CAJ | 학술논문

目的：探讨胎儿镜选择性胎盘血管交通支凝结术（SLCPV）治疗前壁胎盘双胎输血综合征（TTTS）患者的临床结局及其影响因素。方法收集中国医科大学附属盛京医院2011年7月至2014年4月10例经SLCPV治疗的前壁胎盘TTTS患者（前壁胎盘TTTS组）的临床资料进行回顾性分析，并与同期8例经SLCPV治疗的后壁胎盘TTTS患者（后壁胎盘TTTS组）进行对比。患者Quintero分级均在Ⅱ级以上，或者Quintero分级Ⅰ级但同时按美国费城儿童医院心血管功能评分≥5分。前壁胎盘TTTS组患者接受弧形胎儿镜SLCPV治疗，后壁胎盘TTTS组患者接受直形胎儿镜SLCPV治疗。结果（1）手术情况：两组共18例患者，施行手术时的孕周为17周+5～27周+4，平均24.1周；Quintero分级为Ⅲ级12例，Ⅱ级4例；Ⅰ级2例。其中，前壁胎盘TTTS组患者施行手术时的孕周为22周～27周+4，平均25.2周；Quintero分级为Ⅲ级6例，Ⅱ级2例，Ⅰ级2例；平均手术时间40 min，术后发生未足月胎膜早破（PPROM）5例，母体并发症1例（为肠梗阻）。后壁胎盘TTTS组患者施行手术时的孕周为17周+5～27周+4，平均22.7周；Quintero分级为Ⅲ级6例，Ⅱ级2例；平均手术时间28 min；术后发生PPROM 1例，母体并发症1例（为阴沟杆菌败血症）。两组患者均能耐受胎儿镜手术，无术中并发症。（2）术后情况：前壁胎盘TTTS组患者中术后有1例发生肠梗阻并最终发生流产；后壁胎盘TTTS组患者中有1例发生阴沟杆菌败血症。术后两组18例患者的胎儿染色体检测结果均未见异常。（3）两组患者施行手术后已有17例妊娠终止，1例仍在继续妊娠中。其中，前壁胎盘TTTS组患者全部分娩，分娩孕周为24～37周+1，平均32.6周；后壁胎盘TTTS组患者中7例已经分娩，分娩孕周为25周+6～36周+2，平均28.2周。对新生儿定期随访发现1例有胼胝体发育不良，而其同胞胎儿表现正常。两组患者至少一胎存活率为13/17（后壁胎盘TTTS组有1例尚未分娩），双胎存活率10/17。其中，前壁胎盘TTTS组患者至少一胎存活率为8/10，双胎存活率为5/10；后壁胎盘TTTS组患者至少一胎存活率为5/7，双胎存活率为5/7。结论胎儿镜SLCPV对前壁胎盘TTTS和后壁胎盘TTTS均具有很好的治疗效果。前壁胎盘TTTS患者宜采用弧形胎儿镜进行SLCPV；前壁胎盘TTTS患者有较高的PPROM发生率，可能与手术时间长和术中弧形胎儿镜活动范围大有关。目的：探討胎兒鏡選擇性胎盤血管交通支凝結術（SLCPV）治療前壁胎盤雙胎輸血綜閤徵（TTTS）患者的臨床結跼及其影響因素。方法收集中國醫科大學附屬盛京醫院2011年7月至2014年4月10例經SLCPV治療的前壁胎盤TTTS患者（前壁胎盤TTTS組）的臨床資料進行迴顧性分析，併與同期8例經SLCPV治療的後壁胎盤TTTS患者（後壁胎盤TTTS組）進行對比。患者Quintero分級均在Ⅱ級以上，或者Quintero分級Ⅰ級但同時按美國費城兒童醫院心血管功能評分≥5分。前壁胎盤TTTS組患者接受弧形胎兒鏡SLCPV治療，後壁胎盤TTTS組患者接受直形胎兒鏡SLCPV治療。結果（1）手術情況：兩組共18例患者，施行手術時的孕週為17週+5～27週+4，平均24.1週；Quintero分級為Ⅲ級12例，Ⅱ級4例；Ⅰ級2例。其中，前壁胎盤TTTS組患者施行手術時的孕週為22週～27週+4，平均25.2週；Quintero分級為Ⅲ級6例，Ⅱ級2例，Ⅰ級2例；平均手術時間40 min，術後髮生未足月胎膜早破（PPROM）5例，母體併髮癥1例（為腸梗阻）。後壁胎盤TTTS組患者施行手術時的孕週為17週+5～27週+4，平均22.7週；Quintero分級為Ⅲ級6例，Ⅱ級2例；平均手術時間28 min；術後髮生PPROM 1例，母體併髮癥1例（為陰溝桿菌敗血癥）。兩組患者均能耐受胎兒鏡手術，無術中併髮癥。（2）術後情況：前壁胎盤TTTS組患者中術後有1例髮生腸梗阻併最終髮生流產；後壁胎盤TTTS組患者中有1例髮生陰溝桿菌敗血癥。術後兩組18例患者的胎兒染色體檢測結果均未見異常。（3）兩組患者施行手術後已有17例妊娠終止，1例仍在繼續妊娠中。其中，前壁胎盤TTTS組患者全部分娩，分娩孕週為24～37週+1，平均32.6週；後壁胎盤TTTS組患者中7例已經分娩，分娩孕週為25週+6～36週+2，平均28.2週。對新生兒定期隨訪髮現1例有胼胝體髮育不良，而其同胞胎兒錶現正常。兩組患者至少一胎存活率為13/17（後壁胎盤TTTS組有1例尚未分娩），雙胎存活率10/17。其中，前壁胎盤TTTS組患者至少一胎存活率為8/10，雙胎存活率為5/10；後壁胎盤TTTS組患者至少一胎存活率為5/7，雙胎存活率為5/7。結論胎兒鏡SLCPV對前壁胎盤TTTS和後壁胎盤TTTS均具有很好的治療效果。前壁胎盤TTTS患者宜採用弧形胎兒鏡進行SLCPV；前壁胎盤TTTS患者有較高的PPROM髮生率，可能與手術時間長和術中弧形胎兒鏡活動範圍大有關。
목적：탐토태인경선택성태반혈관교통지응결술（SLCPV）치료전벽태반쌍태수혈종합정（TTTS）환자적림상결국급기영향인소。방법수집중국의과대학부속성경의원2011년7월지2014년4월10례경SLCPV치료적전벽태반TTTS환자（전벽태반TTTS조）적림상자료진행회고성분석，병여동기8례경SLCPV치료적후벽태반TTTS환자（후벽태반TTTS조）진행대비。환자Quintero분급균재Ⅱ급이상，혹자Quintero분급Ⅰ급단동시안미국비성인동의원심혈관공능평분≥5분。전벽태반TTTS조환자접수호형태인경SLCPV치료，후벽태반TTTS조환자접수직형태인경SLCPV치료。결과（1）수술정황：량조공18례환자，시행수술시적잉주위17주+5～27주+4，평균24.1주；Quintero분급위Ⅲ급12례，Ⅱ급4례；Ⅰ급2례。기중，전벽태반TTTS조환자시행수술시적잉주위22주～27주+4，평균25.2주；Quintero분급위Ⅲ급6례，Ⅱ급2례，Ⅰ급2례；평균수술시간40 min，술후발생미족월태막조파（PPROM）5례，모체병발증1례（위장경조）。후벽태반TTTS조환자시행수술시적잉주위17주+5～27주+4，평균22.7주；Quintero분급위Ⅲ급6례，Ⅱ급2례；평균수술시간28 min；술후발생PPROM 1례，모체병발증1례（위음구간균패혈증）。량조환자균능내수태인경수술，무술중병발증。（2）술후정황：전벽태반TTTS조환자중술후유1례발생장경조병최종발생유산；후벽태반TTTS조환자중유1례발생음구간균패혈증。술후량조18례환자적태인염색체검측결과균미견이상。（3）량조환자시행수술후이유17례임신종지，1례잉재계속임신중。기중，전벽태반TTTS조환자전부분면，분면잉주위24～37주+1，평균32.6주；후벽태반TTTS조환자중7례이경분면，분면잉주위25주+6～36주+2，평균28.2주。대신생인정기수방발현1례유변지체발육불량，이기동포태인표현정상。량조환자지소일태존활솔위13/17（후벽태반TTTS조유1례상미분면），쌍태존활솔10/17。기중，전벽태반TTTS조환자지소일태존활솔위8/10，쌍태존활솔위5/10；후벽태반TTTS조환자지소일태존활솔위5/7，쌍태존활솔위5/7。결론태인경SLCPV대전벽태반TTTS화후벽태반TTTS균구유흔호적치료효과。전벽태반TTTS환자의채용호형태인경진행SLCPV；전벽태반TTTS환자유교고적PPROM발생솔，가능여수술시간장화술중호형태인경활동범위대유관。
Objective To analyze the clinical outcome and impact factors of twin-to-twin transfusion syndrome (TTTS) with anterior placenta treated by fetoscopic selective laser coagulation of placental vessels(SLCPV). Methods Ten cases of TTTS with anterior placenta and 8 cases with posterior placenta were treated by SLCPV in Shengjing Hospital from July 2011 to April 2014. Clinical data were analyzed retrospectively. Some cases were at Quintero stageⅡor higher stage, others were at Quintero stageⅠbut with cardiovascular score≥5 according to the scoring system of Children′s Hospital of Philadelphia. The anterior placenta cases were treated by curve fetoscopy and the posterior placenta cases were treated by straight fetoscopy. Results (1) Of all the 18 cases, the mean gestational age at SLCPV was 24.1 weeks (17+5 to 27+4 weeks). There were 2 cases at Quintero stageⅠ, 4 at stageⅡand 12 at stageⅢ. The mean gestational age of anterior placenta cases at SLCPV was 25.2 weeks (22 to 27+4 weeks), with 2 cases at Quintero stageⅠ, 2 cases at stage Ⅱ and 6 at stage Ⅲ;5 cases had preterm prelabour rupture of the membranes (PPROM)and 1 case had maternal intestinal obstruction after the operation;the average operation time was 40 minutes. Of the posterior placenta cases, the mean gestational age at SLCPV was 22.7 weeks (17+5 to 27+4 weeks);2 cases were at Quintero stageⅡand 6 cases at stageⅢ. PPROM happened in one case;one case had maternal enterobacter cloacae septicemia;the average operation time was 28 minutes. All the 18 cases could tolerate the operations. There was no intraoperative complication. (2) One anterior placenta case had maternal intestinal obstruction and miscarriage; and one posterior placenta case had enterobacter cloacae septicemia. Karyotype analyses of the all the twins were normal. (3) 17 cases delivered already, including all the 10 anterior placenta cases and 7 posterior placenta cases. One infant had corpus callosum agenesis, but its co-twin was normal. The average gestational age at delivery for anterior placenta cases was 32.6 weeks (24 to 37+1 weeks), an was 28.2 weeks (25+6 to 36+2 weeks) for posterior placenta cases. The fetuses survival rate was 13/17 (one case was still in pregnancy) for at least one twin, and 10/17 for both twins. Both twins survival rates were 5/10, 5/7 for anterior placenta cases and posterior placenta cases, respectively. At least one twin survival rates were 8/10, 5/7 for the two groups respectively. Conclusion SLCPV is suitable for the treatment of TTTS, no matter the placenta is on the anterior wall or posterior wall. The treatment had good outcomes, but more PPROM happened in the anterior placenta cases, which may be associated with operation time and the range of operation.