胎儿镜激光凝固胎盘吻合血管术治疗44例双胎输血综合征临床分析

Clinical effect of fetoscopic laser occlusion of chorioangiopagous vessels for twin-twin transfusion syndrome： experience of an center from China

目的 探讨胎儿镜激光凝固胎盘吻合血管（FLOC）术治疗双胎输血综合征（TTTS）的临床分期与治疗效果、手术并发症及妊娠结局.方法 收集2009年5月至2014年5月在北京大学第三医院进行FLOC治疗的44例TTTS患者的临床资料,对FLOC术的临床分期与治疗效果、手术并发症及妊娠结局进行分析.结果 （1）44例TTTS患者平均年龄为（29±4）岁,中位确诊孕周为20.4周,Quintero临床分期为Ⅰ期7例、Ⅱ期14例、Ⅲ期19例、Ⅳ期4例.（2）44例患者行FLOC手术时中位孕周为21.2周.43例手术顺利完成,1例术中胎盘浅表血管破裂出血,仅行FLOC术的平均手术时间为（60±15） min.（3）TTTS经FLOC术治疗后无效的比例为14％（6/44）,术后胎死宫内的发生率为15％（13/88）,术后孕28周内胎膜破裂的发生率为16％（7/44）,选择性胎儿生长受限（sIUGR）发生率为5％（4/88）,双胎贫血-红细胞增多序列征（TAPS）发生率为5％（2/44）.（4）44例患者中,有19例患者因提前终止妊娠未进入围产期,25例进入围产期,其中Ⅰ、Ⅱ、Ⅲ、Ⅳ期患者分别为4、11、7、3例,Ⅰ、Ⅱ、Ⅲ、Ⅳ期患者双胎均存活分别为4例（4/7）、10例（10/14）、5例（5/19）、3例（3/4）,胎儿总存活率分另为8例（8/14）、21例（75％,21/28）、12例（32％,12/38）、6例（6/8）.FLOC术后平均分娩孕周（34±3）周,供血儿活产22例,活产率为88％（22/25）;受血儿活产25例,活产率为100％（25/25）.供血儿平均出生体质量为（1 631±612）g,受血儿平均出生体质量为（2 071±585）g,两者比较,差异有统计学意义（P=0.016）.进入围产期和双胎均存活的比例分别比较,Ⅲ期显著低于Ⅱ期（P＜0.01）,但与Ⅳ期分别比较,差异均无统计学意义（P＞0.05）;胎儿总存活率为53％（47/88）,双胎均存活率为50％（22/44）,至少一胎存活率为57％（25/44）.（5）TTTS早期（Ⅰ＋Ⅱ期）患者与晚期（Ⅲ＋Ⅳ期）在进入围产期[分别为71％（15/21）及44％（10/23）]和双胎均存活率[分别为67％（14/21）及35％（8/23）]方面比较,差异均无统计学意义（P＞0.05）.在胎儿总存活率方面比较,早期患者高于晚期患者[分别为69％ （29/42）及39％（18/46）],差异有统计学意义（P＜0.01）.（6）新生儿随访发现,供血儿中有12例心脏畸形,受血儿中有5例心脏畸形;供血儿中发生1例早期新生儿死亡,2例影像学检查提示可疑脑损伤;受血儿中发生1例新生儿死亡,2例出生后1个月内影像学检查提示脑损伤.结论 FLOC手术能明显提高TTTS患儿的存活率.Quintero临床分期能否预测TTTS患者的FLOC手术预后尚需进一步研究.TTTS患者有FLOC手术指征时,应积极建议患者和家属尽快接受FLOC手术,可能有助于改善患者预后.

Objective To study the clinical effect of fetoscopic laser occlusion of chorioangiopagous vessels （FLOC） in treating twin to twin transfusion syndrome.Methods The clinical data of 44 consecutive cases of twin to twin transfusion syndrome （TTTS） who had FLOC in the Department of Obstetrics and Gynaecology of Peking University Third Hospital were reviewed and analyzed for perioperative complications,perinatal outcomes and fetal survival rate.Results （1） Patient characteristics：the mean maternal age was （29±4） years,the median gestational age at TTFS being primarily diagnosed was 20.4 weeks,the median gestational age at FLOC was 21.2 weeks.According to the Quintero staging system,there were 9 cases had stages progressed before the operation.（2） FLOC parameter and intraoperative complications：44 cases all could tolerate the operation; there was 1 case of placenta vascular rupture in the operation,no fetal body injury by laser or placental abruption.3 cases underwent cervical cerclage following FLOC.The average operation time of 41 cases alone with FLOC was （60.1± 15.1） minutes.（3） Postoperative complications：the rate of intrauterine fetal death was 15％ （13/88）,the rate of intrauterine growth restriction after FLOC was 5％ （4/88）,the rate of membranes rupture less than 28 weeks was 16％ （7/44）,the rate of TAPS after FLOC was 5％ （2/44）,the rate of membrane sepration after FLOC was 5％ （2/44）.（4） Perinatal outcome and survival rate：there were 25 patients after FLOC had delivered in the perinatal period.The average gestational age of delivery was （33.5±2.7） weeks.The donor fetuses survival rate was 88％ （22/25）,the recipient fetuses survival rate was 100％ （25/25）.The birth weight of donor fetuses was significantly less than that of recipient fetuses （1 631g vs 2 071 g,P=0.016）.From Quintero staging Ⅰ to Ⅳ,the rate that 44 cases of TTTS had entered the perinatal period was 4/7,11/14,7/19,3/4; both twins survival rates were 4/7,10/14,5/19,3/4; all the fetal survival rate was 8/14,75％ （21/28）,32％ （12/38）,6/8,respectively.（5） Compared the early stage （Ⅰ ＋ Ⅱ） with the advanced stage （Ⅲ ＋ Ⅳ）,the rates that 44 cases of TTTS had entered the perinatal period （71％ vs 44％） and that both twins survived （67％ vs 35％） had no statistically significance.The rate that all the fetus survived in the early stage was significantly （69％ vs 39％） more than that in the advanced stage.（6） All the cases of neoborn were followed up till 1 month postpartum,the donor fetuses and the recipient fetuses had 12 and 5 cases of cardiac abnormalities respectively,each had 1 case of neonatal death and 2 cases of neonatal white matter damage.Conclusions FLOC for TTTS is associated with a better survival rate.Quintero staging probably does not effectively predict the fetal diagnosis of TTTS after FLOC.When TTTS diagnosed,the sooner FLOC given,the better fetal prognosis had.