摘要
目的探讨选择性胎儿镜激光凝固胎盘吻合血管(fetoscopic laser occlusion of chorioangiopagous vessels,FLOC)手术与Solomon手术治疗双胎输血综合征(twin-to-twin transfusion syndrome,TTTS)术后胎盘残留吻合血管的差异,及其对术后并发症及胎儿存活率的影响。方法回顾性纳入2018年5月至2020年3月在郑州大学第三附属医院进行FLOC手术的TTTS孕妇59例,按照FLOC手术方式分为Solomon组(33例)和选择性FLOC组(26例)。对其中25例双胎均活产的孕妇的胎盘(Solomon组15个,选择性FLOC组10个)进行灌注,观察残留吻合血管类型及直径。比较2组间胎儿存活率、并发症、胎盘残留吻合血管类型及直径的差异,采用两独立样本t检验、Mann-Whitney U检验及χ^(2)检验或Fisher精确概率法进行统计分析。结果(1)Solomon组手术时间短于选择性FLOC组[74 min(60~90 min)与95 min(81~123 min),Z=2.906,P=0.004],但2组手术时孕周、妊娠终止孕周、手术至妊娠终止间隔时间差异均无统计学意义(P值均>0.05)。(2)Solomon组与选择性FLOC组相比,双胎存活率、一胎存活率、至少一胎存活率及术后双胎贫血-多血质序列征(twin anemia-polycythemia sequence,TAPS)和复发性TTTS的发生率差异均无统计学意义[64%(21/33)与50%(13/26),χ^(2)=1.107;15%(5/33)与35%(9/26),χ^(2)=3.044;79%(26/33)与85%(22/26),χ^(2)=0.326;3%(1/33)与12%(3/26),χ^(2)=1.368;0%(0/33)与4%(1/26),χ^(2)=1.118;P值均>0.05]。(3)胎盘灌注结果:Solomon组与选择性FLOC组相比,残留吻合血管的胎盘的比例以及残留动脉-静脉、静脉-动脉、动脉-动脉和静脉-静脉吻合血管的比例差异均无统计学意义(7/15与6/10,2/8与4/15、3/8与4/15、2/8与5/15、1/8与2/15;Fisher精确概率法,P值均>0.05),但Solomon组残留吻合血管直径小于选择性FLOC组[(0.8±0.3)与(2.2±0.7)mm,t=0.764,P=0.034]。(4)术后4例发生TAPS的孕妇中,1例孕妇胎盘残留2条动脉-静脉吻合,吻合直径分别为0.54 mm和0.43 mm;1例孕妇胎盘残留1条动脉-静脉吻合,吻合直径为0.64 mm;1例孕妇胎盘残留1条动脉-动脉吻合及1条静脉-静脉吻合,吻合直径分别为1.56 mm和1.89 mm。结论与选择性FLOC手术相比,Solomon手术可使TTTS孕妇胎盘残留吻合血管直径减小,但并没有减少术后并发症,也没有改善妊娠结局。
Objective To explore the influence of selective fetoscopic laser occlusion of chorioangiopagous vessels(FLOC)versus Solomon surgery in the management of twin-to-twin transfusion syndrome(TTTS)on procedure-related complications,fetal survival rate,and residual anastomoses.Methods A total of 59 pregnant women with TTTS who underwent FLOC in the Third Affiliated Hospital of Zhengzhou University from May 2018 to March 2020 were retrospectively enrolled and divided into Solomon(n=33)and selective FLOC groups(n=26)based on the FLOC operation method.Placentae of 25 pregnant women(15 in the Solomon group,10 in the selective FLOC group)with both survival twins were perfused to observe the type and diameter of the residual anastomoses.Fetal survival rate,procedure-related complications,and the type and diameter of residual anastomoses were analyzed and compared between the two groups using two independent samples t-test,Mann-Whitney U test,χ^(2) test and Fisher's exact test.Results(1)The operating time of Solomon was shorter than that of selective FLOC[74 min(60-90 min)vs 95 min(81-123 min),Z=2.906,P=0.004].But no statistically significant differences in the gestational week at operation,time of pregnancy end,and the interval between operation and pregnancy end was observed between the two groups(all P>0.05).(2)There was no statistically significant difference in the survival rate of both twins,one fetus,at least one fetus,and the incidence of postoperative twin anemia-polycythemia sequence(TAPS)and recurrent TTTS in the Solomon group and selective FLOC group[64%(21/33)vs 50%(13/26),χ^(2)=1.107;15%(5/33)vs 35%(9/26),χ^(2)=3.044;79%(26/33)vs 85%(22/26),χ^(2)=0.326;3%(1/33)vs 12%(3/26),χ^(2)=1.368;0%(0/33)vs 4%(1/26),χ^(2)=1.118;all P>0.05].(3)There was no statistically significant difference in the number of placentae with residual anastomoses or the number of artery-to-vein,vein-to-artery,artery-to-artery,and vein-to-vein anastomoses between the two groups(7/15 vs 6/10,2/8 vs 4/15,3/8 vs 4/15,2/8 vs 5/15,1/8 vs 2/15;Fisher's exact test,all P>0.05),but the diameter of the residual anastomoses in the Solomon group was smaller than that in the selective FLOC group[(0.8±0.3)and(2.2±0.7)mm,t=0.764,P=0.034].(4)Among the four pregnant women developed TAPS after operation,one patient had two residual artery-to-vein anastomoses in the placenta with diameter of 0.54 mm and 0.43 mm,respectively;one patient had one artery-to-vein anastomosis with a diameter of 0.64 mm;one had one artery-to-artery and one vein-to-vein anastomosis with diameter of 1.56 mm and 1.89 mm,respectively.Conclusions Compared with selective FLOC,Solomon surgery can reduce the vessel diameter of residual anastomoses in women with TTTS,but does not reduce postoperative complications,nor improve the pregnancy outcomes.
作者
冯硕
许雅娟
尹盼
朱特选
程春花
董理
李根霞
Feng Shuo;Xu Yajuan;Yin Pan;Zhu Texuan;Cheng Chunhua;Dong Li;Li Genxia(Department of Obstetrics,Third Affiliated Hospital of Zhengzhou University,Zhengzhou 450000,China)
出处
《中华围产医学杂志》
CAS
CSCD
北大核心
2021年第4期261-266,共6页
Chinese Journal of Perinatal Medicine
基金
河南省医学科技攻关计划联合共建项目(2018020184)。
关键词
双胎输血综合征
胎儿镜检查
激光凝固术
胎盘
选择性外科手术
存活率
Twin-to-twin transfusion syndrome
Fetoscopy
Laser coagulation
Placenta
Elective surgical procedures
Survival rate
