葡萄胎与胎儿共存的多胎妊娠:回顾性病例系列研究

Multiple pregnancies with hydatidiform mole and coexisting fetus:a retrospective case series study

目的评估葡萄胎与胎儿共存(HMCF)的多胎妊娠的产科结局。方法收集2003年1月至2022年12月广州医科大学附属第三医院收治的23例HMCF孕妇资料,其中经组织学证实的13例多胎妊娠,对其产前诊断、产科结局和妊娠滋养细胞肿瘤(GTN)预后进行病例系列分析。结果13例多胎妊娠中(1例三胎、12例双胎),有10例(76.9%)为完全性葡萄胎与胎儿共存(CHMCF),3例(23.1%)为部分性葡萄胎与胎儿共存(PHMCF)。临床表现上,9例孕妇孕期有阴道流血、1例腹痛、3例早发子痫前期和2例无症状。妊娠24周前终止妊娠8例,包括经阴道排胎6例,剖宫取胎1例和子宫切除1例;选择继续妊娠者5例,全部经剖宫产分娩,1例获得两活婴,4例单活婴,活产率100%。有6例妇女围术期输注血制品,5例术后妊娠物残留再次清宫。终止妊娠后,6例产妇术后人绒毛膜促性腺激素(hCG)自然转阴,7例产妇经历了化疗。HMCF中GTN的总发生率为53.8%(7/13),包括3例肺转移全部来自CHMCF孕妇。妊娠24周前终止妊娠的孕妇和选择继续妊娠的孕妇GTN发生率分别为50.0%(4/8)和60.0%(3/5),2例足月分娩的产妇有1例发展为GTN。除外1例子宫切除的妇女,随访了其他后续生育情况,无一例复发滋养细胞疾病。有6例女性正常足月分娩,2例不孕症,2例失访,2例无再生育计划。结论HMCF中CHMCF的发生率明显高于PHMCF,反复阴道流血和宫腔异常混合回声团是最常见的临床表现,结合血清β-hCG有助于鉴别诊断。与24孕周前终止妊娠相比,继续妊娠没有增加持续性GTN的风险,但CHMCF和较高的GTN发生率相关。产科医生应对HMCF多胎妊娠进行个性化管理,权衡终止妊娠的指征。

Objective To assess the obstetric outcome of multiple pregnancies with hydatidiform mole and coexisting fetus(HMCF).Methods Retrospectively collecting data of 23 patients with HMCF who were admitted to the Third Hospital of Guangzhou Medical University from January 2003 to December 2022.A case series of 13 multiple pregnancies confirmed histologically were reported with regard to the prenatal diagnosis,pregnancy outcome,and prognosis of gestational trophoblastic neoplasia(GTN).Results Among the 13 multiple pregnancies(one triple pregnancy and twelve twin pregnancies),we identified 10(76.9%)with complete hydatidiform mole and coexisting fetus(CHMCF)and 3(23.1%)with partial hydatidiform mole and coexisting fetus(PHMCF).During pregnancy,nine women presented vaginal bleeding,one had abdominal pain,three developed early-onset preeclampsia and two were asymptomatic.There were eight patients who chose to terminate before 24 weeks of gestation,including six vaginal evacuations,one cesarean section and one hysterectomy.Another five continued pregnancy and underwent cesarean delivery,resulting in a 100%live-birth rate with four cases of single live-born infant and one case of two live-born infants.There were six women who received blood transfusion and five who experienced repeated curettage for remnants in the perioperative period.After termination of pregnancy,six women showed serumβ-hCG spontaneously turning negative,while seven needed to receive chemotherapy.The overall incidence of GTN in HMCF was 53.8%(7/13),including 3 cases of lung metastases which were from CHMCF.The incidence of GTN was 50.0%(4/8)and 60.0%(3/5)in women who terminated before 24 weeks of gestation and those who chose to continue the pregnancy,respectively.One out of the two term deliveries developed GTN.Except the case who underwent hysterectomy,we followed up the others for subsequent fertility,and no recurrent trophoblastic disease was reported.There were six women with normal term delivery,two infertile,two lost to follow up,and two with no plans for further fertility.Conclusions In cases of HMCF,the prevalence of CHMCF is higher than that of PHMCF.Repeated vaginal bleeding and intrauterine mixed echo are the most common clinical manifestations,and the combination with serumβ-hCG is helpful in the differential diagnosis.Continuation of pregnancy does not add the risk of persistent GTN compared with termination before 24 weeks,but CHMCF is associated with a higher incidence of GTN.Obstetricians should individualize the management of multiple pregnancies with HMCF and weigh the indications for termination of pregnancy.