妊高征患者胎盘床的血流动力学改变
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摘要
前言
妊高征的总发生率为9.4％，易合并胎儿窘迫，胎儿宫内发育迟缓，甚至围产儿死亡，许多文献报道了妊高征患者子宫动脉，胎儿脐动脉，肾动脉及大脑中动脉的血流指标，但是对胎盘床小血管的检测却罕见报道，本文在对脐动脉进行检测的同时，重点观察胎盘床动脉的改变，同时对胎盘床血管进行三维重建，观察正常孕妇及妊高征患者胎盘的三维彩色能量图(3D-CPA)。
材料与方法
研究对象包括妊高征组与正常对照组。妊高征组为2000年10月——2002年2月我院门诊诊断的妊高征患者49例，于孕30周后进行彩色多普勒超声检查，其中轻度妊高征15例，中度妊高征21例，重度妊高征13例，患者检查前未服用任何解痉药物及降压药物治疗。妊高征分类按照乐杰主编《妇产科学》第五版标准。
对照组为孕龄相匹配的正常孕妇，无糖尿病，肾病等妊娠合并症
研究内容应用彩色多普勒技术，对妊高征组及对照组孕妇胎盘床动脉，脐动脉的血流进行检测，检测指标包括搏动指数(PI)，阻力指数(RI)，收缩期最大速度与舒张末期速度之比(S／D)，时间平均流速(TAV)，同时对妊高征组及对照组孕妇的胎盘床血管进行三维重建，观察其空间结构的改变。
研究方法 采用Medson 730D彩色四维超声显像仪，探头频率3-5MHz，孕妇取平卧位，经腹测量胎盘床动脉，脐动脉的血流参数。脐动脉的测量选择在脐带近胎盘附着点2-3cm处，该处的压力梯度小，相对来讲也比较固定。胎盘床动脉的测量：脐动脉
在胎盘根部发出若干分支进入胎盘，选择其中与脐动脉相对应的
一支小动脉，取样线与血管尽量平行，声束与血流夹角控制在15
度以内，获得满意频谱后停帧，各参数的测定取三个以上心动周期
的平均值。
统计学处理 每组测得的数据均以平均数上标准误表示，各
组间参数的比较采用t检验，P＜0．05被认为有意义，P＜O．01被
认为有显著意义，全部数据输入微机，采用SPSS 10．0统计软件对
所得结果进行分析。
结 果
对不同孕周正常孕妇胎盘床动脉的血流参数进行测定，结果
提示：随着孕龄增加，胎盘功能逐渐成熟，表现为胎盘床小动脉的
阻力指标KI，RI，S／D）下降，而TAV升高。34－38周组与30刁4
周组比较差异不显著，说明在孕30－34周后，胎盘床血流各参数
值趋于稳定。
对不同孕周正常孕妇脐动脉的血流参数进行测定，结果显示：
随着孕龄增加，胎盘功能逐渐成熟，脐动脉PI，RJyD值逐渐下
降，而TAV值逐渐升高，在孕30叼4周后各值均趋于稳定。
对妊高征患者胎盘床动脉的血流参数进行测定，结果显示：
PIH孕妇与正常孕妇比较，胎盘床动脉的阻力指标PI，RIyD升
高，平均流速降低。中度PIH与轻度PIH比较JI变化明显，而
RI，S／D，TAV变化不明显，说明在评价妊高征程度方面JI较后三
项指标更为敏感。
对妊高征患者脐动脉的血流进行测定，结果显示：中重度PIH
孕妇与正常孕妇比较，脐动脉的阻力指标PI，RIyD升高，平均
流速降低。轻度PIH孕妇只有PI发生改变，说明在各项阻力指标
中fI的改变最为敏感。
正常组及妊高征组孕妇胎盘的 3 D—CPA图像：
·2·
正常组孕妇胎盘的 3 D—CPA图像：可清晰显示胎儿胎盘血循
环及母体胎盘血循环，在胎盘根部可以看到脐动脉发出若干分支
进人绒毛膜板，然后再分支成更小的绒毛动脉，3 D—CPA图像可
以清晰地显示胎盘床血管的立体树状分支。
妊高征组孕妇胎盘的 3 D—CPA图像：可以看到脐动脉分支及
绒毛动脉数目减少，动脉管径变细，整个胎盘的血液循环减少，并
且随着妊高征程度的加重，这种改变更为明显。
讨 论
一＼正常妊娠生理及胎盘床动脉、脐动脉血流参数的变化
正常妊娠时子宫蜕膜和子宫肌壁内螺旋动脉在胎盘附着处有
滋养层细胞侵蚀，使肌壁弹性消失，螺旋动脉管径变粗，导致血流
阻力下降，胎盘供血量增加以适应胎儿需要，本文对正常孕妇胎盘
床动脉的研究表明，随着孕龄增加，胎盘功能逐渐成熟，表现为胎
盘床动脉阻力指标下降，而TAV升高，各参数值在孕30－34周后
趋于稳定。脐动脉与胎盘床动脉的改变相似。
二、妊高征病理及胎盘床动脉、脐动脉血流参数的变化
妊高征患者的子宫血管系统不发生滋养层细胞侵蚀，胎盘床
绒毛动脉血管内膜纤维性增厚，管腔狭窄，导致胎盘循环阻力增
高。本文对胎盘床动脉进行研究发现，PIH组中，胎盘床动脉各项
阻力指标PI，RI，S／D升高，并且随着妊高征程度的加重，各参数
的改变更为明显，而TAV下降，提示TAV可直接反映子宫胎盘血
流灌注情况，故其有非常实用的临床应用价值，同时进一步证实了
妊高征的子宫胎盘缺血学说。但是，中度组与轻度组比较TAV
差异不显著，说明TAV的降低只能提示有胎盘缺血，但不能据此
来判断病情的轻重，应综合临床症状及体征，如平均动脉压，有无
蛋白尿及浮肿等来综合判断。
轻度PIH中，胎盘床动脉各项阻力指标PI，RI，S／D均升高，
The total morbidity of pregnancy induced hypertension (PIH) was 9. 4%. The complications of PIH include fetal embarrassment, intrauterine growth retardation and perinatal death. Many literatures reported about uterine artery, fetal umbilical artery, renal artery and middle cerebral artery in pregnant women with PIH. But the detection of placenta! bed arteriole was rarely reported. In our study, we detected changes of umbilical artery, mainly of placenta! bed artery. Pla-cental bed vessels were reconstructed by three - dimensional method at the same time. We observed three - dimensional color power angiogra-phy (3D -CPA) of placenta in normal pregnant and PIH women.
Materials and methods
Patients PIH group and normal matched group. In PIH group, 49 cases diagnosed as PIH in our hospital from October, 2000 to February , 2002 were examined by color Doppler ultrasound after the 30th week of gestation, of which 15 cases were mild PIH, 21 cases were moderate PIH, and 13 cases were severe PIH. All the patients had not been treated before the examination. The classification of PIH was according to Gynecotokology (edited by Le jie, 5l edition).
The matched group was normal pregnant women without pregnant complications matching in gestational age, such as diabetes , kidney disease.
Contents Color Doppler ultrasound was used to detect placental bed artery and umbilical artery, the indices included pulsatility index ( PI) , resistance index ( RI) , systolic maximum velocity ( Vmax) /di-astolic minimum velocity ( Vmin) ( S/D) , time average velocity
(TAV) . At the same time, the placenta! bed blood vessels of normal pregnant and PIH women was studied in three - dimensional method in order to observe the changes of spacial structure.
Methods We used Medison 730 D four - dimensional color Doppler ultrasound equipment with 3 - 5 MHz scanner. The gravidas took supine posture. We measured the blood flow parameters of pla-cental bed artery and umbilical artery . The measurement of umbilical artery was 2 ~3cm to the site that umbilical cord entered the placenta , where the pressure gradient was small and relatively fixed. The measurement of placental bed artery ; Umbilical artery separated several branches and entered the placenta , we Chose one of these arteri-oles and set the sampling line parallel to the vessels. The angle between the ultrasound beam and blood flow should be controlled within 15 . We froze the screen when acquiring satisfactory spectrum and took the mean value more than three cardiac cycles.
Statistics treatment All of values were expressed as mean value ?standard error. We used t - test to compare the parameters between groups. P <0. 05 was considered to be significant, P <0.01 was considered to be marked significant. All the parameters were analyzed by SPSS 10. 0 statistic software.
Results
We measured the blood flow parameters of placental bed artery in normal gravidas at different gestational age. The results prompted that; with the increase of gestational age, the placental function became maturer. The results were that the resistance indices ( PI, RI, S/D) of placental bed arteriole decreased, while TAV increased. The difference between 34-38 gestational weeks group and 30 - 34 gestational weeks group wasnt significant, which illustrated that after 30 -
34 gestational weeks, all the parameters of placenta! bed arterioles tended to be stable.
We measured the blood flow parameters of umbilical artery in normal gravidas at different gestational age. The results prompted that; with the increase of gestational age, the placental function became maturer. PI, RI, S/D of umbilical artery decreased gradually, while TAV increased gradually. After 30 -34 gestational weeks, all the parameters tended to be stable.
We measured the blood flow parameters of placental bed artery in PIH patients. The results prompted that; compared with the normal gravidas, the resistance indices (PI, RI, S/D) of placental bed artery in PIH patients were higher, while TAV was lower. Compared with the mild
妊高征的总发生率为9.4％，易合并胎儿窘迫，胎儿宫内发育迟缓，甚至围产儿死亡，许多文献报道了妊高征患者子宫动脉，胎儿脐动脉，肾动脉及大脑中动脉的血流指标，但是对胎盘床小血管的检测却罕见报道，本文在对脐动脉进行检测的同时，重点观察胎盘床动脉的改变，同时对胎盘床血管进行三维重建，观察正常孕妇及妊高征患者胎盘的三维彩色能量图(3D-CPA)。
材料与方法
研究对象包括妊高征组与正常对照组。妊高征组为2000年10月——2002年2月我院门诊诊断的妊高征患者49例，于孕30周后进行彩色多普勒超声检查，其中轻度妊高征15例，中度妊高征21例，重度妊高征13例，患者检查前未服用任何解痉药物及降压药物治疗。妊高征分类按照乐杰主编《妇产科学》第五版标准。
对照组为孕龄相匹配的正常孕妇，无糖尿病，肾病等妊娠合并症
研究内容应用彩色多普勒技术，对妊高征组及对照组孕妇胎盘床动脉，脐动脉的血流进行检测，检测指标包括搏动指数(PI)，阻力指数(RI)，收缩期最大速度与舒张末期速度之比(S／D)，时间平均流速(TAV)，同时对妊高征组及对照组孕妇的胎盘床血管进行三维重建，观察其空间结构的改变。
研究方法 采用Medson 730D彩色四维超声显像仪，探头频率3-5MHz，孕妇取平卧位，经腹测量胎盘床动脉，脐动脉的血流参数。脐动脉的测量选择在脐带近胎盘附着点2-3cm处，该处的压力梯度小，相对来讲也比较固定。胎盘床动脉的测量：脐动脉
在胎盘根部发出若干分支进入胎盘，选择其中与脐动脉相对应的
一支小动脉，取样线与血管尽量平行，声束与血流夹角控制在15
度以内，获得满意频谱后停帧，各参数的测定取三个以上心动周期
的平均值。
统计学处理 每组测得的数据均以平均数上标准误表示，各
组间参数的比较采用t检验，P＜0．05被认为有意义，P＜O．01被
认为有显著意义，全部数据输入微机，采用SPSS 10．0统计软件对
所得结果进行分析。
结 果
对不同孕周正常孕妇胎盘床动脉的血流参数进行测定，结果
提示：随着孕龄增加，胎盘功能逐渐成熟，表现为胎盘床小动脉的
阻力指标KI，RI，S／D）下降，而TAV升高。34－38周组与30刁4
周组比较差异不显著，说明在孕30－34周后，胎盘床血流各参数
值趋于稳定。
对不同孕周正常孕妇脐动脉的血流参数进行测定，结果显示：
随着孕龄增加，胎盘功能逐渐成熟，脐动脉PI，RJyD值逐渐下
降，而TAV值逐渐升高，在孕30叼4周后各值均趋于稳定。
对妊高征患者胎盘床动脉的血流参数进行测定，结果显示：
PIH孕妇与正常孕妇比较，胎盘床动脉的阻力指标PI，RIyD升
高，平均流速降低。中度PIH与轻度PIH比较JI变化明显，而
RI，S／D，TAV变化不明显，说明在评价妊高征程度方面JI较后三
项指标更为敏感。
对妊高征患者脐动脉的血流进行测定，结果显示：中重度PIH
孕妇与正常孕妇比较，脐动脉的阻力指标PI，RIyD升高，平均
流速降低。轻度PIH孕妇只有PI发生改变，说明在各项阻力指标
中fI的改变最为敏感。
正常组及妊高征组孕妇胎盘的 3 D—CPA图像：
·2·
正常组孕妇胎盘的 3 D—CPA图像：可清晰显示胎儿胎盘血循
环及母体胎盘血循环，在胎盘根部可以看到脐动脉发出若干分支
进人绒毛膜板，然后再分支成更小的绒毛动脉，3 D—CPA图像可
以清晰地显示胎盘床血管的立体树状分支。
妊高征组孕妇胎盘的 3 D—CPA图像：可以看到脐动脉分支及
绒毛动脉数目减少，动脉管径变细，整个胎盘的血液循环减少，并
且随着妊高征程度的加重，这种改变更为明显。
讨 论
一＼正常妊娠生理及胎盘床动脉、脐动脉血流参数的变化
正常妊娠时子宫蜕膜和子宫肌壁内螺旋动脉在胎盘附着处有
滋养层细胞侵蚀，使肌壁弹性消失，螺旋动脉管径变粗，导致血流
阻力下降，胎盘供血量增加以适应胎儿需要，本文对正常孕妇胎盘
床动脉的研究表明，随着孕龄增加，胎盘功能逐渐成熟，表现为胎
盘床动脉阻力指标下降，而TAV升高，各参数值在孕30－34周后
趋于稳定。脐动脉与胎盘床动脉的改变相似。
二、妊高征病理及胎盘床动脉、脐动脉血流参数的变化
妊高征患者的子宫血管系统不发生滋养层细胞侵蚀，胎盘床
绒毛动脉血管内膜纤维性增厚，管腔狭窄，导致胎盘循环阻力增
高。本文对胎盘床动脉进行研究发现，PIH组中，胎盘床动脉各项
阻力指标PI，RI，S／D升高，并且随着妊高征程度的加重，各参数
的改变更为明显，而TAV下降，提示TAV可直接反映子宫胎盘血
流灌注情况，故其有非常实用的临床应用价值，同时进一步证实了
妊高征的子宫胎盘缺血学说。但是，中度组与轻度组比较TAV
差异不显著，说明TAV的降低只能提示有胎盘缺血，但不能据此
来判断病情的轻重，应综合临床症状及体征，如平均动脉压，有无
蛋白尿及浮肿等来综合判断。
轻度PIH中，胎盘床动脉各项阻力指标PI，RI，S／D均升高，
The total morbidity of pregnancy induced hypertension (PIH) was 9. 4%. The complications of PIH include fetal embarrassment, intrauterine growth retardation and perinatal death. Many literatures reported about uterine artery, fetal umbilical artery, renal artery and middle cerebral artery in pregnant women with PIH. But the detection of placenta! bed arteriole was rarely reported. In our study, we detected changes of umbilical artery, mainly of placenta! bed artery. Pla-cental bed vessels were reconstructed by three - dimensional method at the same time. We observed three - dimensional color power angiogra-phy (3D -CPA) of placenta in normal pregnant and PIH women.
Materials and methods
Patients PIH group and normal matched group. In PIH group, 49 cases diagnosed as PIH in our hospital from October, 2000 to February , 2002 were examined by color Doppler ultrasound after the 30th week of gestation, of which 15 cases were mild PIH, 21 cases were moderate PIH, and 13 cases were severe PIH. All the patients had not been treated before the examination. The classification of PIH was according to Gynecotokology (edited by Le jie, 5l edition).
The matched group was normal pregnant women without pregnant complications matching in gestational age, such as diabetes , kidney disease.
Contents Color Doppler ultrasound was used to detect placental bed artery and umbilical artery, the indices included pulsatility index ( PI) , resistance index ( RI) , systolic maximum velocity ( Vmax) /di-astolic minimum velocity ( Vmin) ( S/D) , time average velocity
(TAV) . At the same time, the placenta! bed blood vessels of normal pregnant and PIH women was studied in three - dimensional method in order to observe the changes of spacial structure.
Methods We used Medison 730 D four - dimensional color Doppler ultrasound equipment with 3 - 5 MHz scanner. The gravidas took supine posture. We measured the blood flow parameters of pla-cental bed artery and umbilical artery . The measurement of umbilical artery was 2 ~3cm to the site that umbilical cord entered the placenta , where the pressure gradient was small and relatively fixed. The measurement of placental bed artery ; Umbilical artery separated several branches and entered the placenta , we Chose one of these arteri-oles and set the sampling line parallel to the vessels. The angle between the ultrasound beam and blood flow should be controlled within 15 . We froze the screen when acquiring satisfactory spectrum and took the mean value more than three cardiac cycles.
Statistics treatment All of values were expressed as mean value ?standard error. We used t - test to compare the parameters between groups. P <0. 05 was considered to be significant, P <0.01 was considered to be marked significant. All the parameters were analyzed by SPSS 10. 0 statistic software.
Results
We measured the blood flow parameters of placental bed artery in normal gravidas at different gestational age. The results prompted that; with the increase of gestational age, the placental function became maturer. The results were that the resistance indices ( PI, RI, S/D) of placental bed arteriole decreased, while TAV increased. The difference between 34-38 gestational weeks group and 30 - 34 gestational weeks group wasnt significant, which illustrated that after 30 -
34 gestational weeks, all the parameters of placenta! bed arterioles tended to be stable.
We measured the blood flow parameters of umbilical artery in normal gravidas at different gestational age. The results prompted that; with the increase of gestational age, the placental function became maturer. PI, RI, S/D of umbilical artery decreased gradually, while TAV increased gradually. After 30 -34 gestational weeks, all the parameters tended to be stable.
We measured the blood flow parameters of placental bed artery in PIH patients. The results prompted that; compared with the normal gravidas, the resistance indices (PI, RI, S/D) of placental bed artery in PIH patients were higher, while TAV was lower. Compared with the mild
引文
1．《临床产科学》编委会．临床产科学．天津科学技术出版社，1994年12月
2．黄子健，戴常平，等．彩色多普勒超声监测生长迟缓胎儿脐动脉血液循环的变化．中华超声影像学杂志，2001，10(2)：104-105．
3. Robern WB, Khong TY, Brosen I, er al. The placental bed biopsy - review from three europen centers. Am J Obstet Gynecol, 1986,155: 401 - 403
4. De Wolff F, De Wolf- Peeters, Brosens I, et al. The human placental bed: electron microscopic study of trophoblastic invasion of spiral arteries. Am J Obstet Gyneeol, 1980,137:58 - 61
5．尹利荣等．妊高征患者子宫胎盘血管病变及其与妊娠结局的关系．中华妇产科杂志，1998，33(8)：459-461
6．乔福元，闻良珍，许建平，等．彩色多普勒监测妊高征孕妇子宫胎盘血流变化。中华妇产科杂志，1995，30(6)：337-339
7. Murakoshi T, etal . Uterine and spiral artery flow velocity waveforms in pregnancy induced hypertension and /or intrauterine growth retardation. Ultrasound Gynecol, 1996,7 (2): 122 - 8
8．杨玉英，江森，等．妊高征患者血液流变学与脐血流动力学的相关性研究．中华妇产科杂志，1998，33(5)：274-276
9．乐杰主编．妇产科学，第五版．北京人民卫生出版社，2000年12月
10. Arabin B et al. AM J Obstet Gynecol,1993, 169:549-554
11．陈崇佩．妇产科彩色多普勒诊断学．人民卫生出版社，1998年4月
12. D. H. Pretorius, T. R. Nelson, et al. Imaging of placental vascu-
lature using three-dimensional ultrasound and color power Doppler : a preliminary study . Ultrasound in Obstetrics and Gy-necology,1998,12(1) :45-49
2．黄子健，戴常平，等．彩色多普勒超声监测生长迟缓胎儿脐动脉血液循环的变化．中华超声影像学杂志，2001，10(2)：104-105．
3. Robern WB, Khong TY, Brosen I, er al. The placental bed biopsy - review from three europen centers. Am J Obstet Gynecol, 1986,155: 401 - 403
4. De Wolff F, De Wolf- Peeters, Brosens I, et al. The human placental bed: electron microscopic study of trophoblastic invasion of spiral arteries. Am J Obstet Gyneeol, 1980,137:58 - 61
5．尹利荣等．妊高征患者子宫胎盘血管病变及其与妊娠结局的关系．中华妇产科杂志，1998，33(8)：459-461
6．乔福元，闻良珍，许建平，等．彩色多普勒监测妊高征孕妇子宫胎盘血流变化。中华妇产科杂志，1995，30(6)：337-339
7. Murakoshi T, etal . Uterine and spiral artery flow velocity waveforms in pregnancy induced hypertension and /or intrauterine growth retardation. Ultrasound Gynecol, 1996,7 (2): 122 - 8
8．杨玉英，江森，等．妊高征患者血液流变学与脐血流动力学的相关性研究．中华妇产科杂志，1998，33(5)：274-276
9．乐杰主编．妇产科学，第五版．北京人民卫生出版社，2000年12月
10. Arabin B et al. AM J Obstet Gynecol,1993, 169:549-554
11．陈崇佩．妇产科彩色多普勒诊断学．人民卫生出版社，1998年4月
12. D. H. Pretorius, T. R. Nelson, et al. Imaging of placental vascu-
lature using three-dimensional ultrasound and color power Doppler : a preliminary study . Ultrasound in Obstetrics and Gy-necology,1998,12(1) :45-49