孕前糖尿病胎儿超声心动图选择性转诊方案
本研究为回顾性队列研究，纳入2018年7月至2023年7月在一家三级医疗中心分娩的604例孕前糖尿病孕妇。在母胎医学详尽的产科超声扩展心脏切面筛查基础上，对符合其他胎儿超声心动图指征、心脏切面欠佳或异常者行选择性胎儿超声心动图转诊。
要点
- 孕前糖尿病孕妇在三级中心行母胎医学扩展心脏切面筛查，临床显著先天性心脏病均被产前检出。
- 产后检出的微小先天性心脏病均为临床无意义病变，不影响新生儿期处理。
- 选择性转诊策略可将胎儿超声心动图使用率降至27.5%，减少不必要的专项检查。
核心结论
- 在具备母胎医学扩展心脏成像方案的三级中心，选择性胎儿超声心动图转诊可显著减少检查使用率，同时有效识别孕前糖尿病孕妇中所有临床显著先天性心脏病。
研究设计与样本
- 回顾性队列研究，纳入2018年7月至2023年7月在一家三级医疗中心分娩的604例孕前糖尿病（1型或2型）孕妇。
- 由母胎医学超声技师行详细产科超声检查，含扩展心脏切面，由母胎医学医师或胎儿影像专科放射科医师解读。
- 胎儿超声心动图转诊指征为其他AIUM胎儿超声心动图筛查适应证、心脏切面欠佳或心脏切面异常。
- 所有新生儿出院前均接受标准先天性心脏病筛查（体格检查）。
- 主要结局为临床显著先天性心脏病产前检出，定义为出生后一年内可能需要干预的先天性心脏病；次要结局为所有先天性心脏病检出。
关键影像表现/征象
- 604例中56例（9.3%）新生儿存在先天性心脏病。
- 10例（1.7%）为临床显著先天性心脏病，全部产前检出。
- 轻微先天性心脏病中30例（53.5%）产前未识别，仅产后检出。
- 产后检出的病变均为临床无意义病变。
诊断标准与关键数值
- 临床显著先天性心脏病定义为出生后一年内可能需要干预的先天性心脏病。
- 166例（27.5%）孕妇接受了胎儿超声心动图检查。
- 所有糖化血红蛋白超过9.0%的病例中临床显著先天性心脏病亦均被产前检出。
临床应用与阅片要点
- 对孕前糖尿病孕妇可先行母胎医学详细产科超声扩展心脏切面筛查，而非一律推荐胎儿超声心动图。
- 符合其他AIUM胎儿超声心动图指征、心脏切面欠佳或异常时应及时转诊胎儿超声心动图。
- 产后检出的仅为轻微病变时，可在报告中提示临床无显著意义，避免不必要的家长焦虑。
- 该策略依赖母胎医学超声技师经验和扩展心脏切面规范，非三级中心需谨慎外推。
局限性
- 单中心回顾性研究，结果依赖该中心的母胎医学超声技师经验与扩展心脏成像方案。
- 轻微先天性心脏病产后检出依赖出院前体格检查，未说明长期随访中是否有遗漏的临床显著病变。
以上解读依据论文摘要（全文未开放获取或许可不允许翻译转载）。
英文原文（摘要）· 点击展开
OBJECTIVES: Fetal echocardiography (FE) is universally recommended for pregnancies affected by pregestational diabetes. We hypothesized that in an experienced center, the use of a selective FE referral policy detects congenital heart disease (CHD) without missing clinically relevant defects.
METHODS: This was a retrospective cohort study of pregnancies complicated by type 1 or 2 diabetes that underwent detailed obstetric ultrasound and delivered at a tertiary care center between July 2018 and July 2023. The primary outcome was clinically significant prenatal CHD detection, defined as CHD that may require intervention within a year of life, with a secondary outcome of all CHD detection. Detailed obstetric ultrasounds with expanded cardiac views were performed by maternal fetal medicine (MFM) sonographers, with interpretation by MFM physicians or specialized radiologists in fetal imaging. FE was ordered for other AIUM FE screening indications, suboptimal, or abnormal cardiac views. All neonates underwent standard CHD screening prior to discharge by physical exam.
RESULTS: Among 604 eligible pregnancies, 10 (1.7%) clinically significant CHD were diagnosed, with 56 (9.3%) total CHD in neonates. All cases of clinically significant CHD were detected prenatally, even in those with an A1C >9.0. For all minor CHD, 30 cases (53.5%) were not identified prenatally and were only identified postnatally. The postnatally detected lesions all were clinically insignificant. With selective referral, 166 (27.5%) pregnancies underwent FE, representing a significant reduction in FE performed.
CONCLUSION: In a tertiary center with expanded cardiac imaging protocols, selective FE referral substantially reduced FE utilization while effectively identifying all clinically significant CHD in pregnancies with pregestational diabetes.
引用
- Wiley, Noonan, Pai, et al. Selective Fetal Echocardiogram Referral Program for Pregnancies Affected by Pregestational Diabetes. J Ultrasound Med. 2026. PMID: 42234596. doi:10.1002/jum.70324
供执业医师工作参考，不替代临床判断；数值与分级以指南原文为准。