双胎妊娠合并一胎畸形的治疗及围生期管理

Perinatal Management of Twins with Discordant Congenital Defects

目的总结双胎妊娠合并一胎畸形的治疗经验,探讨其围生期管理对策。方法回顾性分析2011年12月至2013年12月在本院分娩的双胎妊娠合并一胎畸形的临床资料。结果共纳入合并胎儿结构畸形或胎儿染色体异常双胎妊娠26例。自然妊娠者16例,体外受精-胚胎移植（IVF-ET）妊娠者10例;双绒毛膜双胎14例,单绒毛膜双胎12例。终止妊娠3例;期待治疗12例,分娩孕周为26^＋3～37^＋6周,11例正常胎儿生长良好,1例正常胎儿因26^＋3周分娩入住新生儿监护病房（NICU）后死亡,1例腹裂胎儿出生时行腹裂修补术,生长良好;选择性终止妊娠11例,9例为经腹畸形胎儿心腔内氯化钾（KCl）注射术,2例行畸形胎儿脐带双极电凝术,11例分娩孕周为25^＋5～38^＋4周,10例正常胎儿生长良好,1例25^＋3周发生胎膜早破放弃保胎流产。结论尽早诊断双胎妊娠合并一胎畸形,诊断后多学科团队应充分评估该次妊娠的双胎儿结局,与患方夫妇进行细致沟通,抉择进一步处理方式——选择性终止妊娠、期待治疗或终止妊娠。

Objective To review the outcomes of perinatal management of twins with discordant congenital defects.Methods We retrospectively examined the cases of twins with discordant congenital defects treated in the West China Second University Hospital from December 2011 to December 2013.Results There were 26 cases of twins（14dichorionic and 12monochorionic）with one anomalous fetus.Of those twins,16 were conceived by nature and 10 by in vitro fertilization and embryo tansfer（IVF-ET）.Counselling services were offered to the parents by a multidisciplinary team about options of pregnancy.Termination of pregnancy was chosen on three monochorionic twins.Twelve pairs of twin were delivered at 26^＋3-37^＋6 weeks gestation.One pair ended with neonatal death,and another one with gastroschisis was given intrapartum fetal operation.Selective termination was chosen on 11 cases using intracardiac injection of potassium chloride under ultrasonographic guidance（9 cases）or bipolar cord coagulation（2cases）.This resulted in ten live births delivered at 25^＋5-38^＋4 gustation and one neonatal death.Conclusion Early diagnosis of twins with discordant congenital defects is important.Multidisciplinary counselling services to parents are recommended for determination of options.Intensive prenatal care is essential in management of twins with discordant congenital defects.