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中国循证儿科杂志

中国循证儿科杂志 ›› 2017, Vol. 12 ›› Issue (4): 241-245.

• 论著 •    下一篇

双胎输血综合征胎儿和生后2天脑损伤的队列研究

唐英，罗红，母得志，杨太珠，朱琦，鲍珊   

  1. 四川大学华西第二医院超声科 四川成都，610041
  • 收稿日期:2017-07-21 修回日期:2017-08-21 出版日期:2017-08-25 发布日期:2017-08-25
  • 通讯作者: 罗红

A cohort study on the brain injury of the fetus and the newborn 2 days after birth with twin-twin transfusion syndrome

TANG Ying, LUO Hong, MU De-zhi, YANG Tai-zhu, ZHU Qi, BAO Shan   

  1. Ultrasonography Department, West China Second University Hospital, Chengdu 610041, China
  • Received:2017-07-21 Revised:2017-08-21 Online:2017-08-25 Published:2017-08-25
  • Contact: LUO Hong

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摘要：

目的：验证双胎输血综合征（TTTS）新生儿脑损伤起源于宫内还是宫外。方法：前瞻性队列研究设计，在同一医院以超声作为TTTS、颅内出血和脑室周围白质软化的诊断工具，纳入孕34周前分娩的接受双胎儿颅脑超声和生后2 d内新生儿颅脑超声检查的TTTS孕妇。排除双胎儿均宫内死亡和双胎之一严重结构异常或染色体异常。结果：47例TTTS孕妇的94例胎儿进入本文分析，孕妇中位年龄31 (18~46) 岁，TTTS诊断孕周16~28周，终止妊娠孕周28~33+5 周。QuinteroⅠ、Ⅱ、Ⅲ、Ⅳ和Ⅴ期分别为7、9、17、8和6例。Ⅴ期6例胎儿期死亡,6例存活胎儿均发生颅内出血合并脑白质软化。88例胎儿超声发现19例脑损伤（21.6%），受血儿5例，供血儿14例，受血儿26.3% vs 供血儿 73.6%，差异有统计学意义（P＜0.05）。TTTS的Ⅲ~Ⅴ级脑损伤17例，Ⅰ~Ⅱ级2例，Ⅲ~Ⅴ级30.3% vs Ⅰ~Ⅱ6.2%，差异有统计学意义（P＜0.05）。孕19~28周接受羊水减量术治疗13/47例（27.7%），均未在治疗后新发现脑损伤。88例均为早产儿，胎龄（30.5±4.5）周。受血儿体重（1 607±438）g，供血儿体重（1 257±403）g，生后24 h因新生儿窒息死亡4例。84例早产儿中头颅超声发现24例脑损伤（28.6%），受血儿9例，供血儿15例，受血儿37.5% vs供血儿 62.5%，差异有统计学意义（P＜0.05）。颅内出血Ⅰ级5例，均为生后诊断且不合并脑白质软化。颅内出血Ⅱ级中，胎儿阶段11例，新生儿阶段增加了4例颅内出血Ⅱ级，其中1例合并脑白质软化，3例转为颅内出血Ⅲ级伴脑白质软化，无死亡。颅内出血Ⅲ级中，胎儿阶段5例均合并脑白质软化，新生儿阶段5例，3例由颅内出血Ⅱ级进展，死亡1例。颅内出血Ⅳ级中，胎儿阶段3例均合并脑白质软化，新生儿阶段2例均由颅内出血Ⅲ级进展，均死亡。结论：TTTS胎儿产前脑受损已出现，与早产共同造成脑损伤，以脑室出血、脑室白质软化为多见。对于所有存活儿都应该进行产前规范的超声监测及生后及时的新生儿头颅超声筛查。

Abstract:

Objective: To verify the source of brain injury in premature infants with twin-twin transfusion syndrome (TTTS) from fetal period or postnatal factors. Methods: A prospective cohort study with TTTS twins was performed whose mothers received fetal ultrasound before the delivery at 34 weeks, and postnatal brain ultrasound was performed within 2 d at the same hospital by ultrasound to diagnose intracranial hemorrhage and(PIVH) cystic periventricular leukomalacia (PVL). The brain injury was scored on fetal and postnatal ultrasounds. The pregnant women with twins died and chromosomal abnormality of one of the twins were excluded.Results: A total of 94 fetuses of the 47 pregnant women with TTTS were analyzed in the study. The median age of the pregnant women was 31 (18-46) years old, and the TTTS were diagnosed between 16 and 28 weeks of gestational age, and the gestational age of 28 ~ 33 + 5 weeks was terminated. 7, 9, 17, 8 and 6 cases were in Quintero Ⅰ, Ⅱ, Ⅲ, Ⅳ and Ⅴ periods respectively, in stage Ⅴ 6 cases of fetal death happened, the partners of 6 cases occurred PIVH and PVL. In all, 19/88 (21.6%) fetuses had brain injury seen on fetal ultrasound, 5 recipients, 14 donors(26.3% vs 73.6 %, P＜ 0.05). 17 fetuses were with Quintero Ⅲ, Ⅳand Ⅴ brain injury and 2 fetuses with Quintero Ⅰ,Ⅱbrain injury (30.3% vs 6.2 %, P＜0.05). Twins of 13/47 cases(27.7%) were not found new patients with brain injury after the treatment of amniotic fluid reduction at 19 ~ 28 weeks of gestation. The gestational age of all 88 cases was (30.5± 4.5) weeks. Recipients weight was (1 607±438) g, donors (1 257±403) g, 4 cases died caused by neonatal asphyxia. In all, 24/84 infants (28.6%) had brain injury seen on postnatal ultrasound. 9 recipients, 15 donors were found (37.5% vs 62.5 %, P＜0.05). There were 5 cases with PIVH Ⅰ, all of them were diagnosed without PVL. PIVH Ⅱ, 11 cases involved fetal stage, and in neonatal stage 4 cases were increased ,including 1 case with PVL. 3 cases developed to PIVH Ⅲ with soften cerebral white matter, no death case. During PIVH Ⅲ, 5 cases in fetal stage were combined with PVL, there were 5 cases at neonatal stage, 3 cases developed from PIVH Ⅱ , and 1 case died. All of the 3 fetuses involved PIVH Ⅳ were with PVL, and 2 cases in neonatal stage were caused by PVIH Ⅲ with PVL, and died.Conclusion: The risk of cerebral injury and neurologic morbidity increased in fetuses and infants TTTS. Severe cerebral lesions detected in TTTS included cystic periventricular leukomalacia (PVL), severe intraventricular hemorrhage (IVH). In view of the increased risk of cerebral injury, cranial ultrasound scans should be performed routinely in all TTTS survivors at birth.