孕周>26周单绒毛膜性双胎妊娠行射频消融减胎术的安全性评价

Safety of radiofrequency ablation for fetal reduction in monochorionic twin pregnancies over 26 weeks of gestation

目的探讨孕周>26周单绒毛膜性双胎妊娠行射频消融减胎术的有效性及安全性。方法回顾性分析2013年5月至2018年7月在重庆医科大学附属第一医院产科行射频消融减胎术的单绒毛膜性双胎妊娠孕妇51例,收集孕妇基本资料、减胎术情况(包括消融时间、功率、循环次数等)、围产期母胎并发症、妊娠结局等临床资料。以减胎孕周为分组依据,将孕妇分为>26周组(17例)与≤26周组(34例),比较2组孕妇术后妊娠结局。采用t检验、秩和检验、χ^2检验或Fisher精确概率法对数据进行统计学分析。结果(1)51例孕妇减胎手术指征包括双胎之一畸形、双胎输血综合征、双胎反向动脉灌注序列征和选择性胎儿生长受限[45.1%(23/51)、15.7%(8/51)、19.6%(10/51)和19.6%(10/51)],其中>26周组手术指征构成(12/17、1/17、0/17和4/17)与≤26周组[32.4%(11/34)、20.6%(7/34)、29.4%(10/34)和17.7%(6/34)]比较差异具有统计学意义(P=0.009)。>26周组孕妇术中消融时间长于≤26周组[M(min^max),20(7~40)与15(3~29) min,Z=2.550,P=0.011]。(2)51例孕妇减胎孕周(23.7±4.7)周,范围为15周^+1~32周^+6;术后保留胎儿总存活率为86.3%(44/51),早产的发生率为50.0%(22/44)。>26周组与≤26周组减胎孕周分别为(28.9±2.5)和(21.1±3.1)周,范围分别为26周^+1~32周^+6和15周^+1~25周^+2。减胎孕周>26周组术后保留胎儿存活率[17/17与79.4%(27/34)]及早产的发生率[12/17与37.0%(10/27),χ^2=4.697]均高于≤26周组(P值均<0.05)。结论与减胎孕周≤26周的孕妇相比,减胎孕周>26周的孕妇手术指征主要为双胎之一畸形,尽管可能增加早产的风险,但保留胎儿的存活率较高,术后母婴并发症并未明显增加。因此,射频消融减胎术应用于减胎孕周>26周的孕妇是相对安全有效的。

Objective To investigate the efficacy and safety of radiofrequency ablation for fetal reduction in monochorionic twin pregnancies at gestational age over 26 weeks. Methods A retrospective study was performed based on the clinical data of 51 patients who underwent fetal reduction by radiofrequency ablation in the First Affiliated Hospital of Chongqing Medical University from May 2013 to July 2018. Clinical data including basic information, surgical data (such as ablation duration, power and the number of cycles), perinatal complications and pregnancy outcomes were collected. Differences in pregnancy outcomes were compared between the group with gestational age >26 weeks (n=17, group A) and that ≤26 weeks (n=34, group B) using t-test, rank-sum test and Chi-square test or Fisher's exact test. Results (1) The indications of fetal reduction were malformation in one of the twins, twin-to-twin transfusion syndrome, twin reversed arterial perfusion sequence and selective intrauterine growth restriction [45.1%(23/51), 15.7%(8/51), 19.6%(10/51) and 19.6%(10/51)]. The differences in the proportion of different indications between group A and B were statistically significant [12/17, 1/17, 0/17, 4/17 vs 32.4%(11/34), 20.6%(7/34), 29.4%(10/34), 17.7%(6/34), P=0.009]. Those in the group A required longer operation duration than the group B [M(min-max), 20(7-40) vs 15(3-29) min, Z=2.550, P=0.011].(2) The gestational age of the 51 patients was (23.7±4.7) weeks (15^+1-32^+6 weeks), the overall survival rate of the remaining fetuses was 86.3%(44/51) and the preterm birth rate was 50.0%(22/44). The gestational age at operation was (28.9±2.5) weeks (26^+1-32^+6 week) in group A and (21.1±3.1) weeks (15^+1-25^+2 weeks) in group B. The survival rate of the remaining fetuses and the preterm birth rate in group A were significantly higher than those in group B [17/17 vs 79.4%(27/34), P=0.046;12/17 vs 37.0%(10/27),χ^2=4.697, P=0.030]. Conclusions Fetal reduction at gestational age >26 weeks, of which the main surgical indication is malformation in one of the twins, may increase the risk of preterm birth, but can improve the overall survival rate of the remaining fetuses without increasing the maternal and infant morbidity. Therefore, radiofrequency ablation is a safe and effective procedure for twin pregnancies >26 weeks of gestation.