中华围产医学杂志
中華圍產醫學雜誌
중화위산의학잡지
CHINESE JOURNAL OF PERINATAL MEDICINE
2014年
6期
365-369
,共5页
孙路明%周奋翮%邹刚%杨颖俊%周艳%孙琦%段涛
孫路明%週奮翮%鄒剛%楊穎俊%週豔%孫琦%段濤
손로명%주강핵%추강%양영준%주염%손기%단도
双生,单绒毛膜%妊娠并发症%妊娠减少,多胎%导管消融术%妊娠结局
雙生,單絨毛膜%妊娠併髮癥%妊娠減少,多胎%導管消融術%妊娠結跼
쌍생,단융모막%임신병발증%임신감소,다태%도관소융술%임신결국
Twin,monochorionic%Pregnancy complications%Pregnancy reduction,multifetal%Catheter ablation%Pregnancy outcome
目的：评估射频消融减胎技术治疗单绒毛膜性双胎妊娠并发症的安全性和有效性。方法回顾性分析2012年1月1日至2013年12月31日，在同济大学附属第一妇婴保健院胎儿医学部接受射频消融减胎技术治疗并已分娩的单绒毛膜性双胎妊娠孕妇共34例的临床资料。记录手术孕周、手术所需的循环数、母儿并发症及分娩孕周等情况，并随访保留胎儿出生后的生长发育情况。保留胎儿出生后28 d仍存活计为存活儿，存活率=（存活儿例数/保留胎儿例数）×100%。分析影响保留胎儿存活率的相关因素。采用Fisher精确概率法进行统计分析。结果（1）手术情况：平均手术孕周（20.7±3.1）周（16+1~27+6周），穿刺成功率100%（34/34），手术循环数1~6次。（2）保留胎儿存活率：34例保留胎儿中，2例因妊娠28周前胎膜早破流产或引产，3例因严重贫血胎死宫内或引产，2例不明原因胎死宫内，共7例保留胎儿死亡。活产27例，平均分娩孕周（36.4±4.1）周（26+4~40周），新生儿平均出生体重（2913±978） g（1080~4600 g）。27例保留胎儿出生后28 d仍存活，存活率79%（27/34），随访至3月~1.5岁，均未发现严重神经系统后遗症。（3）影响保留胎儿结局的因素：妊娠16+1~、20~和24~27+6周行射频消融减胎术的3组比较，保留胎儿严重贫血或胎死宫内发生率（2/15、2/13与1/6）、妊娠28周前胎膜早破发生率（1/15、4/13与1/6）及保留胎儿出生后28 d存活率（13/15、10/13与4/6）的差异均无统计学意义（P值均>0.05）。手术指征为严重的选择性胎儿生长受限（50%，17/34）、单绒毛膜性双胎合并一胎结构异常（24%，8/34）、双胎反向动脉灌注序列（18%，6/34）和双绒毛膜性三羊膜囊三胎（9%，3/34），不同手术指征组保留胎儿严重贫血或胎死宫内发生率（3/17、2/8、0/6与0/3）、妊娠28周前胎膜早破发生率（3/17、0/8、2/6与1/3）及保留胎儿出生后28 d存活率（12/17、6/8、6/6与3/3）比较，差异均无统计学意义（P值均>0.05）。手术所需循环次数<3次与≥3次2组比较，保留胎儿严重贫血或胎死宫内发生率（10%与2/5）、妊娠28周前胎膜早破发生率（17%与2/5）间差异均无统计学意义（P值均>0.05）。循环次数≥3次组保留胎儿出生后28 d的存活率低于循环次数<3次组（2/5与86%，P<0.05）。结论目前有限的资料提示，采用射频消融技术减胎治疗单绒毛膜性双胎妊娠特殊并发症安全有效。
目的：評估射頻消融減胎技術治療單絨毛膜性雙胎妊娠併髮癥的安全性和有效性。方法迴顧性分析2012年1月1日至2013年12月31日，在同濟大學附屬第一婦嬰保健院胎兒醫學部接受射頻消融減胎技術治療併已分娩的單絨毛膜性雙胎妊娠孕婦共34例的臨床資料。記錄手術孕週、手術所需的循環數、母兒併髮癥及分娩孕週等情況，併隨訪保留胎兒齣生後的生長髮育情況。保留胎兒齣生後28 d仍存活計為存活兒，存活率=（存活兒例數/保留胎兒例數）×100%。分析影響保留胎兒存活率的相關因素。採用Fisher精確概率法進行統計分析。結果（1）手術情況：平均手術孕週（20.7±3.1）週（16+1~27+6週），穿刺成功率100%（34/34），手術循環數1~6次。（2）保留胎兒存活率：34例保留胎兒中，2例因妊娠28週前胎膜早破流產或引產，3例因嚴重貧血胎死宮內或引產，2例不明原因胎死宮內，共7例保留胎兒死亡。活產27例，平均分娩孕週（36.4±4.1）週（26+4~40週），新生兒平均齣生體重（2913±978） g（1080~4600 g）。27例保留胎兒齣生後28 d仍存活，存活率79%（27/34），隨訪至3月~1.5歲，均未髮現嚴重神經繫統後遺癥。（3）影響保留胎兒結跼的因素：妊娠16+1~、20~和24~27+6週行射頻消融減胎術的3組比較，保留胎兒嚴重貧血或胎死宮內髮生率（2/15、2/13與1/6）、妊娠28週前胎膜早破髮生率（1/15、4/13與1/6）及保留胎兒齣生後28 d存活率（13/15、10/13與4/6）的差異均無統計學意義（P值均>0.05）。手術指徵為嚴重的選擇性胎兒生長受限（50%，17/34）、單絨毛膜性雙胎閤併一胎結構異常（24%，8/34）、雙胎反嚮動脈灌註序列（18%，6/34）和雙絨毛膜性三羊膜囊三胎（9%，3/34），不同手術指徵組保留胎兒嚴重貧血或胎死宮內髮生率（3/17、2/8、0/6與0/3）、妊娠28週前胎膜早破髮生率（3/17、0/8、2/6與1/3）及保留胎兒齣生後28 d存活率（12/17、6/8、6/6與3/3）比較，差異均無統計學意義（P值均>0.05）。手術所需循環次數<3次與≥3次2組比較，保留胎兒嚴重貧血或胎死宮內髮生率（10%與2/5）、妊娠28週前胎膜早破髮生率（17%與2/5）間差異均無統計學意義（P值均>0.05）。循環次數≥3次組保留胎兒齣生後28 d的存活率低于循環次數<3次組（2/5與86%，P<0.05）。結論目前有限的資料提示，採用射頻消融技術減胎治療單絨毛膜性雙胎妊娠特殊併髮癥安全有效。
목적：평고사빈소융감태기술치료단융모막성쌍태임신병발증적안전성화유효성。방법회고성분석2012년1월1일지2013년12월31일，재동제대학부속제일부영보건원태인의학부접수사빈소융감태기술치료병이분면적단융모막성쌍태임신잉부공34례적림상자료。기록수술잉주、수술소수적순배수、모인병발증급분면잉주등정황，병수방보류태인출생후적생장발육정황。보류태인출생후28 d잉존활계위존활인，존활솔=（존활인례수/보류태인례수）×100%。분석영향보류태인존활솔적상관인소。채용Fisher정학개솔법진행통계분석。결과（1）수술정황：평균수술잉주（20.7±3.1）주（16+1~27+6주），천자성공솔100%（34/34），수술순배수1~6차。（2）보류태인존활솔：34례보류태인중，2례인임신28주전태막조파유산혹인산，3례인엄중빈혈태사궁내혹인산，2례불명원인태사궁내，공7례보류태인사망。활산27례，평균분면잉주（36.4±4.1）주（26+4~40주），신생인평균출생체중（2913±978） g（1080~4600 g）。27례보류태인출생후28 d잉존활，존활솔79%（27/34），수방지3월~1.5세，균미발현엄중신경계통후유증。（3）영향보류태인결국적인소：임신16+1~、20~화24~27+6주행사빈소융감태술적3조비교，보류태인엄중빈혈혹태사궁내발생솔（2/15、2/13여1/6）、임신28주전태막조파발생솔（1/15、4/13여1/6）급보류태인출생후28 d존활솔（13/15、10/13여4/6）적차이균무통계학의의（P치균>0.05）。수술지정위엄중적선택성태인생장수한（50%，17/34）、단융모막성쌍태합병일태결구이상（24%，8/34）、쌍태반향동맥관주서렬（18%，6/34）화쌍융모막성삼양막낭삼태（9%，3/34），불동수술지정조보류태인엄중빈혈혹태사궁내발생솔（3/17、2/8、0/6여0/3）、임신28주전태막조파발생솔（3/17、0/8、2/6여1/3）급보류태인출생후28 d존활솔（12/17、6/8、6/6여3/3）비교，차이균무통계학의의（P치균>0.05）。수술소수순배차수<3차여≥3차2조비교，보류태인엄중빈혈혹태사궁내발생솔（10%여2/5）、임신28주전태막조파발생솔（17%여2/5）간차이균무통계학의의（P치균>0.05）。순배차수≥3차조보류태인출생후28 d적존활솔저우순배차수<3차조（2/5여86%，P<0.05）。결론목전유한적자료제시，채용사빈소융기술감태치료단융모막성쌍태임신특수병발증안전유효。
To assess the perinatal outcomes following selective feticide through radiofrequency ablation (RFA) in complex monochorionic pregnancies. Methods In this retrospective observational study, 34 cases of complex monochorionic pregnancies treated with RFA for selective feticide and delivered at the Shanghai First Maternity and Infant Hospital between January 1, 2012 and December 31, 2013, were included. Gestational age at RFA, the number of RFA cycles, maternal and fetal complications, gestational age at delivery, neonatal outcomes at 28 days after birth and neonatal development after birth were recorded. Fetal survival rate were defined as the number of survivors at 28 days after birth divided by the number of remaining fetuses after RFA. Factors affecting fetal survival rate were also analyzed. Statistical analysis was performed using Fisher's exact test. Results (1) The process for RFA:The gestatinal age for the procedure was (20.7±3.1) weeks(16+1-27+6 weeks). The successful rate of procedures was 100%(34/34) and the cycle number for RFA was 1-6 times. (2)Fetal complications and survival rate of remaining fetuses after RFA:there were six pregnant women suffering from premature rupture of membrane (PROM) before 28 weeks. Among those women, one had miscarriaged at 25 weeks, one chose to terminate at 26 weeks and the remaining four chose to continue the pregnancy. There were three remaining fetuses developing fetal severe anemia with hydrops after RFA. Two of them had fetal demises 2 days after the procedures and one chose to have termination. Another two cases with discordant fetal anomalies had fetal demises with unknown reasons one day after RFA. There were 27 remaining fetuses after RFA who survived until 28 days after birth. The mean gestational age at delivery was(36.4±4.1)weeks (26+4-40 weeks) and the mean birth weight was (2 913± 978) g (1 080-4 600 g). The overall fetal survival rate 28 days after birth was 79%(27/34). There were no abnormal findings in antenatal magnetic resonance imaging (MRI) four weeks after the procedure and no abnormal development of nervous system in the surviving neonates between 3 months old and 1.5 years old. (3) Factors affecting fetal survival rate :There were no significant differences identified in the rate of fetal severe anemia and fetal demise (2/15, 2/13 and 1/6), the rate of PROM before 28 weeks (1/15, 4/13 and 1/6) and survival rate of 28 days after birth (13/15, 10/13 and 4/6)among three groups with different gestational age (16+1-, 20- and 24-27+6 weeks) for RFA(all P>0.05). The indications for RFA included severe selective intrauterine growth restriction (50%, 17/34), discordant for fetal abnormalities(24%, 8/34) , twin reversed arterial perfusion sequence(18%, 6/34)and dichorionic or monochorionic triamniotic pregnancy (9%, 3/34). There were also no significant differences noted in the rate of fetal complications and fetal demise(3/17, 2/8, 0/6, 0/3), the rate of PROM before 28 weeks (3/17, 0/8, 2/6, 1/3)and survival rate of 28 days after birth among different groups (12/17, 6/8, 6/6, 3/3) with different indications for RFA(all P>0.05) . No significant differences observed in the rate of fetal complications and fetal demise(10% and 2/5)and the rate of PROM before 28 weeks (17%and 2/5)between two groups with different cycle numbers for RFA (<3 times and≥3 times, all P<0.05), while the group with cycle number ≥ 3 times had lower survival rate 28 days after birth than the group with cycle number<3 times for RFA (2/5 vs 86%, P<0.05). Conclusions RFA is one of effective and safe procedures for selective feticide in complex monochorionic pregnancies.
