Simedbull
Simedbull
Ҫԡ ŷ ǡѺ Դ
   
 
Simedbull
ش
շ , Ѻ ,
ûԹ鹢ͧ㨷á㹤 (Fetal Heart Rate Assessment)
͹Ѳ صѳԺ, ..,½ 侺, ..
˹Ǫʵôзá㹤, ҤԪٵʵ-ǪԷ, ᾷʵҪҺ, ԷԴ ا෾ҹ .
Ŵ:

Ӥѭ: ûԹ鹢ͧ㨷á㹤 (Fetal Heart Rate Assessment)
˹: -


˵ ҾءҾ㹺 繡Ǻ¼Ծͧҡͧʹ Ѵ͡͹Ҩҡ͡


ûԹ鹢ͧ㨷á㹤 ѵػʧͻԹآҾͧá㹤¡ôٻẺѡɳС鹢ͧ ٻẺ鹢ͧ㨷軡 reassuring pattern ٻẺѹѺá軡 ѵػʧѡͧõǨ鹢ͧ㨷á ͻͧѹªԵͧáҡäʹС÷ѵõҧ ǹѵػʧͧա§§ͧԸաê¤ʹҧ ҨԴѹµкҷͧá㹤

þѲҢͧ㨷á㹤
㨷áաþѲҵáؤ - ѻ աþѲҢͧ͢¡÷ӧҹͧ»ҷ Ѩ·Ǻ鹢ͧ㨨ӧҹ㹪ǧؤҡӴѺ ѧ ֧դ֧ѲҡЪǧͧ㨷á㹤 ͷԹԨ١ͧҷáա鹢ͧ㨷軡

кҷѵѵ (Autonomic nervous system)
պҷ͡þѲФǺѵҡ鹢ͧ㨷á㹤 ¹ŧѵҡ鹢ͧռҨҡ÷ӧҹͧкҷѵѵ sympathetic parasympathetic ѡɳзѹ (push-pull fashion) á㹤աõͺʹͧ͡áе鹨ҡкҷѵѵ ա¹ŧѵҡ鹢ͧ 㹷ҧçաõͺʹͧҷáդԴ

кҷ Parasympathetic
к ԷԾŵ͡÷ӧҹͧ㨴ѧ
. chronoopic affect ռ㹡Ŵѵҡ鹢ͧ
. oscillatory affect ռŵ fetal heart rate variability

кҷ parasympathetic Сͺ鹻ҷ鹰ҹ 鹻ҷǡ (vagus nerve) ըش鹷 medulla oblongata »ҷ§ sinoatrial (SA) atrioventricular (AV) nodes áе鹻ҷǡ 觼觡ʻҷҡ SA node ŧ 㹢зѺ駡 acetylcholine ( atropine) »÷ǡ зѵҡ鹢ͧ㨷á٧ ͡ҡ кҷ parasympathetic ѧǺ÷ӧҹͧ basal heart rate tone ¹ŧ R intervals ʴ¹ŧͧ beat-to-beat variability

ؤҡкҷ parasympathetic ԷԼҧҡѵҡ鹢ͧ㨷á㹤 觨ҡзáؤҳ ѻ ѵҡ鹢ͧ 駵͹ҷ 駵͹ҷ 㹢зؤ ѻ 㹷áؤ¡ ѻо beat-to-beat variability ҷáؤҡ ѻѧ辺 beat-to-beat variability ҷáդԴ Ъǧҹ繪ǧþѲкҷ parasympathetic Ѳó

кҷ Sympathetic
㹷áؤú˹кҷ sympathetic Шµ㹡ͧ͢㨷á áекҷ sympathetic з norepinephrine 觷ѵҡ鹢ͧ ѧ鹢ͧç кҷ sympathetic ԷԾŵ͡÷ӧҹͧ㨷áҧҡ 㨷á軡ѧͧ stress 㹺ҧҳʹ͡ҡ㨴

㹷áؤҡ鹨ѵҡ鹢ͧ㨷 駤Фç ͷáա͹㹪ǧؤ ѻ ѵҡ鹢ͧ㨷٧鹻ҳ ͧá軡 Ш 㹪ǧؤ ѻ 㹪ǧؤ͹ ѻ зáա͹Ǩѵҡ鹢ͧ㨷á٧鹻ҳ 駵͹ҷ ҹҳ Թҷ Ш٧鹻ҳ 駵͹ҷչҹҳ Թҷ 㹪ǧؤѧ ѻ ѵҡ鹢ͧ㨷٧Ӥѭ觪ҷáѧл 繡ôҧ·á㹤-

÷ӧҹͧкҷ sympathetic parasympathetic 㹡÷ӧҹͧ㨷á㹤 ¡ѭҳҹҧٹǺС鹢ͧ㨷ͧǹ (medullar cardiorespiratory center) 觻Сͺ
. chemoreceptors
. baroreceptors
. кҷǹҧ ٹǺõѺ 繵
. кǺ
. ٹäǺҳʹ

ûѺ÷ӧҹѵѵԢͧٹѧǢҧ㹪ǧ зԴ¹ŧѵҡ鹢ͧ㨷á㹤 baseline variability

õͺʹͧͧʹʹ͡âҴҫ͡ਹ
ҳҫ͡ਹ§á鹡Ѻҳҫ͡ਹôѺ ҳʹ¹ѧ١ á зáʹáШ¢ͧʹաҫ͡ਹ٧ѧͧ͢á㹤 ѧ鹡÷á㹤Ѻҳҫ͡ਹŴŧ ֧ҨԴҡôäá͹ҧҧҳҫ͡ਹ㹵Ŵŧ äǢͧѺкҧԹ ҨԴҡԴԢͧá á͡ǡ͹˹ СâҴʹá ͤԴԷ١ͧ ١ᵡ١Ѻáеա˴ѴҡԹ ФԴԢͧǷá㹤 áǡó鹢ͧ㨼Դ աáдͧ͢á㹤ͧ 繵

СâҴҫ͡ਹ硹ªǤ Сеٹ chemoreceptor dzʹʹᴧ carotid · receptor ѭҳѧҹͧ ʹѧзӤѭ ͧ ǡá ͡ҡҹͧѧͺʹͧ͡áе鹢ͧ alpha-sympathetic ա˴ѴǢͧʹʹᴧdz·ҧ (peripheral arterial beds) 觨зѹԵ٧ ǹ barroeceptor ʹͧСâҴҫ͡ਹ ѭҳѧҹͧաáекҷǡʷ㨢ͧá㹤 鹪ŧ 觨зԴԴѵҡ鹢ͧẺ late variable decelerations ¢鹡Ѻ˵آͧТҴҫ͡ਹ Դҡк¹ʹáԴ Դҡáдͧ͢á㹤

͡ҡ ѧաõͺʹͧͧкҷǹ noradrenergic 觶١Ǻ¢ͧҧ·áͧ Դ˴ѴǢͧʹʹҨҡǡ䵨ҡâҴҫ͡ਹ ͡âҴҫ͡ਹŧ õͺʹͧͧк÷ӧҹ sympathetic ж١ӨѴ ѧ ֧辺ѵҡ鹢ͧ㨷

ҡâҴҫ͡ਹԴعçйҹ зԴ persistent bradycardia Դ late deceleration ͧ ѹ ѹѺáӧҹͧ ͡ҡѧԴ loss of variability ·شԴ¹ŧͧкҧǿԡͧá㹤 ͹ Ф֧Ǣͧͧ͢á㹤Դ

෤Ԥ÷ fetal monitoring
ûԹҾͧá㹤ö¡ͧŤùԤ㹡ѧá㹤 (electronic fetal monitoring), §٧ õǨѴǢͧʹʹʹá㹤 (Doppler velocimetry)

. ͧŤùԤ㹡ѧá㹤
(Electronic fetal monitoring)
繡Ѵѵҡ鹢ͧ㨷á㹤Ǻѹ֡ŧٻẺͧҿ Ẻ external internal fetal monitoring

External fetal monitoring
繡Ѵѵҡ鹢ͧ㨷á¡ǵǨ§٧ҧdz˹觢ͧ㨷á˹ҷͧʵյ駤 ͧͨѭҳ Doppler 繤ͧ͹Ǣͧ㨷á㹤㹢зաúպѴǢͧ atrium ventricle ͧФӹdzѵҡ鹢ͧ㨷á㹤ԴԴҴ·ش Ըդӹdz蹹¡ autocorrelation ԸչзԴٻẺ鹢ͧ㨷á§ѺõǨ fetal electrocardiogram (ECG)

Internal fetal monitoring
ԸաѴѵҡ鹢ͧ㨷á㹤 invasive ¡ bipolar spiral electrode ʹҹͧʹ价ҧҡ١ᷧdzзá 㹢ǡѹ electrode ա˹ҧ˹ҢҢͧʵյ駤͡ӨѴ俿ҷҨúǹ electrode 㹨繵Ѵ㨢ͧá㹤Фӹdzѵҡ鹢ͧ㨷á㹤ҧҧ R-wave ѭҳЪѴਹҡ㹡Ѵ baseline beat-to-beat variability ٧ ѭҳúǹйҡеͧ autocorrelation ҡ

. 蹤٧
§٧㹡ûԹ biophysical profile ѴǢͧ¹ʹͧá㹤 ١ҧҧҧ㹪ǧҡ͹ʹ ҧá ÷ͺ ҧ ѧջª㹡ôŷá㹪ǧҧäʹ,

ѴǢͧ¹ͧʹ (Doppler velocimetry)
ѴǢͧ¹ͧʹʹ umbilical artery ¡õǨѴ resistance to flow, systolic end-diastolic flow ١㹡ûԹáաԭԺ⵷Դ áաԭԺ⵪㹤 ͷáդ§͡ªԵ㹪ǧáʹ §ѴǢͧ¹ʹͧʹʹumbilical artery §ҧǷҹҨջª

ҧá õǨѴѧзáաԭԺ⵪㹤 й㹡ûԹá

Biophysical profile
ԸչԸշҡõǨѴѵҡ鹢ͧ㨷á㹤¡ͧŤùԤ㹡ѧá㹤 Ѻ§٧㹡ûԹ ͹ ֧Ǣͧͧ͢á㹤 лҳӤ

ٻẺ鹢ͧ㨷á㹤 (Fetal heart rate patterns)
ٻẺͧ鹢ͧ㨷á㹤 觶١ѹ֡ͧŤùԤ㹡ѧá㹤 ٻẺ reassuring non-reassuring pattern

Reassuring fetal heart rate pattern
ѧǢҧٻẺ鹢ͧ㨷軡Ԥ reassuring pattern ·á㹤ǨٻẺͧ鹢ͧẺ reassuring pattern 㹪ǧáʹç ա͹Ƿ active ٻẺͧ reassuring Сͺ仴
. ѵҡ鹢ͧ㨷á㹤դ»ҳ - 駵͹ҷ
. 辺ѡɳТͧ decelerations
. آͧá㹤դѹѺѵҡ鹢ͧ㨷ѡɳ accelerations
. Fetal heart rate variability դһԻҳ - 駵͹ҷ

ٻẺ鹢ͧ㨷á㹤¹ŧ仨ҡ硹觪ҷáդԴ ٻẺ early deceleration (ѵҡ鹢ͧ㨷áŴŧ繨ѧǡѺ١ա˴Ѵ) mild bradycardia (ѵҡ鹢ͧ㨻ҳ - 駵͹ҷ) դѹѺ÷зá١աáе鹼ҹкҷǡ ·áʹ繡ôա㹪ǧáʹԴ

ѡɳС鹢ͧ㨷ԴҧѹѺѡɳТͧááʹͧѺѡҷѹ ¡ѵҡ鹢ͧ㨷Դ仨ҡѡɳлԴѧҧҡ ѡɳ fetal arrhythmias ѡعç 繻㹪ǧ ѧʹ persistent tachyarrhythmias Դҹҹªѹ ѡ˵آͧкӢͧá㹤 persistent bradyarrhythmias ѡѹѺä㨢ͧá cardiomyopathy ä systemic lupus erythrematosus ѡ·ԴТҴҫ͡ਹʹ繡ô㹢зá㹤
þѡɳС鹢ͧ㨷٧ (Fetal heart rate accelerations) mild variable decelerations 觪кҷѵѵա÷ӧҹ軡

Non-reassuring fetal heart rate patterns
ǹ˭ٻẺ͹зáѡͧáûԹ áҨʹ繡ôҡ͹ ҧáТҴҫ͡ਹͧá㹤Ѻ áʹ繡ô

Non-reassuring fetal heart rate patterns Сͺ
. Late decelerations ѡɳТͧ fetal heart rate ٻ U-shaped ա˴ѴǢͧ١ ѵҡ鹢ͧ㨷á㹤ŧ СѺлա˴ѴǢͧ١ mild late decelerations Դҡԡҵͺʹͧͧкҷǹҧ͡âҴҫ͡ਹ 㹢з severe late decelerations ѡ繼Ũҡá÷ӧҹͧµç ҧ¢ͧá㹢й pH ŧ зáդ§зؾҾСõ»ԡԴ͹ҧ٧ late decelerations variability к觺͡ʹ繡ô㹷á 觡ѧԴҹѡ

. Sinusoidal heart rate ٻẺ variability ѡɳФ sine wave ժǧҷԴ鹤ҳ - ͺ͹ҷ amplitude - 駵͹ҷ ҡԴ sinusoidal pattern 繼ŨҡâҴҫ͡ਹдѺҹҧ ѡ㹷áѡɳЫմ ٻẺ sinusoidal դѹѺѵҡõ¢ͧá٧ õǨԴá¡ʹdzšҤ pH ѧ辺áդԴ ٻẺ sinusoidal ֧͡С͹ªԵͧá㹤 (preterminal stage) áʹ繡ô

. Variable decelerations ѡɳС鹢ͧ㨷á㹤Ŵŧѹ ҨѹѹѺ˴ѴǢͧ١ ѡɳФ¡ҿ U-, V- W- shaped Ѻ mild moderate variable decelerations ѡɳ late component ժǧҡԴѵҡ鹢ͧŴŧҡѡ ШСѺС鹢ͧ㨷á軡ѹǴ (rapid return) ͡ҡѡɳдѧѡԴ鹪Ǥ駪ǤҡԴʹ 辺դѹѺʹ繡ôͤṹ APGAR

çѹ severe variable decelerations ѡɳТͧ late component áѺС鹢ͧ㨷軡Ԫ ѧ˴ѴǢͧ١شŧ (delayed return) ѧ pH ͧáŴŧ ͡ҡѧ鹢ͧ㨷áѡɳ loss of variability rebound tachycardia ҹҡ ҷ ѵҡ鹵ӡ 駵͹ҷ ҷá㹤ѺѡɳФԴԴѧǨعçСԹҹҹ鹵

Fetal distress patterns
´ͧá㹤ѴмԴͧá ˵ءõͤԡâͧáѺ ѡѹѺТҴҫ͡ਹФôҧ·á (fetal acidemia) ¹ŧѧѡդѹҧ٧ѺûѺǢͧк¹ʹͧҧ·á㹤 դ繷еͧ nonreassuring fetal heart rate patterns

ٻẺѵҡ鹢ͧ㨷á§ٻẺѹѺ´ͧá㹤ԧ (true fetal distress)-
. Undulating baseline ա¹ŧ鹢ͧẺ tachycardia bradycardia Ѻѹ ѡŴŧͧ variability ҧ¹ŧͧѵҡ鹢ͧ
. Severe bradycardia ѵҡ鹢ͧ㨵ӡ 駵͹ҷ ҹҹ ҷ աŴŧ仢ͧ variability
. Tachycardia with diminished variability ѹѺҷѺ ੾ҧ;Ѻ non-reassuring periodic patterns late decelerations

ٻẺͧѵҡ鹢ͧ㨴ѧö㹡õǨѴͧáʹ繡ô͢Ҵҫ͡ਹ

Antepartum fetal surveillance
էҹԨ㴷ʹѺʹعԸաõǨآҾá㹤Ը ЪŴ§ͧõ¢ͧá㹤 ҧáõǨآҾͧá㹤ѧ繷㹷áդ§͡ªԵ㹪ǧáʹ٧ 㹷ҧѧ¡ԡ÷ͺҹ㹢зѧ͢š֡Ҩҡ Ҩѧաŧ֡͡ҡѹ ѧ ֧ǨآҾá㹤ͷҺҷáդ§͡õ㹪ǧáʹ٧ 觤è֧ʵյ駤դԴäá㹢е駤 ѹԵ٧ 繾 ä äҹ áԭԺ⵪㹤 õ駤ὴ 繵

õǨآҾͧá㹤Сͺ non-stress test (NST), biophysical profile (BPP), oxytocin challenge test (OCT) modified BPP

Non-stress test (NST)
NST öͧŤùԤ㹡ѧá㹤 õǨöѹշ÷ӧҹͧкҷ§㨷á㹤ӧҹó 觨㹪ǧؤҳ - ѻ ѡǨѹ㹪ǧؤ - ѻ 繪ǧкҷ§㨷áӧҹóش õǨöءѹѻФ駢鹡Ѻͺ觪ͧǨ
. Reactive test ¶֧ õǨ fetal heart rate accelerations ҡ 駵͹ҷ˹ baseline йҹҡ Թҷ 繨ӹǹҧ 㹪ǧ ҷ
. Non-reactive test ¶֧ õǨ辺 fetal heart rate accelerations ѡɳдѧ 㹪ǧҡ ҷբ ҨѹѺá͹˹ áաù͹Ѻ ҷʵյ駤ѺСٺ áդԴ ͷáТҴҫ͡ਹ ҡ֡Ҵ meta-analysis 辺ҡ glucose ʵյ駤 áе鹷á㹤§ЪŴغѵԡóͧ non-reactive test,

ҵǨ non-reactive NST 繵Ǻ͡ non-reassuring fetal heart rate pattern 觷á㹤繵ͧѺõǨԸʹ á㹤Ǩ non-reactive NST դ¢ͧ umbilical vein pH ҳ . ± . 㹢зáǨ͹ǷԴԨ pH . ± . ôѡҢ鹡Ѻҡ÷ҧԹԡӤѭ ҷáú˹Ǥصԡõ駤 㹷áʹ͹˹ ôѡҢ鹡ѺõѴԹ㨢ͧᾷ ÷ӡ÷ͺ (ancillary tests) Ҩջª㹡ա§صԡõ駤㹷á͹˹ С÷ͺ NST §ԸդҼźǡǧ٧֧ -

÷ͺ (ancillary tests)

Vibroacoustic stimulation
õǨö觡Դ§ҧ˹ҷͧͧʵյ駤 ǡе鹷á㹤áͺʹͧա͹ ԸաùöŴ㹡õǨ NST ŴŢͧ non-reactive ŧ żŢͧ NST ¹ŧ-

Oxytocin challenge test (OCT)
¡ oxytocin ҷҧʹʹӢͧʵյ駤 ͡е١ա˴Ѵǻҳ ҷ öżѧ
. Positive test ¶֧õǨ late deceleratations 仢ͧ˴ѴǢͧ١ ѧżҡ˴ѴǢͧ١й¡ ҷա
. Negative test ¶֧õǨ辺 late variable decelerations
. Equivocal-suspicious pattern Сͺ¡õǨ intermittent late non-significant variable decelerations ҧ equivocal-hyperstimulatory pattern лСͺ¡õǨ fetal heart decelerations Դ㹪ǧ˴ѴǢͧ١ء ҷ йҹҡ Թҷ
. Unsatisfactory test ¶֧ ÷ͺöż͡˴ѴǢͧ١¡ ҷ

Positive test ¶֧ ÷á reserve ŴŧѹѺԴԢͧѵҡ鹢ͧҧäʹ֧ - equivocal-suspicious test variable decelerations Դ鹫 ѹ ѡѹѺáѺдͧ͢á㹤ͧҡйӤӹ

֡ҺҧҧҤԴԢͧ OCT դѹѺáԴҡҤԴԢͧ NST ҧá §ҹ ʴ OCT зӹ¤ԴԢͧáա NST

šзͷáԡԴ (perinatal outcome)
ѵҡõ¢ͧááʹѧҡǨ normal NST OCT դһҳ . . ͷááʹ , µӴѺ źǡǧѡ 㹡֡ǡѹѧҤ§ͧѵҡõ¢ͧááʹѧҡǨ non-reactive NST, reactive positive OCT non-reactive positive OCT դ , ͷááʹ , ӴѺ ѧ鹡żšõǨդԴԨеͧзӴ¤Ѵѧ ûԹآҾͧá㹤¡ NST, OCT, BPP з觡÷ cordocentesis ҨеͧԨóͪ㹡õѴԹ㹡ôŷá㹤 ֧ôá͹ͧʵյ駤ҨԴԴԢͧá㹤 ҹعçǺ 繵

äʹ
ʹ͹˹բͺ觪Ѻ·Ǩ non-reassuring test 㹪ǧ͹ʹ Ѻ׹ѹ¡õǨԸ ·áú˹դ繷еͧǨ׹ѹԸ ͵Ǩ non-reassuring test öصԡõ駤ѹ ҧäʹõԴ鹢ͧ㨢ͧá㹤С˴ѴǢͧ١ʹ ҵǨ late variable decelerations Դ鹫 ѹ ê¤ʹѹյͺ觪ҧٵʵ ԸռҤʹͧͪ¤ʹҧͧʹ

ػ
ûԹ鹢ͧ㨷á㹤੾ЪǧС͹ʹТ纤ʹ դӤѭջªҧҡ㹡õǨԴآҾͧá㹤 ੾·ʵյ駤ǧشդ§٧ (high risk pregnancy) ͷá㹤դ§͡âҴҫ͡ਹ㹪ǧе駤áʹҧ١ͧǴ 觼ѵҡõоԡâͧááʹŴŧ
͡ҧԧ
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