胎儿脐动脉栓塞31例临床分析

Clinical analysis of 31 cases of fetal umbilical artery thrombosis

目的分析产前超声诊断为胎儿脐动脉栓塞孕妇的超声表现、临床特征、高危因素及妊娠期管理要点。方法回顾性分析2017年7月至2022年7月,浙江大学医学院附属妇产科医院分娩的31例产前超声诊断且出生后证实为胎儿脐动脉栓塞孕妇的临床资料,包括一般情况、妊娠合并症和并发症以及妊娠结局。21例确诊后行延长孕周期待观察,其中低分子量肝素(LMWH)治疗10例(LMWH组),单纯期待观察11例(单纯观察组),对两组孕妇的一般情况和妊娠结局进行比较。结果31例胎儿脐动脉栓塞孕妇的年龄为(30.2±4.7)岁,其中5例(16%,5/31)为高龄(≥35岁)孕妇,诊断孕周为(32.9±4.0)周,终止妊娠孕周为(35.6±2.9)周;15例(48%)发生胎儿窘迫,11例(35%)发生胎儿生长受限,3例(10%)胎死宫内。活产28例(行子宫下段剖宫产术26例,阴道分娩2例),死胎3例均为引产后阴道娩出。28例活产儿中新生儿轻度窒息4例,重度窒息2例。确诊后即刻终止妊娠10例,其诊断孕周为(35.9±2.9)周。确诊后延长孕期期待21例,其诊断孕周为(31.4±3.7)周,其中LMWH组延长孕周的中位数为7.9周(4.6~9.4周),均活产;单纯观察组延长孕周的中位数为0.6周(0.0~1.0周),2例胎死宫内;延长孕周时间比较,差异有统计学意义(P=0.002)。结论超声检查是产前发现胎儿脐动脉栓塞的首选方法,妊娠中晚期超声检查发现新发的单脐动脉时需警惕脐动脉栓塞。决定期待治疗或即刻终止妊娠需视孕周及胎儿情况而定,期待过程中应重视胎动主诉,尽早予LMWH抗凝治疗可能改善妊娠结局。

Objective To analyze the ultrasonic manifestations,clinical features,high risk factors and key points of pregnancy management in prenatal diagnosis of umbilical artery thrombosis(UAT).Methods The data of 31 pregnant women of UAT diagnosed by prenatal ultrasonography and confirmed after birth from July 2017 to July 2022 at the Women′s Hospital,Zhejiang University School of Medicine were retrospectively analyzed,including the maternal characteristics,pregnancy outcomes and fetal complications.In addition,the baseline data and pregnancy outcomes were compared in 21 patients who continued pregnancy after diagnosis of UAT.Of the 21 UAT cases that continued pregnancy,10 cases were treated with low molecular weight heparin(LMWH;LMWH treatment group),while the other 11 patients had expectant treatment(expectant treatment group).Results The age of the 31 pregnant women was(30.2±4.7)years,of which 5 cases(16%,5/31)were advanced age pregnant women.The gestational age at diagnosis was(32.9±4.0)weeks,and the gestational age at termination of pregnancy was(35.6±2.9)weeks.In 31 fetuses with UAT,15 cases(48%)had fetal distress,11 cases(35%)had fetal growth restriction,and 3 cases(10%)had intrauterine stillbirth.There were 28 cases of live births,including 26 cases by cesarean section and 2 cases by vaginal delivery.There were also 3 stillbirths,all delivered vaginally.Four neonates had mild asphyxia and two newborns had severe asphyxia.Among the 31 cases,10 cases were terminated immediately after diagnosis,the gestational age at diagnosis was(35.9±2.9)weeks.Another 21 pregnancies continued,and their gestational age at diagnosis was(31.4±3.7)weeks.The median prolonged gestational age in LMWH treatment group was 7.9 weeks(4.6-9.4 weeks),and all were live births.The median prolonged gestational age in the expectant treatment group was 0.6 weeks(0.0-1.0 weeks),and 2 cases were stillbirths.There was a statistically significant difference in prolonged gestational age(P=0.002).Conclusions Ultrasound is the preferred method for prenatal detection of UAT.Clinicians need to be vigilant for UAT when a newly identified single umbilical artery is detected by ultrasound in the second or third trimesters.The decision to continue or terminate the pregnancy depends on the gestational age and the condition of fetus.Attention should be paid to fetal movements as the pregnancy continues.The treatment of LMWH as soon as possible after diagnosis of UAT may improve the pregnancy outcome.