多胎妊娠妇女孕中期选择性减胎术的临床应用

目的 通过对多胎妊娠妇女于孕中期行选择性减胎术,研究其手术指症、时机、安全性、目标胎儿的选择标准和减灭胎儿数,探讨选择性减胎术在改善多胎妊娠结局中的作用.方法 对37例孕12周+1～25周多胎妊娠孕妇(6例双胎、21例三胎、8例四胎、2例五胎,共117个胎儿)在超声引导下经腹行选择性减胎术,按产科医疗指征,在拟被减的46个胎儿心脏内注射10%氯化钾2～5 ml,见胎心逐渐减慢至停跳视为减胎术成功.术后定期产前检查和监测凝血功能,记录妊娠期并发症及妊娠结局.结果 (1)成功率:共减去胎儿46个,减胎成功率为100%(46/46个胎儿),已有27例孕妇分娩,获24个健康新生儿,妊娠成功率为88.9%(24/27).(2)分娩孕周:＞36周分娩者15例;32～36周7例;28～32周3例;＜28周流产者2例;正在妊娠中10例.平均分娩孕周(34.9±4.1)周,孕28周后分娩率为92.6%(25/27).(3)新生儿平均出生体重:单胎妊娠新生儿平均出生体重为(3014±640)g,双胎妊娠为(2557±573)g,三胎妊娠中除1例两个胎儿存活(出生体重分别为1400及1500 g)外,其余均死亡.(4)安全性:除2例单羊膜囊双胎在减灭1个胎儿后,另1个胎儿随即死亡外,其余多胎妊娠妇女的保留胎儿均未发生胎死宫内.(5)并发症:37例多胎妊娠妇女中仅3例发生子痫前期,减胎术后均无凝血功能障碍发生.(6)阴道流血:有13例孕妇减胎术前发生阴道流血,其中1例在妊娠13周强烈要求减胎,减胎术后于孕22周流产;另12例均在阴道流血停止1周以上后施行减胎.结论 (1)孕中期选择性多胎妊娠减胎术,可以有效减少多胎妊娠胎儿数目、避免异常胎儿出生,降低孕产妇并发症,提高新生儿出生体重.(2)胎儿保留数目以达双胎为好.(3)减胎术前有阴道流血者,避免在流血期间减胎,应选择在流血停止1周以上进行.(4)孕中期多胎妊娠减胎术不会造成孕妇的凝血功能障碍,也不会造成保留胎儿的宫内死亡,安全性好;减胎术后子痫前期的发病率明显下降.     

多胎妊娠中孕期选择性减胎术

中孕期妊娠选择性减胎术主要目的是减少多胎妊娠胎儿数、减灭异常胎儿,改善多胎妊娠结局。在排除单绒毛膜双胎的情况下,药物减胎比较成熟和安全,一般在妊娠 11～24 周实施,妊娠成功率接近自然双胎。对于单绒毛膜双胎采用血管闭塞的技术进行选择性减胎,国内多采用射频消融,一般选择在15～27周。手术适应证、手术时机、手术方法以及术者的熟练程度与妊娠结局有关。减胎术前应行超声检查判断绒毛膜性、诊断早期胎儿异常和识别双胎特殊并发症。     

选择性减胎术在中期妊娠的应用

目的　探讨选择性减胎术在中期妊娠的应用及其注意事项。　方法　对 19例多胎妊娠孕妇在妊娠 12～ 2 5周行选择性减胎术。其中双胎 6例 ,三胎 11例 ,四胎、六胎各 1例。在超声引导下经腹向胎儿心内或胸腔内注入高浓度的氯化钾。　结果　 6例双胎除 1例单绒毛膜双胎外均获减胎成功 ;11例三胎 ,除 1例减胎后计划生育引产 ,1例单卵三胎外 ,9例中 7例减胎成功 ,2例减胎后流产 ;1例四胎减胎成功 ;1例六胎减胎后流产。　结论　选择性减胎术可成功应用于妊娠中期 ,母亲无严重的并发症 ,但有一定的流产率。如果减胎术前能排除单卵双胎或单卵三胎 ,或能选择近宫底的妊娠囊进行减胎 ,或能将被减胎儿的羊水抽尽 ,或推迟减胎的时间 ,可能会降低流产率。     

多胎妊娠减胎术发展现状

近30年多胎妊娠的发生率显著增加,对于母婴的围产期结局产生了极大的影响。多胎妊娠减胎术通过在妊娠中减去一个或多个胎儿,避免多胎分娩,可改善妊娠结局。影响减胎术后结局的临床因素主要为减胎孕周、手术方式、起始及最终胚胎的数量以及是否合并单绒毛膜多胎。此外,减胎术前的产前诊断对于选择减胎对象有着准确的指导。本文就多胎妊娠减胎术现状及影响其妊娠结局的相关临床因素做一综述。     

辅助生殖技术单卵双胎相关因素分析及含单绒毛膜双胎三胎妊娠减除单绒毛膜双胎之一的临床结局比较

目的探讨辅助生殖技术(ART)治疗后行多胎妊娠减胎术中单卵双胎(MZT)的发生和三胎妊娠行单绒毛膜双胎中一胎减胎术保留双胎者的临床结局。方法回顾性分析ART治疗后行经阴道多胎妊娠减胎术的196例患者的临床资料,分析比较MZT在不同分组中的发生情况,同时比较其中伴单绒毛膜双胎的三胎妊娠减单绒毛膜双胎之一者(A组)与不伴单绒毛膜双胎的三胎妊娠减胎后保留双胎者(B组)的临床结局。结果 (1)196例患者中MZT所占比率为44.39%(87/196)。MZT占比率在体外受精(IVF)组(0.85%)、卵胞质内单精子显微注射(ICSI)组(0.66%)、冻融胚胎移植(FET)组(0.78%)和人工授精(AIH/AID)组(0.16%)间比较差异有统计学意义(P=0.001);在辅助孵化(AH)组(1.48%)和无AH组(0.44%)间比较差异亦有统计学意义(P=0.000)。MZT占比率在高龄(≥35岁)和非高龄患者中(P=0.330)及卵裂期胚胎移植组和囊胚期胚胎移植组组间(P=0.950)比较差异无统计学意义。(2)A组和B组患者的平均年龄、平均孕周、新生儿的平均胎龄、平均胎儿出生体质量、流产率、早期流产率、晚期流产率、早产率、足月产率、活产率、低出生体质量儿发生率、新生儿出生缺陷率和妊娠并发症率比较,差异均无统计学意义(P0.05)。结论 ART行多胎妊娠减胎术的患者中MZT所占几率很高,为减少MZT的发生,尽量选择单胚胎移植;A组和B组患者临床结局无统计学差异,单绒毛膜双胎中一胎减胎术可能是安全而可行的。     

射频消融选择性减胎术技术规范(2017)

<正>随着辅助生殖技术的发展,多胎妊娠的发生率逐年增高,其中单绒毛膜双胎(MC),因并发症发生率较高,越来越受到全世界学者的广泛关注。在单绒毛膜双胎妊娠中,早产、流产、胎儿发育异常及围产期死亡率均较高,其中胎儿结构发育异常的发生率是双绒毛膜双胎妊娠的3倍,是单胎妊娠的5倍~([1])。因此,为了改善此类胎儿的预后,采用血管阻断的选择性减胎术用于单绒毛膜双胎减     

对单绒毛膜双胎中异常胎儿行脐带双极电凝减胎术的研究

目的 探讨脐带双极电凝法对单绒毛膜双胎中异常胎儿进行选择性减胎术的临床应用价值.方法 选择2007年2-3月中山大学附属第一医院妇产科胎儿医学中心收治的3例一胎异常的单绒毛膜双胎孕妇,其中2例为双胎输血综合征,1例双胎之一为无心畸形,在超声和胎儿镜的引导下应用双极电凝法阻断异常胎儿的脐带血流,以减灭异常胎儿.术后超声连续监测存活胎儿的大脑中动脉和脐动脉的血流频谱,并随访其发育以及母-胎手术并发症.分娩时检查胎儿及胎盘.结果 3例孕妇分别在孕21、22和24周时,应用脐带双极电凝法成功阻断异常胎儿的脐带血流.已经分娩的两例中,1例在减胎术后7 d,死胎发生胎膜破裂,孕32周剖宫产娩出一健康男婴;另1例孕38周剖宫产娩出一健康男婴.2个新生儿1分钟和5分钟Apgar评分均为10分.两例孕妇产后经胎盘病理检查确认为单绒毛膜双胎,死胎脐带可见明显的电凝痕迹.例3目前孕35周,随访结果正常.结论 脐带双极电凝减胎术是适用于单绒毛膜双胎的有效减胎手段,有助于改善正常胎儿的妊娠结局.     

九例射频消融选择性减胎术的疗效及观察

目的: 探讨射频消融减胎术（radio frequency ablation,RFA）对复杂性多胎妊娠的疗效。方法: 回顾性分析2017年4月—2019年5月在武汉大学人民医院行RFA治疗的9例患者的临床资料,总结其临床疗效,包括流产、早产、足月产、活产、分娩方式和新生儿体质量等。结果: 9例患者中有2例是双绒毛膜三羊膜囊妊娠,有5例为单绒毛膜双羊膜囊双胎之一胎儿畸形行减胎术,1例为双胎输血综合征（twin-twin transfusion syndrome,TTTS）Ⅲ期减胎,1例为双胎之一选择性胎儿生长受限（selective fetal growth restriction,sFGR）Ⅱ型行选择性减胎术。9例患者均一次性RFA成功,手术成功率100%,均无手术并发症,仅1例于减胎术后2周流产,其余均获得活产。结论: RFA对复杂性多胎妊娠是一种安全有效且损伤小的宫内治疗方式,在临床上应该根据绒毛膜性及患者的意愿选择合适的减胎方式。     

多胎妊娠孕中期行选择性减胎术13例临床分析

<正>多胎妊娠胎儿异常发生率、母体并发症发生率明显高于单胎妊娠,且妊娠预后往往很差。为改善多胎妊娠的预后和结局,近年多胎妊娠减胎术逐渐得到重视,开始用于妊娠的各个阶段。妊娠早期多胎妊娠减胎术国内外报道较多,妊娠中期的选     

复杂性双胎妊娠中射频消融减胎术的应用

复杂性双胎妊娠发生一胎胎死宫内时，由于胎儿间存在大量的交通血管，可能导致另一胎儿的急性失血、低血压休克和死亡，故部分单绒毛膜双羊膜囊并发症患者需行选择性减胎术，以降低存活胎儿的脑损伤风险。目前射频消融是应用较多的一种技术，本文介绍了射频消融减胎术的原理、手术过程及围手术期处理和手术并发症，并与其他常见减胎手段进行比较。     

Impact of fetal sex in pregnancy-induced hypertension and preeclampsia in Japan

The male antigen (HY), the elevated level of fetal antigen in twin pregnancies, and the increased number of MHC mismatches in dizygotic twin pregnancies might affect immunological tolerance during pregnancy. Using the Perinatal Database of the Japanese Society for Obstetrics and Gynecology, we studied the occurrence of pregnancy-induced hypertension (PIH) and preeclampsia in mothers delivering singleton babies and in those delivering monochorionic diamniotic (MD) twin pregnancies and dichorionic diamniotic (DD) twin pregnancies at 125 centers of the perinatal network in Japan from 2001 through 2005. In singleton pregnancies, pregnant women carrying female fetuses had a significantly higher incidence of PIH and preeclampsia compared with those carrying male fetuses. In MD twin pregnancies, compared with mothers carrying male-male fetuses, those carrying female-female fetuses had significantly higher incidences of PIH and preeclampsia and a marked difference was observed in primiparous cases. In DD twin pregnancies, the incidences of PIH and preeclampsia were significantly higher in mothers with female-female fetuses than those with male-male fetuses, while those with male-female fetuses had intermediate values. The incidence of PIH and preeclampsia in MD twin pregnancies was similar to that in DD twin pregnancies with male-male fetuses or female-female fetuses. The male antigen and the increased number of MHC mismatches in DD twin pregnancies were not a risk factor for PIH and preeclampsia. Female fetal sex was a risk factor for PIH and preeclampsia.     

Scanning for chorionicity: comparison between sonographers and perinatologists

OBJECTIVE: In most prenatal settings, twin pregnancies are initially evaluated by sonographers. Pregnancies diagnosed as monochorionic are subsequently referred to perinatologists or specialists in fetal medicine for the confirmation of chorionicity. In order to assess this screening strategy, we have compared the diagnosis of chorionicity made by the sonographers in the ultrasound department with the diagnosis done in the fetal medicine unit. METHODS: A cohort of women presenting with twin pregnancy and booked for prenatal care at University College London Hospitals over a 4-year period were investigated prospectively. All women were scanned at their initial visit at 11-14 weeks in the ultrasound department (US), and were subsequently referred to the Fetal Medicine Unit (FMU) for a second ultrasound evaluation. Ultrasound data were compared and diagnosis of chorionicity was confirmed by examination of the inter-twin membranes after delivery. RESULTS: Chorionicity was determined in 172 twin cases by the two different departments. The overall rate of concordant chorionicity determination between both units was 90.1%. The rate of discordant results in dichorionic pregnancies was extremely small, 1 in 119 pregnancies (0.8%). The rate of discordant results for monochorionic diamniotic pregnancies was 5.5%. Monoamniotic pregnancies were over-diagnosed by the US technicians. DISCUSSION: These results demonstrate that DC/DA chorionicity is accurately determined by sonographers at less than 14 weeks. In our opinion, it is both efficient and safe to rely on the diagnosis of the sonographers in DC/DA pregnancies in early pregnancy. In such pregnancies, a decision can be made either not to refer these patients for further evaluation of chorionicity by the fetal medicine team or to postpone the referral to after 14 weeks.     

Monochorionic high-order multiple pregnancies and multifetal pregnancy reduction

OBJECTIVE: To study the frequency and obstetric outcome of monochorionic multiple pregnancies in a population referred for fetal reduction. METHODS: Data charts of all patients with multifetal (> or =3) pregnancies referred for fetal reduction over the last 10 years were reviewed for the presence of monochorionic twin pairs or triplets. RESULTS: Twenty-nine of 239 high-order multiple pregnancies contained a monochorionic component (12.1%), eight of which were monochorionic triplets. Half of all naturally conceived pregnancies contained a monochorionic component. High-order multiple pregnancies with a monochorionic component resulted significantly more frequently from natural conceptions (7 of 29) than multichorionic pregnancies (7 of 210) (P =.001). Fetal reduction of the monochorionic twin pair in 21 pregnancies resulted in eight twin and 13 singleton pregnancies; mean gestational age at delivery was, respectively, 34.3 +/- 2.9 and 39.2 +/- 1.4 weeks. Pregnancy loss rate was one of 21 (4.8%). In the remaining eight multiple pregnancies with a monochorionic triplet present, three were complicated by a twin reversed arterial perfusion sequence, and two couples requested a first trimester termination of pregnancy. Fetal reduction of the monochorionic triplet in a dichorionic quadruplet pregnancy resulted in a normal pregnancy outcome. In two monochorionic triplet pregnancies, fetal reduction to monochorionic twin pregnancies with bipolar coagulation of the umbilical cord resulted in a favorable pregnancy outcome. CONCLUSION: Monochorionic twins or triplets are frequently part of naturally conceived high-order multiple pregnancies. Reduction of the monochorionic twin pairs improves pregnancy outcome. Monochorionic triplet pregnancies show a high complication rate, but may benefit from fetal reduction by cord coagulation.     

Multifetal pregnancy reduction of triplet and higher-order multiple pregnancies to twins

This systematic review was performed to assess the effects of multifetal pregnancy reduction for women with triplet and higher-order multiple pregnancies on fetal loss, preterm birth, and perinatal and infant mortality and morbidity. From nonrandomized studies, multifetal pregnancy reduction seems to be an effective treatment option, with outcomes comparable to those obtained from twin pregnancies conceived spontaneously or after assisted reproductive techniques.     

双胎输血综合征的预测和诊治进展

双胎输血综合征（twin-twin transfusion syndrome,TTTS）是单绒毛膜双胎妊娠的严重并发症,目前仍然是全球胎儿医学专家面临的主要挑战。在TTTS中,通过共享胎盘中的血管吻合支进行双胎输血会引起严重的血液动力学失衡,是导致围生儿死亡的主要原因。所有单绒毛膜双胎中约有10%~15%会发展成TTTS,通常发生在妊娠的第16周至第26周之间,其严重程度取决于胎盘内血管吻合支的类型、数量和直径。产前管理的进步使胎儿围生期、生存期延长,新生儿并发症（包括脑损伤和神经发育障碍）的发生率降低。因此,早期发现,严密监测,选择合适的治疗方法,尽量延长孕周,选择合适的时机终止妊娠,是降低单绒毛膜双胎围生儿死亡的关键。对TTTS的发病机制、预测、诊断和治疗进行综合分析,同时对激光治疗后存活胎儿远期神经系统损伤问题进行总结。     

Obstetric complications of twin pregnancies

Advances in assisted reproductive technology and increases in the proportion of maternities in older women have both contributed to the steep increase in the incidence of twin pregnancies since the 1980s. Maternal and perinatal complications are higher in twins than in singleton pregnancies. A significant proportion of perinatal mortality and morbidity among twins is due to the high incidence of preterm delivery and the added complication of twin-to-twin transfusion syndrome (TTTS) in monochorionic twins. Monochorionic twins also have a much higher rate of perinatal mortality than dichorionic twins, the greatest risk being before fetal viability (<24 weeks gestation). Early diagnosis of twins and their chorionicity, close fetal surveillance, particularly of monochorionic twins, and prompt therapeutic intervention in TTS are necessary to reduce perinatal mortality. Intrapartum management in the hospital setting with anaesthetic and neonatal facilities, as well as critical assessment of mode of delivery, have led to better outcomes. Ultrasonography is a valuable tool in the management of twin pregnancy. This chapter briefly summarises these topics, with a particular focus on recent literature.     

辅助生殖技术受孕单绒毛膜双羊膜囊双胎妊娠特殊并发症的分析

目的:探讨辅助生殖技术(ART)受孕单绒毛膜双羊膜囊(MCDA)双胎妊娠特殊并发症及胎儿的结构异常发生情况。方法:回顾性分析2010.06~2013.09期间由ART受孕在本院产检及分娩的44例MCDA双胎妊娠患者的临床资料(ART受孕组),分析MCDA双胎的特殊并发症及胎儿结构异常,并与同期的自然受孕的MCDA双胎组(自然受孕组,n=360)进行比较。结果:ART受孕组母体平均年龄及BMI均较自然受孕组明显增高(P0.01),组间初产妇比例无统计学差异(P0.05)。MCDA双胎妊娠中双胎输血综合征(TTTS)81例,占20.0%;选择性宫内生长受限(sIUGR)47例,占11.6%,双胎反向动脉灌注序列(TRAPS)10例,占2.5%;胎儿结构异常25例,占6.2%。ART受孕组与自然受孕组MCDA双胎特殊并发症及胎儿结构异常的发生风险无统计学差异(P0.05)。结论:ART受孕对MCDA双胎妊娠特殊并发症及胎儿结构异常的发生无明显影响。     

单绒毛膜单羊膜囊双胎脐带打结二例

单绒毛膜单羊膜囊（monochorionic monoamnionic,MCMA）单卵双胎是双胎妊娠中极罕见的一种类型,为极高危的双胎妊娠。由于两胎儿共用一个羊膜腔,两胎儿之间无胎膜分隔,因脐带缠绕和打结而发生宫内意外的可能性较大。对于双胎妊娠的孕妇应尽早明确其绒毛膜性质,一旦诊断为MCMA双胎,应提高警惕,在指南推荐的妊娠周数及时终止妊娠,改善母儿结局。回顾性报道山西省妇幼保健院2例MCMA双胎妊娠脐带形成真结并成功分娩的病例,以提高产科医师对早期诊断并分辨双胎绒毛膜性的意识,当诊断为MCMA双胎时,要特别关注脐带形态学及结构学上的异常,并加强对MCMA双胎妊娠孕妇的产前管理。     

Perinatal outcome and neurological follow up of the cotwins in twin pregnancies complicated by single intrauterine death

Objective

To review the outcome of twin pregnancies complicated by single fetal intrauterine death (IUD) managed at our Centre and to evaluate the neurological follow up of the surviving cotwins.

Study design

Twenty-three twin pregnancies (10 dichorionic and 13 monochorionic diamniotic) complicated by IUD in the II or III trimester were seen at our Centre during the study period (2001–2006). All patients were managed conservatively unless non-reassuring signs of fetal well-being were present at ultrasound examination or CTG after 28 weeks, suggesting immediate delivery. Serial scans after the diagnosis of single death were performed and, in addition, eight monochorionic twin pregnancies underwent prenatal MRI in order to identify the presence of cerebral lesions in the survivors. Live born surviving cotwins underwent neurological follow up.

Results

In the monochorionic group one cotwin died in utero and one in the neonatal period with a perinatal survival rate of 83.4% (10/12) (excluding one case who opted for termination of pregnancy); in the dichorionic group perinatal survival rate was 100%. In all monochorionic cases there were no signs of ischemic brain lesions in the surviving cotwins at the diagnosis of single death and during ultrasonographic follow up. In monochorionic pregnancies prenatal MRI, when performed, was negative for signs of brain damage in the surviving cotwins. Gestational age at delivery was not statistically different between monochorionic and dichorionic pregnancies (36 (range, 28.4–40.2) vs. 34.6 (range, 28.2–41.3) weeks) (p = 0.6) and the rate of early preterm delivery before 32 weeks was 23.8% (5/21) and independent from chorionicity (18.2% vs. 30%, p = 0.5). Neurodevelopmental follow up was available for 18/20 live born survivors (85%) and was normal in all but one twin; this case was born from a dichorionic pregnancy with a suspicion of congenital infection.

Conclusions

Our data confirmed a trend to a higher risk of perinatal mortality of cotwins in monochorionic twin pregnancies compared to dichorionic ones. In our experience prenatal ultrasound and MRI were useful to exclude cerebral lesions in utero and subsequent neurological sequelae in surviving monochorionic cotwins, even if definitive conclusions, especially on MRI, are limited by the small number of cases in our study.