CAJ | 학술논문

目的分析双胎反向动脉灌注序列征(twin reversed arterial perfusion sequence,TRAP)的临床特点,探讨其产前评估方法及临床处理.方法回顾25例TRAP产前诊断及超声检查结果,包括无心胎估重和脐血流、泵血胎心功能及大脑中动脉收缩期峰值流速,分析其临床处理及妊娠结局.采用Fisher精确概率法进行统计学分析.结果 (1)16例泵血胎行羊水染色体核型分析,发现1例嵌合型46,XX[ 36]/46,XY[ 14].(2)根据超声评估,巨大无心胎占87.0％(20/23),86.4％(19/22)的病例两胎脐动脉阻力指数差值≤0.20,提示无心胎血供丰富,66.7％(10/15)的泵血胎出现心功能失代偿,泵血胎大脑中动脉收缩期峰值流速＞1.5中位数的倍数者占75.0％(12/16),提示贫血.(3)血供丰富者发生巨大无心胎的比例(94.7％,18/19)高于血供不丰富者(1/3),差异有统计学意义(Fisher精确概率法,P=0.04).巨大无心胎者泵血胎发生心功能失代偿的比例(83.3％,10/12)高于非巨大无心胎发生心功能失代偿的比例(0/3),差异有统计学意义(Fisher精确概率法,P=0.02).(4)11例首诊后选择引产终止妊娠,14例继续妊娠者泵血胎存活率为64.3％(9/14).继续妊娠者中3例首诊时不伴泵血胎心功能异常的非巨大无心胎选择保守观察,2例足月分娩,1例病情进展而引产；11例泵血胎心功能异常或贫血的巨大无心胎中5例选择保守观察,其中1例流产,3例病情进展(1例引产、2例早产),1例病情稳定至分娩；另外6例选择脐带电凝,5例成功,其中4例泵血胎存活.结论泵血胎的产前诊断结果、心功能状态、贫血、无心胎发育程度及脐血供是TRAP产前评估的重要指标,应根据产前评估结果对TRAP进行及时处理.
목적 분석쌍태반향동맥관주서렬정(twin reversed arterial perfusion sequence,TRAP)적림상특점,탐토기산전평고방법급림상처리.방법 회고25례TRAP산전진단급초성검사결과,포괄무심태고중화제혈류、빙혈태심공능급대뇌중동맥수축기봉치류속,분석기림상처리급임신결국.채용Fisher정학개솔법진행통계학분석.결과 (1)16례빙혈태행양수염색체핵형분석,발현1례감합형46,XX[ 36]/46,XY[ 14].(2)근거초성평고,거대무심태점87.0％(20/23),86.4％(19/22)적병례량태제동맥조력지수차치≤0.20,제시무심태혈공봉부,66.7％(10/15)적빙혈태출현심공능실대상,빙혈태대뇌중동맥수축기봉치류속＞1.5중위수적배수자점75.0％(12/16),제시빈혈.(3)혈공봉부자발생거대무심태적비례(94.7％,18/19)고우혈공불봉부자(1/3),차이유통계학의의(Fisher정학개솔법,P=0.04).거대무심태자빙혈태발생심공능실대상적비례(83.3％,10/12)고우비거대무심태발생심공능실대상적비례(0/3),차이유통계학의의(Fisher정학개솔법,P=0.02).(4)11례수진후선택인산종지임신,14례계속임신자빙혈태존활솔위64.3％(9/14).계속임신자중3례수진시불반빙혈태심공능이상적비거대무심태선택보수관찰,2례족월분면,1례병정진전이인산；11례빙혈태심공능이상혹빈혈적거대무심태중5례선택보수관찰,기중1례유산,3례병정진전(1례인산、2례조산),1례병정은정지분면；령외6례선택제대전응,5례성공,기중4례빙혈태존활.결론 빙혈태적산전진단결과、심공능상태、빈혈、무심태발육정도급제혈공시TRAP산전평고적중요지표,응근거산전평고결과대TRAP진행급시처리.
Objective To analyze the clinical characteristics of twin reversed arterial perfusion sequence (TRAP),and investigate its prenatal evaluation and clinical management.Methods Karyotype results and ultrasound data of 25 TRAP cases were retrospectively reviewed,including estimated weight and umbilical blood flow of acardiac twin,cardiac function and middle cerebral artery peak systolic velocity of pump twin.Various managements and the outcomes were analyzed.Results (1) Karyotype of amniotie fluid were tested in 16 pump twins.Mosaicism was found in 1 case (46,XX[36]/46,XY [14]).(2) According to the ultrasound evaluation,large acardia accounted for 87.0％ (20/23) cases.Abundant blood perfusion (inter-twin difference of umbilical resistance index ≤0.20) was indicated in 86.4％ (19/22) cases.Decompensation of cardiac function was suggested in 66.7％ (10/15) pump twins.Fetal anemia of pump twin indicated by middle cerebral artery peak systolic velocity＞1.5 multiples of the median was diagnosed in 75.0％ (12/16) cases.(3) The acardiac twin with abundant blood perfusion was more likely to be a large acardia than those without [94.7％(18/19) vs 1/3,Fisher exact test,P=0.04]; More pump twin with large acardia tended to have cardiac decompensation than non-large acardia pump twins [83.3 ％ (10/12) vs 0/3,Fisher exact test,P=0.02].(4) Eleven patients chose to terminate their pregnancies after being diagnosed.In 14 cases who continue the pregnancies,the survival rate of pump twin was 64.3％ (9/14).In 3 cases of non-large acardia without cardiac decompensation of pump twin,the patients selected conservative observation resulting in 2 term deliveries and 1 termination of pregnancy due to for exacerbation.Among 11 cases with large acardia,which the pump twins were complicated by cardiac decompensation or anemia,five cases selected conservative observation.One ended in spontaneous abortion; three exacerbated (one termination and two cesarean section before term with living births) ; one was stable until delivery.Another 6 cases received bipolar cord coagulation,and successful interruptions of acardiac blood flow were achieved in 5 cases among which 4 pump twins survived.Conclusions Prenatal diagnosis,cardiac function and fetal anemia of pump twin,together with the growth and blood supply of acardia are important indexes for prenatal evaluation of TRAP,on which our prompt management should be based.