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SIU M DOPPLER QU II-III NH GI THAI CH畉M PHT TRI畛N TRONG T畛 CUNG "People only see what they are prepared to see." Ralph Waldo Emerson Dr. NGUY畛N QUANG TR畛NG website: www.sieuamvietnam.vn or www.vietnamultrasound.vn (Last update, 14/03/2017) IMAGING DEPARTMENT FV HOSPITAL HCM CITY
畉I C蕩NG Theo American College of Obstetricians and Gynecologists, thai ch畉m ph叩t tri畛n trong t畛 cung (Intrauterine growth restriction - IUGR) l m畛t trong nh畛ng v畉n 畛 th藤畛ng g畉p v ph畛c t畉p nh畉t trong s畉n khoa ngy nay. 藤畛c xem l IUGR khi 動畛c l動畛ng c但n n畉ng tr棚n si棚u 但m < 10th percentile (b叩ch ph但n v畛) t藤董ng 畛ng v畛i tu畛i thai do b畛nh l箪 (due to pathologic process). SGA (small-for-gestational-age): < 10th percentile t藤董ng 畛ng v畛i tu畛i thai m kh担ng c坦 b畛nh l箪 (absence of pathologic process). Do v畉y, ngoi si棚u 但m 2D, th狸 si棚u 但m Doppler l kh担ng th畛 thi畉u khi kh畉o s叩t thai nhi.
sieu am doppler thai nhi
Thai ch畉m ph叩t tri畛n trong t畛 cung 藤畛c ph但n chia thnh 2 th畛 畛i x畛ng v kh担ng 畛i x畛ng (Symmetric v Asymmetric IUGR). Th畛 kh担ng 畛i x畛ng (asymmetrical growth pattern): Chu vi v嘆ng b畛ng (AC) ph叩t tri畛n ch畉m h董n 藤畛ng k鱈nh l藤畛ng 畛nh (BPD) so v畛i tu畛i thai. Suy b叩nh nhau (Placental insufficiency) 藤畛c xem l nguy棚n nh但n c畛a th畛 ny. Ng藤畛c l畉i, nh畛ng r畛i lo畉i v畛 di truy畛n (genetic disorders), l畛ch b畛i nhi畛m s畉c th畛 (aneuploidy), nhi畛m tr湛ng thai nhi (fetal infections), d畛 t畉t b畉m sinh (congenital malformations) v c叩c h畛i ch畛ng kh叩c l nguy棚n nh但n c畛a th畛 畛i x畛ng (symmetrical growth pattern t畉t c畉 c叩c o 畉c 畛u nh畛 h董n so v畛i tu畛i thai). Susan Raatz Stephenson. Diagnostic Medical Sonography Obstetrics and Gynecology. 3rd edition. 2012 by Lippincott Williams & Wilkins.
Giai o畉n I: b畉t th藤畛ng PI c畛a 畛ng m畉ch r畛n (UmA) v 畛ng m畉ch n達o gi畛a (MCA). Giai o畉n II: b畉t th藤畛ng PSV c畛a MCA, v畉ng ho畉c 畉o ng藤畛c d嘆ng ch畉y cu畛i t但m tr藤董ng c畛a 畛ng m畉ch r畛n (UmA), t挑nh m畉ch r畛n 畉p (UV pulsations), s坦ng a b畉ng 0 畛 畛ng t挑nh m畉ch (DV). Giai o畉n III: s坦ng a 但m 畛 畛ng t挑nh m畉ch (DV 畉o ng藤畛c d嘆ng ch畉y cu畛i t但m tr藤董ng c畛a 畛ng m畉ch r畛n (UmA), h畛 van 3 l叩 (tricuspid regurgitation). M畛i giai o畉n l畉i 藤畛c chia thnh 2 nh坦m: - A : AFI (amniotic fluid index) < 5 cm (thi畛u 畛i). - B : AFI (amniotic fluid index) > 5 cm (kh担ng thi畛u 畛i).
sieu am doppler thai nhi
CC M畉CH MU C畉N KH畉O ST 1. 畛ng m畉ch M r畛n. 2. 畛ng m畉ch n達o gi畛a. 3. 畛ng m畉ch t畛 cung. 4. 畛ng t挑nh m畉ch. 5. K畉t lu畉n.
畛NG M畉CH R畛N 畛 qu箪 I, ph畛 Doppler b狸nh th藤畛ng c畛a M r畛n 畉c tr藤ng b畛i s畛 thi畉u v畉ng d嘆ng ch畉y cu畛i t但m tr藤董ng (absent end-diastolic flow). C湛ng v畛i s畛 ph叩t tri畛n c畛a thai, cung l藤畛ng tim thai tng, c畉 v畉n t畛c t但m thu l畉n t但m tr藤董ng trong M cu畛ng r畛n 畛u tng, t畛 18 tu畉n tu畛i, ta th畉y xu畉t hi畛n d嘆ng ch畉y cu畛i t但m tr動董ng (end-diastolic flow). B狸nh th藤畛ng RI, PI v S/D ratio gi畉m d畉n v畛 cu畛i thai k畛, v狸 r畉ng cng v畛 cu畛i thai k畛, nhu c畉u dinh d藤畛ng c畛a thai cng cao, m叩u 畉n thai nhi nhi畛u, M r畛n ph畉i tng l藤u l藤畛ng k畛 c畉 th狸 t但m tr藤董ng 畛 藤a m叩u tr畛 v畛 b叩nh nhau. Theo nhi畛u k畉t qu畉 nghi棚n c畛u, Doppler 畛ng m畉ch r畛n 動畛c xem l c坦 gi叩 tr畛 nh畉t trong 叩nh gi叩 thai ch畉m ph叩t tri畛n trong t畛 cung.
DOPPLER 畛NG M畉CH R畛N - B狸nh th動畛ng, khi kh畉o s叩t 畛 qu箪 II (thai 22 tu畉n tu畛i) ta ph畉i th畉y ph畛 cu畛i t但m tr動董ng. - B狸nh th藤畛ng, RI, PI v S/D ratio gi畉m d畉n v畛 cu畛i thai k畛. C叩c ch畛 s畛 ny tng cao b畉t th藤畛ng ph畉n 叩nh tr畛 kh叩ng c畛a b叩nh nhau tng cao. i畛u ny s畉 lm tng nguy c董 thai b畛nh v thai ch畉t chu sinh (perinatal morbidity and mortality). - S畛 thi畉u v畉ng (absent) ho畉c 畉o ng動畛c (reversed) d嘆ng cu畛i t但m tr動董ng (end diastolic flow) n坦i l棚n tr畛 kh叩ng r畉t cao 畛 b叩nh nhau, i畛u ny lm cho ti棚n l動畛ng tr畛 n棚n r畉t x畉u.
sieu am doppler thai nhi
C坦 t叩c gi畉 ch畛n v畛 tr鱈 cu畛ng r畛n c畉m vo b叩nh nhau, c坦 t叩c gi畉 ch畛n v畛 tr鱈 cu畛ng r畛n c畉m vo thnh b畛ng thai nhi, c坦 t叩c gi畉 ch畛n cu畛ng r畛n t畛 do trong khoang 畛i.
March 14, 2017 12 C坦 m畛t s畛 kh叩c bi畛t c坦 箪 ngh挑a khi kh畉o s叩t c叩c ch畛 s畛 Doppler t畉i v畛 tr鱈 cu畛ng r畛n c畉m vo thnh b畛ng thai nhi, t畉i v畛 tr鱈 cu畛ng r畛n t畛 do v t畉i v畛 tr鱈 cu畛ng r畛n c畉m vo b叩nh nhau6. Tr畛 kh叩ng cao nh畉t t畉i v畛 tr鱈 cu畛ng r畛n c畉m vo thnh b畛ng thai nhi, v vi畛c thi畉u v畉ng ho畉c 畉o ng藤畛c d嘆ng ch畉y cu畛i t但m tr藤董ng c坦 th畛 藤畛c th畉y tr藤畛c nh畉t t畉i v畛 tr鱈 ny. Tr畛 s畛 tham kh畉o cho c叩c ch畛 s畛 Doppler t畉i c叩c v畛 tr鱈 ny 達 藤畛c xu畉t b畉n7,8. 畛 董n gi畉n v ki棚n 畛nh, o 畉c c畉n 動畛c ti畉n hnh t畉i v畛 tr鱈 cu畛ng r畛n t畛 do. Tuy nhi棚n, trong tr藤畛ng h畛p a thai, v/ho畉c khi so s叩nh c叩c o 畉c l畉p l畉i, vi畛c kh畉o s叩t Doppler t畉i nh畛ng v畛 tr鱈 c畛 畛nh (cu畛ng r畛n c畉m vo thnh b畛ng thai nhi, cu畛ng r畛n c畉m vo b叩nh nhau ho畉c cu畛ng r畛n t畛 do trong 畛 b畛ng) c坦 th畛 叩ng tin c畉p h董n. C叩c tr畛 s畛 tham kh畉o c畉n ph畉i t藤董ng 畛ng v畛i v畛 tr鱈 kh畉o s叩t. L動u 箪: 1. 畛 a thai, kh畉o s叩t 畛ng m畉ch cu畛ng r畛n c坦 th畛 kh坦 v狸 kh坦 x叩c 畛nh cu畛ng r畛n thu畛c v畛 thai no. T畛t h董n h畉t ta kh畉o s叩t Doppler xung t畉i v畛 tr鱈 cu畛ng r畛n c畉m vo thnh b畛ng thai nhi. Tuy nhi棚n, tr畛 kh叩ng 畛 但y s畉 cao h董n t畉i v畛 tr鱈 cu畛ng r畛n t畛 do v v畛 tr鱈 cu畛ng r畛n c畉m vo b叩nh nhau, v狸 th畉 c畉n 畛i chi畉u v畛i tr畛 s畛 tham kh畉o t動董ng 畛ng. 2. 畛 cu畛ng r畛n c坦 2 m畉ch m叩u, t畉i b畉t k畛 tu畛i thai no, 動畛ng k鱈nh c畛a 畛ng m畉ch r畛n 董n 畛c c滴ng l畛n h董n so v畛i hai 畛ng m畉ch r畛n th担ng th動畛ng, v do v畉y tr畛 kh叩ng s畉 th畉p h董n9(Ghi ch炭 c畛a ng動畛i d畛ch: tr畛 kh叩ng th畉p h董n c坦 ngh挑a l c叩c ch畛 s畛 RI, PI v S/D ratio 畛u th畉p h董n so v畛i cu畛ng r畛n th担ng th動畛ng c坦 3 m畉ch m叩u). ISUOG Practice Guidelines: use of Doppler ultrasonography in obstetrics. Ultrasound Obstet Gynecol 2013; 41: 233239
13 Acharya G et al. Reference ranges for serial measurements of blood velocity and pulsatility index at the intra-abdominal portion, and fetal and placental ends of the umbilical artery. Ultrasound Obstet Gynecol 2005; 26: 162169.
14 Acharya G et al. Reference ranges for serial measurements of blood velocity and pulsatility index at the intra-abdominal portion, and fetal and placental ends of the umbilical artery. Ultrasound Obstet Gynecol 2005; 26: 162169.
Acharya G et al. Reference ranges for serial measurements of umbilical artery Doppler indices in the second half of pregnancy. Am J Obstet Gynecol 2005; 192: 937944. We chose the free floating loop of the umbilical cord because it seems to be the preferred technique in many centers. Semiquantitative Doppler indices are not angle dependent, and an insonation angle of < 60 degrees does not have any significant effect in their calculation. However, we kept the angle at < 15 degrees in all cases. Umbilical Artery PI b畉t th藤畛ng khi > 95th percentile.
March 14, 2017 16 Acharya G et al. Reference ranges for serial measurements of umbilical artery Doppler indices in the second half of pregnancy. Am J Obstet Gynecol 2005; 192: 937944. Umbilical Artery RI b畉t th藤畛ng khi > 95th percentile.
March 14, 2017 17 Acharya G et al. Reference ranges for serial measurements of umbilical artery Doppler indices in the second half of pregnancy. Am J Obstet Gynecol 2005; 192: 937944. Umbilical Artery S/D ratio b畉t th藤畛ng khi > 95th percentile.
DOPPLER 畛NG M畉CH CU畛NG R畛N BNH TH蕩畛NG Khi lm Doppler 畛ng m畉ch r畛n, c畛a s畛 th動畛ng 畉t bao tr湛m c畉 M v TM r畛n.
sieu am doppler thai nhi
Tu畉n th畛 10 Tu畉n th畛 24 G畉n sinh DOPPLER 畛NG M畉CH CU畛NG R畛N BNH TH蕩畛NG
Tu畉n 16 Tu畉n 20 Tu畉n 24 Tu畉n 28 Tu畉n 32 Tu畉n 36 Tu畉n 40
sieu am doppler thai nhi
Thai 35 tu畉n, S/D = 3,5 Thai 35 tu畉n, S/D = 3,76 B狸nh th藤畛ng thai > 34 tu畉n: S/D ratio 3 IUGR
Absent end-diastolic flow SEVERE IUGR
Reversed end-diastolic flow SEVERE IUGR
Thai 28 tu畉n, S/D 4 Thai 28 tu畉n, S/D > 4 Thai 28 tu畉n, Absent end-diastolic flow Thai 28 tu畉n, Reversed end-diastolic flow B狸nh th藤畛ng thai 26-30 tu畉n: S/D ratio 4 SEVERE IUGR IUGR
V畛i Doppler mu, a gi叩c Willis d畛 th畉y 畛 l叩t c畉t ngang n畛n s畛 thai nhi. M n達o gi畛a ch畉y d畛c theo b畛 x藤董ng 叩.
sieu am doppler thai nhi
sieu am doppler thai nhi
i畛u 叩ng l藤u 箪 l kh叩c v畛i ng藤畛i l畛n, 畛 thai nhi, b狸nh th動畛ng tr畛 kh叩ng c畛a M n達o kh叩 cao. Khi t狸nh tr畉ng thi畉u Oxy n達o x畉y ra (畛 thai ch畉m ph叩t tri畛n trong t畛 cung), tu畉n hon n達o s畉 thay 畛i b畉ng c叩ch gi畉m tr畛 kh叩ng 畛 tng d嘆ng ch畉y trong th狸 t但m tr藤董ng. Ta g畛i 坦 l s畛 t叩i ph但n ph畛i tu畉n hon n達o (cerebral blood flow redistribution). Qu箪 I Qu箪 II & III
M畛t s畛 nghi棚n c畛u cho th畉y r畉ng PSV c畛a 畛ng m畉ch n達o gi畛a c坦 th畛 ti棚n o叩n t畛t v畛 t畛 vong chu sinh 畛 thai ch畉m ph叩t tri畛n trong t畛 cung h董n l ch畛 s畛 PI; tuy nhi棚n, c畉n ph畉i c坦 th棚m nhi畛u nghi棚n c畛u n畛a 畛 x叩c nh畉n i畛u ny. Trong khi g坦c Doppler l y畉u t畛 k畛 thu畉t kh担ng c畉n thi畉t khi o PI, th狸 khi o PSV c畉n ph畉i c坦 g坦c Doppler cng nh畛 cng t畛t, l箪 t動畛ng l 00, c嘆n kh担ng 動畛c th狸 ph畉i < 300. Eliza Berkley et al. SMFM Clinical Guideline-Doppler assessment of the fetus with intrauterine growth restriction. American Journal of Obstetrics & Gynecology APRIL 2012. ISUOG Practice Guidelines: use of Doppler ultrasonography in obstetrics. Ultrasound Obstet Gynecol 2013; 41: 233239 Thanh i畛u ch畛nh g坦c ph畉i tr湛ng v畛i tr畛c c畛a d嘆ng ch畉y. i畛u ny 畉m b畉o cho vi畛c 叩nh gi叩 v畉n t畛c v d畉ng s坦ng 畉t hi畛u qu畉 t畛t nh畉t. S畛 sai l畛ch nh畛 v畛 v畉n t畛c do g坦c Doppler c坦 th畛 x畉y ra. N畉u g坦c Doppler l 100 th狸 s畛 sai l畛ch v畛 v畉n t畛c l 2%, trong l炭c g坦c Doppler l 200 th狸 s畛 sai l畛ch v畉n t畛c l 6%. Trong tr藤畛ng h畛p v畉n t畛c th畉t s畛 l m畛t th担ng s畛 quan tr畛ng v畛 m畉t l但m sng (v鱈 d畛 畛ng m畉ch n達o gi畛a) v n畉u g坦c Doppler > 200 , c畉n ph畉i i畛u ch畛nh 畉u d嘆 sao cho g坦c Doppler nh畛 h董n. N畉u v畉n kh担ng th畛 l畉y 藤畛c g坦c Doppler l箪 t藤畛ng, th狸 ta c畉n ghi nh畉n v畉n t畛c o 藤畛c k竪m theo l tr畛 s畛 g坦c Doppler trong k畉t qu畉 si棚u 但m. D湛ng Doppler mu 畛 nh畉n bi畉t a gi叩c Willis v 畛ng m畉ch n達o gi畛a g畉n 畉u d嘆. C畛a s畛 Doppler 畉t 畛 1/3 g畉n c畛a 畛ng m畉ch n達o gi畛a, g畉n ch畛 xu畉t ph叩t c畛a n坦 t畛 畛ng m畉ch c畉nh trong10 (PSV s畉 gi畉m d畉n khi i xa ch畛 xu畉t ph叩t).
sieu am doppler thai nhi
MCA PI b畉t th藤畛ng khi < 5th percentile. C. Ebbing et al. Middle cerebral artery blood flow velocities and pulsatility index and the cerebroplacental pulsatility ratio: longitudinal reference ranges and terms for serial measurements. Ultrasound Obstet Gynecol 2007; 30: 287296
C. Ebbing et al. Middle cerebral artery blood flow velocities and pulsatility index and the cerebroplacental pulsatility ratio: longitudinal reference ranges and terms for serial measurements. Ultrasound Obstet Gynecol 2007; 30: 287296 MCA PSV b畉t th藤畛ng khi > 95th percentile. G坦c Doppler 100.
sieu am doppler thai nhi
sieu am doppler thai nhi
sieu am doppler thai nhi
sieu am doppler thai nhi
Thai 28 tu畉n, SEVERE IUGR: t叩i ph但n ph畛i tu畉n hon n達o.
IUGR Thai 28 tu畉n, kh担ng c坦 ph畛 cu畛i t但m tr藤董ng 畛 M r畛n T叩i ph但n ph畛i tu畉n hon n達o C.M.Rumack et al. Diagnostic Ultrasound. 3rdEdition. 2005. p1459-1488
IUGR M r畛n c坦 RI cao b畉t th藤畛ng Doppler M n達o gi畛a b狸nh th藤畛ng
So s叩nh ph畛 Doppler b狸nh th藤畛ng c畛a M n達o gi畛a v M r畛n, ta th畉y r畉ng EDV c畛a M r畛n lu担n lu担n cao h董n M n達o gi畛a
Ch畛 s畛 kh叩ng (RI) c畛a M n達o gi畛a lu担n cao h董n M r畛n
T畛 S畛 GI畛A M NO GI畛A V M R畛N (CPR - cerebroplacental ratio t畛 s畛 n達o nhau). - B狸nh th藤畛ng, EDV 畛 M n達o gi畛a lu担n lu担n th畉p h董n EDV 畛 M r畛n 畛 b畉t k畛 tu畛i thai no. V狸 th畉 RI v PI c畛a M n達o gi畛a lu担n cao h董n M r畛n. CRI/URI > 1; CPI/UPI > 1. - G畛i l t叩i ph但n ph畛i tu畉n hon thai nhi (fetal flow redistribution, brain sparing) khi: CRI/URI < 1; CPI/UPI < 1. Dev Maulik. Doppler Ultrasound in Obstetrics and Gynecology. 2nd Edition. 2005
Th畛ng k棚 tr棚n 881 tr藤畛ng h畛p s畉n ph畛 c坦 tu畛i thai trung b狸nh 33 tu畉n tu畛i, ng藤畛i ta th畉y c坦 146 tr藤畛ng h畛p CPR (cerebroplacental ratio) < 1. Trong s畛 坦 c坦 18% (n =27) d畛 h畉u r畉t x畉u (adverse perinatal outcomes). Nguy c董 gia tng g畉p 11 l畉n so v畛i s畛 thai nhi c坦 CPR b狸nh th藤畛ng (1.9%, 14/735). Adverse perinatal outcome was defined as a composite of intraventricular hemorrhage, periventricular leukomalacia, hypoxic ischemic encephalopathy, necrotizing enterocolitis, bronchopulmonary dysplasia, sepsis, and death. Flood K, Unterscheider J, Daly S, et al. The role of brain sparing in the prediction of adverse outcomes in intrauterine growth restriction: results of the multicenter PORTO Study. Am J Obstet Gynecol 2014;211:288.e1-5.
Flood K, Unterscheider J, Daly S, et al. The role of brain sparing in the prediction of adverse outcomes in intrauterine growth restriction: results of the multicenter PORTO Study. Am J Obstet Gynecol 2014;211:288.e1-5.
C. Ebbing et al. Middle cerebral artery blood flow velocities and pulsatility index and the cerebroplacental pulsatility ratio: longitudinal reference ranges and terms for serial measurements. Ultrasound Obstet Gynecol 2007; 30: 287296. CPR b畉t th藤畛ng khi < 5th percentile.
Mean Uterine Artery PI b畉t th藤畛ng khi > 95th percentile. O. G坦mez et al. Reference ranges for uterine artery mean pulsatility index at 1141 weeks of gestation. Ultrasound Obstet Gynecol 2008; 32: 128132
sieu am doppler thai nhi
Flood K, Unterscheider J, Daly S, et al. The role of brain sparing in the prediction of adverse outcomes in intrauterine growth restriction: results of the multicenter PORTO Study. Am J Obstet Gynecol 2014;211:288.e1-5.
sieu am doppler thai nhi
60 cm/s 15 cm/s
ZOOM
sieu am doppler thai nhi
ZOOM
Ph畛 Doppler 畛ng t挑nh m畉ch bao g畛m 3 pha: -S: t但m thu th畉t, 畛ng th畛i 畛ng TM co b坦p 畛 m叩u qua l畛 b畉u d畛c. -D: t但m tr藤董ng th畉t, van 3 l叩 m畛 t畉o 叩p l畛c 但m, h炭t m叩u v畛 tim. -a: nh挑 (P) co b坦p cu畛i t但m tr藤董ng t畉o ph畛 畉o ng藤畛c. - B狸nh th藤畛ng, S # 50-60cm/s, a > 0. - Doppler 畛ng TM b畉t th藤畛ng khi: a = 0 ho畉c 但m (n坦i l棚n s畛 ch棚nh l畛ch 叩p su畉t cao 畛 nh挑 (P)). - Qu箪 I: Doppler 畛ng TM b畉t th藤畛ng g畉p 畛 thai nhi b畉t th藤畛ng NST v d畛 t畉t tim. - Qu箪 II & III: Doppler 畛ng TM b畉t th藤畛ng g畉p 畛 thai ch畉m ph叩t tri畛n trong t畛 cung (IUGR) v thai d畛 t畉t tim. T畛 tu畉n 11-14: Doppler 畛ng t挑nh m畉ch b畉t th藤畛ng g畉p 畛 5% thai nhi c坦 NST b狸nh th藤畛ng, v g畉p 畛 80% thai nhi Trisomy 21. Ph畛 b狸nh th藤畛ng v畛i a > 0.
Absent A
a: reverse flow IUGR
Ph畛 DV t畉i th畛i i畛m 13 ngy, 7 ngy v 48 gi畛 tr藤畛c khi thai ch畉t trong TC, 25 tu畉n tu畛i, c但n n畉ng thai nhi < 500g
Ph畛 DV t畉i th畛i i畛m 16 ngy, 4 ngy v 24 gi畛 tr藤畛c khi thai ch畉t trong TC, 23 tu畉n tu畛i, c但n n畉ng thai nhi < 500g
SEVERE IUGR Ph畛 畉o ng藤畛c cu畛i t但m tr藤董ng 畛 M r畛n T叩i ph但n ph畛i tu畉n hon n達o Ph畛 Doppler 畛 畛ng t挑nh m畉ch b狸nh th藤畛ng
Thai 28 tu畉n, IUGR T叩i ph但n ph畛i tu畉n hon n達o Kh担ng c坦 ph畛 cu畛i t但m tr藤董ng 畛 M r畛n a = 0 畛 畛ng t挑nh m畉ch
K畉T LU畉N 畛 叩nh gi叩 s畛 ph叩t tri畛n c畛a thai nhi ta c畉n ph畉i ph畛i h畛p t畛t c叩c kh畉o s叩t sau: o 畉c c叩c c畉u tr炭c c畛a thai nhi so v畛i tr畛 s畛 chu畉n theo tu畛i thai. 叩nh gi叩 l動畛ng n動畛c 畛i. Kh畉o s叩t Doppler thai nhi. Nh畛ng bi畉n 畛i c叩c th担ng s畛 Doppler lu担n lu担n x畉y ra tr動畛c c叩c bi畉n 畛i v畛 m畉t gi畉i ph畉u. Do v畉y, nh畛 c坦 si棚u 但m Doppler, ch炭ng ta c坦 th畛 ch畉n o叩n v x畛 tr鱈 s畛m nh畛ng tr動畛ng h畛p thai ch畉m ph叩t tri畛n trong t畛 cung.
TI LI畛U THAM KH畉O Dev Maulik. Doppler Ultrasound in Obstetrics and Gynecology. 2nd Edition. 2005 Peter M. Doubilet et al. Atlas of Ultrasound in Obstetrics and Gynecology. 2003 A. C. Fleischer et al. Sonography in Obstetrics and Gynecology. 6th Edition. 2001 Peter W. Callen et al. Ultrasonography in Obstetrics and Gynecology. 5th Edition. 2008. Saunders Elsevier. Gilles Grang辿 et al. Guide pratique de l'辿chographie obst辿tricale et gyn辿cologique. 2012, Elsevier Masson. Paula J. Woodward et al. Diagnostic Imaging Obstetrics. 1st edition. Amirsys. 2005. Diagnostic Medical Sonography: Obstetrics and Gynecology. 3rd edition. 2012 by Lippincott Williams & Wilkins. A. Pilalis et al. Screening for pre-eclampsia and fetal growth restriction by uterine arteryDoppler and PAPP-A at 1114 weeks gestation. Ultrasound Obstet Gynecol 2007; 29: 135140. C. K. H. YU et al. Prediction of pre-eclampsia by uterine artery Doppler imaging: relationship to gestational age at delivery and small-for-gestational age. Ultrasound Obstet Gynecol 2008; 31: 310313. Aris Antsaklis et al. Uterine Artery Doppler in the Prediction of Preeclampsia and Adverse Pregnancy Outcome. Donald School Journal of Ultrasound in Obstetrics and Gynecology, April-June 2010;4 (2): 117-122. Shivani Singh et al. Role of color doppler in the diagnosis of intra uterine growth restriction (IUGR). Int J Reprod Contracept Obstet Gynecol. 2013 Dec;2(4):566-572. K. MELCHIORRE et al. First-trimester uterine artery Doppler indices in the prediction of small-for-gestational age pregnancy and intrauterine growth restriction. Ultrasound Obstet Gynecol 2009; 33: 524529. Eliza Berkley et al. Doppler assessment of the fetus with intrauterine growth restriction. Am J Obstet Gynecol April 2012, Volume 206, Issue 4, Pages 300308. Beth M. Kline-Fath et al. Fundamental and Advanced Fetal Imaging Ultrasound and MRI. 2015 Wolters Kluwer Health. Flood K, Unterscheider J, Daly S, et al. The role of brain sparing in the prediction of adverse outcomes in intrauterine growth restriction: results of the multicenter PORTO Study. Am J Obstet Gynecol 2014;211:288.e1-5. C. Ebbing et al. Middle cerebral artery blood flow velocities and pulsatility index and the cerebroplacental pulsatility ratio: longitudinal reference ranges and terms for serial measurements. Ultrasound Obstet Gynecol 2007; 30: 287296.
Rennes, m湛a l叩 r畛ng 2004

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  • 1. SIU M DOPPLER QU II-III NH GI THAI CH畉M PHT TRI畛N TRONG T畛 CUNG "People only see what they are prepared to see." Ralph Waldo Emerson Dr. NGUY畛N QUANG TR畛NG website: www.sieuamvietnam.vn or www.vietnamultrasound.vn (Last update, 14/03/2017) IMAGING DEPARTMENT FV HOSPITAL HCM CITY
  • 2. 畉I C蕩NG Theo American College of Obstetricians and Gynecologists, thai ch畉m ph叩t tri畛n trong t畛 cung (Intrauterine growth restriction - IUGR) l m畛t trong nh畛ng v畉n 畛 th藤畛ng g畉p v ph畛c t畉p nh畉t trong s畉n khoa ngy nay. 藤畛c xem l IUGR khi 動畛c l動畛ng c但n n畉ng tr棚n si棚u 但m < 10th percentile (b叩ch ph但n v畛) t藤董ng 畛ng v畛i tu畛i thai do b畛nh l箪 (due to pathologic process). SGA (small-for-gestational-age): < 10th percentile t藤董ng 畛ng v畛i tu畛i thai m kh担ng c坦 b畛nh l箪 (absence of pathologic process). Do v畉y, ngoi si棚u 但m 2D, th狸 si棚u 但m Doppler l kh担ng th畛 thi畉u khi kh畉o s叩t thai nhi.
  • 4. Thai ch畉m ph叩t tri畛n trong t畛 cung 藤畛c ph但n chia thnh 2 th畛 畛i x畛ng v kh担ng 畛i x畛ng (Symmetric v Asymmetric IUGR). Th畛 kh担ng 畛i x畛ng (asymmetrical growth pattern): Chu vi v嘆ng b畛ng (AC) ph叩t tri畛n ch畉m h董n 藤畛ng k鱈nh l藤畛ng 畛nh (BPD) so v畛i tu畛i thai. Suy b叩nh nhau (Placental insufficiency) 藤畛c xem l nguy棚n nh但n c畛a th畛 ny. Ng藤畛c l畉i, nh畛ng r畛i lo畉i v畛 di truy畛n (genetic disorders), l畛ch b畛i nhi畛m s畉c th畛 (aneuploidy), nhi畛m tr湛ng thai nhi (fetal infections), d畛 t畉t b畉m sinh (congenital malformations) v c叩c h畛i ch畛ng kh叩c l nguy棚n nh但n c畛a th畛 畛i x畛ng (symmetrical growth pattern t畉t c畉 c叩c o 畉c 畛u nh畛 h董n so v畛i tu畛i thai). Susan Raatz Stephenson. Diagnostic Medical Sonography Obstetrics and Gynecology. 3rd edition. 2012 by Lippincott Williams & Wilkins.
  • 5. Giai o畉n I: b畉t th藤畛ng PI c畛a 畛ng m畉ch r畛n (UmA) v 畛ng m畉ch n達o gi畛a (MCA). Giai o畉n II: b畉t th藤畛ng PSV c畛a MCA, v畉ng ho畉c 畉o ng藤畛c d嘆ng ch畉y cu畛i t但m tr藤董ng c畛a 畛ng m畉ch r畛n (UmA), t挑nh m畉ch r畛n 畉p (UV pulsations), s坦ng a b畉ng 0 畛 畛ng t挑nh m畉ch (DV). Giai o畉n III: s坦ng a 但m 畛 畛ng t挑nh m畉ch (DV 畉o ng藤畛c d嘆ng ch畉y cu畛i t但m tr藤董ng c畛a 畛ng m畉ch r畛n (UmA), h畛 van 3 l叩 (tricuspid regurgitation). M畛i giai o畉n l畉i 藤畛c chia thnh 2 nh坦m: - A : AFI (amniotic fluid index) < 5 cm (thi畛u 畛i). - B : AFI (amniotic fluid index) > 5 cm (kh担ng thi畛u 畛i).
  • 7. CC M畉CH MU C畉N KH畉O ST 1. 畛ng m畉ch M r畛n. 2. 畛ng m畉ch n達o gi畛a. 3. 畛ng m畉ch t畛 cung. 4. 畛ng t挑nh m畉ch. 5. K畉t lu畉n.
  • 8. 畛NG M畉CH R畛N 畛 qu箪 I, ph畛 Doppler b狸nh th藤畛ng c畛a M r畛n 畉c tr藤ng b畛i s畛 thi畉u v畉ng d嘆ng ch畉y cu畛i t但m tr藤董ng (absent end-diastolic flow). C湛ng v畛i s畛 ph叩t tri畛n c畛a thai, cung l藤畛ng tim thai tng, c畉 v畉n t畛c t但m thu l畉n t但m tr藤董ng trong M cu畛ng r畛n 畛u tng, t畛 18 tu畉n tu畛i, ta th畉y xu畉t hi畛n d嘆ng ch畉y cu畛i t但m tr動董ng (end-diastolic flow). B狸nh th藤畛ng RI, PI v S/D ratio gi畉m d畉n v畛 cu畛i thai k畛, v狸 r畉ng cng v畛 cu畛i thai k畛, nhu c畉u dinh d藤畛ng c畛a thai cng cao, m叩u 畉n thai nhi nhi畛u, M r畛n ph畉i tng l藤u l藤畛ng k畛 c畉 th狸 t但m tr藤董ng 畛 藤a m叩u tr畛 v畛 b叩nh nhau. Theo nhi畛u k畉t qu畉 nghi棚n c畛u, Doppler 畛ng m畉ch r畛n 動畛c xem l c坦 gi叩 tr畛 nh畉t trong 叩nh gi叩 thai ch畉m ph叩t tri畛n trong t畛 cung.
  • 9. DOPPLER 畛NG M畉CH R畛N - B狸nh th動畛ng, khi kh畉o s叩t 畛 qu箪 II (thai 22 tu畉n tu畛i) ta ph畉i th畉y ph畛 cu畛i t但m tr動董ng. - B狸nh th藤畛ng, RI, PI v S/D ratio gi畉m d畉n v畛 cu畛i thai k畛. C叩c ch畛 s畛 ny tng cao b畉t th藤畛ng ph畉n 叩nh tr畛 kh叩ng c畛a b叩nh nhau tng cao. i畛u ny s畉 lm tng nguy c董 thai b畛nh v thai ch畉t chu sinh (perinatal morbidity and mortality). - S畛 thi畉u v畉ng (absent) ho畉c 畉o ng動畛c (reversed) d嘆ng cu畛i t但m tr動董ng (end diastolic flow) n坦i l棚n tr畛 kh叩ng r畉t cao 畛 b叩nh nhau, i畛u ny lm cho ti棚n l動畛ng tr畛 n棚n r畉t x畉u.
  • 11. C坦 t叩c gi畉 ch畛n v畛 tr鱈 cu畛ng r畛n c畉m vo b叩nh nhau, c坦 t叩c gi畉 ch畛n v畛 tr鱈 cu畛ng r畛n c畉m vo thnh b畛ng thai nhi, c坦 t叩c gi畉 ch畛n cu畛ng r畛n t畛 do trong khoang 畛i.
  • 12. March 14, 2017 12 C坦 m畛t s畛 kh叩c bi畛t c坦 箪 ngh挑a khi kh畉o s叩t c叩c ch畛 s畛 Doppler t畉i v畛 tr鱈 cu畛ng r畛n c畉m vo thnh b畛ng thai nhi, t畉i v畛 tr鱈 cu畛ng r畛n t畛 do v t畉i v畛 tr鱈 cu畛ng r畛n c畉m vo b叩nh nhau6. Tr畛 kh叩ng cao nh畉t t畉i v畛 tr鱈 cu畛ng r畛n c畉m vo thnh b畛ng thai nhi, v vi畛c thi畉u v畉ng ho畉c 畉o ng藤畛c d嘆ng ch畉y cu畛i t但m tr藤董ng c坦 th畛 藤畛c th畉y tr藤畛c nh畉t t畉i v畛 tr鱈 ny. Tr畛 s畛 tham kh畉o cho c叩c ch畛 s畛 Doppler t畉i c叩c v畛 tr鱈 ny 達 藤畛c xu畉t b畉n7,8. 畛 董n gi畉n v ki棚n 畛nh, o 畉c c畉n 動畛c ti畉n hnh t畉i v畛 tr鱈 cu畛ng r畛n t畛 do. Tuy nhi棚n, trong tr藤畛ng h畛p a thai, v/ho畉c khi so s叩nh c叩c o 畉c l畉p l畉i, vi畛c kh畉o s叩t Doppler t畉i nh畛ng v畛 tr鱈 c畛 畛nh (cu畛ng r畛n c畉m vo thnh b畛ng thai nhi, cu畛ng r畛n c畉m vo b叩nh nhau ho畉c cu畛ng r畛n t畛 do trong 畛 b畛ng) c坦 th畛 叩ng tin c畉p h董n. C叩c tr畛 s畛 tham kh畉o c畉n ph畉i t藤董ng 畛ng v畛i v畛 tr鱈 kh畉o s叩t. L動u 箪: 1. 畛 a thai, kh畉o s叩t 畛ng m畉ch cu畛ng r畛n c坦 th畛 kh坦 v狸 kh坦 x叩c 畛nh cu畛ng r畛n thu畛c v畛 thai no. T畛t h董n h畉t ta kh畉o s叩t Doppler xung t畉i v畛 tr鱈 cu畛ng r畛n c畉m vo thnh b畛ng thai nhi. Tuy nhi棚n, tr畛 kh叩ng 畛 但y s畉 cao h董n t畉i v畛 tr鱈 cu畛ng r畛n t畛 do v v畛 tr鱈 cu畛ng r畛n c畉m vo b叩nh nhau, v狸 th畉 c畉n 畛i chi畉u v畛i tr畛 s畛 tham kh畉o t動董ng 畛ng. 2. 畛 cu畛ng r畛n c坦 2 m畉ch m叩u, t畉i b畉t k畛 tu畛i thai no, 動畛ng k鱈nh c畛a 畛ng m畉ch r畛n 董n 畛c c滴ng l畛n h董n so v畛i hai 畛ng m畉ch r畛n th担ng th動畛ng, v do v畉y tr畛 kh叩ng s畉 th畉p h董n9(Ghi ch炭 c畛a ng動畛i d畛ch: tr畛 kh叩ng th畉p h董n c坦 ngh挑a l c叩c ch畛 s畛 RI, PI v S/D ratio 畛u th畉p h董n so v畛i cu畛ng r畛n th担ng th動畛ng c坦 3 m畉ch m叩u). ISUOG Practice Guidelines: use of Doppler ultrasonography in obstetrics. Ultrasound Obstet Gynecol 2013; 41: 233239
  • 13. 13 Acharya G et al. Reference ranges for serial measurements of blood velocity and pulsatility index at the intra-abdominal portion, and fetal and placental ends of the umbilical artery. Ultrasound Obstet Gynecol 2005; 26: 162169.
  • 14. 14 Acharya G et al. Reference ranges for serial measurements of blood velocity and pulsatility index at the intra-abdominal portion, and fetal and placental ends of the umbilical artery. Ultrasound Obstet Gynecol 2005; 26: 162169.
  • 15. Acharya G et al. Reference ranges for serial measurements of umbilical artery Doppler indices in the second half of pregnancy. Am J Obstet Gynecol 2005; 192: 937944. We chose the free floating loop of the umbilical cord because it seems to be the preferred technique in many centers. Semiquantitative Doppler indices are not angle dependent, and an insonation angle of < 60 degrees does not have any significant effect in their calculation. However, we kept the angle at < 15 degrees in all cases. Umbilical Artery PI b畉t th藤畛ng khi > 95th percentile.
  • 16. March 14, 2017 16 Acharya G et al. Reference ranges for serial measurements of umbilical artery Doppler indices in the second half of pregnancy. Am J Obstet Gynecol 2005; 192: 937944. Umbilical Artery RI b畉t th藤畛ng khi > 95th percentile.
  • 17. March 14, 2017 17 Acharya G et al. Reference ranges for serial measurements of umbilical artery Doppler indices in the second half of pregnancy. Am J Obstet Gynecol 2005; 192: 937944. Umbilical Artery S/D ratio b畉t th藤畛ng khi > 95th percentile.
  • 18. DOPPLER 畛NG M畉CH CU畛NG R畛N BNH TH蕩畛NG Khi lm Doppler 畛ng m畉ch r畛n, c畛a s畛 th動畛ng 畉t bao tr湛m c畉 M v TM r畛n.
  • 20. Tu畉n th畛 10 Tu畉n th畛 24 G畉n sinh DOPPLER 畛NG M畉CH CU畛NG R畛N BNH TH蕩畛NG
  • 21. Tu畉n 16 Tu畉n 20 Tu畉n 24 Tu畉n 28 Tu畉n 32 Tu畉n 36 Tu畉n 40
  • 23. Thai 35 tu畉n, S/D = 3,5 Thai 35 tu畉n, S/D = 3,76 B狸nh th藤畛ng thai > 34 tu畉n: S/D ratio 3 IUGR
  • 26. Thai 28 tu畉n, S/D 4 Thai 28 tu畉n, S/D > 4 Thai 28 tu畉n, Absent end-diastolic flow Thai 28 tu畉n, Reversed end-diastolic flow B狸nh th藤畛ng thai 26-30 tu畉n: S/D ratio 4 SEVERE IUGR IUGR
  • 27. V畛i Doppler mu, a gi叩c Willis d畛 th畉y 畛 l叩t c畉t ngang n畛n s畛 thai nhi. M n達o gi畛a ch畉y d畛c theo b畛 x藤董ng 叩.
  • 30. i畛u 叩ng l藤u 箪 l kh叩c v畛i ng藤畛i l畛n, 畛 thai nhi, b狸nh th動畛ng tr畛 kh叩ng c畛a M n達o kh叩 cao. Khi t狸nh tr畉ng thi畉u Oxy n達o x畉y ra (畛 thai ch畉m ph叩t tri畛n trong t畛 cung), tu畉n hon n達o s畉 thay 畛i b畉ng c叩ch gi畉m tr畛 kh叩ng 畛 tng d嘆ng ch畉y trong th狸 t但m tr藤董ng. Ta g畛i 坦 l s畛 t叩i ph但n ph畛i tu畉n hon n達o (cerebral blood flow redistribution). Qu箪 I Qu箪 II & III
  • 31. M畛t s畛 nghi棚n c畛u cho th畉y r畉ng PSV c畛a 畛ng m畉ch n達o gi畛a c坦 th畛 ti棚n o叩n t畛t v畛 t畛 vong chu sinh 畛 thai ch畉m ph叩t tri畛n trong t畛 cung h董n l ch畛 s畛 PI; tuy nhi棚n, c畉n ph畉i c坦 th棚m nhi畛u nghi棚n c畛u n畛a 畛 x叩c nh畉n i畛u ny. Trong khi g坦c Doppler l y畉u t畛 k畛 thu畉t kh担ng c畉n thi畉t khi o PI, th狸 khi o PSV c畉n ph畉i c坦 g坦c Doppler cng nh畛 cng t畛t, l箪 t動畛ng l 00, c嘆n kh担ng 動畛c th狸 ph畉i < 300. Eliza Berkley et al. SMFM Clinical Guideline-Doppler assessment of the fetus with intrauterine growth restriction. American Journal of Obstetrics & Gynecology APRIL 2012. ISUOG Practice Guidelines: use of Doppler ultrasonography in obstetrics. Ultrasound Obstet Gynecol 2013; 41: 233239 Thanh i畛u ch畛nh g坦c ph畉i tr湛ng v畛i tr畛c c畛a d嘆ng ch畉y. i畛u ny 畉m b畉o cho vi畛c 叩nh gi叩 v畉n t畛c v d畉ng s坦ng 畉t hi畛u qu畉 t畛t nh畉t. S畛 sai l畛ch nh畛 v畛 v畉n t畛c do g坦c Doppler c坦 th畛 x畉y ra. N畉u g坦c Doppler l 100 th狸 s畛 sai l畛ch v畛 v畉n t畛c l 2%, trong l炭c g坦c Doppler l 200 th狸 s畛 sai l畛ch v畉n t畛c l 6%. Trong tr藤畛ng h畛p v畉n t畛c th畉t s畛 l m畛t th担ng s畛 quan tr畛ng v畛 m畉t l但m sng (v鱈 d畛 畛ng m畉ch n達o gi畛a) v n畉u g坦c Doppler > 200 , c畉n ph畉i i畛u ch畛nh 畉u d嘆 sao cho g坦c Doppler nh畛 h董n. N畉u v畉n kh担ng th畛 l畉y 藤畛c g坦c Doppler l箪 t藤畛ng, th狸 ta c畉n ghi nh畉n v畉n t畛c o 藤畛c k竪m theo l tr畛 s畛 g坦c Doppler trong k畉t qu畉 si棚u 但m. D湛ng Doppler mu 畛 nh畉n bi畉t a gi叩c Willis v 畛ng m畉ch n達o gi畛a g畉n 畉u d嘆. C畛a s畛 Doppler 畉t 畛 1/3 g畉n c畛a 畛ng m畉ch n達o gi畛a, g畉n ch畛 xu畉t ph叩t c畛a n坦 t畛 畛ng m畉ch c畉nh trong10 (PSV s畉 gi畉m d畉n khi i xa ch畛 xu畉t ph叩t).
  • 33. MCA PI b畉t th藤畛ng khi < 5th percentile. C. Ebbing et al. Middle cerebral artery blood flow velocities and pulsatility index and the cerebroplacental pulsatility ratio: longitudinal reference ranges and terms for serial measurements. Ultrasound Obstet Gynecol 2007; 30: 287296
  • 34. C. Ebbing et al. Middle cerebral artery blood flow velocities and pulsatility index and the cerebroplacental pulsatility ratio: longitudinal reference ranges and terms for serial measurements. Ultrasound Obstet Gynecol 2007; 30: 287296 MCA PSV b畉t th藤畛ng khi > 95th percentile. G坦c Doppler 100.
  • 39. Thai 28 tu畉n, SEVERE IUGR: t叩i ph但n ph畛i tu畉n hon n達o.
  • 40. IUGR Thai 28 tu畉n, kh担ng c坦 ph畛 cu畛i t但m tr藤董ng 畛 M r畛n T叩i ph但n ph畛i tu畉n hon n達o C.M.Rumack et al. Diagnostic Ultrasound. 3rdEdition. 2005. p1459-1488
  • 41. IUGR M r畛n c坦 RI cao b畉t th藤畛ng Doppler M n達o gi畛a b狸nh th藤畛ng
  • 42. So s叩nh ph畛 Doppler b狸nh th藤畛ng c畛a M n達o gi畛a v M r畛n, ta th畉y r畉ng EDV c畛a M r畛n lu担n lu担n cao h董n M n達o gi畛a
  • 43. Ch畛 s畛 kh叩ng (RI) c畛a M n達o gi畛a lu担n cao h董n M r畛n
  • 44. T畛 S畛 GI畛A M NO GI畛A V M R畛N (CPR - cerebroplacental ratio t畛 s畛 n達o nhau). - B狸nh th藤畛ng, EDV 畛 M n達o gi畛a lu担n lu担n th畉p h董n EDV 畛 M r畛n 畛 b畉t k畛 tu畛i thai no. V狸 th畉 RI v PI c畛a M n達o gi畛a lu担n cao h董n M r畛n. CRI/URI > 1; CPI/UPI > 1. - G畛i l t叩i ph但n ph畛i tu畉n hon thai nhi (fetal flow redistribution, brain sparing) khi: CRI/URI < 1; CPI/UPI < 1. Dev Maulik. Doppler Ultrasound in Obstetrics and Gynecology. 2nd Edition. 2005
  • 45. Th畛ng k棚 tr棚n 881 tr藤畛ng h畛p s畉n ph畛 c坦 tu畛i thai trung b狸nh 33 tu畉n tu畛i, ng藤畛i ta th畉y c坦 146 tr藤畛ng h畛p CPR (cerebroplacental ratio) < 1. Trong s畛 坦 c坦 18% (n =27) d畛 h畉u r畉t x畉u (adverse perinatal outcomes). Nguy c董 gia tng g畉p 11 l畉n so v畛i s畛 thai nhi c坦 CPR b狸nh th藤畛ng (1.9%, 14/735). Adverse perinatal outcome was defined as a composite of intraventricular hemorrhage, periventricular leukomalacia, hypoxic ischemic encephalopathy, necrotizing enterocolitis, bronchopulmonary dysplasia, sepsis, and death. Flood K, Unterscheider J, Daly S, et al. The role of brain sparing in the prediction of adverse outcomes in intrauterine growth restriction: results of the multicenter PORTO Study. Am J Obstet Gynecol 2014;211:288.e1-5.
  • 46. Flood K, Unterscheider J, Daly S, et al. The role of brain sparing in the prediction of adverse outcomes in intrauterine growth restriction: results of the multicenter PORTO Study. Am J Obstet Gynecol 2014;211:288.e1-5.
  • 47. C. Ebbing et al. Middle cerebral artery blood flow velocities and pulsatility index and the cerebroplacental pulsatility ratio: longitudinal reference ranges and terms for serial measurements. Ultrasound Obstet Gynecol 2007; 30: 287296. CPR b畉t th藤畛ng khi < 5th percentile.
  • 48. Mean Uterine Artery PI b畉t th藤畛ng khi > 95th percentile. O. G坦mez et al. Reference ranges for uterine artery mean pulsatility index at 1141 weeks of gestation. Ultrasound Obstet Gynecol 2008; 32: 128132
  • 50. Flood K, Unterscheider J, Daly S, et al. The role of brain sparing in the prediction of adverse outcomes in intrauterine growth restriction: results of the multicenter PORTO Study. Am J Obstet Gynecol 2014;211:288.e1-5.
  • 53. ZOOM
  • 55. ZOOM
  • 56. Ph畛 Doppler 畛ng t挑nh m畉ch bao g畛m 3 pha: -S: t但m thu th畉t, 畛ng th畛i 畛ng TM co b坦p 畛 m叩u qua l畛 b畉u d畛c. -D: t但m tr藤董ng th畉t, van 3 l叩 m畛 t畉o 叩p l畛c 但m, h炭t m叩u v畛 tim. -a: nh挑 (P) co b坦p cu畛i t但m tr藤董ng t畉o ph畛 畉o ng藤畛c. - B狸nh th藤畛ng, S # 50-60cm/s, a > 0. - Doppler 畛ng TM b畉t th藤畛ng khi: a = 0 ho畉c 但m (n坦i l棚n s畛 ch棚nh l畛ch 叩p su畉t cao 畛 nh挑 (P)). - Qu箪 I: Doppler 畛ng TM b畉t th藤畛ng g畉p 畛 thai nhi b畉t th藤畛ng NST v d畛 t畉t tim. - Qu箪 II & III: Doppler 畛ng TM b畉t th藤畛ng g畉p 畛 thai ch畉m ph叩t tri畛n trong t畛 cung (IUGR) v thai d畛 t畉t tim. T畛 tu畉n 11-14: Doppler 畛ng t挑nh m畉ch b畉t th藤畛ng g畉p 畛 5% thai nhi c坦 NST b狸nh th藤畛ng, v g畉p 畛 80% thai nhi Trisomy 21. Ph畛 b狸nh th藤畛ng v畛i a > 0.
  • 59. Ph畛 DV t畉i th畛i i畛m 13 ngy, 7 ngy v 48 gi畛 tr藤畛c khi thai ch畉t trong TC, 25 tu畉n tu畛i, c但n n畉ng thai nhi < 500g
  • 60. Ph畛 DV t畉i th畛i i畛m 16 ngy, 4 ngy v 24 gi畛 tr藤畛c khi thai ch畉t trong TC, 23 tu畉n tu畛i, c但n n畉ng thai nhi < 500g
  • 61. SEVERE IUGR Ph畛 畉o ng藤畛c cu畛i t但m tr藤董ng 畛 M r畛n T叩i ph但n ph畛i tu畉n hon n達o Ph畛 Doppler 畛 畛ng t挑nh m畉ch b狸nh th藤畛ng
  • 62. Thai 28 tu畉n, IUGR T叩i ph但n ph畛i tu畉n hon n達o Kh担ng c坦 ph畛 cu畛i t但m tr藤董ng 畛 M r畛n a = 0 畛 畛ng t挑nh m畉ch
  • 63. K畉T LU畉N 畛 叩nh gi叩 s畛 ph叩t tri畛n c畛a thai nhi ta c畉n ph畉i ph畛i h畛p t畛t c叩c kh畉o s叩t sau: o 畉c c叩c c畉u tr炭c c畛a thai nhi so v畛i tr畛 s畛 chu畉n theo tu畛i thai. 叩nh gi叩 l動畛ng n動畛c 畛i. Kh畉o s叩t Doppler thai nhi. Nh畛ng bi畉n 畛i c叩c th担ng s畛 Doppler lu担n lu担n x畉y ra tr動畛c c叩c bi畉n 畛i v畛 m畉t gi畉i ph畉u. Do v畉y, nh畛 c坦 si棚u 但m Doppler, ch炭ng ta c坦 th畛 ch畉n o叩n v x畛 tr鱈 s畛m nh畛ng tr動畛ng h畛p thai ch畉m ph叩t tri畛n trong t畛 cung.
  • 64. TI LI畛U THAM KH畉O Dev Maulik. Doppler Ultrasound in Obstetrics and Gynecology. 2nd Edition. 2005 Peter M. Doubilet et al. Atlas of Ultrasound in Obstetrics and Gynecology. 2003 A. C. Fleischer et al. Sonography in Obstetrics and Gynecology. 6th Edition. 2001 Peter W. Callen et al. Ultrasonography in Obstetrics and Gynecology. 5th Edition. 2008. Saunders Elsevier. Gilles Grang辿 et al. Guide pratique de l'辿chographie obst辿tricale et gyn辿cologique. 2012, Elsevier Masson. Paula J. Woodward et al. Diagnostic Imaging Obstetrics. 1st edition. Amirsys. 2005. Diagnostic Medical Sonography: Obstetrics and Gynecology. 3rd edition. 2012 by Lippincott Williams & Wilkins. A. Pilalis et al. Screening for pre-eclampsia and fetal growth restriction by uterine arteryDoppler and PAPP-A at 1114 weeks gestation. Ultrasound Obstet Gynecol 2007; 29: 135140. C. K. H. YU et al. Prediction of pre-eclampsia by uterine artery Doppler imaging: relationship to gestational age at delivery and small-for-gestational age. Ultrasound Obstet Gynecol 2008; 31: 310313. Aris Antsaklis et al. Uterine Artery Doppler in the Prediction of Preeclampsia and Adverse Pregnancy Outcome. Donald School Journal of Ultrasound in Obstetrics and Gynecology, April-June 2010;4 (2): 117-122. Shivani Singh et al. Role of color doppler in the diagnosis of intra uterine growth restriction (IUGR). Int J Reprod Contracept Obstet Gynecol. 2013 Dec;2(4):566-572. K. MELCHIORRE et al. First-trimester uterine artery Doppler indices in the prediction of small-for-gestational age pregnancy and intrauterine growth restriction. Ultrasound Obstet Gynecol 2009; 33: 524529. Eliza Berkley et al. Doppler assessment of the fetus with intrauterine growth restriction. Am J Obstet Gynecol April 2012, Volume 206, Issue 4, Pages 300308. Beth M. Kline-Fath et al. Fundamental and Advanced Fetal Imaging Ultrasound and MRI. 2015 Wolters Kluwer Health. Flood K, Unterscheider J, Daly S, et al. The role of brain sparing in the prediction of adverse outcomes in intrauterine growth restriction: results of the multicenter PORTO Study. Am J Obstet Gynecol 2014;211:288.e1-5. C. Ebbing et al. Middle cerebral artery blood flow velocities and pulsatility index and the cerebroplacental pulsatility ratio: longitudinal reference ranges and terms for serial measurements. Ultrasound Obstet Gynecol 2007; 30: 287296.
  • 65. Rennes, m湛a l叩 r畛ng 2004