【摘要】：目的探討射頻消融(Radiofrency ablation,RFA)選擇性減胎術治療復雜性單絨毛膜多胎妊娠的安全性及有效性,分析影響妊娠結局的因素。方法回顧性分析2011年7月22日至2017年3月16日在山東大學附屬省立醫(yī)院接受射頻消融選擇性減胎術治療且已分娩的復雜性單絨毛膜多胎妊娠病例的臨床資料。記錄孕婦年齡、孕次、受孕方式、減胎指征、手術時的孕周、穿刺情況、手術所需的循環(huán)數(shù)、母兒并發(fā)癥、分娩孕周、分娩方式、新生兒體重及隨訪保留胎兒生后生長發(fā)育等情況。保留胎兒存活率為接受射頻消融選擇性減胎患者中保留胎兒存活者所占的比例。分析影響妊娠結局的相關因素。采用卡方檢驗和Fisher確切概率法分析多個樣本率之間的差異,采用Kruskal-Wallis H秩和檢驗分析不符合方差分析條件的多組計量數(shù)據之間的差異。結果從2011年07月22日到2017年3月16日,共有71例復雜性多胎病例接受了RFA減胎治療。其中,含單絨毛膜雙胎的三胎及以上妊娠要求減少胎兒數(shù)量者20例(28.2%),單絨毛膜雙胎一胎兒畸形者21例(29.6%),單絨雙胎妊娠出現(xiàn)雙胎輸血綜合征(twin to twin transfusion syndrome,TTTS)20例(28.1%),嚴重的選擇性宮內生長受限(selective intrauterine growth restriction,sIUGR)7例(9.9%),雙胎反向動脈灌注序列征(twin reversed arterial perfusion sequence,TRAP)3例(4.2%)。平均手術孕周為(20.4±3.5)周(14.7～27.7周)。穿刺成功率100%(71/71)。57例1個循環(huán)即完全阻斷血流,11例需2個循環(huán),3例需3個循環(huán)。所有手術在技術上都是成功的。術后12例患者流產,其中9例于孕28周前發(fā)生胎膜早破流產(7例發(fā)生于術后2周內),1例患者術后5天因高熱、宮縮過頻流產,2例患者因宮縮難以抑制流產;5例不明原因胎死宮內(保留胎兒均于術后24小時內胎心消失);共17例患者保留胎兒死亡。54例患者其保留胎兒存活,保留胎兒存活率為76.1%。平均分娩孕周為(36.6±2.9)周(29.1～41.1周),新生兒平均出生體重(2633±601)g(1250～3750g),34周前早產率為20.4%(11/54),37周前早產率為40.7%(22/54)。術后隨訪未發(fā)現(xiàn)視網膜病變、顱內出血、壞死性小腸結腸炎及嚴重的神經系統(tǒng)后遺癥等。不同手術指征組間保留胎兒存活率、平均分娩孕周、新生兒平均體重、流產率、胎死宮內率及37周前早產率均無統(tǒng)計學差異,P值均0.05;34周前早產率之間的差異具有統(tǒng)計學意義,P值0.05,其中多胎妊娠減少胎兒數(shù)目組、TTTS組及TRAP組保留胎兒34周前早產率明顯高于單絨毛膜雙胎一胎兒畸形組及sIUGR組。手術時的孕周與妊娠結局間并無相關性。手術循環(huán)次數(shù)與保留胎兒存活率、平均分娩孕周、新生兒平均體重、流產率、34周前早產率、37周前早產率間無相關性,P值均0.05;但與胎死宮內率有相關性,P值0.05,隨著循環(huán)次數(shù)增加,胎死宮內率逐漸增高。結論射頻消融選擇性減胎術是治療復雜性單絨多胎妊娠的一種安全、有效的方法。手術指征會影響保留胎兒34周前早產率,循環(huán)次數(shù)會影響保留胎兒胎死宮內率。
[Abstract]:Objective To investigate the safety and efficacy of selective reduction of fetus with radiofrequency ablation (RFA) in the treatment of complicated multiple single chorionic pregnancy and analyze the factors influencing pregnancy outcome. The clinical data of complicated single chorionic multifetal pregnancies were recorded, including the age of the pregnant woman, the number of pregnancies, the gestational age, the mode of conception, the indication of reduction, the gestational age at the time of operation, the puncture, the number of cycles needed for the operation, the complications of mother and infant, the gestational age of delivery, the mode of delivery, the weight of the newborn and the postnatal growth and development of the fetus. Survival rate was the proportion of those who retained fetal survival in patients undergoing selective reduction by radiofrequency ablation. Factors affecting pregnancy outcome were analyzed. Differences between multiple sample rates were analyzed by Chi-square test and Fisher exact probability method. Kruskal-Wallis H-rank sum test was used to analyze multigroup measurements that did not meet the criteria for analysis of variance. Results From July 22, 2011 to March 16, 2017, a total of 71 cases of complicated multiple pregnancy received RFA treatment. Among them, 20 cases (28.2%) of triplets with single chorionic twins and above required fewer fetuses, 21 cases (29.6%) of single chorionic twins with one fetal malformation, and single chorionic twins with twin transfusion syndrome. Twenty patients (28.1%) had twin to twin transfusion syndrome (TTTS), seven patients (9.9%) had severe selective intrauterine growth restriction (sIUGR), and three patients (4.2%) had twin reversed arterial perfusion sequence (TRAP). The mean gestational age was (20.4 (+3.5) weeks (14.7-27.7 weeks). The success rate of puncture was 100% (71/71). 57 cases (71/71). One cycle was completely blocked, 11 cases needed two cycles, and 3 cycles. The average gestational age was (36.6 2.9) weeks (29.1 41.1 weeks), and the average birth weight was (2633 601) g (12.1) g (12. The preterm birth rate was 20.4% (11/54) before 34 weeks and 40.7% (22/54) before 37 weeks. No retinopathy, intracranial hemorrhage, necrotizing enterocolitis and severe neurological sequelae were found during the follow-up. Fetal survival rate, mean gestational age, average neonatal weight, abortion rate, fetal death in uterus were maintained among the groups with different surgical indications. There was no significant difference in the preterm birth rate and the preterm birth rate before 37 weeks, P value was 0.05; the difference between preterm birth rate before 34 weeks was statistically significant, P value was 0.05. The preterm birth rate before 34 weeks in the group of multiple pregnancy reduction, TTTS group and TRAP group was significantly higher than that in the group of single chorionic twin-one fetal malformation and sIUGR group. There was no correlation between the number of operation cycles and fetal survival rate, mean gestational weeks, average neonatal weight, abortion rate, preterm delivery rate before 34 weeks, preterm delivery rate before 37 weeks, P value was 0.05, but it was correlated with the intrauterine rate of fetal death, P value was 0.05, with the increase of circulation times, the intrauterine rate of fetal death gradually increased. Fetal reduction is a safe and effective method for the treatment of complicated single-cashmere multiple pregnancy. The indication of operation will affect the premature delivery rate before 34 weeks of fetal retention, and the number of cycles will affect the intrauterine fetal death rate.
【學位授予單位】：山東大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R714.23

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1 孫路明;周奮翮;鄒剛;楊穎俊;周艷;孫琦;段濤;;射頻消融減胎技術治療34例單絨毛膜性雙胎妊娠并發(fā)癥的妊娠結局[J];中華圍產醫(yī)學雜志;2014年06期

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