|摘要||目的 探讨复杂性多胎妊娠在胎儿镜下行脐带结扎减胎术的临床效果及其安全性.方法 收集2009年1月至2012年11月北京大学第三医院因复杂性多胎妊娠行胎儿镜下脐带结扎减胎术的孕妇18例,其中选择性宫内生长受限(sIUGR)6例,双胎妊娠中1胎畸形4例,双胎反向动脉灌流(TRAP)4例,双绒毛膜双羊膜囊(DCDA)三胎1例,单绒毛膜三羊膜囊(DCTA)三胎1例,单绒毛膜双羊膜囊(MCDA)双胎+瘢痕子宫妊娠1例,双胎输血综合征(TTS)伴受血胎儿心脏畸形1例.于孕17 ～ 27周“时,在联合麻醉下对孕妇行胎儿镜下脐带结扎减胎术,对手术情况和胎儿结局进行分析.结果 (1)18例孕妇减胎术均获成功,平均手术时间为63 min(24 ～156 min).术中平均出血量为7.6 ml(5～20 ml),手术时平均孕周为21周(17 ～ 27周+6),新生儿平均出生体质量为2441 g(1000～3400 g).(2)手术拟保留胎儿20例,术后监测发现存活胎儿畸形而引产2例,TRAP减胎术后间隔3 ～14周发生不明原因胎死宫内3例,最终出生15例活产儿,其中1例孕28周分娩的早产儿出现重度呼吸窘迫综合征(RDS)和缺血缺氧性脑病,家属放弃治疗而死亡.14例活产儿随访3 ～51个月,其生长发育情况均正常.(3)妊娠至28周以上14例,延长孕周5～21周(平均为13周+4),分娩孕周为28～ 38周(平均33周+1),早期早产3例,晚期早产(34 ～ 36周+6)3例.结论 胎儿镜下脐带结扎应用于复杂性多胎妊娠的减胎术安全有效,无严重临床并发症发生.
Objective To evaluate the clinical effect and safety of umbilical cord ligation in the fetocide of complicated monochorionic multiple gestations.Methods From January 2009 to December 2012,clinical data of 18 women with complicated monochorionic multiple gestations who experienced intrauterine percutaneous umbilical cord ligation in Peking University Third Hospital were collected.Among the patients,6 were selective intrauterine growth restriction (1 with type Ⅰ,4 with type Ⅱ,1 with type Ⅲ) ; 4 were acrania or hydropic twins; 4 were aeardiac twins,2 were complicated triplet gestation; 1 was twin-twin transfusion syndrome with right ventricular dysplasia and 1 was monochorionic diamniotic (MCDA) with caesarean section history.The procedure was performed under both endoscopic and sonographic guidance.The gestational age at the time of the procedure were 17-27 +6 weeks.The procedure and perinatal outcome were analyzed.Results (1) The procedure was performed successfully in all the 18 cases.The average duration of the procedure was 63 min (24-156 min).The blood loss was 7.6 ml (5-20 ml).The mean gestational age at the time of the procedure was 20 weeks (17-27 +6 weeks).The average birth weight of the neonates was 2441 g(1000-3400 g).(2) There were 20 fetuses survived.Two fetuses had cardiac anomalies and were terminated in the following 2-3 weeks.Intrauterus fetal demise occured in 3 twin reverse arterial perfusion syndrome (TRAP) cases 3-14 weeks after the procedure.1 case delivered as early preterm birth at 28 weeks and the neonate died of respiratory distress syndrome (RDS) and hypoxie-ischemicencephalopathy (HIE).Fourteen neonates were in healthy and normal development by 3-51 months' followup.(3) Fourteen cases delivered at more than 28 weeks (28-38 weeks,averagely 33 + 1 weeks).The gestational weeks were prolonged by 5-21 weeks (averagely 13 +4 weeks).Among them,3 case were early preterm birth (28-33 weeks) and 3 were late preterm birth (34-36 weeks).Conclusion Percutaneous umbilical cord ligation is a reliable technique for the fetocide of complicated monochrionic mutilple gestations,especially for monochronic monoamniotie pregnancies.|