臨床婦人科産科64巻4号

2010年04月発行

今月の臨床 これを読めばすべてわかる―最新の産婦人科超音波診断

IV　産科における超音波診断─妊娠中・後期 ［胎児の血流計測と循環機能評価］

3．下大静脈，静脈管，臍帯静脈の血流計測とその意義

著者： 青木昭和¹

所属機関： ¹島根大学医学部産婦人科

ページ範囲：P.673 - P.683

文献概要

　胎児機能評価法は，胎児心拍数モニタリングや超音波パルスドプラ法による臍帯動脈・中大脳動脈血流計測が広く利用されている．しかし，胎児・胎盤循環においては，胎盤からの血液は臍帯静脈を介して胎児静脈系に入ること，臍帯では静脈のほうが動脈より圧迫を受けやすいこと，胎児心臓のポンプ機能低下は中心静脈圧に速やかに反映されることなどを考えると，静脈系を中心とした血流動態把握もきわめて重要である．一般的に超音波血流計測でのPI・RI上昇は測定部位より末梢に血管抵抗の高い場所があることを示す．よって，臍帯動脈PI・RIの上昇は胎盤における血管抵抗の上昇を意味し，胎盤機能不全の指標となる．一方，臍帯静脈をはじめとする各種静脈波形は，心臓への静脈還流を含む胎児全身の循環動態を強く反映しており胎児機能不全の指標となる．よって厳密にはこの2つの計測系は意味するものが異なる点を理解しなければならない．

　胎盤から臍帯を通って胎児右房へ至る過程では，静脈波形は主に以下の3つの要因に左右される．（1）胎児循環不全（心不全）などのように中心静脈圧上昇による心拍の逆行性伝播の影響，（2）胎盤機能不全などによる胎盤からの循環血液量減少と酸素化障害の影響，（3）臍帯圧迫，臍静脈瘤，静脈管欠損などの静脈ルート自体の異常による影響．ここでは静脈血流波形のなかでも，特に実践に即した臨床的視点から臍帯静脈，臍静脈，静脈管，下大静脈について述べる．

参考文献

1）Skulstad SM, Kiserud T, rasmussen S : The effect of vascular constriction on umbilical venous pulsation. Ultrasound Obstet Gynecol 23 : 126-130, 2004

2）Reed KL, Chaffin DG, Anderson CF, Newman AT : Umbilical venous velocity pulsations are related to atrial contraction pressure waveforms in fetal lambs. Obstet Gynecol 89 : 953-956, 1997

3）Hofstaetter C, Dubiel M, Gudmundsson S : Two types of umbilical venous pulsation and outcome of high-risk pregnancy. Early Human Development 61 : 111-117, 2001

4）Quintero RA, Dickinson JE, Morales WJ, et al : Stage-based treatment of twin-twin transfusion syndrome. Am J Obstet Gynecol 188 : 1333-1340, 2003

5）Russel Z, Quintero RA, Kontopoulos EV : What is definition of pulsatile umbilical venous flow in twin-twin transfusion syndrome? Am J Obstet Gynecol 199 : 634 e1-634 e4, 2008

6）Nakai Y, Imanaka M, Nishio J, et al : Umbilical venous pulsation associated with hypercoiled cord in growth-retarded fetuses. Gynecol Obstet Invest 430 : 6-7, 1997

7）Wolman I, Gull I, Fait G, et al : Persistent right umbilical vein : incidence and significance. Ultrasound Obstet Gycol 19 : 562-564, 2002

8）Yang PY, Wu JL, Yeh GP, et al : Prenatal diagnosis of persistent right umbilical vein using three-dimensional sonography with power Doppler. Taiwanese J Obstet Gynecol 46 : 43-46, 2007

9）Bradley E, Kean L, Twining P, et al : Persistent right umbilical vein in a fetus with Noonan's syndrome : a case report. Ultrasound Obstet Gynecol 17 : 76-78, 2001

10）Ipek A, Kurt A, Tosun O, et al : Prenatal diagnosis of fetal intra-abdominal umbilical vein varix : report of 2 cases. J Clin Ultrasound 36 : 48-50, 2008

11）Allen SL, Bagnall C, Roberts AB, et al : Thrombosing umbilical vein varix. J ultrasound Med 17 : 189-192, 1998

12）Sepulveda W, Mackenna A, Sanchez J, et al : Fetal prognosis in varix of the intrafetal umbilical vein. J Ultrasound Med 17 : 171-175, 1998

13）Fung TY, Leung TN, Leung TY, et al : Fetal intra-abdominal umbilical vein varix : what is the clinical significance? Ultrasound Obstet Gynecol 25 : 149-154, 2005

14）Bellotti M, Pennati G, Pardi G, et al : Dilatation of the ductus venosus in human fetuses : ultrasonographic evidence and mathematical medeling. Am J Physiol 275 : H1759-H1767, 1998

15）Smrcek JM, Krapp M, Axt-fliedner R, et al : Atypical ductus venosus blood flow pattern in fetuses with severe tricuspid valve regurgitation. Ultrasound Obstet Gynecol 26 : 180-182, 2005

16）Carvalho FHC, Moron AF, Mattar R, et al : Ductus venosus Doppler velocimetry in the prediction of acidemia at birth : which is the best parameter? Prenat Diagn 25 : 1212-1216, 2005

17）Francisco RP, Miyadahira S, Zugaib M : Predicting pH at birth in absent or reversed end-diastolic velocity in the umbilical arteries. Obstet Gynecol 107 : 1042-1048, 2006

18）Baschat AA, Guclu S, Kush ML, et al : Harman CR. Venous Doppler in the prediction of acid-base status of growth-restricted fetuses with elevated placental blood flow resintance. Am J Obstet Gynecol 191 : 277-284, 2004

19）Schwarze A, Gembruch U, Krapp M, et al : Qualitative venous Doppler flow waveform analysis in preterm intrauterine growth-restricted fetuses with ARED flow in the umbilical artery-correlation with short-term outcome. Ultrasound Obstet Gynecol 25 : 573-579, 2005

20）Alves SKA, Francisco RPV, Miyadahira S, et al : Ductus venosus Doppler and postnatal outcome in fetuses with absent or reversed end-diastlic flow in the umbilical arteries. Eur J Obstet Gynecol Reprod Biol 141 : 100-103, 2008

21）Figueras F, benavides A, Roi MD, et al : Monitoring of fetuses with intrauterine growth restriction : longitudinal changes in ductus venosus and aortic isthmus flow. Ultrasound Obstete Gynecol 33 : 39-43, 2009

22）Baschat AA, Viscardi RM, Hussey-Gardner B, et al : Infant neurodevelopment following fetal growth restriction : relationship with antepartum surveillance parameters. Ultrasound Obstet Gynecol 33 : 44-50, 2009

23）Nomura RMY, Cabar FR, Costa VN, et al : Cardiac troponin T as a biochemical marker of cardiac dysfunction and ductus venosus Doppler velocimetry. Eur J Obstet Gynecol Reprod Biol 2009（in press）

24）Rizzo G, Capponi A, Vendola M, et al : Relationship between aortic isthmus and ductus venosus velocity waveforms in severe growth restricted fetuses. Prenat Diagn 28 : 1042-1047, 2008

25）Andrade EH, Crispi F, Serralde JAB, et al : Contribution of the myocardial performance index and aortic isthmus blood flow index to predicting mortality in preterm growth-restricted fetuses. Ultrasound Obstet Gynecol 34 : 430-436, 2009

26）Teixeira LS, Leite J, Viegas MJBC, et al : Ductus venosus Doppler velocimetry in the first trimester : a new finding. Ultrasound Obstet Gynecol 31 : 261-265, 2008

27）Maiz N, Valencia C, Kagan KO, et al : Ductus venosus Doppler in screening for trisomies 21, 18 and 13 and Turner syndrome at 11-13 weeks of gestation. Ultrasound Obstet Gynecol 33 : 512-517, 2009

28）Berg C, Kamil D, Geipel A, et al : Absence of ductus venosus-importance of umbilical venous drainage site. Ultrasound Obstet Gynecol 28 : 275-281, 2006

29）V-Raman N, Murphy KW, Ghaus K, et al : Congenital absence of portal vein in the fetus : a case report. Ultrasound Obstet Gynecol 17 : 71-75, 2001

30）Sau A, Sharland G, Simpson J : Agenesis of the ductus venosus associated with direct umbilical venous return into the heart-case series and review of literature. Prenat Diagn 24 : 418-423, 2004

31）Volpe P, Marasini M, Caruso G, et al : Prenatal diagnosis of ductus venosus agenesis and its association with cytogenetic/congenital anomalies. Prenat Diagn 22 : 995-1000, 2002

32）Stringer MD : The clinical anatomy of congenital portosystemic venous shunts. Clin. Anat 21 : 147-157, 2008

33）Manning N, Impey L, Lindsell D, et al : Prenatally diagnosed portocaval shunt and postnatal outcome : a case report. Prenat Diagn 24 : 537-540, 2004

34）Kanzaki T, Chiba Y : Evaluation of the preload condition of the fetus by inferior vena cava blood flow pattern. Fetal Diagn Ther 5 : 168-174, 1990

35）Baschat AA, Gembruch U, Harman CR : The sequence of changes in Doppler and biophysical parameters as severe fetal growth restriction worsens. Ultrasound Obstet Gynecol 18 : 571-577, 2001

36）Baschat AA, Viscardi RM, Gardner BH, et al : Infant neurodevelopment following fetal growth restriction : relationship with antepartum surveillance parameters. Ultrasound Obstet Gynecol 33 : 44-50, 2009

37）Turan S, Turan OM, Berg C, et al : Computerized fetal heart rate analysis, Doppler ultrasound and biophysical profile score in the prediction of acid-base status of growth-restricted fetuses. Ultrasound Obstet Gynecol 30 : 750-756, 2007