摘要
目的观察经胎盘转运地高辛治疗胎儿心力衰竭的临床疗效及安全性;探讨心血管整体评分(CVPS)和心室作功指数(Tei指数)对胎儿心力衰竭评估及治疗的指导意义。方法按照研究设计,纳入2008年5月至2011年12月四川大学华西第二医院(我院)产前诊断的胎儿心力衰竭连续病例,知情同意下根据患胎父母意愿分为地高辛组及病例对照组。地高辛组经多学科会诊确定个体化经胎盘转运地高辛治疗方案。对病例对照组进行临床观察。动态监测两组患胎CVPS及心室Tei指数并观察妊娠结局。同时纳入同期在我院建卡的健康孕妇及胎儿作为正常组,分别于妊娠20、24、28、32、36周及产前观察CVPS及心室Tei指数演变。结果①地高辛组共纳入10例胎儿心力衰竭病例,其中4例胎儿心房扑动(AF)、3例胎儿室上性心动过速(SVT)、2例轻型胎儿杂合型地中海贫血(MA)、1例胎儿扩张性心肌病(DCM)。AF、SVT及MA患胎经地高辛治疗后心力衰竭得到控制,治疗后孕期顺利,足月顺产,随访10～55个月,生长发育良好,Bayley婴幼儿发育量表测试显示患儿智力及行为发育均正常;治疗过程中CVPS逐渐上升,达到或接近10分,心室Tei指数逐渐下降,均接近正常组水平。②病例对照组共纳入9例胎儿心力衰竭病例,其中4例AF、3例SVT、2例MA。其中1例AF、1例SVT分别于观察5及7d后自然转复为窦性心律,其后转入地高辛组,给予地高辛治疗,孕期顺利,足月顺产。其余病例进行临床观察后,其CVPS逐渐降低,心室Tei指数逐渐升高,最后终止妊娠。③地高辛组1例观察到胃肠道不良反应,地高辛减量后症状消失。结论地高辛作为治疗胎儿心力衰竭的一线药物具有重要的临床价值,安全性较好;随胎儿心力衰竭控制,胎儿CVPS逐渐上升,心室Tei指数下降,两者呈负相关关系;CVPS和心室Tei指数能有效指导经胎盘转运药物产前治疗胎儿心力衰竭;及时有效的产前治疗能明显改善疾病预后。
Objective To study the clinical efficacy and safety of transplacental digoxin therapy to fetal heart failure, and to investigate the significance of cardiovascular profile score （ CVPS ） and myocardial performance index （ Tel index） in assessment and evaluating treatment efficacy of fetal heart failure. Methods According to the research protocol, with written informed consent, fetal heart failure cases, diagnosed in West China Second University Hospital of Sichuan University from May 2008 to December 2011, were consecutively recruited. Based on the parents＇ decisions, the included subjects received transplacental digoxin therapy or short-term clinical observation only. During the clinical course, fetal CVPS and ventricular Tei index were dynamically monitored, pregnant outcomes were observed and recorded. A number of healthy pregnant women and fetuses were enrolled to provide reference levels of cardiac function, who were registered in West China Second University Hospital for their routine antenatal care, the fetal CVPS and right ventricular Tel index were dynamically measured and recorded at the time points of 20, 24, 28, 32, 36 gestational weeks and until delivery. Results ~ Twelve cases with fetal heart failure including 6 cases of fetal atrial flutter （AF）. 3 cases of fetal suoraventricular tachvcardia （SVT）, 2 cases of fetal anemia （MA） and 1 case of fetal dilatedcardiomyopathy （DCM）, received digoxin treatment. Seven subjects including 4 AF, 3 SVT and 2 MA were not treated with digoxin and were treated as controls. After a consultation the individual protocol of transplacental digoxin therapy was determined. Fetal heart failure was gradually controlled in AF, SVT and MA fetuses with transplaeental digoxin therapy, and achieved uneventful post-therapy pregnancy and full-term delivery. CVPS increased gradually, at or near the 10 points, left and right ventrieular Tei index decreased gradually, closed to normal range. After 10 to 55 months follow-ups, evaluation from Bayley Scale of Infant Development（ BSID）revealed the normal growth and development of physique and mentality in all the enrolled children. （~） The 7 subjects in control group manifested as gradually decreased CVPS and increased Tei index, and had pregnancy termination finally after short-term clinical observation. Thirty healthy pregnant women and their healthy fetuses were enrolled to provide 10 time points active comparable reference values for CVPS and Tei index measurements. With the gestational age progression, fetal right ventrieular Tel index decreased gradually, the value was O. 48 ＋ 0.05 at 20 gestational weeks and decreased to 0.38 ＋ 0.04 before delivery. Only gastrointestinal reaction was reported in one case from digoxin group and disappeared after reduction of the does. Conclusions Digoxin stood first on the list of medicaments has important clinical value in clinical treatment for fetal heart failure. With the alleviating of fetal heart failure, CVPS increases gradually, and ventricular Tei index decreases, with the negative correlation between them. CVPS and Tel index can effectively guide the prenatal transplacental digoxin therapy for fetal heart failure. Timely and effective prenatal intervention can significantly improve the prognosis of the suffered fetuses.
出处
《中国循证儿科杂志》
CSCD
2013年第1期15-21,共7页
Chinese Journal of Evidence Based Pediatrics
基金
国家自然科学基金:30872545
81070136
81270226
长江学者和创新团队发展计划:IRT0935
