早孕期超声筛查多胎胎儿巨膀胱的临床价值CSCD

目的探讨早孕期超声筛查多胎胎儿巨膀胱的图像特征及临床价值。方法对2011年1月至2016年4月在南京医科大学鼓楼临床医学院产前诊断中心受检的2159例多胎妊娠孕妇产前检查资料进行回顾性分析,于妊娠11~13+6周行早孕期超声筛查,并于胎儿正中矢状面测量膀胱长径,彩色多普勒显示双脐动脉,对检出的多胎巨膀胱胎儿,追踪妊娠过程及临床结局。结果早孕期超声筛查检出多胎之一巨膀胱胎儿6例,膀胱长径均大于7 mm,彩色多普勒均显示双脐动脉,其中双胎妊娠5例(为双胎之一胎儿巨膀胱),三胎妊娠1例(为三胎之一胎儿巨膀胱)。2例自然妊娠双胎之一巨膀胱胎儿均经引产终止妊娠,术后大体病理显示巨膀胱胎儿为梅干腹综合征。4例体外受精-胚胎移植多胎胎儿中,2例经早孕期选择性减胎术减去巨膀胱胎儿,其中1个正常胎儿足月活产,另一胎儿于孕32周超声显示双肾回声增强,行基因芯片检查,发现17 q12存在约1.5 Mb缺失;1例双胎妊娠孕妇未选择产前干预,其中巨膀胱胎儿死产,另一胎儿存活;1例双绒毛膜双羊膜囊三胎中单绒毛膜单羊膜囊双胎于孕13+2周自然胎死宫内,另一正常胎儿足月分娩。结论早孕期超声筛查可有效地检出及诊断多胎胎儿巨膀胱,重视多胎妊娠胎儿巨膀胱的早期产前诊断并及时干预,有助于产科处理并改善妊娠结局。     

早孕期超声筛查多胎胎儿巨膀胱的临床价值

目的探讨早孕期超声筛查多胎胎儿巨膀胱的图像特征及临床价值。方法对2011年1月至2016年4月在南京医科大学鼓楼临床医学院产前诊断中心受检的2159例多胎妊娠孕妇产前检查资料进行回顾性分析,于妊娠11~13+6周行早孕期超声筛查,并于胎儿正中矢状面测量膀胱长径,彩色多普勒显示双脐动脉,对检出的多胎巨膀胱胎儿,追踪妊娠过程及临床结局。结果早孕期超声筛查检出多胎之一巨膀胱胎儿6例,膀胱长径均大于7 mm,彩色多普勒均显示双脐动脉,其中双胎妊娠5例(为双胎之一胎儿巨膀胱),三胎妊娠1例(为三胎之一胎儿巨膀胱)。2例自然妊娠双胎之一巨膀胱胎儿均经引产终止妊娠,术后大体病理显示巨膀胱胎儿为梅干腹综合征。4例体外受精-胚胎移植多胎胎儿中,2例经早孕期选择性减胎术减去巨膀胱胎儿,其中1个正常胎儿足月活产,另一胎儿于孕32周超声显示双肾回声增强,行基因芯片检查,发现17 q12存在约1.5 Mb缺失;1例双胎妊娠孕妇未选择产前干预,其中巨膀胱胎儿死产,另一胎儿存活;1例双绒毛膜双羊膜囊三胎中单绒毛膜单羊膜囊双胎于孕13+2周自然胎死宫内,另一正常胎儿足月分娩。结论早孕期超声筛查可有效地检出及诊断多胎胎儿巨膀胱,重视多胎妊娠胎儿巨膀胱的早期产前诊断并及时干预,有助于产科处理并改善妊娠结局。     

不同绒毛膜性质三胎妊娠减一胎的临床结局

目的 分析不同绒毛膜性质三胎妊娠减灭一胎的有效性和可行性。方法 回顾性分析33例经辅助生殖技术治疗获三胎妊娠,且孕6～10周行经阴道减胎术患者,其中14例双绒毛膜三羊膜囊（dichorionic-triamniotic,DCTA）三胎妊娠为DCTA组,19例三绒毛膜三羊膜囊（trichorionic-triamniotic,TCTA）三胎妊娠为TCTA组。通过病例资料匹配选择同期获双绒毛膜双羊膜囊（dichorionic-diamniotic,DCDA）双胎妊娠且未行减胎术的患者60例作为DCDA组。比较三组患者的临床妊娠结局、妊娠期并发症和新生儿情况。结果 所有减胎患者术中均保留双胎,无减胎失败病例。减胎术后1 d,DCTA组有10例（71.4%）出现单绒毛膜双羊膜囊（monochorionic-diamniotic,MCDA）保留胎儿自然减灭,TCTA组无自然减胎,差异有统计学意义（P <0.05）。术后1周至孕晚期,三组自然减胎和自然流产的发生率差异均无统计学意义（P> 0.05）。DCTA组单胎活产率（75%）及平均分娩孕周[（38.3±2.2）周],均显著高于TC...     

早孕期超声筛查双胎妊娠的价值

目的 探讨超声在早孕期（孕11~13⁺⁶周）双胎妊娠筛查中的价值。方法 选取接受早孕期超声筛查的196名双胎孕妇,判断其绒毛膜性及羊膜性,测量胎儿头臀长及颈项透明层（NT）厚度,系统检查胎儿结构,检查胎儿是否存在结构畸形,并随访妊娠结局。结果 196名双胎孕妇中,双绒毛膜囊双羊膜囊（DCDA）双胎149名,单绒毛膜囊双羊膜囊（MCDA）双胎43名,单绒毛膜囊单羊膜囊（MCMA）双胎4名。超声筛查共发现36名孕妇存在异常胎儿,包括DCDA双胎30名,MCDA双胎4名,MCMA双胎2名。DCDA双胎中异常胎儿30胎,均为双胎之一异常,其中1胎为多发畸形（脊柱及双下肢发育异常）,1胎可见颈部水囊瘤,25胎停止发育,3胎NT增厚。MCDA共检出异常胎儿6胎,1胎双胎之一为无心畸胎;1胎双胎之一颈部水囊瘤形成;双胎中1胎胚胎停育,另1胎颈部水囊瘤形成;双胎均停止发育。MCMA双胎中,1胎双胎之一脑膜脑膨出,另2胎为胸腹连体双胎。结论 早孕期超声检查对于确定绒毛膜性和羊膜性双胎以及筛查胎儿严重结构畸形和双胎特有并发症具有重要临床意义。     

超声引导下孕中期选择性多胎妊娠减胎术23例分析

目的 探讨超声引导下孕中期选择性多胎妊娠减胎术的临床应用价值。方法 超声引导下对23例孕中期多胎妊娠进行选择性减胎术，其中多胎妊娠中异常胎儿减胎7例，要求减少胎儿数目16例。结果 对23例孕妇施行减胎术共26例次，一次减胎成功率96．2％（25／26），再次减胎矫正后成功率100％。共手术减灭胎儿25个（2例四胎妊娠同时减去2个胎儿）。23例全部分娩。其中〉36周分娩者12例，32-36周7例，28-32周2例，〈28周2例（流产）。在23例分娩的孕妇中20例获存活健康新生儿32名，妊娠成功率86．96％。结论 超声引导下孕中期选择性多胎妊娠减胎术是一种方法简单、定位准确、安全可靠、有效的微创操作技术，为多胎妊娠的管理提供了一个新的方法。     

含单绒毛膜双胎的三胎妊娠孕妇减胎术后妊娠结局分析

目的 比较含单绒毛膜双胎的三胎妊娠孕妇行单绒毛膜双胎1胎或2胎减灭术的临床结局,探讨多胎妊娠减胎术的效果。方法 含单绒毛膜双胎的三胎妊娠孕妇170例,均于孕7～9周行经阴道超声引导下胚胎抽吸术减胎。151例减灭单绒毛膜双胎中1胎,术后3 d复查超声提示双胎存活71例,80例单胎存活者均为单绒毛膜单胎;19例减灭单绒毛膜双胎2胎,术后3 d复查超声提示单绒毛膜单胎均存活。以双胎存活71例为双胎组,单胎存活99例为单胎组,比较2组年龄、体质量指数、孕次、术前流产次数等临床资料;比较2组孕期流产及活产情况,分娩孕周,妊娠期并发症发生率,足月产、极早产和早产率,新生儿体质量、NICU治疗率。结果 2组年龄、体质量指数、孕次、术前流产次数及减胎孕周比较差异均无统计学意义(P>0.05)。单胎组孕期流产5例(术后4周内流产1例),活产胎儿94个;双胎组孕期流产9例(术后4周内流产2例)、孕期自然减为单胎12例,活产胎儿112个。2组均无缺陷儿出生。单胎组分娩孕周、新生儿体质量[(38.74±1.84)周、(3.24±0.60)kg]均大于双胎组[(36.93±2.30)周、(2.52±0.4...     

多胎妊娠经阴道抽吸减胎术的临床结局分析

[目的]探讨多胎妊娠经减胎术的安全性、最佳的手术时机及临床妊娠的结局.[方法]选择经辅助生殖技术受孕及自然受孕的多胎妊娠行减胎术的患者150例,停经6～14周,采用抽吸法减胎,其中129例随访获知妊娠结局.[结果]减胎术后流产率13.2％ (17/129),早产41.9％ (54/129),足月产44.9％ (58/129);孕中期(12周后)减胎后的流产率显著高于孕早期(12周前)(P ＜0.05),但双胎之一宫内死亡率比较无显著差异(P＞0.05);减一胎者和减一胎以上者的流产率和双胎之一宫内死亡率比较无显著差异(P＞0.05).[结论]经阴道胚胎抽吸减胎术是一种安全、有效、操作简单的手术方法,但减胎术宜在孕早期进行.     

双胎之一胎死宫内34例的妊娠结局分析

目的探讨双胎妊娠一胎胎死宫内的病因、临床处理及影响妊娠结局的相关因素。方法回顾性分析2003年1月至2012年12月在中山大学孙逸仙纪念医院住院分娩的双胎妊娠一胎胎死宫内病例共34例。结果双胎之一胎死宫内的发生率为6.8%,34例中双绒毛膜双胎18例,单绒毛膜双胎9例(其中单羊膜腔双胎3例),绒毛膜性不详7例。一胎胎死宫内发生于早期妊娠8例,中期妊娠13例,晚期妊娠13例。共有24例进行期待治疗,期待治疗时间中位数为62.5(41~209)d,分娩孕周中位数为32.6(16.0~38.7)周。妊娠早期发生一胎胎死宫内组,在存活儿活产数、分娩孕周及出生体重方面均高于妊娠中、晚期组。双绒毛膜双胎发生一胎胎死宫内组,在存活儿活产数、分娩孕周及出生体重方面均高于单绒毛膜双胎组及绒毛膜性不详组。结论绒毛膜性、死胎发生的孕周及终止妊娠的孕周是影响妊娠结局的重要因素。加强母儿监测,进行适当的期待治疗,是改善妊娠结局的有效方式。     

单绒毛膜囊双胎妊娠的并发症及其超声诊断

近年双胎妊娠的发生率为1%～2%,有明显上升趋势;其中1/4是单绒毛膜囊双胎,约3/4是双绒毛膜囊双胎[1].双胎妊娠病死率为单胎妊娠的4～6倍,其中单绒毛膜囊双胎发病率和死亡率明显增加的主要原因在于双胎胎盘绒毛膜板存在连接两个胎儿循环的吻合血管,可能会出现双胎输血综合征、双胎动脉反向灌注序列征、双胎贫血-多血序列征、选择性胎儿宫内发育迟缓等多种并发症[1];同时双胎之一死亡后,另一胎也会出现多囊性脑软化等特殊表现.     

射频消融术在胎儿宫内治疗中的初步探索

目的探讨超声引导下射频消融术在胎儿宫内治疗中的初步应用。方法本组6例孕妇,其中双胎输血综合征(TTTS)3例,单绒毛膜囊双胎伴其中一胎重度宫内生长受限(sIUGR)2例,此5例均在超声引导下行射频消融减胎术;另1例单胎胎盘绒毛膜血管瘤伴胎儿严重贫血,在超声引导下行血管瘤射频消融治疗术。结果 5例被减胎儿在2~3次射频加热循环后血流消失,保留胎儿手术过程心脏搏动均正常;1例胎盘绒毛膜血管瘤射频消融治疗术,经过4次射频加热循环后,血管瘤内血流明显减少,术中胎儿心脏搏动正常。5例减胎术,其中4例均剖宫产出健康新生儿,1例术后流产;1例胎盘绒毛膜血管瘤治疗术,术后流产。结论射频消融术是可以用于胎儿宫内治疗的一种可操作的微创手术,它具有一定安全性及可靠性,可有效提高保留胎儿的出生质量。     

产前超声诊断三胎妊娠伴双胎无心脐动脉反向灌注序列征

目的总结三胎妊娠伴双胎无心脐动脉反向灌注序列征（TRAPS）胎儿产前超声图像特点。 方法对2001年4月至2017年4月经湖北省妇幼保健院产前超声诊断和生后检查确诊的6例三胎妊娠伴TRAPS胎儿超声与病理检查结果进行对照分析,总结TRAPS胎儿产前超声图像特点。 结果产前超声显示：（1）6例三胎妊娠伴TRAPS胎儿中无心畸胎均有发育不良的下肢（1例有发育不良上肢）,无胸腔、无心脏结构及心管搏动,5例无头颅结构,1例有发育不良头;4例有脊柱和腹腔结构;4例为单脐动脉,5例伴全身皮肤水肿;彩色多普勒示脐动脉反向灌注朝向胎儿体内,2例产前超声末显示脐动脉及胎儿体内血流。（2）6例泵血儿解剖结构均正常,羊水过多2例,羊水正常4例。胎儿期发生心功能不全3例（1例中孕早期好转存活,2例宫内死胎）。（3）6例第三胎儿中5例解剖结构正常,1例多发畸形。胎儿预后：6例三胎妊娠伴TRAPS胎儿中1例剖宫产产下2个正常男婴,1个死胎（无心畸胎）;其余5例三胎均预后不良（5例泵血儿中4例宫内死胎,1例早产死亡;5例第三胎儿中1例宫内死胎,2例早产死亡,2例引产;5例无心畸胎中4例宫内血流阻断,1例生后死胎）。产后病理检查显示6例均为三胎妊娠伴TRAPS,其中4例为双绒毛膜三羊膜三胎妊娠,1例为双绒毛膜双羊膜三胎妊娠;1例为单绒毛膜三羊膜三胎妊娠。 结论三胎妊娠伴TRAPS为罕见而严重的多胎妊娠并发症,产前超声有特有的声像图特点,彩色多普勒超声有较高的诊断价值。     

Early diagnosis,follow‐up,and prenatal treatment of a case of TRAP sequence occurring in a dichorionic triamniotic triplet pregnancy

We are reporting a case of twin reversed arterial perfusion (TRAP) sequence occurring in a dichorionic triamniotic triplet pregnancy with successful percutaneous prenatal treatment and excellent neonatal outcome. TRAP sequence was diagnosed at 11 weeks in a spontaneous dichorionic‐triamniotic triplet. Sonographic assessment showed persistent arterial flow and development of hydrops in the acardiac twin. Percutaneous cord interstitial laser coagulation was performed, and the co‐twin subsequently developed growth restriction. The 9‐month‐old twins have a normal developmental course. This report confirms that fetal intervention is indicated in cases of TRAP sequence in which the acardiac twin presents a significant enlargement on follow‐up sonographic examinations. © 2009 Wiley Periodicals, Inc. J Clin Ultrasound 2009     

Prenatal Diagnosis of Spontaneous Septostomy in Dichorionic Diamniotic Twins and Review of the Literature

Objective. We present 2 cases of spontaneous septostomy in dichorionic diamniotic twins and review the literature regarding the incidence, etiology, and complications of this condition. Methods. The following key words were used in the literature search: “rupture dividing membrane twin,” “disruption dividing membrane twin,” “pseudomonoamniotic twin,” “spontaneous septostomy twin,” “interfetal membrane disruption,” “intertwin membrane rupture,” and “intertwin membrane disruption.” Results. We present 2 cases in which an intertwin membrane defect was found prenatally in dichorionic diamniotic twins. In both cases, a portion of one twin's body was found traversing the spontaneous septostomy and in the sac of its cotwin. Umbilical cord Doppler studies showed no abnormalities in either case as the cord crossed the membrane disruption. In both cases, the fetuses had no notable sequelae from the ruptured intertwin membrane. The literature review revealed no cases of spontaneous septostomy in dichorionic diamniotic twins but 15 cases in monochorionic diamniotic twins. Possible etiologies include chorioamnionitis, trauma or physical rupture by the fetuses, developmental disturbances represented by amniotic plica, and polyhydramnios. In cases of monozygotic twins, a vascular etiology could explain this rare defect with formation of anastomoses of the outer embryonic vasculature. Complications of the spontaneous septostomy cases identified in the literature included cord entanglement (8 cases), preterm delivery (9 cases), and death (8 cases), although our 2 cases had minimal complications. Conclusions. Spontaneous septostomy in dichorionic diamniotic twins has not previously been reported.     

Dichorionic quadruplet pregnancy comprising monozygotic triplets and singleton after intracytoplasmic sperm injection and transfer of two fresh embryos: a case report

Monozygotic triplet pregnancies are very rare in assisted reproductive technology, and the relationship between monozygotic multiple pregnancies and several assisted reproductive techniques, including blastocyst transfer, remains unclear. Here, the case of a 28-year-old female patient with dichorionic quadruplet pregnancy following intracytoplasmic sperm injection and transfer of two day-3 fresh embryos, without assisted hatching, is reported. At 7 weeks following embryo transfer, the dichorionic quadruplet pregnancy, comprising monozygotic monochorionic triamniotic (MCTA) triplets plus a singleton, was detected by a transabdominal ultrasound scan. After counselling, the patient underwent selective reduction of the MCTA triplet pregnancy at 7 weeks after embryo transfer. The remaining singleton pregnancy was uneventful, resulting in a live birth at 38⁺ weeks. As the predictors of monozygotic multiple gestations remain poorly characterized, clinicians and patients should give great consideration to the risks associated with monozygotic multiple pregnancies, even if the patient has not undergone blastocyst transfer.     

Multifetal pregnancy reduction of both fetuses of a monochorionic pair by intrathoracic potassium chloride injection of one fetus.

The purpose of this study was to determine if a monochorionic pair of fetuses in a higher-order multiple gestation can be reduced by injecting only one fetus with potassium chloride. Three quadruplet and two quintuplet gestations, each with a monochorionic pair of fetuses, were referred for pregnancy reduction. In each case, reduction was performed by injecting one of the monochorionic pair with potassium chloride. Patients returned for a follow-up sonogram within 1 week of the procedure. The reductions were performed at an average 12.1 weeks' gestation, with a range of 10.7 to 14.0 weeks. Follow-up scans 4 to 7 days after the procedure showed that both monochorionic fetuses were dead and all other fetuses were alive. One quintuplet pregnancy underwent a second reduction procedure to twins. One quintuplet and two quadruplet pregnancies that were reduced to twins resulted in the birth of live twins between 30.8 weeks and 36.8 weeks' gestations. The third quadruplet pregnancy reduced to twins is still ongoing; the mother is pregnant with twins at 20 weeks' gestation. The quintuplet pregnancy reduced to triplets resulted in delivery of live triplets at 24.1 weeks' gestation, but two of the neonates died in the first few days of life. Reduction of both fetuses of a monochorionic pair in a higher-order multiple gestation can be accomplished by intrathoracic injection of potassium chloride into only one of the pair.     

Conjoined twins in a triplet pregnancy: early prenatal diagnosis with three-dimensional ultrasound and review of the literature.

We report two cases of conjoined twins complicating a triplet pregnancy diagnosed by two-dimensional ultrasound in the first trimester and evaluated further by three-dimensional ultrasound. A review of the literature over the last 30 years revealed 11 other cases diagnosed prenatally by ultrasound. Overall, three (23%) of these 13 pregnancies were achieved by assisted reproductive techniques and 10 (77%) were diagnosed before 18 weeks. Four women opted for termination of the whole pregnancy and three were managed expectantly, with two delivering before 32 weeks. Two monochorionic pregnancies underwent selective feticide with intrauterine demise of the non-conjoined fetus in both cases. All four dichorionic pregnancies undergoing selective termination or spontaneous embryo reduction to singleton in the first trimester resulted in term delivery of the non-conjoined fetus. The rare condition of conjoined twins in a triplet pregnancy poses a significant obstetric challenge from both diagnostic and management points of view. Accurate determination of chorionicity in these cases plays a critical role in determining management and outcome.     

Placental volume in twin and triplet pregnancies measured by three-dimensional ultrasound at 11 + 0 to 13 + 6 weeks of gestation.

OBJECTIVE: To compare the placental volume at 11 + 0 to 13 + 6 weeks' gestation between singleton and multiple pregnancies and to examine the possible effect of chorionicity on placental volume. METHODS: The placental volume was measured by three-dimensional (3D) ultrasound using the Virtual Organ Computer-aided AnaLysis (VOCAL) technique in 290 consecutive twin and 37 triplet pregnancies at 11 + 0 to 13 + 6 weeks of gestation. For the comparison of twin, triplet and singleton placental volumes each measurement was expressed as a multiple of the median (MoM) for singletons, previously established from the study of 417 normal fetuses at 11 + 0 to 13 + 6 weeks of gestation. RESULTS: Median twin and triplet placental volumes were 1.66 and 2.28 MoM for singletons, respectively. In twins the placental volumes increased significantly with gestation from a median of 83.6 mL (5th and 95th centiles: 56.0 mL and 124.9 mL) at 11 + 0 weeks to 149.3 mL (5th and 95th centiles: 100.0 mL and 223.1 mL) at 13 + 6 weeks. The median MoM in monochorionic twins was not significantly different from that in dichorionic twins with fused placentas or dichorionic twins with separate placentas. In triplets the placental volumes increased significantly with gestation from a median of 114.9 mL (5th and 95th centiles: 77.6 mL and 170.1 mL) at 11 weeks to 217.9 mL (5th and 95th centiles: 147.2 mL and 322.5 mL) at 13 + 6 weeks. There were no significant differences in total placental volume between monochorionic and dichorionic triplets, monochorionic and trichorionic triplets, or dichorionic and trichorionic triplets. CONCLUSIONS: Placental volume in multiple pregnancies does not depend on chorionicity, and the rate of placental growth between 11 and 13 + 6 weeks is not significantly different between singletons, twins and triplets. Moreover, for a given gestational age the placental volume corresponding to each fetus in twins and triplets is 83% and 76%, respectively, of the placental volume in singletons.     

The "twin peak" sign: reliable evidence of dichorionic twinning.

In twin pregnancies with a single placental zone, the presence of a triangular projection of placental tissue beyond the chorionic surface, extending between the layers of the intertwin membrane, has provided reliable evidence that there are two fused placentas (dichorionic, diamniotic) rather than a single shared placenta (monochorionic, diamniotic). This observation, dubbed the "twin peak" sign, was identified in 15 twin pregnancies, all proven to be dichorionic at birth, and in five triplet pregnancies, all proven to be trichorionic. This finding is produced by proliferating chorionic villi growing into the potential space between the two layers of chorion in the intertwin membrane. The single chorion of a monoplacental twin pregnancy serves as an intact barrier, preventing villi from growing between the two amniotic layers. A decision sequence incorporating the use of the twin peak sign is described for determining the type of twinning that has occurred.     

Membrane thickness in ultrasound prediction of chorionicity of twin gestations

A retrospective review of sonograms performed on 75 twin gestations was performed to evaluate the ability of sonography to distinguish monochorionic from dichorionic gestations based on the thickness of the membrane separating the fetuses. Clinical or pathologic evidence of chorionicity and amnionicity was available in all cases. A thick membrane had a predictive value of 83% for dichorionicity and was seen in 89% of the first sonograms obtained on dichorionic gestations. Of third trimester dichorionic pregnancies, a thick membrane was seen in only 52%. A thin membrane on the initial study had a predictive value for monochorionic diamniotic pregnancy of 83%, but was seen in only 54% of cases. There was 100% intraobserver and 91% interobserver concordance in interpretation of membrane thickness. Technical factors important in interpretation of membrane thickness are discussed. The appearance of the membrane can be useful in sonographic evaluation of chorionicity and amnionicity in twin gestations, but should be used in conjunction with all other information available.