双胎输血综合征经胎儿镜下胎盘血管交通支激光凝固术治疗的效果分析

Analysis of the effect of laser coagulation of the placental vascular communicating branches under fetoscopy for twin-fetal blood transfusion syndrome

目的探讨双胎输血综合征(TTTs)经胎儿镜下胎盘血管选择性交通支激光凝固术(SLPCV)治疗的临床效果和围产儿结局。方法收集2018年10月至2020年6月于西北妇女儿童医院行SLPCV治疗的11例TTTs患者的临床资料,回顾性分析手术情况及妊娠结局。结果本研究TTTs患者平均年龄(29.73±3.02)岁,自然受孕9例,辅助生殖技术助孕2例。手术及术后情况:(1)行胎儿镜下SLPCV术时平均孕周为(21.05±2.16)周;(2)术后胎儿总存活率为59.09%(13/22),双胎存活率为54.55%(6/11),至少一胎存活率为63.64%(7/11),供血儿存活6例(54.55%),平均出生体质量为(1560±368)g;受血儿存活7例(63.64%),平均出生体质量为(1750±354)g;(3)Quintero临床分期为Ⅰ期1例、Ⅱ期2例、Ⅲ期8例、Ⅳ期0例,其中Ⅰ期、Ⅱ期术后均双胎存活,Ⅲ期术后胎儿总存活率为43.75%(7/16),其中双胎存活率为37.50%(3/8),至少一胎存活率为50.00%(4/8);(4)胎盘位置为前壁3例,后壁7例,底左侧壁1例,前壁双胎存活率及至少一胎存活率均为66.67%(2/3),后壁双胎存活率及至少一胎存活率均为42.86%(3/7),底左侧壁双胎均存活;(5)平均手术时间为(94.45±18.83)min,平均术后继续妊娠天数为(52.55±32.56)天,平均分娩孕周为(28.56±5.74)周;(6)流产3例,剖宫产8例;(7)术后胎膜早破(PROM)总发生率为36.36%(4/11),胎儿发生双胎贫血红细胞增多序列征(TAPS)总发生率为9.09%(1/11)。结论TTTs经胎儿镜下SLPCV治疗临床效果可靠,手术时机选择妊娠20周左右效果及预后较好;患者Ⅰ~Ⅱ期、前壁胎盘者存活率较高,对于确诊的TTTs患者应根据临床条件选择合适的治疗方式,尽早干预。

Objective To explore the clinical effects and perinatal outcome of twin-fetal transfusion syndromes(TTTs)by fetoscopy laser coagulation of selective communicating branches of placental vessels(SLPCV).Methods The clinical data of 11 patients with TTTs who underwent SLPCV treatment in Northwest Women’s and Children’s Hospital from October 2018 to June 2020 were collected,and the surgical status and pregnancy outcome were retrospectively analyzed.Results The average age of patients with TTTs in this study was(29.73±3.02)years,including 9 cases of natural conception,and 2 cases of assisted reproductive technology.Surgery and post-operative conditions:(1)The average gestational week for SLPCV under fetal surgery was(21.05±2.16)weeks.(2)The overall survival rate of the fetus after surgery was 59.09%(13/22),and the twin survival rate was 54.55%(6/11),the survival rate of at least one child was 63.64%(7/11),6 cases(54.55%)of the blood donor survived,and the average birth weight was(1560±368)g;7 cases(63.64%)of the recipient survived,the average birth weight was(1750±354)g.(3)Quintero clinical staging was 1 case in stage Ⅰ,2 cases in stage Ⅱ,8 cases in stage Ⅲ,and 0 cases in stageⅣ,respectively.Among them,twins survived after surgery of stage Ⅰ and Ⅱ.The overall survival rate of the fetus after surgery of stage Ⅲ was 43.75%(7/16),among which the twin survival rate was 37.50%(3/8),and the survival rate of at least one child was 50.00%(4/8).(4)There were 3 cases in the anterior wall,7 cases in the posterior wall,and 1 case in the left bottom wall.The survival rate of anterior twins and the survival rate of at least one child were both 66.67%(2/3),and the survival rate of posterior twins and at least one child were both 42.86%(3/7),and the twins on the bottom left wall survived.(5)The average operation time was(94.45±18.83)min,the average postoperative pregnancy days were(52.55±32.56)days,and the average gestational week was(28.56±5.74)weeks.(6)There were 3 cases of miscarriage and 8 cases of cesarean section.(7)The total incidence of postoperative premature rupture of membranes(PROM)was 36.36%(4/11),and the total incidence of fetal twin anemia polycythemia syndrome(TAPS)was 9.09%(1/11).Conclusion The clinical effect of SLPCV treatment with TTTs under fetoscopy is reliable,and there is a good effect and prognosis when the operation timing is around 20 weeks of pregnancy.There is a higher survival rate in patients with stage Ⅰ to Ⅱ and anterior placenta.For confirmed TTTs patients,the appropriate choice should be based on clinical conditions intervention as soon as possible.