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中华医学超声杂志（电子版）

中华医学超声杂志（电子版） ›› 2024, Vol. 21 ›› Issue (06) : 552 -562. doi: 10.3877/cma.j.issn.1672-6448.2024.06.002

指南与规范

ISUOG实践指南：孕晚期胎儿超声检查解读
彭彦卿1, 孙立涛1,†()   
  1. 1. 310000　杭州，浙江省人民医院（附属人民医院）肿瘤中心超声医学科　杭州医学院
  • 收稿日期:2024-01-31 出版日期:2024-06-01
  • 通信作者: 孙立涛

Interpretation of ISUOG Practice Guidelines: performance of thirdtrimester obstetric ultrasound scan

Yanqing Peng, Litao Sun†()   

  • Received:2024-01-31 Published:2024-06-01
  • Corresponding author: Litao Sun
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彭彦卿, 孙立涛. ISUOG实践指南：孕晚期胎儿超声检查解读[J]. 中华医学超声杂志（电子版）, 2024, 21(06): 552-562.

Yanqing Peng, Litao Sun. Interpretation of ISUOG Practice Guidelines: performance of thirdtrimester obstetric ultrasound scan[J]. Chinese Journal of Medical Ultrasound (Electronic Edition), 2024, 21(06): 552-562.

超声具有实时、无创、无辐射的优势，随着超声仪器分辨率的提高及技术的革新，从最初的胎儿生长测量到现在的畸形筛查、产时超声甚至是宫内治疗，超声对各个孕周胎儿检查都具有不可替代的重要作用。国际妇产科超声协会（International Society of Ultrasound in Obstetrics and Gynecology，ISUOG）在发表了关于早孕期、中孕期的超声检查指南后，在2024年1月发表了"晚孕期的超声检查指南"[1]，其目的是为规范孕晚期超声检查流程，为妇产科超声的临床应用提供指导，并将其作为临床实践的参考标准。此前尚未有关于晚孕期的超声检查指南，现针对其要点进行解读。

表1 国际妇产科超声学会指南中使用的证据等级和推荐等级
等级 等级说明
证据等级  
1++ 高质量的荟萃分析，对随机对照试验或具有极低偏倚风险的随机对照试验的系统回顾
1+ 进行良好的荟萃分析，对随机对照试验或具有低偏倚风险的随机对照试验的系统回顾
1- 荟萃分析，对具有高偏倚风险的随机对照试验的系统回顾
2++ 对病例对照或队列研究或高质量病例对照或队列研究的高质量系统综述，混杂、偏倚或偶然的风险很低，且因果关系的可能性很高
2+ 进行良好的病例对照或队列研究，混杂风险低，偏倚或偶然，中度这种关系是因果关系的概率
2- 病例对照或队列研究的混杂、偏倚或偶然和显著的风险关系不是因果关系
3 非分析性研究，例如病例报告、病例系列
4 专家意见
推荐等级  
A 至少一项荟萃分析、系统回顾或随机对照试验，证据等级评定为1++，直接适用于目标人群；或对随机对照试验进行系统回顾，或主要包括证据等级评定为1+的研究，并证明结果的总体一致性
B 证据主体，包括直接适用于目标人群并证明结果总体一致性的评定为2++的研究；或来自评定为1++或1+的研究的外推证据
C 证据主体，包括直接适用于目标人群并证明结果总体一致性的评定为2+的研究；或来自评定为2++的研究的外推证据
D 证据等级评定为3或4；或从2+的研究推断的证据
良好实践点 根据指南制定小组的临床经验推荐的最佳实践
图1 孕晚期超声测量胎儿头围
图2 妊娠晚期胎儿腹围（AC）的超声测量
图3 孕晚期胎儿股骨长度的超声测量
图4 羊水过多，定义为羊水指数>25 cm（图a）或最大垂直深度>8 cm（图b）
图5 孕晚期经腹获取的脐动脉多普勒波形
图6 孕晚期经头部获取的大脑中动脉多普勒波形
图7 孕晚期经腹静脉导管多普勒波形：胎儿腹部的横切面（图a）和纵切面（图b）
图8 孕晚期经腹获取的子宫动脉多普勒图像及波形
图9 胎儿颅内结果超声图像。图a：妊娠晚期超声成像显示的正常胎儿脑结构。图b：第三脑室和侧脑室扩张，伴脑室内高回声（脑室内出血3级）。图c：在颅底后部中线（Galen静脉动脉瘤），超声显示无回声的管状区域内彩色血流信号
图10 正常妊娠晚期胎儿心脏切面。图a：四腔心切面，显示了左右心腔的对称性。右心部分可能比左心部分稍大，但明显的不对称提示应进行详细的评估。图b：三血管气管切面。图c：左心室流出道切面
图11 三血管切面上主动脉明显小于动脉导管可能提示主动脉缩窄
图12 胎儿左右侧膈肌（箭头）纵向检查
图13 巨大的胎儿卵巢囊肿，囊肿隔膜不完整，囊内低回声，提示囊内出血（复杂囊肿）
图14 妊娠晚期胎儿肾超声成像图。图a：妊娠晚期胎儿肾的正常形态（纵切面），周围低回声区为肾锥体。图b：重度肾积水（冠状位），肾盏扩张，肾皮质变薄
图15 低置胎盘超声图像。如果胎盘下缘距离宫颈内口20 mm或以上，阴道分娩被认为是安全的选择。然而，在妊娠36周时，当这个距离在10~20 mm之间时，也可能安全地阴道分娩
图16 胎盘植入超声图片。图a：紧邻膀胱的胎盘增厚（箭头）。图b：具有不规则子宫膀胱界面的胎盘腔隙
图17 前置血管，定义为未受保护的胎儿血管穿过宫颈口上方的膜，或穿过距子宫颈内口<20 mm的距离
图18 妊娠晚期使用最大垂直深度（DVP）进行羊水评估
图19 妊娠晚期羊水回声较均匀，常为弱回声，这是由于胎儿胎粪的存在
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