多胎妊娠选择性减胎术的时机对妊娠结局的影响

Timing of selective multifetal pregnancy reduction in second trimester and pregnant outcomes

目的比较不同孕周实施减胎术后的妊娠结局，分析选择性减胎术（简称减胎术）的手术时机对妊娠结局的影响。方法选择2002年1月至2012年2月期间，在山东大学附属省立医院产科就诊的辅助生殖技术（assisted reproductive technology，ART）后妊娠的双（多）胎妊娠孕妇302例，其中减胎组为三胎和四胎妊娠孕妇152例，分别于妊娠12～13＋6（91例）、14～15＋6（32例）、16～2＋6周（29例）接受了减胎术，对照组为ART后妊娠的双胎妊娠孕妇150例。手术方法采用超声引导下经腹胎儿心脏注射氯化钾。采用回顾性分析方法，记录分娩孕周和新生儿出生体重，观察妊娠期糖尿病和妊娠期高血压疾病的发病情况。采用t检验、单因素方差分析或χ2检验进行统计学分析。结果减胎组流产率（14．5％，22／152）高于对照组（6．7％，10／150），差异有统计学意义（χ2=4．857，P〈0．05）；妊娠16～24＋6周减胎组流产率（31．0％，9／29）分别高于妊娠12～13＋6周减胎组（8．8％，8／91）和对照组，差异均有统计学意义（χ2分别为7．212、12．749，P〈O．05）；妊娠12～13’。和14～15＋6周减胎组流产率（15．6％，5／32）分别与对照组比较，差异均无统计学意义（χ2分别为0．370、1．739，P〉0．05）。减胎组和对照组的平均分娩孕周分别为（36．9±1．8）周和（37±1.8）周，重体重儿出生体重分别为（2720．4±455．0）g和（2729．1±413．8）g、轻体重儿出生体重分别为（2409．2±412．6）g和（2416．2±436。8）g，差异均无统计学意义（f分别为-0．346、-0，163、-0．136，P〉0．05）。减胎组和对照组妊娠28～34周分娩率分别为6．2％（8／130）和6．4％（9／140）、胎儿生长不均称发生率分别为12．3％（16／130）和11．4％（16／140）、妊娠期糖尿病发病率分别为3．1％（4／130）和2．1％（3／140），妊娠期高血压疾病发病率分别为11．5％（15／130）和8．6％（12／140），差异均无统计学意义（χ2分别为0．009、0．050、0．659、0．010，P〉0．05）。结论实施选择性减胎术将多胎妊娠减至双胎，术后存在流产风险。掌握适宜的手术时机，在妊娠16周前手术，能够在一定程度上降低流产率。

Objective To compare the outcomes of multifetal pregnancy reduction （MFPR） performed at different gestational ages, and to analyze the influence on pregnancy outcomes. Methods Data of 302 women with multifetal pregnancies conceived after assisted reproductive technology （ART） from January 2002 to February 2012 in Department of Obstetrics and Gynecology of Provincial Hospital Affiliated to Shandong University were collected and divided into two groups. The study grovp involved 152 multifetal pregnancy cases （triplets or quadruplets）, which were further divided into three subgroups according to the timing of MFPR to twins, 12-13＋6 （n= 91）, 14-15＋6 （n=32） and 16-24＋6 gestational weeks （n=29） cases. MFPR was performed by trans abdominal The control group involved 150 twin pregnancy intra cardiac injection of 10% potassium chloride （KC1） solution under ultrasound guidance. Gestational age of delivery, birth weight, incidence of gestational diabetes mellitus （GDM） and hypertensive disorder complicating pregnancy （HDCP） were analyzed by t test, one-way ANOVA or Chi square test. Results Pregnancy loss rate of the study group （14.5%, 22/152） was higher than that （6.7G, 10/150） of control group, χ2=4.857, P〈 0.05. Pregnancy loss rate of the subgroup undergoing MFPR during 16-24＋6 gestational weeks （31. 0% ,9/29） was higher than that during 12-13＋6 gestational weeks （8.8%, 8/91,χ2=7.212, P〈0.05） and that of control group （χ2=12.749, P〈0.05）. There were no differences in pregnancy loss rate between control group and MFPR during 12 13＋6 gestational weeks （χ2=0. 370, P〉0.05）, and during 14-15＋6 gestational weeks （15.6%, 5/32, χ2 = 1. 739, P 〉 0.05）. No statistically significant difference was found between the study group and control group in mean gestational age at delivery [（36. 9±1. 8） weeks vs （37.0±1.8） weeks, t=-0. 346, P〉0.05], mean birth weight of large babies [（2720.4±455.0） g vs （2729.1±413.8） g, t=-0.163, P〉0.051 and small babies [（2409. 2±412. 6） g vs （2416.2±436.8） g, t= 0.136, P〉0.05]. There were no differences between the study group and control group in delivery rate at 28-34 gestational weeks [-6.20/oo （8/130） vs6.4G （9/140）, X2 0.009, P〉0.05], birth weight discordance rate [-12.3% （16/130） vs 11.4% （16/140）, χ2 =0.050, P〉0.05], GDM rate [-3.1% （4/130） vs 2.1% （3/140）, Z2-0.659, P〉0.05] and HDCP rate [11. 5 （15/130） vs 8.6% （12/140）, χ2= 0.010, P〉0.05]. Conclusions There is risk of pregnancy loss after MFPR, but MFPR before 16 weeks of gestation might decrease the risk.