单卵三胎及四胎妊娠射频消融减胎术的安全性及有效性

Safety and efficacy of radiofrequency fetal ablation for monozygotic triplet and quadruplet pregnancies

目的探讨采用射频消融术对单卵三胎及四胎妊娠进行选择性减胎术的安全性及有效性。方法回顾性分析2014年3月至2017年1月在山东大学附属省立医院产科行射频减胎术的8例单卵三胎及四胎妊娠孕妇的病历资料。8例均在超声监视下行射频消融选择性减胎术，7例单卵三胎妊娠，均三胎减至双胎；1例单卵四胎妊娠，四胎减至双胎。采用描述性方法对孕妇围手术期的情况，以及母儿结局及新生儿随访情况进行分析。结果（1）7例被减胎儿在射频消融术1个加热循环后血流停止，1例被减胎儿在2个加热循环后血流停止。被减胎儿在术后心跳逐渐减慢，1例于术后10min心跳完全消失；4例20—25min心跳完全消失；3例40min心跳完全消失。8例术后保留胎儿的心跳均正常。（2）8例孕妇术后均定期产前检查。1例孕26周诊断妊娠期糖尿病，孕30周”住院保胎治疗4d；1例术后1d即接受住院保胎治疗2周，孕35周诊断重度子痫前期；1例术后6d发热，住院后抗感染治疗，入院当天发展为难免流产；其余5例孕妇各项产前检查未见明显异常。（3）除1例流产外，其余7例均继续妊娠并分娩两活婴，均为剖宫产分娩，其中未足月胎膜早破早产（分别为孕35周^＋1和孕33周）2例，重度子痫前期早产（孕35周＋4）1例，4例足月分娩。新生儿出生后1及5min Apgar评分均在7分以上，3例接受新生儿科住院治疗，其中1例新生儿病理性黄疸，1例新生儿喉鸣，1例早产儿，接受儿科治疗后均好转。截至2018年9月，随访14例新生儿各项指标均未见异常。结论对单卵三胎及四胎妊娠施行射频消融减胎术，是一种可行的治疗方法。

Objective To investigate the safety and efficacy of radiofrequency fetal ablation （RFA） in the treatment of monozygotic triplet and quadruplet pregnancies. Methods We analyzed retrospectively the clinical data of eight gravidas, including seven monozygotic triplets and one monozygotic quadruplets admitted to the Department of Obstetrics, Shandong Provincial Hospital Affiliated to Shandong University from March 2014 to January 2017. All of the eight women accepted ultrasound-guided selective fetal reduction by RFA to reduce to twins. Descriptive methods were used to analyze the perioperative status of the gravidas, maternal and fetal outcomes and neonatal follow-up. Results （1） In seven cases, the fetuses were deprived of blood flow after one heating cycle of radiofrequency ablation, while in the other, blood flow was stopped after two heating cycles. Heart beats of the reduced fetuses slowed down gradually after RFA, and stopped at 10, 20-25 and 40 minutes after operation in one, four and three cases, respectively. The conserved fetus showed normal heartbeats. （2） All patients accepted regular obstetrical examination after RFA. One was diagnosed with gestational diabetes mellitus at 26 weeks, and hospitalized for 4 d because of preterm labor at 30＋6 weeks. One women was hospitalized to receive a two-week tocolysis treatment one day after surgery, and diagnosed with severe preeclampsia at 35 weeks. One patient who had a fever six days after surgery and was hospitalized for antiinfection treatment progressed to inevitable abortion on the day of admission. The other five pregnant women had no abnormalities. （3） Except for one miscarriage, the rest seven cases all continued the pregnancy until delivery by cesarean, among which two with preterm premature rupture of membranes eventually delivered before term （35＋2 and 33 weeks）, one with severe preeclampsia also preterm delivered （35＋4 weeks） and four term deliveries. Apgar scores at 1 and 5 minutes of all newborns were over 7. Three of the 14 newborns were hospitalized and recovered, including one pathological jaundice, one laryngeal stridor and one premature. The last follow-up in September 2018 of all 14 babies did not show any abnormalities. Conclusions RFA is a feasible treatment for monozygotic triplets and quadruplets.