双绒毛膜三羊膜囊三胎妊娠的围产结局分析

Perinatal outcomes of dichorionic triamniotic triplet pregnancy

目的通过分析双绒毛膜三羊膜囊(DCTA)三胎妊娠孕妇的临床资料,探讨不同处理方式对DCTA三胎妊娠围产结局的影响。方法回顾性分析2010年1月1日至2020年1月1日于北京大学第三医院进行产前检查并分娩的57例DCTA三胎妊娠孕妇的临床资料。首先单纯以减少胎儿数目为目的进行分组,分为期待妊娠组(27例)和选择性减胎组(30例),进一步将选择性减胎组根据不同减胎方式分为保留单绒毛膜双羊膜囊(MCDA)双胎组、保留双绒毛膜双羊膜囊(DCDA)双胎组以及保留单胎组3个亚组。比较期待妊娠组以及选择性减胎组3个亚组围产结局的差异。结果选择性减胎组分娩孕周为(34.5±5.7)周、足月产率为53%(16/30),分别高于期待妊娠组的(29.9±6.0)周、7%(2/27);选择性减胎组流产率为10%(3/30),低于期待妊娠组的33%(9/27);两组分别比较,差异均有统计学意义(P均<0.05)。选择性减胎组的孕产期并发症及新生儿ICU(NICU)入住率也显著低于期待妊娠组(P<0.05)。选择性减胎组中,保留MCDA双胎组(6例)、保留DCDA双胎组(13例)、保留单胎组(11例)的分娩孕周分别为(32.2±4.3)、(33.0±6.3)、(37.4±4.7)周,流产率分别为1/6、1/13、1/11,早产率分别为4/6、7/13、0/11,足月产率分别为1/6、5/13、10/11,至少一胎儿存活率分别为5/6、12/13、10/11,NICU入住率分别为6/8、9/18、0/10。保留单胎组足月产率最高,NICU入住率最低,分别与各组比较,差异均有统计学意义(P均<0.05)。保留DCDA双胎组比期待妊娠组的足月产率高,差异有统计学意义(P<0.05)。结论DCTA三胎妊娠风险高,早期减去MCDA双胎保留单胎的足月产率最高、新生儿结局最佳。对于希望保留双胎继续妊娠的孕妇,应充分告知风险,可考虑减去MCDA中的一胎,保留DCDA双胎继续妊娠。

Objective To analyze the perinatal outcomes in different methods of multifetal pregnancy reduction in dichorionic triamniotic(DCTA)triplet pregnancy.Methods A retrospective analysis was performed on 57 cases of DCTA triplets in Peking University Third Hospital from January 1,2010 to January 1,2020,including 27 cases in expectant pregnancy group and 30 cases in selective fetal reduction(FR)group.The selective FR group was further divided into 3 subgroups according to different FR methods:retaining monochorionic dichorionic(MCDA)group,retaining dichorionic dichorionic(DCDA)group,and retaining singleton group.The perinatal outcomes of expectant pregnancy group and 3 subgroups of selective FR group were compared.Results The gestational weeks in selective FR group was(34.5±5.7)weeks,and full-term delivery rate was 53%(16/30),respectively higher than those of the expectant pregnancy group(29.9±6.0)weeks and 7%(2/27).The miscarriage rate of the selective FR group was 10%(3/30),lower than that of the expectant pregnancy group(33%,9/27).The differences between the two groups were statistically significant(all P<0.05).The ratios of pregnancy complications and newborn admission to neonatal ICU(NICU)in the selective FR group were lower than those of the expectant pregnancy group(all P<0.05).In the selective FR group,the gestational weeks in retaining MCDA group(6 cases),retaining DCDA group(13 cases),and retaining singleton group(11 cases)were(32.2±4.3),(33.0±6.3),and(37.4±4.7)weeks;the miscarriage rates were 1/6,1/13,and 1/11;the premature delivery rates were 4/6,7/13,and 0/11;the full-term delivery rates were 1/6,5/13,and 10/11;pregnancies with at least 1 survivor rates were 5/6,12/13,and 10/11;NICU occupancy rates were 6/8,9/18 and 0/10,respectively.The retaining singleton group had the highest rate of full-term delivery and the lowest rate of NICU occupancy.Compared with other groups,the differences were statistically significant(all P<0.05).The full-term delivery rate was significantly higher in the retaining DCDA group than that of the expectant pregnancy group(P<0.05).Conclusions The risk of DCTA triplet pregnancy is high.Reduction of the MCDA pair to singleton has the highest rate of full-term delivery and the lowest rate of NICU occupancy.For pregnant women who wish to retain twin pregnancy,the risk should be fully informed,and consider reduction of one fetus of the MCDA and retaining DCDA twins to continue pregnancy.