71例双胎输血综合征的妊娠结局

Outcomes of patients with twin-twin transfusion syndrome： a report of 71 cases

目的 探讨双胎输血综合征（twin-twin transfusion syndrome,TTTS）的治疗及其围产结局. 方法 2007年1月1日至2012年12月31日在北京大学第三医院住院的TTTS孕妇71例纳入研究.71例孕妇分别采取期待治疗、羊水减量、胎儿镜激光治疗或选择性减胎治疗.回顾性分析所有病例的分期、治疗方式与围产结局的关系.采用卡方检验、单因素方差分析及非参数检验比较不同分期及不同治疗方式患者的围产结局差异. 结果 采取期待治疗者25例,至少一胎存活＞30 d的比例为32％（8/25）,活产新生儿中脑损伤发生率为5/15.羊水减量治疗者16例,至少一胎存活＞30 d的比例为4/16,活产新生儿中脑损伤发生率为3/15.接受胎儿镜激光凝固交通血管术治疗25例,至少一胎存活＞30 d的比例为60％（15/25）,高于期待治疗组及羊水减量组（x2=4.938,P=0.045; x2=5.056,P=0.043）,活产新生儿中脑损伤发生率为7％（2/28）,低于期待治疗组（x2=4.702,P=0.040）,但与羊水减量组差异无统计学意义（x2=1.490,P=0.320）.5例孕妇选择减胎治疗,1例行胎儿镜脐带结扎术减胎后分娩单活胎,4例行射频消融减胎后1例流产,另3例足月分娩.Ⅰ期患者妊娠结局最好,至少一胎存活＞30 d的比例为12/18,明显高于Ⅲ、Ⅳ期患者（分别为4/1 7和6/18）（x2值分别为4.933和2.778,P值均＜0.05）.Ⅳ期患者至少一胎存活＞30 d的比例仅是Ⅰ期患者的一半（6/18与1 2/1 8）,活产新生儿中脑损伤发生率高达4/12,但与Ⅰ、Ⅱ和Ⅲ期患者[分别为16％（4/25）、0/14和2/11]相比差异无统计学意义（x2-5.361,P=0.118）. 结论 TTTS严重影响胎儿预后,早期诊断和处理可改善预后.胎儿镜下激光凝固交通血管术治疗TTTS可提高胎儿存活率,降低新生儿脑损伤发生率.

Objective To summarize the treatments and perinatal outcomes of patients with twin-twin transfusion syndrome （ TTTS ） . Methods Seventy one cases of TTTS hospitalized in Peking University Third Hospital from January 1, 2007 to December 31,2012 were included into the study. They were treated with expectant therapy, amnioreduction, laser surgery or selective fetal reduction. The relationship between outcomes and different staging or treatment procedures of these cases were retrospectively analyzed, and the differences were compared by analysis of variances, Chi-square test and nonparametric test. Results Twenty-five cases received expectant treatment. The rate that at least one baby survived more than 30 days was 32% （ 8/25 ）, and 5/15 of the live babies had neonatal brain injury. Sixteen cases received amnioreduction, of which the rate that at least one baby survived more than 30 days was 4/16, and 3/15 of the live babies had brain injury. Twenty-five cases received fetoscopic laser coagulation of vascular anastomoses. The rate that at least one baby survived more than 30 days was 60% （ 15/25 ） , which was higher than that of the expectant group and amnioreduction group （2＂2=4.938, P=0.045 andz2=5.056, P=0.043 ） ; the brain injury rate among the live babies was 7% （ 2/28 ）, which was lower than that of the expectant group （X2=4.702, P=0.040 ） , but similar to the amnioreduction group （X2=1.490, P=0.320 ） . Five patients received selective fetal reduction operation. Among which, one received fetoscopic cord ligation and delivered one healthy baby; the other four cases received radio frequency ablation, after which one was aborted and three delivered at full term. The rate that at least one baby survived more than 30 days was 12/18 in 18 cases with stage I TTTS, which was better than that in stage III and IV （ 4/17 and 6/18 ） （x^2=4.933 and 2.778, both P〈0.05 ） . The rate that at least one baby survived more than 30 days in stage IV cases was only half of that in stage I （ 6/18 vs 12/18 ） , and the brain injury rate among the live babies was 4/12, similar to that in stage I , II and III [ 16% （ 4/25 ） , 0/14 and 2/11, Z2=5.361, P=0.118]. Conelusion The prognosis of TTTS is very poor, early diagnosis and early treatment could improve the outcomes. Fetoscopic laser coagulation ensures a relatively higher survival rate and low brain injury rate for TTTS.