【摘要】：研究目的 近年來,雙胎妊娠發(fā)生率明顯上升。據(jù)統(tǒng)計(jì),其中約1/4為單絨毛膜雙胎,3/4為雙絨毛膜雙胎。而由于胎盤表面廣泛血管吻合支的存在,從而導(dǎo)致包括雙胎輸血綜合征(TTTS)、選擇性宮內(nèi)生長受限(sIUGR)、雙胎反向動脈灌注序列征(TRAPS)、雙胎貧血-多血序列征(TAPS)、雙胎之一宮內(nèi)死亡等并發(fā)癥的發(fā)生,使得單絨毛膜雙胎的母兒不良結(jié)局發(fā)生率增加。對于TTTS,國內(nèi)外做了大量研究,胎盤間的動脈-靜脈吻合支及胎盤份額不均等被認(rèn)為是發(fā)病的重要原因,且動脈-靜脈吻合支為主要原因；但是近年有研究發(fā)現(xiàn),在sIUGR及正常MC雙胎等非TTTS中有更為復(fù)雜的血管吻合關(guān)系,這一點(diǎn)可能在胎盤份額不均等的雙胎胎兒宮內(nèi)生長發(fā)育過程中對較小胎盤的胎兒起到保護(hù)作用,延緩了雙胎生長發(fā)育不一致的進(jìn)展。本文通過對非TTTS單絨毛膜雙胎的胎盤血管進(jìn)行灌注,并對既往相關(guān)研究進(jìn)行回顧,以了解非TTTS單絨毛膜雙胎的胎盤特點(diǎn)(包括胎盤份額差異、臍帶插入位置、臍帶血管數(shù)量、血管吻合支數(shù)量及直徑等),驗(yàn)證其對胎兒生長發(fā)育產(chǎn)生的影響,幫助理解這些常見并發(fā)癥的發(fā)病機(jī)制以及臨床表現(xiàn)。 研究方法 選擇研究對象為自2013年7月至2014年2月期間,于山東省立醫(yī)院產(chǎn)科分娩的單絨毛膜雙胎病例,其中需要排除的為確診為TTTS以及雙絨毛膜雙胎妊娠的病例。對其胎盤以有色染料灌注后拍攝平面圖片,并對胎盤份額、臍帶附著方式、血管吻合支的數(shù)量、來源以及分娩孕周、產(chǎn)前B型超聲結(jié)果、新生兒出生體重、新生兒Apgar評分等數(shù)據(jù)進(jìn)行記錄和分析。 研究結(jié)果 灌注成功的樣本共有11例。 11個樣本中雙胎間胎盤份額差異平均為32.73%±20.22%；胎盤份額差異≥20%共7例(63.64%)。 在11個胎盤的22個附著點(diǎn)中,臍帶中央型附著為12個(54.55%),球拍狀胎盤(邊緣型)為3個(13.64%),帆狀胎盤的為7個(31.82%)；其中兩個中央附著的2例(18.18%),一個中央附著一個非中央附著的8例(72.73%),兩個非中央附著的1例(9.09%)。 可觀察到明顯的動脈-動脈(A-A)吻合支的為9例(81.82%),平均直徑為0.16cm±0.11。 新生兒出生體重差異與胎盤份額差異之間存在顯著正相關(guān)關(guān)系,與動脈-動脈吻合支之間未發(fā)現(xiàn)明顯相關(guān)性；新生兒出生體重差異越大,帆狀胎盤發(fā)生率越高。 研究結(jié)論 通過胎盤灌注研究與文獻(xiàn)回顧表明,存在新生兒出生體重差異的單絨毛膜雙胎有其獨(dú)特的胎盤特點(diǎn),以胎盤份額不均等、高帆狀胎盤率為特征,研究中未發(fā)現(xiàn)血管吻合支與新生兒生長發(fā)育的明顯相關(guān)性。
[Abstract]:Objective to increase the incidence of twin pregnancy in recent years. According to statistics, about 1 / 4 of them are single chorionic twins and 3 / 4 are double chorionic twins. The presence of extensive vascular anastomoses on the surface of the placenta leads to (TTTS), selective intrauterine growth restriction, (sIUGR), reverse arterial perfusion sequence sign, (TRAPS), twin anemia and multiple blood sequence sign (TAPS), including twin transfusion syndrome. Complications such as intrauterine death increased the incidence of maternal and fetal adverse outcomes in single chorionic twins. A large number of studies have been done on TTTS, both at home and abroad. The arterio-venous anastomoses between placenta and the uneven placental share are considered to be the important causes of the disease, and the arterial-venous anastomosis branch is the main cause. However, recent studies have found that there are more complex vascular anastomoses in non-TTTS, such as sIUGR and normal MC twins, which may play a protective role in the intrauterine growth and development of twins with unequal placental shares. The growth and development of twin twins were delayed. Placental vessels were perfused in non TTTS single chorionic twins and previous studies were reviewed to understand the placental characteristics of non TTTS single chorionic twins (including placental share differences, umbilical cord insertion location, and the number of umbilical cord blood vessels). The number and diameter of vascular anastomoses were used to verify the effects of vascular anastomosis on fetal growth and development, and to help understand the pathogenesis and clinical manifestations of these common complications. Methods from July 2013 to February 2014, single chorionic twins delivered in the Department of Obstetrics of Shandong Provincial Hospital were selected as subjects, among which the cases diagnosed as TTTS and double chorionic twin pregnancy should be excluded. After the placenta was infused with colored dye, the placenta share, the way of umbilical cord attachment, the number of anastomotic branches, the origin of the placenta, the gestational weeks of delivery, the results of prenatal B-mode ultrasound, and the birth weight of the newborn were taken. Neonatal Apgar score and other data were recorded and analyzed. Results A total of 11 cases were successfully perfused. In 11 samples, the average difference of placental share was 32.73% 鹵20.22%, and the difference of placental share was 鈮，

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