美国医学超声协会胎儿超声心动图操作指南

美国医学超声协会胎儿超声心动图操作指南 美国医学超声协会胎儿超声心动图操作指南 一、简介 先天性心脏病是导致胎儿死亡的主要原因，死亡率约为6‰。准确的产前诊断能够改善婴儿的预后，尤其在需要前列腺素来维持动脉导管通畅的病例中更为重要。胎儿超声心动图普遍认为是产前评价胎儿心脏畸形的最详细的检查手段。其检查手段是在“基本”和“基本扩展”胎儿成像指南基础上延伸而出的，即胎儿心脏四腔心和流出道切面。胎儿超声心动图只有在有确切的原因的情况下，并且最大限度的减少由于采集诊断信息而暴露在超声下的时间的情况下进行。有时，额外或特殊的检查手段比如彩色多普勒是必须的。但并不是所有的畸形都能够检出，以下指南将最大限度的探查大部分临床严重的先心病。 二、人员的资质及责任 参照AIUM官方文件《医师培训指南、诊断超声检查评估与解释、AIUM超声实践指南》 三、指征 胎儿超声心动图指征基于先心病的亲代及胎儿危险因素。然而，大多数病例并没有明确的已知的高位因素。胎儿超声心动图的普通指征是(也不局限与此): 母体指征 自身免疫抗体，抗Ro(SSA)/抗La(SSB) 家族遗传疾病(如:马凡综合症) 先心病家族史 试管婴儿 代谢性疾病(如:糖尿病和苯丙酮尿症) 至畸源接触(如:类视黄醇和锂) 四、检查申请 书面或电子申请超声心动图检查应提供详细的信息以更好的完成检查。 检查申请必须由临床医生或其他有资格的健康中心出具，并提供相关临床资料，并且因遵守相关法律和当地健康结构规定。 五、检查说明 (a) construct safe volunteers is a global task. This work is the bureau Party committee according to the required to make the Council an important deployment. It is the significant move that strengthen the comprehensive management of social management, to maintain the stability of the overall situation of social order, is to do a good job of prevention and treatment work under the new situation, constructing the harmonious relationship between the police and the people of a strong starting point, with the central, the provincial, city and county on strengthening and innovating social management, do a good job work of the masses of the major decision is consistent with the spirit. (II) volunteers in peace building is the concrete embodiment of the basic principles of public security work. Combining the basic principles of public security work is the specialized agencies and the broad masses, we carry out Pingan volunteer work is public security organs take the direct embodiment of the mass line, the fundamental purpose is extending public security work in the new platform, absorb the social personnel involved in peace building and create a whole society to participate in the construction, and the broad participation of the masses in the situation, and effectively improve the safety and satisfaction of the people. 以下部分为胎儿超声心动图详细或选择性推荐。 A 综述 胎儿超声心动图通常在孕18到22周进行。有些先心病可能在更早孕周发现。最佳的图像是胎儿心尖向前或朝向孕妇腹壁。由于声影(如:孕妇肥胖或胎儿俯卧体位)使得全面的检查十分困难，特别是在晚孕期更是如此。所以由于心脏显像欠佳多次观察是必要的。检查者可以通过调节各种参数来获得最好的图像，比如焦点、频率、增益、图像放大、时间分辨率、谐波成像及多普勒相关参数(比如:血流速度、壁滤波、帧频)。 B 心脏图像参数:基本要求 胎儿超声心动图是对心脏结构及功能的全面评价。检查包括三个节段的:心房、心室、大动脉及其连接。节段分析法包括以下连接及关系: 心房位置 房室连接 心室与动脉流出到的连接 每个节段的异常都需要对其他伴随异常进行评价比如:心脏位置、心房异构、主动脉骑跨、房间隔缺损、室间隔缺损、心肌肥厚、体循环或肺静脉的异常连接、卵圆孔关闭、心室比例失调、动脉缩窄及二三尖瓣发育异常。 C 灰阶图像(推荐) 关键切面的获取有助于诊断信息的获得(图1-3)。 应该获得以下切面: 四腔心 左室流出道 右室流出道 (a) construct safe volunteers is a global task. This work is the bureau Party committee according to the required to make the Council an important deployment. It is the significant move that strengthen the comprehensive management of social management, to maintain the stability of the overall situation of social order, is to do a good job of prevention and treatment work under the new situation, constructing the harmonious relationship between the police and the people of a strong starting point, with the central, the provincial, city and county on strengthening and innovating social management, do a good job work of the masses of the major decision is consistent with the spirit. (II) volunteers in peace building is the concrete embodiment of the basic principles of public security work. Combining the basic principles of public security work is the specialized agencies and the broad masses, we carry out Pingan volunteer work is public security organs take the direct embodiment of the mass line, the fundamental purpose is extending public security work in the new platform, absorb the social personnel involved in peace building and create a whole society to participate in the construction, and the broad participation of the masses in the situation, and effectively improve the safety and satisfaction of the people. 图1 三血管及气管切面 (a) construct safe volunteers is a global task. This work is the bureau Party committee according to the required to make the Council an important deployment. It is the significant move that strengthen the comprehensive management of social management, to maintain the stability of the overall situation of social order, is to do a good job of prevention and treatment work under the new situation, constructing the harmonious relationship between the police and the people of a strong starting point, with the central, the provincial, city and county on strengthening and innovating social management, do a good job work of the masses of the major decision is consistent with the spirit. (II) volunteers in peace building is the concrete embodiment of the basic principles of public security work. Combining the basic principles of public security work is the specialized agencies and the broad masses, we carry out Pingan volunteer work is public security organs take the direct embodiment of the mass line, the fundamental purpose is extending public security work in the new platform, absorb the social personnel involved in peace building and create a whole society to participate in the construction, and the broad participation of the masses in the situation, and effectively improve the safety and satisfaction of the people. 图2 短轴切面(心室及流出道) (a) construct safe volunteers is a global task. This work is the bureau Party committee according to the required to make the Council an important deployment. It is the significant move that strengthen the comprehensive management of social management, to maintain the stability of the overall situation of social order, is to do a good job of prevention and treatment work under the new situation, constructing the harmonious relationship between the police and the people of a strong starting point, with the central, the provincial, city and county on strengthening and innovating social management, do a good job work of the masses of the major decision is consistent with the spirit. (II) volunteers in peace building is the concrete embodiment of the basic principles of public security work. Combining the basic principles of public security work is the specialized agencies and the broad masses, we carry out Pingan volunteer work is public security organs take the direct embodiment of the mass line, the fundamental purpose is extending public security work in the new platform, absorb the social personnel involved in peace building and create a whole society to participate in the construction, and the broad participation of the masses in the situation, and effectively improve the safety and satisfaction of the people. 图3 主动脉弓 导管弓 上腔静脉 (a) construct safe volunteers is a global task. This work is the bureau Party committee according to the required to make the Council an important deployment. It is the significant move that strengthen the comprehensive management of social management, to maintain the stability of the overall situation of social order, is to do a good job of prevention and treatment work under the new situation, constructing the harmonious relationship between the police and the people of a strong starting point, with the central, the provincial, city and county on strengthening and innovating social management, do a good job work of the masses of the major decision is consistent with the spirit. (II) volunteers in peace building is the concrete embodiment of the basic principles of public security work. Combining the basic principles of public security work is the specialized agencies and the broad masses, we carry out Pingan volunteer work is public security organs take the direct embodiment of the mass line, the fundamental purpose is extending public security work in the new platform, absorb the social personnel involved in peace building and create a whole society to participate in the construction, and the broad participation of the masses in the situation, and effectively improve the safety and satisfaction of the people. 下腔静脉 D 多普勒检查(心脏血流异常时推荐) 使用光谱、连续、彩色和或能量多普勒来评价下列结构的血流或心律异常: 肺静脉 卵圆孔 房室瓣 房室间隔 主、肺动脉瓣 动脉导管 主动脉弓 E.M型超声心动图(心率或心律异常时推荐) M 型超声心动图显示一个薄的取样容积内结构随时间的变化。较高的时间分辨率有助于心室收缩的评价。能够分辨房性、室性心律失常，及它们之间的关系。其他方法如:脉冲多普勒或者组织多普勒也被用来评价胎儿心律失常。 F.心脏生物学测量(在结构异常时推荐) 胎儿心脏测量的正常范围根据不同孕周或胎儿大小而不同，数据已经以百分位数和z积分的形式公布。每个个体的测量应使用M型或二维图像，包括以下参数: 主动脉及肺动脉瓣环水平内径 主动脉弓及峡部内径 舒末期心室内径，紧贴房室瓣下 心室自由壁及室间隔的厚度，紧贴房室瓣下 额外测量按需要而定，包括: 心室收缩内径 心房的横径 (a) construct safe volunteers is a global task. This work is the bureau Party committee according to the required to make the Council an important deployment. It is the significant move that strengthen the comprehensive management of social management, to maintain the stability of the overall situation of social order, is to do a good job of prevention and treatment work under the new situation, constructing the harmonious relationship between the police and the people of a strong starting point, with the central, the provincial, city and county on strengthening and innovating social management, do a good job work of the masses of the major decision is consistent with the spirit. (II) volunteers in peace building is the concrete embodiment of the basic principles of public security work. Combining the basic principles of public security work is the specialized agencies and the broad masses, we carry out Pingan volunteer work is public security organs take the direct embodiment of the mass line, the fundamental purpose is extending public security work in the new platform, absorb the social personnel involved in peace building and create a whole society to participate in the construction, and the broad participation of the masses in the situation, and effectively improve the safety and satisfaction of the people. 肺动脉分支内径 G.补充切面(可选) 其他附属成像模式，比如3或4维超声，已经应用于心脏结构异常和定量胎儿血流参数(比如心输出量)的应用。多普勒超声和斑点追踪技术被用来描述心室的应变和心肌指数的测量。 六、及存档 充足的存档对高质量病例管理是必要的。胎儿超声心动图检查和说明应该永久存储。所用的图像包括正常和异常的都应该存档。异常时应该同时附有测量数据。图形应标注病人信息、仪器信息、检查日期、以及图像左右方向。正式报告(最终报告)应收录在病人的医疗档案中。超声的检查应有临床适应症，并且遵守相关法律及当地健康结构的规定。报告应符合AIUM超声检查标准。 七、仪器要求 胎儿超声心动图检查应该使用实时探头扫查。因此应使用扇形、凸阵及经阴道探头。尽量将探头频率调至最佳，值得注意分辨率与扫查深度是相互制约的。对目前设备而言，经腹壁探查时经常使用频率为3.5MHz或更高，而经阴道扫查时频率为5MHz或更高。超声声影及母体体型肥胖均可限制高频探头的使用，从而限制了心脏高分辨率解剖信息的获得。 八、质量控制及提高、安全性、感染控制、患者教育 质量控制及提高、安全性、感染控制的执行应符合AIUM超声实践标准及指南。 仪器的工作辐射监控应符合AIUM超声实践标准及指南。 九、ALARA 原则 每次检查的益处及风险应同时评估。在控制声能输出及扫查时间时应遵守ALARA原则(低声能、短时间)。更详细见AIUM发布的医学超声安全。 (a) construct safe volunteers is a global task. This work is the bureau Party committee according to the required to make the Council an important deployment. It is the significant move that strengthen the comprehensive management of social management, to maintain the stability of the overall situation of social order, is to do a good job of prevention and treatment work under the new situation, constructing the harmonious relationship between the police and the people of a strong starting point, with the central, the provincial, city and county on strengthening and innovating social management, do a good job work of the masses of the major decision is consistent with the spirit. (II) volunteers in peace building is the concrete embodiment of the basic principles of public security work. Combining the basic principles of public security work is the specialized agencies and the broad masses, we carry out Pingan volunteer work is public security organs take the direct embodiment of the mass line, the fundamental purpose is extending public security work in the new platform, absorb the social personnel involved in peace building and create a whole society to participate in the construction, and the broad participation of the masses in the situation, and effectively improve the safety and satisfaction of the people.