选择性胎儿镜下激光凝固术治疗双胎输血综合征的临床效果和围产儿结局

Pregnancy outcome after fetoscopic laser photocoagulation for twin-twin transfusion syndrome： experience of an emerging center from China

目的 探讨选择性胎儿镜下激光凝固（FLP）术治疗双胎输血综合征（TTTS）的临床效果和围产儿结局.方法 回顾性分析2012年1月-2013年8月同济大学附属第一妇婴保健院胎儿医学中心行选择性FLP术治疗的33例TTTS患者的临床资料,观察围手术期母儿并发症及围产儿结局.对部分患者分娩后的胎盘进行灌注检查并观察其结果.结果 （1）33例TTTS患者行胎儿镜下选择性FLP术的平均孕周为（22.0±2.3）周,平均手术时间为（86±32） min,平均分娩孕周为33周＋6,手术至分娩的时间平均为（9±5）周.（2）33例患者的胎儿总存活率为70％ （46/66）;其中两胎均存活17例,两胎存活率为52％（17/33）,仅一胎存活12例,仅一胎存活率为36％ （12/33）,至少一胎存活29例,至少一胎存活率为88％（29/33）.供血儿存活21例（64％,21/33）,平均出生体质量为（1 805 ±523）g;受血儿存活25例（76％,25/33）,平均出生体质量为（2 214±600）g.（3）TTTS分期Ⅰ期4例,至少一胎存活4例,胎儿总存活率为7/8;Ⅱ期9例,至少一胎存活7例,胎儿总存活率为12/18;Ⅲ期11例,至少一胎存活10例,胎儿总存活率为68％（15/22）;Ⅳ期9例,至少一胎存活8例,胎儿总存活率为12/18.（4）选择性FLP术后有4例孕妇发生两胎均丢失;3例胎儿发生特殊并发症,其中2例为双胎贫血红细胞增多序列征（TAPS）;2例孕妇术后3周内发生胎膜早破.（5）对7例患者进行分娩后胎盘灌注检查结果显示,6例未见残留血管吻合支,仅1例存在残留胎盘血管吻合支.结论 选择性FLP术治疗TTTS临床效果可靠,能显著提高围产儿的存活率,明显改善围产儿结局;同时,伴发的母体并发症较少.

Objective To evaluate pregnancy outcomes after selective fetoscopic laser photocoagulation （SFLP） for twin-to-twin transfusion syndrome （TTTS）.Methods A total of 33 cases of TTTS were treated by SFLP in Shanghai First Maternity and Infant Hospital from January 2012 to August 2013.Clinical data on perinatal outcomes,fetaland maternalcomplicationswere recorded and retrospectively analyzed.Results （1） The mean gestational age for SFLP was （22.0 ± 2.3） weeks,the mean time for SFLP was （86 ± 32） minutes,the mean gestational age for delivery was 33 ＋6 weeks,the gestational age between SFLP and delivery was （9 ± 5） weeks.（2） The perinatal survival rate 28 days after the delivery was 70% （46/66）.The survival rate was 52% （17/33） for both twins,36% （12/33） for one twin,88% （29/33） for at least one twin.Of all the survival twins,there were 21 donor twins （64%,21/33） with the mean birth weight at delivery was （1 805 ± 523） g and 25 recipient twins （76%,25/33） with the mean birth weight （2 214 ±600） g.（3） There were 4 cases at TTTS stage Ⅰ,9 at TTTS stage Ⅱ,11 at TTTS stage Ⅲ,9 at TTTS stage Ⅳ ;the survival number for at least one twin was 4,7,10,8 respectively; the total survival rate was 7/8,12/18,68% （15/22）,12/18 respectively.（4） Four cases had both twins demises.3 fetuses had special fetal complications with 2 of them developing twin anemia-polycythemia sequence （TAPS）.Two cases had preterm premature rupture of membrane （PPROM） within 3 weeks after SFLP.（5）Placental injections were performed in 7 cases with SFLP after delivery.Residual anastomosis was identified in one case.Conclusion As an emerging center,our study demonstrated favorable fetal outcomes with less maternal complications after SFLP for TTTS.