摘要
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。
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＆#39;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.
出处
《中华围产医学杂志》
CAS
北大核心
2014年第6期365-369,共5页
Chinese Journal of Perinatal Medicine
关键词
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
Twin,monochorionic
Pregnancy complications
Pregnancy reduction,multifetal
Catheter ablation
Pregnancy outcome
