合并选择性胎儿生长受限影响双胎输血综合征孕妇的术后结局

Postoperative outcomes of twin-twin transfusion syndrome complicated with selective intrauterine growth restriction

目的分析双胎输血综合征（twin-twin transfusion syndrome，TTTS）患者行胎儿镜下激光凝固胎盘吻合血管术（fetoscopic laser occlusion of chorioangiopagous vessels，FLOC）后的妊娠结局，探讨合并选择性胎儿生长受限（selective intrauterine growth restriction，sIUGR）对TTTS患者术后结局的影响。方法本研究为回顾性研究，研究对象为2008年9月至2014年9月在北京大学第三医院产科就诊的116例Ⅰ-Ⅳ期TTTS患者，其中44例接受了FLOC。分析各期TTTS合并sIUGR的比例，随访44例接受FLOC者的妊娠结局，同时比较各期TTTS患者的妊娠结局。采用χ2检验或Fisher精确概率法对数据行统计学分析。结果（1）不同分期TTTS患者双胎均存活的比例差异有统计学意义（Ⅰ-Ⅳ期分别为4/7、10/14、5/19和3/4，χ2=7.840，P=0.038），其中Ⅲ期双胎均存活的比例低于Ⅱ期，但差异尚未见统计学意义（P＇=0.008）。4组胎儿总存活率差异有统计学意义[分别为8/14、75%（21/28）、32%（12/38）和6/8，χ2=14.016，P=0.002]，其中Ⅲ期胎儿存活率低于Ⅱ期（P＇〈0.008）。合并sIUGR的TTTS Ⅲ期患者，FLOC术后胎儿总存活率低于不合并sIUGR的患者[21%（6/28）与6/10，P〈0.05]。（2）116例TTTS患者中，63例（54%）合并sIUGR。其中，Ⅰ-Ⅳ期合并sIUGR患者分别占40%（14/35）、48%（11/23）、78%（28/36）和46%（10/22），差异有统计学意义（χ2=11.963，P=0.007）。Ⅲ期合并sIUGR的比例高于Ⅰ期（χ2=10.482，P＇=0.002）；Ⅲ期与Ⅱ期合并sIUGR的比例分别高于Ⅳ期，但差异尚无统计学意义。 结论Ⅲ期TTTS患者FLOC术后双胎均存活率或胎儿总存活率较低，可能与这些患者当中合并sIUGR者较多有关。

Objective To evaluate the efficacy of fetoseopie laser occlusion of chorioangiopagous vessels （FLOC） in treatment of twin-twin transfusion syndrome （TTTS） and to investigate the incidence of TTTS complicated with selective intrauterine growth restriction （sIUGR） for better understanding the effects of sIUGR as a complication of TTTS on pregnancy outcomes. Methods A retrospective study was performed on 116 gravidas who were diagnosed with TTTS of Quintero stage Ⅰ- Ⅳ in Peking University Third Hospital from September 2008 to September 2014. Among them, 44 cases received FLOC therapy. The incidences of sIUGR in each Quintero stage of TTTS were analyzed. Pregnancy outcomes of those 44 cases treated with FLOC were observed and the differences among four stage groups were analyzed. Chi-square or Fisher exact test was performed for statistical analysis. Results （1） The survival rates of both twins from stage Ⅰ to Ⅳ groups were 4/7, 10/14, 5/19 and 3/4, respectively, with statistically significant difference （x2=7.840, P=0.038）, but that in stage Ⅲ group was lower than in stage Ⅱ group without significant difference （P=0.008）. Differences in the total fetal survival rate among the four groups were statistically significant [8/14, 75% （21/28）, 32% （12/38） and 6/8, x2=14,016, P=0.002]. The total fetal survival rate in stage llI group was significantly lower than that in stage Ⅱ group （P〈0.008）. In patients with stage Ⅲ TTTS, those complicated with slUGR, after receiving FLOC therapy, showed a lower total fetal survival rate than those without slUGR [21% （6/28） vs 6/10, P〈0.05]. （2） Among the 116 TTTS patients, there were 63 cases （54%） with sIUGR complication. Patients with slUGR complication in TTTS stages Ⅰ to Ⅳ groups accounted for 40% （14/35）, 48% （11/23）, 78% （28/36） and 46% （10/22）, respectively, and the differences were significant （x2=11.963, P=0.007）. The incidence of sIUGR in stage Ⅲ group was greater than that in stage Ⅰ group （x2=10.482, P=0.002）, and those in both stage Ⅲ and Ⅱ groups were higher than in stage Ⅰ group without significant difference. Conclusions TTTS patients in stage Ⅲ have lower survival rate of both twins and total fetal survival rates after FLOC therapy, which may be related to a higher incidence of concurrent sIUGR.