微波消融技术在复杂性单绒毛膜双胎选择性减胎术中的应用

Microwave ablation for selective feticide in complicated monochorionic twin pregnancies

目的评估超声引导下经皮微波消融技术在复杂性单绒毛膜双胎妊娠选择性减胎术中的可行性、安全性及短期预后。 方法回顾性分析2015年7月1日至2016年6月30日间在北京大学第三医院接受微波消融选择性减胎术的22例复杂性单绒毛膜双胎孕妇的病例资料。记录手术并发症、胎儿结局及随访生后60 d婴儿的神经系统发育等情况。采用单因素方差分析、Mann-Whitney U检验、χ2检验或Fisher精确概率法对数据进行统计学分析。结果22例手术指征分别为：5例双胎之一畸形，5例严重双胎输血综合征（twin-twin transfusion syndrome，TTTS），3例双胎反向动脉灌注（twin reversed arterial perfusion，TRAP），9例选择性胎儿宫内生长受限（selective intrauterine growth restriction，sIUGR）。手术均顺利完成。22例中，3例（13.6%）术后胎死宫内，1例（4.5%）胎膜早破流产，总流产率为18.2%（4/22）。18例分娩活婴，平均分娩孕周（35.5±4.2）周（26~40周＋2），平均出生体重（2 380±778） g（800~3 430 g）。18例中，4例小于32周早产，其中1例极低出生体重儿（孕26周分娩，体重800 g）死亡，另17例婴儿均顺利出院，新生儿存活率为17/18，总的胎儿存活率为77.3%（17/22）。是否合并羊水过多、胎盘是否位于前壁、被减胎儿是否位于宫腔下方对于手术流产率、胎儿存活率等均无明显影响（P值均〉0.05）。22例母亲均无严重并发症发生。17例随访至婴儿生后60 d，影像学检查均未发现脑损伤。结论超声引导经皮微波消融可用于复杂性单绒毛膜双胎妊娠的选择性减胎治疗，但减胎术对后代的远期预后影响仍需扩大样本量进一步的研究。

ObjectiveTo evaluate the feasibility, safety and short-term fetal outcome of ultrasound-guided percutaneous microwave ablation for selective feticide in complicated monochorionic twin pregnancies.MethodsTwenty-two patients who underwent microwave ablation for selective fetal reduction in Peking University Third Hospital between July 2015 and June 2016 were retrospectively studied. Surgical complications, fetal outcomes and neural development at age of 60 days were recorded. One-way ANOVA, Mann-Whitney U test, Chi-square or Fisher＇s exact test was used for statistical analysis.ResultsIndications of the 22 patients for selective feticide included five cases of twin pregnancy with one anomalous fetus, five cases of severe twin-twin transfusion syndrome （TTTS）, three cases of twin reserved arterial perfusion （TRAP） and nine cases of selective intrauterine growth restriction （sIUGR）. All surgeries were successful under regional anesthesia. Four pregnancies （18.2%, 4/22） ended in miscarriage following surgery, three of which were caused by intrauterine fetal death （13.6%, 3/22） and one by premature rupture of membranes before 26 weeks of gestation （4.5%, 1/22）. Totally, 18 babies were born alive at an average gestational age of （35.5±4.2） weeks （26~40 weeks＋2） and with an average birth weight of （2 380±778） g （800~3 430 g）, and four of them were preterm infants less than 32 weeks of gestation. Except for one extremely low birth weight infant, whose gestational age was 26 weeks at birth and birth weight was 800 g, died two days after birth, 17 infants were discharged alive, giving an neonatal survival rate of 17/18. The total fetal survival rate was 77.3% （17/22）. Polyhydramnios, placenta location, and position of the fetus being aborted showed no significant effect on miscarriage or fetal survival rate （all P〉0.05）. No severe maternal complications occurred. No brain injuries were detected by imaging examination in 17 infants who were followed up to 60 days of age.ConclusionsUltrasound-guided percutaneous microwave ablation can be used for selective feticide in complicated monochorionic twin pregnancies. Further studies are needed to evaluate its effects on long-term fetal outcome.