Geç başlangıçlı ve yapısal gelişme geriliği izlenen fetüslerde doppler ve kardiyak verilerin değerlendirilmesi
Evaluation of doppler and cardiac data in fetuses with late onset and structural growth retardation
Yazar: EZGİ TURGUT
Danışman: PROF. DR. DENİZ KARÇAALTINCABA
Gazi Üniversitesi / Tıp Fakültesi / Kadın Hastalıkları ve Doğum Ana Bilim Dalı
Derece: Tıpta Yan Dal Uzmanlık, 2020
Konu: Kadın Hastalıkları ve Doğum = Obstetrics and Gynecology
Dizin: Elektrokardiyografi = Electrocardiography ; Fetal gelişim = Fetal development ; Fetal gelişme geriliği = Fetal growth retardation ; Fetal hastalıklar = Fetal diseases ; Kalp = Heart ; Kalp hastalıkları = Heart diseases ; Prenatal teşhis = Prenatal diagnosis ; Ultrasonografi = Ultrasonography

Özet:
Amaç: FGR ve SGA izlenen fetüsların Doppler parametrelerini ve kardiyak yapısal
ve fonksiyonel bulgularını değerlendirmek gebelik sonuçlarını kar ıla tırmaktır.
Yöntem: Prospektif kohort çalı ma olarak dizayn edildi. Gazi Üniversitesi Hastanesine takip olan gebeler çalı maya dahil edildi. Gebeler fetal ağırlık, CPR oranı ve uterin arter Doppler verilerine göre gruplara ayrılmı tır. Fetal ağırlığın 3 p altında olduğu ve/veya fetal ağırlığın 3-10 p arasında olup beraberinde CPR <5p veya uterin arter PI >95 p saptandığı grup FGR; fetal ağırlık 3-10 p arasında olup beraberinde CPR ve uterin arter PI değerlerinin normal saptandığı grup SGA ve fetal ağırlığın 10 p üzerine saptandığı kontrol grubu olmak üzere üç gruba ayrıldı. Fetal kardiyak ultrasonografik değerlendirme tüm gebelere 36. gebelik haftasında yapıldı.
Bulgular: Çalı maya 73 hasta dahil edildi. Ortalama ya  kontrol grubunda 295; SGA grubunda 264 ve FGR grubunda 285 idi (p=0,59). Doğum ağırlıkları sırasıyla kontrol grubunda 3320318, SGA grubunda 2524143 ve FGR grubunda 2287205 (p<0,001) olup tüm grupların birbiri arasında anlamlı fark mevcuttu. YYB ihtiyacı kontrol grubunda 1(%3) hastada, SGA grubunda 2 (%10) ve FGR grubunda 12 (%60) hastada mevcuttu (p<0,001). FGR grubunda YYB ihtiyacı SGA ve kontrol grubundan anlamlı olarak yüksekti. DV PI ve Aortik istmus PI değerleri açısından gruplar arasında fark yoktu (p=0,836, p=0,937). Kardiyotorasik oran hem FGR hemde SGA grubunda kontrol grubundan yüksek saptandı (p=0,005, p=0,001). Sağ sferik indeksler gruplar arasında benzerdi (p=0,856) ancak sol sferik indeksi FGR grubunda kontrole kıyasla anlamlı olarak dü ük tespit edildi (p=0.046). FGR grubunda SGA ve kontrol grubuna kıyasla sol ventrikül duvar kalınlığında anlamlı azalma görülmü tür (p=0,019, p=0,006). Sağ/sol ventrikül duvar kalınlığı oranı FGR de hem kontrol hem de SGA grubuna kıyasla artmı tır (p<0,001, p=0,021). Triküspit ve mitral kapak oranları FGR de anlamlı olarak SGA ve kontrol grubundan dü üktür (p=0,039 ve p=0,034). Fetal kardiyak fonksiyonel
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bulgular kar ıla tırıldığında aort ve pulmoner maksimal hız benzer saptanmı tır (p=0,649, p=0,173). LVOT MPI, ICT ve IRT FGR grubunda kontrol grubuna kıyasla anlamlı olarak yüksektir (p=0,002, p=0,017, p=0,038). Triküspit ve mitral E/A oranı benzerdir (p=0,101, p=0,586). TAPSE değeri gruplar arasında benzer (p=0,146) iken MAPSE değeri FGR grubunda kontrol grubuna kıyasla anlamlı olarak dü üktür (p=0,024).
Sonuç: Kardiyak yapısal ve fonksiyonel değerlendirmede hem normale kıyasla hem de SGA ya kıyasla geç ba langıçlı FGR grubunda doğum zamanlaması ve kötü perinatal sonuçların önlenmesi konusunda yardımcı olabilecek erken kardiyak fonkisyon bozukluklar izlenmi tir. Triküspit kapak ölçümü, sağ base apex boyutu, triküspit/mitral kapak oranları ve sol sferisite indeksinde sadece FGR de azalmı tır. Bunlar sağ kalbin yüksek dirence maruz kalması ile ili kili olabilir. FGR de artmı  volüme sekonder olduğu dü ünülen sol ventrikül duvar kalınlıkları ince olarak bulunmu , sağ/sol ventrikül duvar kalınlığı oranında artı  izlenmi tir. Bu durumun beyin koruyucu etkinin bir göstergesi olduğu dü ünülmü tür. FGR grubunda sol kalpte sistolik fonsiyonun bir göstergesi olan Mapse değerinin belirgin olarak azaldığı tespit edilmi , sağ kalpte ise bu durum gösterilememi tir. FGR de MPI, ICT, IRT belirgin olarak artmı tır. FGR ve SGA ayrımında artmı  MPI belirlenmesi potansiyel bir ayırıcı olabilir.
Anahtar kelimeler: Fetal geli im geriliği, duktus venosus Doppler, aortik istmus Doppler, fetal kardiyak morfoloji, fetal kardiyak fonksiyon

Abstract:
Objective: To compare the Doppler parameters and cardiac structural and
functional findings of fetuses with FGR and SGA.
Method: It was designed as a prospective cohort study. Pregnant women who were followed in Perinatology depertment of Gazi University Hospital was included in this study. Pregnant women are divided into three groups according to fetal weight, CPR rate and uterine artery Doppler. Pregnant patients whose fetal weight were below 3 p and / or fetal weight between 3-10 p and CPR <5p or uterine artery PI> 95 p were included in FGR group; and those whose CPR and uterine artery PI values were found to be normal and fetal weight were 3-10 p were included in SGA group. Fetal weight which were above 10 p were included in the control group. Fetal cardiac ultrasonographic Doppler was performed to all pregnant women at 36 weeks of gestation.
Results: 73 patients were included in the study. Average age in control group was 295; 264 in the SGA group and 285 in the FGR group respectively (p=0,59). Birth weights were 3320318 in the control group, 2524143 in the SGA group, 2287205 in the FGR group, respectively (p<0,001) and there was significant difference between each groups. There were 1 (3%) patients in the control group, 2 (10%) in the SGA group and 12 (60%) in the FGR group who needed NICU (p<0,001). In the FGR group NICU requirement was significantly higher compare to SGA and control group. There was no difference between the groups in terms of DV Doppler PI and Aortic isthmus Doppler PI (p=0,836, p=0,937). Cardiothoracic ratio was found to be higher in FGR and SGA group than control group (p = 0.005, p = 0.001). The right spherical indices were similar between the groups (p = 0.856), but the left spherical index in FGR was found to be lower than the control (p = 0.046). There was significant decrease in the left ventricular wall thickness in FGR group than SGA and control groups (p=0,019, p=0,006). The right / left ventricular wall ratio increased in FGR compare to control and SGA (p = 0.021 and p <0.001).
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Tricuspid and mitral valve ratios were significantly lower in FGR than the SGA and control groups (p = 0.039 and p = 0.034). When fetal cardiac functional findings were compared, aorta and pulmonary maximal velocity were similar (p=0,649, p=0,173). LVOT MPI, ICT and IRT were significantly higher in the FGR group compared to the control group ((p=0,002, p=0,017, p=0,038). Tricuspid and mitral E/A ratio were similar (p=0,101, p=0,586). While the TAPSE values were similar between the groups (p = 0.146), the MAPSE value was significantly lower in the FGR group control unit (p = 0.024).
Conclusion: In cardiac structural and functional evaluation, both compared to normal and SGA, some early findings of cardiac dysfunction were found in the late onset FGR group which may help in the timing of delivery and prevention of poor perinatal outcomes. Tricuspid valve measurement, right base apex size, tricuspid / mitral valve ratios and left sphericity index decreased only in FGR which may be related to the high resistance of the right heart. Considered to be secondary to the increased volume in FGR; left ventricular wall thicknesses were found to be thin, and an increase in the ratio of right / left ventricular wall thickness was observed. This situation is thought to be an indicator of brain protective effect. In the FGR group, Mapse value, which is an indicator of systolic function in the left heart, was found to be significantly decreased, but this effect was not shown in the right heart. MPI, ICT, IRT were significantly increased in FGR. Increased MPI may be used in the differentiation of FGR and SGA.
Key words: Fetal developmental retardation, ductus venosus Doppler, aortic isthmus Doppler, fetal cardiac morphology, fetal cardiac function