255.84±653.21
对照组	89	29.27±2.75	26.94±2.63	33.47±2.60	8.43±1.08	30.54±1.97	29.28±2.89	6.48±0.57	2267.27±602.13
t值	?	-0.418	-1.292	-1.909	0.047	-0.217	0.9777	-0.675	-0.115
P值	?	0.677	0.198	0.058	0.963	0.829	0.330	0.500	0.909

表1 帆状胎盘组与对照组孕妇及胎儿一般资料比较（±s）

组别	例数	孕妇年龄（岁）	体质量指数	孕周（周）	BPD（cm）	HC（cm）	AC（cm）	FL（cm）	EFW（g）
帆状胎盘组	70	29.50±3.20	26.37±2.95	31.89±7.38	8.44±0.74	30.47±2.19	29.88±4.93	6.42±0.60	2255.84±653.21
对照组	89	29.27±2.75	26.94±2.63	33.47±2.60	8.43±1.08	30.54±1.97	29.28±2.89	6.48±0.57	2267.27±602.13
t值	?	-0.418	-1.292	-1.909	0.047	-0.217	0.9777	-0.675	-0.115
P值	?	0.677	0.198	0.058	0.963	0.829	0.330	0.500	0.909

表2 帆状胎盘组与对照组胎儿心功能的比较（±s）

组别	例数	IRT（ms）	ICT（ms）	ET（ms）	MPI	MV-E/A	TV-E/A	HR（次/min）	UA-PI	MCA-PI	DV-PI
帆状胎盘组	70	45.63±7.29	35.34±7.37	169.39±11.52	0.48±0.04	0.72±0.13	0.74±0.12	144.32±8.95	0.98±0.12	1.83±0.38	0.48±0.20
对照组	89	41.64±6.40	33.17±7.93	168.41±14.22	0.45±0.05	0.69±0.11	0.71±0.10	144.90±9.91	0.88±0.11	1.88±0.56	0.51±0.20
t值	?	3.715	1.781	0.474	4.593	1.041	1.829	0.704	-5.492	-0.522	-0.830
P值	?	0.000	0.077	0.636	0.000	0.300	0.070	0.380	0.001	0.603	0.408

表2 帆状胎盘组与对照组胎儿心功能的比较（±s）

组别	例数	IRT（ms）	ICT（ms）	ET（ms）	MPI	MV-E/A	TV-E/A	HR（次/min）	UA-PI	MCA-PI	DV-PI
帆状胎盘组	70	45.63±7.29	35.34±7.37	169.39±11.52	0.48±0.04	0.72±0.13	0.74±0.12	144.32±8.95	0.98±0.12	1.83±0.38	0.48±0.20
对照组	89	41.64±6.40	33.17±7.93	168.41±14.22	0.45±0.05	0.69±0.11	0.71±0.10	144.90±9.91	0.88±0.11	1.88±0.56	0.51±0.20
t值	?	3.715	1.781	0.474	4.593	1.041	1.829	0.704	-5.492	-0.522	-0.830
P值	?	0.000	0.077	0.636	0.000	0.300	0.070	0.380	0.001	0.603	0.408

表3 帆状胎盘组与对照组新生儿一般资料比较

组别	例数	出生孕周（周，±s）	新生儿体重（g，±s）	新生儿身高（cm，±s）	性别［例（%）］
帆状胎盘组	70	38.80±1.62	3288.80±520.27	50.07±1.69	41（57.5）
对照组	89	39.04±1.00	3380.20±367.16	50.11±0.94	50（54.3）
统计值	?	t=-1.100	t=-1.258	t=-0.171	χ²=0.188
P值	?	0.274	0.211	0.8654	0.665

表3 帆状胎盘组与对照组新生儿一般资料比较

组别	例数	出生孕周（周，±s）	新生儿体重（g，±s）	新生儿身高（cm，±s）	性别［例（%）］
帆状胎盘组	70	38.80±1.62	3288.80±520.27	50.07±1.69	41（57.5）
对照组	89	39.04±1.00	3380.20±367.16	50.11±0.94	50（54.3）
统计值	?	t=-1.100	t=-1.258	t=-0.171	χ²=0.188
P值	?	0.274	0.211	0.8654	0.665

表4 帆状胎盘组与对照组妊娠不良结局比较［例（%）］

组别	例数	胎儿窘迫	新生儿转ICU	新生儿窒息	呼吸性酸中毒
帆状胎盘组	70	9（12.7）	14（19.7）	2（2.8）	3（4.2）
对照组	89	0	0	0	0
χ²值	?	12.344	19.845	2.624	3.960
P值	?	0.000	0.000	0.105	0.047

表4 帆状胎盘组与对照组妊娠不良结局比较［例（%）］

组别	例数	胎儿窘迫	新生儿转ICU	新生儿窒息	呼吸性酸中毒
帆状胎盘组	70	9（12.7）	14（19.7）	2（2.8）	3（4.2）
对照组	89	0	0	0	0
χ²值	?	12.344	19.845	2.624	3.960
P值	?	0.000	0.000	0.105	0.047

图13 MPI预测不良妊娠结局的受试者工作特征曲线下面积

1	Melcer Y, Maymon R, Pekar-Zlotin M, et al. Evaluation of the impact of vase previa on feto-placental hormonal synthesis and fetal growth [J]. Eur J Obstet Gynecol Reprod Biol, 2017, 215: 193-196.
2	Ream M, Ray AM, Chandra R, et al. Early fetal hypoxia leads to growth restriction and myocardial thinning [J]. Am J Physiol Regul Integr Comp Physiol, 2008, 295(2): R583-R595.
3	Lewis RM, Cleal JK, Hanson MA. Review: Placenta, evolution and lifelong health [J]. Placenta, 2012, 33 Suppl: S28-S32.
4	Gaillard R, Steegers EA, Tiemeier H, et al. Placental vascular dysfunction, fetal and childhood growth, and cardiovascular development the generation R study [J]. Circulation, 2013, 128(20): 2202-2210.
5	Heinonen S, Ryynänen M, Kirkinen P, et al. Velamentous umbilical cord insertion may be suspected from maternal serum alpha-fetoprotein and hCG [J]. Br J Obstet Gynaecol, 1996, 103(3): 209-213.
6	Salafia CM, Silberman L, Herrera NE, et al. Placental pathology at term associated with elevated midtrimester serum alpha-fetoprotein concentration [J]. Am J Obstet Gynecol, 1988, 158(5): 1064-1066.
7	Tsutsumi T, Ishii M, Eto G, et al. Serial evaluation for myocardial performance in fetuses and neonates using a new Doppler index [J]. Pediatr Int, 1999, 41(6): 722-727.
8	Eidem BW, Edwards JM, Cetta F. Quantitative assessment of fetal ventricular function: establishing normal values of the myocardial performance index in the fetus [J]. Echocardiography, 2001, 18(1): 9-13.
9	Api O, Emeksiz MB, Api M, et al. Modified myocardial performance index for evaluation of fetal cardiac function in pre-eclampsia [J]. Ultrasound Obstet Gynecol, 2009, 33(1): 51-57.
10	Friedman D, Buyon J, Kim M, et al. Fetal cardiac function assessed by Doppler myocardial performance index (Tei Index) [J]. Ultrasound Obstet Gynecol, 2003, 21(1): 33-36
11	Karabulut A, Doğan A, Tuzcu AK, et al. Myocardial Performance Index for Patients with Overt and Subclinical Hypothyroidism [J]. Med Sci Monit, 2017, 23: 2519-2526.
12	Goroshi M, Chand D. Myocardial Performance Index (Tei Index): A simple tool to identify cardiac dysfunction in patients with diabetes mellitus [J]. Indian Heart J, 2016, 68(68): 83-87.
13	Song ES, Yoon S, Cho JH, et al. Serial evaluation of myocardial function using the myocardial performance index in Kawasaki disease [J]. World J Pediatr, 2018, 14(3): 259-268.
14	Olson JM, Samad BA, Alam M, et al. Myocardial performance index determined by Tissue Doppler Imaging in patients with systolic heart failure predicts poor long-term prognosis: An observational cohort study [J]. J Card Fail, 2016, 22(8): 611-617.
15	Bhorat IE, Bagratee J, Pillay M, et al. Determination of the myocardial performance index in deteriorating grades of intrauterine growth restriction and its link to adverse outcomes [J]. Prenat Diagn, 2015, 35(3): 266-273.
16	Chawengsettakul S, Russameecharoen K, Wanitpongpan P. Fetal cardiac function measured by myocardialperformance index of small-for-gestational age fetuses [J]. J Obstet Gynaecol Res, 2015, 41(2): 222-228.
17	Cui W, Roberson DA, Chen Z, et al. Systolic and diastolic time intervals measured from Doppler tissue imaging: normal values and Z-score tables, and effects of age, heart rate, and body surface area [J]. J Am Soc Echocardiogr, 2008, 21(4): 361-370.
18	Van Mieghem T, Gucciardo L, Lewi P, et al. Validation of the fetal myocardial performance index in the second and third trimesters of gestation [J]. Ultrasound Obstet Gynecol, 2009, 33(1): 58-63.
19	Yerlikaya G, Pils S, Springer S, et al. Velamentous cord insertion as a risk factor for obstetric outcome: a retrospective case–control study [J]. Arch Gynecol Obstet, 2016, 293(5): 975-981.
20	Yampolsky M, Salafia CM, Shlakhter O, et al. Centrality of the umbilical cord insertion in a human placenta influences the placental efficiency [J]. Placenta, 2009, 30(12): 1058-1064.
21	Bhorat IE, Bagratee JS, Pillay M, et al. Use of the myocardial performance index as a prognostic indicator of adverse fetal outcome in poorly controlled gestational diabetic pregnancies [J]. Prenat Diagn, 2014, 34(13): 1301-1306.

[1]	陈绍琦, 庄泽敏, 陈庆子, 谭学瑞. 超声智能检测技术测量正常中晚孕胎儿右心心肌做功指数[J]. 中华医学超声杂志（电子版）, 2021, 18(02): 188-192.
[2]	吴玲玲, 尹玉竹, 梅志雄, 侯红瑛. 妊娠合并帆状胎盘对围生结局的影响[J]. 中华妇幼临床医学杂志(电子版), 2011, 07(05): 443-445.

阅读次数

全文

摘要

选择文件类型/文献管理软件名称

选择包含的内容

Myocardial performance index for evaluation of fetal cardiac function in pregnant women with velamentous cord insertion

模态框（Modal）标题

选择文件类型/文献管理软件名称

选择包含的内容

Myocardial performance index for evaluation of fetal cardiac function in pregnant women with velamentous cord insertion