胎儿颈部肿块的多学科联合诊治模式探讨：附4例病例报道

Multidisciplinary diagnosis and treatment for fetal neck mass

目的通过建立包括子宫外产时处理（ex-uterointrapartumtreatment，EXIT）技术的多学科联合诊治模式，提高颈部肿块胎儿的成活率和生存质量。方法对2007年9月至2010年2月共4例产前诊断颈部肿块胎儿采用了多学科联合诊治的模式，包括妊娠期定期监测、产时实施EXIT手术、新生儿再次评估和手术治疗等。结果4例均在妊娠37周后行选择性EXIT手术分娩，平均分娩孕周为37^＋4周（37～38^＋3周），平均出生体重为2972g（2600-3250g），手术时间（从子宫切开到断脐）平均为4min（2～7min）。初次诊断孕龄为29^＋4周（24～34周），颈部肿块最大为6．2cm×5．8cm×6．8cm，最小为3．0em×2．0cm×1．0cm。2例提示有气管移位并羊水过多，2例有气管压迫但羊水量正常。3例患儿出生后依赖机械通气，增强CT提示气管明显受压或移位，在出生后6～8d接受了手术治疗；1例在出生后再次评估时发现肿块没有完全压迫气管，拔管后可自主呼吸，未选择新生儿期手术。术后诊断肠源性囊肿1例、淋巴管瘤2例和梨状窝瘘1例。4例患儿随访情况均良好。结论胎儿颈部肿块的处理是贯穿整个围产期的、多学科联合的诊治过程。为提高颈部肿块胎儿的成活率和生存质量，建立一个多学科联合诊治的团队和模式十分必要。

Objective To investigate the effect of multidisciplinary diagnosis and treatment including ex-utero intrapartum treatment （EXIT） procedure to improve the prenatal survival rate of fetus with neck mass. Methods Multidisciplinary diagnosis and treatment model were carried out in four pregnancy women with fetal neck mass from September 2007 to February 2010. The model included prenatal assessment and monitoring, EXIT procedure during cesarean section, neonatal reassessment and surgical treatment by the cooperation of obstetricians, neonatologists, children surgeons, sonographers and anesthetists. Results All patients underwent cesarean section after 37 gestational weeks. Mean delivery time was 37＋4 weeks （37-38＋3 weeks）; mean birth weight was 2972 g （2600-3250 g）; mean operation time was 4 min （2-7 min）. The gestational age of primary diagnosis of fetal neck mass was 24-34 gestational weeks. After delivery, the size of neck mass was from 3.0 cm× 2.0 cm× 1.0 cm to 6.2 cm×5.8 cm×6.8 cm. The tracheal compression and displacement were found by color doppler ultrasound scan and magnetic resonance imaging in all cases. Two of them were completed with polyhydramnios and the others with normal volume of amniotic fluid. EXIT procedure was successfully carried out during cesarean section. Neonatal reassessment showed the trachea of three infants were obviously compressed and lapsed by enhanced CT; the infants relied on mechanical, ventilation after birth and underwent operation on day 6 to 8. Tracheal impression was not presented in one infant and trachea cannula was removed on the second day, operation was not performed. All. of those infants had good outcomes. Conclusions The multidisciplinary diagnosis and treatment model, including EXIT procedure, is a safe, efficient and feasible strategy, which is necessary for fetus with neck mass.