多胎妊娠妇女孕中期选择性减胎术的临床应用

Clinical study of selective multifetal pregnancy reduction in second trimester

目的通过对多胎妊娠妇女于孕中期行选择性减胎术,研究其手术指征、时机、安全性、目标胎儿的选择标准和减灭胎儿数,探讨选择性减胎术在改善多胎妊娠结局中的作用。方法对37例孕12周^(+1)～25周多胎妊娠孕妇(6例双胎、21例三胎、8例四胎、2例五胎,共117个胎儿)在超声引导下经腹行选择性减胎术,按产科医疗指征,在拟被减的46个胎儿心脏内注射10%氯化钾2～5 ml,见胎心逐渐减慢至停跳视为减胎术成功。术后定期产前检查和监测凝血功能,记录妊娠期并发症及妊娠结局。结果 (1)成功率:共减去胎儿46个,减胎成功率为100%(46/46个胎儿),已有27例孕妇分娩,获24个健康新生儿,妊娠成功率为88.9%(24/27)。(2)分娩孕周:>36周分娩者15例;32～36周7例;28～32周3例;<28周流产者2例;正在妊娠中10例。平均分娩孕周(34.9±4.1)周,孕28周后分娩率为92.6%(25/27)。(3)新生儿平均出生体重:单胎妊娠新生儿平均出生体重为(3014±640)g,双胎妊娠为(2557±573)g,三胎妊娠中除1例两个胎儿存活(出生体重分别为1400及1500 g)外,其余均死亡。(4)安全性:除2例单羊膜囊双胎在减灭1个胎儿后,另1个胎儿随即死亡外,其余多胎妊娠妇女的保留胎儿均未发生胎死宫内。(5)并发症:37例多胎妊娠妇女中仅3例发生子痫前期,减胎术后均无凝血功能障碍发生。(6)阴道流血:有13例孕妇减胎术前发生阴道流血,其中1例在妊娠13周强烈要求减胎,减胎术后于孕22周流产;另12例均在阴道流血停止1周以上后施行减胎。结论 (1)孕中期选择性多胎妊娠减胎术,可以有效减少多胎妊娠胎儿数目、避免异常胎儿出生,降低孕产妇并发症,提高新生儿出生体重。(2)胎儿保留数目以达双胎为好。(3)减胎术前有阴道流血者,避免在流血期间减胎,应选择在流血停止1周以上进行。(4)孕中期多胎妊娠减胎术不会造成孕妇的凝血功能障碍,也不会造成保留胎儿的宫内死亡,安全性好;减胎术后子痫前期的发病率明显下降。

Objective To investigate the operative indication, timing, method, selective standards of feticided fetus and the number of reduced fetuses of selective multifetal pregnancy reduction in second trimester, and the pregnancy outcome of multifetal pregnancy by this operation. Methods Tram-abdominal selective multifetal pregnancy reductions in 37 cases of multiple pregnancy （twins 6 cases, triplets 21cases, quadruplets 8 cases, and quintuplets 2 cases） during 12^＋1 -25 weeks were performed under ultrasound guidance The fetus to be reduced was injected potassium chloride （KCl） intracardiacally until the fetal hearteat stopped gradually. Totally 46 fetuses were reduced. Periodic prenatal examination and monitoring of coagulation function were carried out after the procedure. The pregnancy complications and pregnancy outcome of all cases were recorded. Results （ 1 ） The successful ratio of reduction was 100% （46/46 fetuses） and the successful pregnancy ratio was 88. 9% （ 24/27 ）. （ 2 ） Among all the 37 cases, fifteen deliveried after 36 weeks, seven deliveried in 32 - 36 weeks, three deliveried in 28 - 32 weeks, two aborted after feticide, and ten cases were in pregnancy at the time of this study. The mean gestational age of all was （34.9±4. 1） weeks, and the delivery ratio after 28 weeks was 92.6% （25/27）. （3） The mean birth weight of singletons was （3014 ±640）g, and of twins was （2557 ±573）gy The neonates of three triplets all died except for in one case two fetuses were alive. （4） Except in two cases after reducing one fetus of monoamniotic twins, another one died within 24 hours, the remaining fetuses were all alive. （5） Pre-eelampsia occurred in three cases. None of the cases had blood coagulation disturbances. Conclusion （ 1 ） Selective multifetal pregnancy reduction in second trimester can feticide the abnormal fetus objectively or reduce the fetal number effectively. It is a safe procedure to decrease the complications of multifetal pregnancy and increase the birth weight. （2） If the intention is reducing the fetal number, we choose the fetus who lies in the fundus uteri and reduce the multifetal pregnancy to twins. （3） It is advised to aviod performing the procedure during vaginal bleeding. We reduce fetus after vaginal bleeding stops for one or more weeks. （4） Selective second-trimester multifetal pregnancy reduction will not result in the disturbance of blood coagulation and the death of remaining fetus. The incidence of pre-eclampsia is decreased after multifetal pregnancy reduction.