王歡
[摘要] 目的 研究分析雙胎妊娠絨毛膜性對母兒結(jié)局影響。方法 該研究方便選取連云港市婦幼保健院2015年1—12月住院分娩的雙胎孕婦167例及新生兒334例作為研究對象,結(jié)合雙胎絨毛性質(zhì)將其分為DCDA組與MCDA組,觀察各個孕婦并發(fā)癥及新生兒情況指標(biāo)。 結(jié)果 DCDA組分娩周數(shù)為(35.71±2.07)周,MCDA組分娩周數(shù)為(34.40±2.82)周,組間對比差異有統(tǒng)計學(xué)意義(t=4.710,P<0.05)。在胎膜早破、妊娠期高血壓以及產(chǎn)后出血并發(fā)癥對比方面,兩組雙胎孕婦比較差異無統(tǒng)計學(xué)意義(P>0.05)。MCDA組雙胎獨(dú)有并發(fā)癥即TTTS與TRAPS/TAPS,發(fā)生幾率29.59%、2.04%。MCDA組sIUFR發(fā)生幾率更高,早產(chǎn)較為嚴(yán)重,新生兒出生體重較輕,兩組比較差異有統(tǒng)計學(xué)意義(P<0.05)。在新生兒轉(zhuǎn)NICU、新生兒窒息、新生兒RDS、新生兒感染、先天性心臟病等并發(fā)癥比較方面,MCDA組發(fā)生幾率明顯高于DCDA組,兩組比較差異有統(tǒng)計學(xué)意義(P<0.05)。結(jié)論 通過孕早期絨毛膜性的診斷,可以制定個性化的孕期監(jiān)護(hù)干預(yù)措施,以減少母兒的不良預(yù)后。
[關(guān)鍵詞] 雙胎妊娠;絨毛膜性;孕期管理
[中圖分類號] R4 ? ? ? ? ?[文獻(xiàn)標(biāo)識碼] A ? ? ? ? ?[文章編號] 1674-0742(2020)10(a)-0039-03
The Effect of Chorionicity in Twin Pregnancy on Maternal and Infant Outcome
WANG Huan
Department of Obstetrics, Maternal and Child Health Hospital of Lianyungang, Lianyungang, Jiangsu Province, 222000 China
[Abstract] Objective To study and analyze the effect of chorionicity in twin pregnancy on maternal and infant outcomes. Methods In this study, convenient selected 167 twin pregnant women and 334 newborns who were hospitalized for delivery in Lianyungang Maternal and Child Health Hospital in January to December 2015 were used as the research objects. Combined with the nature of the villus of twins, they were divided into DCDA group and MCDA group, and each pregnant woman was observed of complications and neonatal condition indicators. Results The delivery weeks of the DCDA component were (35.71±2.07) weeks, and the delivery weeks of the MCDA component were (34.40±2.82) weeks. The differences between the two groups was statistically significant(t=4.710, P<0.05). In the comparison of premature rupture of membranes, hypertension during pregnancy, and complications of postpartum hemorrhage, the difference between the two groups of twin pregnant women was not statistically significant(P>0.05). The unique complications of twins in the MCDA group, namely TTTS and TRAPS/TAPS, occurred in 29.59% and 2.04%. The probability of sIUFR in the MCDA group was higher, preterm delivery was more serious, and the birth weight of the newborn was lighter. The difference between the two groups was statistically significant(P<0.05). In comparison of complications such as neonatal transfer to NICU, neonatal asphyxia, neonatal RDS, neonatal infection, and congenital heart disease, the incidence of MCDA group was significantly higher than that of DCDA group, and the the difference between the two groups was statistically significant(P<0.05). Conclusion Through the diagnosis of chorionicity in the first trimester, personalized pregnancy monitoring intervention measures can be formulated to reduce the adverse prognosis of mothers and children.
[Key words] Twin pregnancy; Chorionic; Management druing pregnancy
雙胎妊娠產(chǎn)婦受生殖科技水平及高齡、再婚育產(chǎn)婦的數(shù)量提升,其母兒并發(fā)癥率明顯高于單胎[1],如何通過孕期的監(jiān)護(hù)與處理來降低母兒不良預(yù)后,成為產(chǎn)科醫(yī)師關(guān)注的焦點(diǎn)。雙胎妊娠可以結(jié)合絨毛膜性將其分成雙絨毛膜雙羊膜囊雙胎(DCDA)、單絨毛膜雙羊膜囊雙胎(MCDA),而二者雙胎在臨床上較為多見。由于雙胎妊娠容易誘發(fā)早產(chǎn)、妊娠期高血壓、胎盤早破等并發(fā)癥狀。現(xiàn)如今,生殖技術(shù)手段不斷提升,也使雙胎妊娠發(fā)生幾率逐漸增多,造成雙胎早產(chǎn)發(fā)生幾率的增加。為了進(jìn)一步分析雙胎妊娠母兒接受早孕絨毛膜性診斷及孕期管理的影響,以該院2015年1—12月期間住院分娩的雙胎孕婦167例及新生兒334例作為研究對象,以期為臨床雙胎妊娠研究提供更多的參考依據(jù),現(xiàn)報道如下。
1 ?資料與方法
1.1 ?一般資料
該研究方便選取該院分娩的雙胎孕婦167例及新生兒334例作為研究對象,其中初產(chǎn)婦112例,經(jīng)產(chǎn)婦55例;分娩方式:132例剖宮產(chǎn),35例陰道分娩。結(jié)合雙胎絨毛性質(zhì)將其分為DCDA組(雙絨毛膜雙羊膜雙胎236例)與MCDA組(單絨毛膜雙羊膜雙胎98例),全部孕婦分娩孕周≥28周;孕前無并發(fā)癥;該次妊娠無減胎史。相關(guān)診斷按《婦產(chǎn)科學(xué)》第8版標(biāo)準(zhǔn)。全部孕婦均通過該院倫理委員會批準(zhǔn),孕婦與孕婦家屬知曉該次研究,并簽署《知情同意書》。
1.2 ?方法
人員與設(shè)備:人員選取獲得職業(yè)醫(yī)師資格,同時參加過雙胎妊娠產(chǎn)前超聲培訓(xùn)的超聲醫(yī)師擔(dān)任;超聲儀,具備圖像記錄和圖文報告管理系統(tǒng)[2]。①在孕6~9周期間,利用妊娠囊數(shù)目進(jìn)行診斷。在超聲的引導(dǎo)下,DC雙胎可見宮腔內(nèi)存有兩個分離GS。而MC雙胎可見一個GS中有含有兩個卵黃囊、胚芽[3-4]。②在孕10~14周期間,可以將雙胎間胎盤交界部位與羊膜形態(tài)作為診斷依據(jù)。在超聲的引導(dǎo)下,DC雙胎可見兩個胎盤,且胎盤獨(dú)立,如兩胎盤融合,可以在胎盤和胎膜隔融處見得三角形突起,此突起為“雙胎峰”或者“λ”征;對于MC雙胎可見一個胎盤,其中胎盤和胎膜呈“T”征或兩胎間無胎膜隔[5-6]。
1.3 ?統(tǒng)計方法
該次研究采用SPSS 19.0統(tǒng)計學(xué)軟件進(jìn)行數(shù)據(jù)分析,計量資料以(x±s)表示,行t檢驗(yàn);計數(shù)資料以頻數(shù)表示,行χ2檢驗(yàn),P<0.05為差異有統(tǒng)計學(xué)意義。
2 ?結(jié)果
2.1 ?兩組孕婦分娩周數(shù)與并發(fā)癥情況對比
DCDA組分娩周數(shù)為(35.71±2.07)周,MCDA組分娩周數(shù)為(34.40±2.82)周,組間對比差異有統(tǒng)計學(xué)意義(t=4.710,P<0.05)。在胎膜早破、妊娠期高血壓以及產(chǎn)后出血并發(fā)癥對比方面,兩組雙胎孕婦比較差異無統(tǒng)計學(xué)意義(P>0.05),見表1。
2.2 ?兩組胎兒及新生兒并發(fā)癥情況、出生體重對比
MCDA組雙胎獨(dú)有并發(fā)癥即TTTS與TRAPS/TAPS,發(fā)生幾率29.59%、2.04%。MCDA組sIUFR發(fā)生幾率更高,早產(chǎn)較為嚴(yán)重,新生兒出生體重較輕,兩組比較差異有統(tǒng)計學(xué)意義(P<0.05),即DCDA組新生兒出生體重(2 312.56±460.01)g,MCDA組新生兒出生體重(2 035.77±523.52)g,差異有統(tǒng)計學(xué)意義(t=4.804,P<0.05)。在新生兒轉(zhuǎn)NICU、新生兒窒息、新生兒RDS、新生兒感染、先天性心臟病等并發(fā)癥比較方面,MCDA組發(fā)生幾率明顯高于DCDA組,兩組比較差異有統(tǒng)計學(xué)意義(P<0.05),見表2。
3 ?討論
由于我國胎兒醫(yī)學(xué)才剛剛起步,屬于新型學(xué)科,我國缺少接受正規(guī)教育培訓(xùn)的胎兒醫(yī)學(xué)醫(yī)師,缺乏明確的診療規(guī)范程序[7]。①孕早期絨毛膜性的診斷是孕期規(guī)范標(biāo)準(zhǔn)的基礎(chǔ),應(yīng)按照高危妊娠進(jìn)行優(yōu)化,根據(jù)不同的絨毛膜性,制定個性化隨訪方案,及時處理并發(fā)癥,改善母兒結(jié)局。②雙胎妊娠與單胎相比有較高的并發(fā)癥率[8-9]。美國一項(xiàng)橫斷面研究顯示,孕早期確診的TTTS,頻繁超聲監(jiān)測[10],Ⅰ期TTTS超聲監(jiān)測供血胎兒膀胱,可預(yù)測胎兒預(yù)后[11]。③研究中,在雙胎輸血綜合征、選擇性胎兒生長受限、新生兒低于出生體重、窒息以及死亡發(fā)生幾率方面,不同絨毛膜性組間差異有統(tǒng)計學(xué)意義(P<0.05),說明圍產(chǎn)兒的不良預(yù)后與絨毛膜性相關(guān)。MC雙胎妊娠共用一個胎盤,兩個胎盤之間存在多種血管相吻合的現(xiàn)象,因此復(fù)雜性雙胎的發(fā)生幾率是DC雙胎的3.4%左右[12],TTTS及sIUGR是其嚴(yán)重的并發(fā)癥,流產(chǎn)率、早產(chǎn)率、圍產(chǎn)兒死亡率均易增加,局灶性腦損傷在TTTS中更為常見[13],Ⅱ型sIUGR小胎兒出現(xiàn)持續(xù)性舒張期血流缺失或倒置,更容易導(dǎo)致不良結(jié)局[14]。孕期并發(fā)癥及胎兒的異常,亦增加醫(yī)療干預(yù)及提前終止妊娠的幾率,而早產(chǎn)本身也增加新生兒的不良預(yù)后[15]。④建立規(guī)范化診療機(jī)制,其中以構(gòu)建專業(yè)的醫(yī)師團(tuán)隊為主導(dǎo),產(chǎn)科醫(yī)師與生化檢驗(yàn)、遺傳篩查、超聲影像、新生兒科室、兒外科室、兒童康復(fù)科室等醫(yī)師參與其中。⑤對醫(yī)學(xué)團(tuán)隊及下級醫(yī)院醫(yī)生進(jìn)行專業(yè)知識培訓(xùn)。⑥建立雙胎妊娠門診。⑦二級醫(yī)院一旦發(fā)現(xiàn)復(fù)雜性雙胎及MC雙胎,均應(yīng)轉(zhuǎn)診至三級醫(yī)院。該院雖為三級甲等婦幼保健院,但針對部分復(fù)雜性雙胎,仍需要將其轉(zhuǎn)診至有胎兒醫(yī)學(xué)專業(yè)的醫(yī)院,做好相應(yīng)的轉(zhuǎn)診工作。
該次研究結(jié)果表明,DCDA組分娩周數(shù)為(35.71±2.07)周,MCDA組分娩周數(shù)為(34.40±2.82)周,組間對比差異有統(tǒng)計學(xué)意義(P<0.05)。在胎膜早破、妊娠期高血壓以及產(chǎn)后出血并發(fā)癥對比方面,兩組雙胎孕婦比較差異無統(tǒng)計學(xué)意義(P>0.05)。MCDA組雙胎獨(dú)有并發(fā)癥即TTTS與TRAPS/TAPS,發(fā)生幾率29.59%、2.04%。MCDA組sIUFR發(fā)生幾率更高,早產(chǎn)較為嚴(yán)重,新生兒出生體重較輕(P<0.05)。在新生兒轉(zhuǎn)NICU、新生兒窒息、新生兒RDS、新生兒感染、先天性心臟病等并發(fā)癥比較方面,MCDA組發(fā)生幾率明顯高于DCDA組(P<0.05)。由此可見,通過運(yùn)用早孕期絨毛膜性診斷方法,可以根據(jù)患者實(shí)際狀況,為其制定針對性孕期監(jiān)護(hù)干預(yù)措施,以此改善母兒預(yù)后效果,降低并發(fā)癥發(fā)生幾率。該研究與李彥軍等人[16]研究結(jié)果相一致,均證實(shí)在兩組雙胎孕婦并發(fā)癥比較差異無統(tǒng)計學(xué)意義(P>0.05);另外,兩組分娩周數(shù)相比[(35.72±2.08)周vs(34.41±2.83)周],差異有統(tǒng)計學(xué)意義(P<0.05),說明該次研究具有一定的可行性。
綜上所述,通過孕早期絨毛膜性的診斷,可以制定個性化的孕期監(jiān)護(hù)干預(yù)措施,以減少母兒的不良預(yù)后,具有較高的臨床應(yīng)用價值。
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(收稿日期:2020-07-11)