不同血管分布类型双胎输血综合征接受胎儿镜激光凝固胎盘吻合血管术后的胎盘特点及妊娠结局

Pregnancy outcome and placental characteristics of twin-to-twin transfusion syndrome with different vascular patterns following fetoscopic laser surgery

目的:探讨胎盘浅表血管分布类型对双胎输血综合征接受胎儿镜激光凝固胎盘吻合血管术后的妊娠结局和残留吻合血管的影响。方法:回顾性分析2014年4月至2019年4月于北京大学第三医院产科行胎儿镜激光凝固胎盘吻合血管术,且最终在本院分娩的57例双胎输血综合征患者的临床资料和分娩后胎盘灌注特点。根据胎盘浅表血管分布类型,将这些患者分为平行型、交错型、混合型和单羊膜型,比较不同类型患者的手术情况、妊娠结局和残留吻合血管发生的差异。采用方差分析、非参数检验、χ2检验(或Fisher精确概率法)进行统计学分析。结果:(1)57例患者以胎盘浅表血管分布分类,包括交错型39例(68.4%)、混合型9例(15.8%)、平行型8例(14.0%)和单羊膜型1例(1.7%)。(2)剔除单羊膜型病例后,平行型的发病孕周和手术孕周大于交错型和混合型[分别为23.0周(22.0~26.3周)、21.0周(17.0~24.7周)和22.6周(21.3~23.9周),H=10.306,P=0.006;25.0周(22.6~26.3周)、22.0周(17.4~24.9周)和23.2周(22.4~24.0周),H=9.926,P=0.007;P’值均<0.0167]。各类型患者的手术时间和术式差异无统计学意义,终止妊娠孕周、新生儿出生体重、出生体重差额比等差异亦无统计学意义。(3)在残留吻合血管直径方面,交错型小于混合型[分别为0.6 mm(0.1~5.0 mm)和1.4 mm(0.3~5.1 mm),P’<0.0167],而与平行型[0.9 mm(0.2~3.6 mm)]相比,差异无统计学意义;平行型与混合型相比,差异亦无统计学意义。在脐带插入点距离比方面,交错型分别大于平行型和混合型[分别为0.66(0.59~1.00)、0.49(0.25~0.55)和0.48(0.42~0.53),H=22.545,P<0.001,P’值均<0.0167];而平行型与混合型相比,差异无统计学意义。结论:胎盘浅表血管分布类型可能影响双胎输血综合征胎儿镜激光术后吻合血管残留。术前应充分评估胎盘浅表血管分布类型,个体化制定手术方案,降低吻合血管残留的发生率。

Objective To evaluate the effect of different superficial vascular patterns on pregnancy outcome and residual anastomosis following laser coagulation in placentae with twin-to-twin transfusion syndrome(TTTS).Methods This study retrospectively collected and analyzed the clinical data and postnatal placenta perfusion characteristics of 57 cases of TTTS who received fetoscopic laser occlusion of chorioangiopagous vessels(FLOC)and delivered at Peking University Third Hospital from April 2014 to April 2019.According to the vascular pattern,all the cases are divided into four groups,which were parallel,staggered,mixed,and monoamniotic groups.Differences in the operation time and method,pregnancy outcome,and residual vascular anastomosis between the four groups were compared using analysis of variance,non-parametric tests,and Chi-square(or Fisher's exact)tests.Results Among the 57 cases,the staggered,mixed,parallel,and monoamniotic types were accounted for 68.4%(39/57),15.8%(19/57),14.0%(8/57),and 1.7%(1/57),respectively.After exclusion of one case of monoamniotic type,gestational weeks at onset and surgery in the parallel group were both later than the staggered and mixed groups[23.0(22.0-26.3)weeks vs 21.0(17.0-24.7)weeks and 22.6(21.3-23.9)weeks,H=10.306,P=0.006;25.0(22.6-26.3)weeks vs 22.0(17.4-24.9)weeks and 23.2(22.4-24.0)weeks,H=9.926,P=0.007;all P'<0.0167].There was no statistical significance in the differences in operation time and method,gestational age at the end of the pregnancy,neonatal birth weight,or birth weight discordance between the three groups.The diameter of residual vascular anastomosis of women in the staggered group was less than that in the mixed group[0.6(0.1-5.0)mm vs 1.4(0.3-5.1)mm,P'<0.0167],but no significant difference was observed in the parallel-group[0.9(0.2-3.6)mm]neither with the mixed or staggered group.The staggered group was noted for an increased distance ratio of umbilical cord insertion compared with the parallel and the mixed group[0.66(0.59-1.00)vs 0.49(0.25-0.55)and 0.48(0.42-0.53);P'<0.0167].There was no significant difference between the parallel and the mixed groups.Conclusions Placental superficial vascular patterns may affect the residual vascular anastomosis in women with TTTS following FLOC,which should be thoroughly evaluated before the operation to develop an individual management plan to reduce residual anastomosis incidence.