云南省及周边高海拔地区心脏缺陷胎儿的超声心动图分析

Analysis on echocardiographic data of fetal heart defects at high altitude in Yunnan province and surrounding high altitude areas

目的了解云南省及周边高海拔地区胎儿心脏缺陷的现状及影响其妊娠结局的社会因素。方法本研究为回顾性研究。连续纳入2017年6月至2021年1月于云南省阜外心血管病医院超声科行胎儿超声心动图检查并确诊为心脏缺陷的病例。根据胎儿心脏出生缺陷临床预后评分体系和分级标准对入选病例的预后进行评级(Ⅰ至Ⅳ级),分析比较各预后等级病例的比例及病种分布情况、妊娠结局。依据妊娠结局将病例分为继续妊娠组和终止妊娠组,采用多因素logistic回归分析影响妊娠结局选择的社会因素。结果收集到行胎儿超声心动图检查病例4929例,4464例(90.57%)来源于云南省及周边高海拔地区。最终纳入心脏缺陷病例2166例,其中先天性心脏病(先心病)998例,心脏肿瘤、心肌病及心律失常93例,卵圆孔、动脉导管异常及正常变异1075例。孕妇年龄为(29.2±5.0)岁,孕(25.6±3.8)周。预后等级为Ⅰ至Ⅳ级的例数分别为1037例(47.88%)、620例(28.62%)、314例(14.50%)、44例(2.03%),未分级者151例(6.97%)。病种分布情况方面,正常变异和主动脉弓发育偏细分别占42.66%(924/2166)和5.22%(113/2166);评级为Ⅱ级的病例中占比排名前3位的病种为室间隔缺损、主动脉缩窄和轻-中度肺动脉瓣狭窄,均为简单先心病,在所有心脏缺陷病例中占比分别为11.63%(252/2166)、3.92%(85/2166)和2.35%(51/2166),在先心病病例中占比分别为25.25%(252/998)、8.52%(85/998)和5.11%(51/998);评级为Ⅲ级、Ⅳ级病例中以复杂先心病居多,且病种较为分散,Ⅲ级中较常见的为完全型大动脉转位[占所有心脏缺陷病例的2.40%(52/2166)、占所有先心病病例的5.21%(52/998)]和Ⅰ至Ⅲ型肺动脉闭锁合并室间隔缺损[占所有心脏缺陷病例的2.17%(47/2166)、占所有先心病病例的4.71%(47/998)],Ⅳ级中较常见的是单心室[占所有心脏缺陷病例的0.74%(16/2166)、占所有先心病病例的1.60%(16/998)]和左心发育不良综合征[占所有心脏缺陷病例的0.65%(14/2166)、占所有先心病病例的1.40%(14/998)]。成功随访1084例,其中出生675例,终止妊娠392例,自然流产17例。预后等级Ⅰ至Ⅳ级的病例中终止妊娠者占比逐渐增加[等级内占比分别为5.24%(21/401)、27.78%(70/252)、89.54%(214/239)和95.56%(43/45)],在终止妊娠的病例中预后等级为Ⅲ级者占比最高[54.59%(214/392)];终止妊娠病例中病种分布主要为复杂先天畸形或预后极差的病种(Ⅲ、Ⅳ级),可见正常变异或预后好的Ⅰ、Ⅱ级病例[在终止妊娠病例中占比分别为5.36%(21/392)和17.86%(70/392)]。多因素logistic回归分析结果显示,低学历(高中及以下:OR=2.73,95%CI 1.26~5.93,P<0.001;文盲:OR=3.27,95%CI 1.29~7.10,P<0.001)和低家庭收入(年收入<10万元:OR=2.47,95%CI 1.69~5.12,P<0.001)是选择终止妊娠的影响因素。结论云南省及周边高海拔地区心脏出生缺陷胎儿中,病种分布以简单或低危病种为主,但复杂畸形特别是预后差的病种占比也较高;部分预后良好的病例被终止妊娠,孕妇的文化程度和家庭收入可能会影响其对心脏缺陷胎儿妊娠结局的选择。

Objective To explore the current situation of fetal heart defects in Yunnan Province and surrounding high altitude areas and the social factors affecting pregnancy outcome.Methods This is a retrospective study.Pregnant woman who underwent fetal echocardiography and diagnosed as fetal cardiac defects in Yunnan Fuwai Cardiovascular Hospital from June 2017 to January 2021 were included.According to the clinical prognostic risk scoring system and grading criteria of fetal cardiac birth defects,the cases were divided into gradeⅠtoⅣ.The disease distribution and proportion of each prognostic grade,pregnancy outcomes were analyzed and compared.The cases were divided into continued pregnancy group and terminated pregnancy group according to pregnancy outcome.The social factors that may affect the selection of pregnancy outcomes were analyzed by multivariate logistic regression analysis.Results A total of 4929 fetal echocardiography examination data were collected,and 4464 cases(90.57%)were from Yunnan Province and surrounding high altitude areas.2166 cases of heart defects were finally analyzed,including 998 cases of congenital heart disease(CHD),93 cases of cardiac tumors,cardiomyopathy and arrhythmia,1075 cases of foramen ovale,ductus arteriosus abnormalities and normal variations.The pregnant women were(29.2±5.0)years old with(25.6±3.8)gestational weeks.The number of cases with prognostic grade fromⅠtoⅣwas 1037(47.88%),620(28.62%),314(14.50%),and 44(2.03%),respectively.And 151 cases(6.97%)were not classified.The cases of normal variation and thin aortic arch development accounted for 42.66%(924/2166),5.22%(113/2166),respectively.The top 3 diseases of gradeⅡwere ventricular septal defect,coarctation of aorta and mild-moderate pulmonary stenosis,respectively,and their distribution was 11.63%(252/2166),3.92%(85/2166)and 2.35%(51/2166)respectively in all cases of heart defects,and 25.25%(252/998),8.52%(85/998)and 5.11%(51/998)respectively in cases of CHD.Among the cases rated as gradeⅢandⅣ,most of them were complicated congenital heart disease,and the disease types are scattered.The more common cases in gradeⅢwere complete transposition of great arteries(accounting for 2.40%(52/2166)of all cases with heart defects,5.21%(52/998)of all cases with CHD)and pulmonary artery occlusion(typeⅠtoⅢ)with ventricular septal defect(accounting for 2.17%(47/2166)of all cases with heart defects,and 4.71%(47/998)of all cases with CHD).In gradeⅣ,single ventricle(0.74%(16/2166)of all cases with heart defects,1.60%(16/998)of all cases with CHD)and left ventricular dysplasia syndrome(0.65%(14/2166)of all cases with heart defects,1.40%(14/998)of all cases with CHD)are more common.A total of 1084 cases were successfully followed up,and 675 cases were born,392 cases were terminated,spontaneous abortion occurred in 17 cases.The proportion of terminated pregnancy cases was significantly increased from gradeⅠtoⅣ,accounting for 5.24%(21/401),27.78%(70/252),89.54%(214/239)and 95.56%(43/45),respectively.Among the terminated pregnancy cases,those with gradeⅢaccounted for the highest proportion(54.59%(214/392)).The distribution of terminated pregnancy cases was mainly complex congenital malformations or diseases with very poor prognosis(pregnancy outcome gradeⅢandⅣ),and proportion of terminated pregnancy with pregnancy outcome gradeⅠandⅡcases(normal variation or good prognosis)accounted for 5.36%(21/392)and 17.86%(70/392),respectively.The results of multivariate logistic regression analysis showed that pregnant women with low education(high school and below:OR=2.73,95%CI 1.26-5.93,P<0.001;illiteracy:OR=3.27,95%CI 1.29-7.10,P<0.001)and low family income(Annual income<100000 yuan:OR=2.47,95%CI 1.69-5.12,P<0.001)were more likely to choose termination of pregnancy in case of fetal heart defect.Conclusion In Yunnan province and the surrounding high altitude areas,the disease distribution of fetal heart defect is mainly simple or low-risk disease,but the complex malformation,especially the disease with poor pregnancy outcome,accounts for a relative high proportion.Pregnancy termination also occurs in some cases with good pregnancy outcome.The education level and family income of pregnant women may affect their choice of pregnancy outcome in case of fetal heart defect.