多胎妊娠孕中期选择性减胎术后不良妊娠结局危险因素分析

目的探讨多胎妊娠孕中期选择性减胎术后发生不良妊娠结局的危险因素。方法收集2004年5月至2015年9月在山东大学附属省立医院产科住院的经腹多胎妊娠减胎术后发生流产、早产的孕妇68例,并按照每年1∶2的比例随机抽取减胎术后妊娠结局良好的孕妇共136例为对照组;分别从年龄、体重、妊娠方式、早孕期阴道流血情况、减胎术前白细胞计数、总产次、减胎前胎儿数、减胎指征、减胎次数、减胎时孕周、被减胎儿数、保留胎儿数、减胎时有无穿过胎盘、穿刺次数、减胎前有无阴道炎、术后抗生素的使用天数方面收集两组孕妇减胎时的临床资料,进行统计学分析。经腹多胎妊娠减胎术采用目标胎儿心内或颅内氯化钾注射法。结果 (1)初步分析年龄、减胎前胎儿数、保留胎儿数、术中有无穿过胎盘、穿刺次数是减胎后妊娠结局的影响因素(P0.05),其他因素对减胎后妊娠结局无明显影响(P0.05)。(2)Logistic多因素回归分析显示术中有无穿过胎盘是独立影响因素(β=-1.143,P0.005)。结论减胎时穿刺针通过胎盘是经腹减胎术不良妊娠结局的独立危险因素,手术中穿刺位点尽量避开胎盘可能会改善妊娠结局。     

多胎妊娠中孕期选择性减胎术

中孕期妊娠选择性减胎术主要目的是减少多胎妊娠胎儿数、减灭异常胎儿,改善多胎妊娠结局。在排除单绒毛膜双胎的情况下,药物减胎比较成熟和安全,一般在妊娠 11～24 周实施,妊娠成功率接近自然双胎。对于单绒毛膜双胎采用血管闭塞的技术进行选择性减胎,国内多采用射频消融,一般选择在15～27周。手术适应证、手术时机、手术方法以及术者的熟练程度与妊娠结局有关。减胎术前应行超声检查判断绒毛膜性、诊断早期胎儿异常和识别双胎特殊并发症。     

辅助生殖后中孕期多胎妊娠减胎相关问题

辅助生育技术增加多胎妊娠,通过限制胚胎移植数目及取消卵巢高反应周期,高数目多胎妊娠的风险在减少。因多胎妊娠母儿风险增加,有些情况下选择性中期妊娠减胎术是必要的。减胎术一般保留至2个胎儿,减胎后妊娠成功率随初始胎儿数的增加而降低。绒毛膜性的确定对于围产期管理至关重要。中期妊娠减胎术的手术方法根据绒毛膜性不同而选择药物注射或脐带血管闭塞法。辅助生殖技术也增加单绒毛膜双胎的发生。当单绒毛膜双胎发生血管吻合异常和胎盘共享不均时,可能导致不良结局,为复杂性双胎。多胎妊娠减胎可优化孕妇和留存胎儿的健康状况,但少数可能发生整个妊娠丢失。应正确把握减胎指征,尊重孕妇和家属的知情选择。     

多胎妊娠药物选择性减胎术后不良妊娠结局的相关因素分析

目的:分析年龄、减胎孕周、减胎数量、保留胎儿数量对多胎妊娠药物选择性减胎术后妊娠结局的影响。方法:回顾性分析2016～2019年于山东省妇幼保健院行多胎妊娠药物选择性减胎术的患者416例,随访至本次妊娠结束,其中流产28例,早产114例,足月产274例。采用单因素及多分类Logistic回归分析妊娠年龄、减胎孕周、被减胎儿数量、保留胎儿数量与不良妊娠结局(早产及流产)的关系;并对孕周<34周早产组(41例)与孕周≥34周早产组(73例)在以上相关因素中的发生占比进行比较。结果:(1)单因素分析示：行药物选择性减胎术时保留不同胎儿数量的孕妇,术后流产率、早产率及足月产率的比较,差异有统计学意义(P<0.05)。减胎时孕妇年龄、减胎孕周和被减胎数量不同,术后孕妇妊娠结局比较,差异均无统计学意义(P>0.05)。(2)多分类Logistic回归分析示：减胎时年龄、减胎孕周和保留胎儿数量对术后孕妇的不良妊娠结局有影响,其中年龄≥40岁、减胎孕周≥14周和保留胎儿数量≥2胎是减胎术后发生早产的独立危险因素(OR>1,P<0.05),而年龄30～35岁、年龄≥40岁和保留胎儿数量≥2胎是减胎术后导致流产的独立危险因素(OR>1,P<0.05)。(3)孕周<34周与孕周≥34周早产孕妇间不同年龄段的比较,差异有统计学意义(P<0.05),其中孕周<34周孕妇中年龄<30岁的占比(56.1%)高于孕周≥34周孕妇(32.9%)。结论:被减胎儿数量不是减胎术后发生不良妊娠结局的危险因素,术前的评估指标更应该关注孕妇年龄、减胎时孕周、保留胎儿的数量;年龄<30岁的患者行多胎妊娠药物选择性减胎术应尽量避免早期早产的发生。     

多胎妊娠孕中期行选择性减胎术13例临床分析

<正>多胎妊娠胎儿异常发生率、母体并发症发生率明显高于单胎妊娠,且妊娠预后往往很差。为改善多胎妊娠的预后和结局,近年多胎妊娠减胎术逐渐得到重视,开始用于妊娠的各个阶段。妊娠早期多胎妊娠减胎术国内外报道较多,妊娠中期的选     

多胎妊娠妇女孕中期选择性减胎术的临床应用

目的 通过对多胎妊娠妇女于孕中期行选择性减胎术,研究其手术指症、时机、安全性、目标胎儿的选择标准和减灭胎儿数,探讨选择性减胎术在改善多胎妊娠结局中的作用.方法 对37例孕12周+1～25周多胎妊娠孕妇(6例双胎、21例三胎、8例四胎、2例五胎,共117个胎儿)在超声引导下经腹行选择性减胎术,按产科医疗指征,在拟被减的46个胎儿心脏内注射10%氯化钾2～5 ml,见胎心逐渐减慢至停跳视为减胎术成功.术后定期产前检查和监测凝血功能,记录妊娠期并发症及妊娠结局.结果 (1)成功率:共减去胎儿46个,减胎成功率为100%(46/46个胎儿),已有27例孕妇分娩,获24个健康新生儿,妊娠成功率为88.9%(24/27).(2)分娩孕周:＞36周分娩者15例;32～36周7例;28～32周3例;＜28周流产者2例;正在妊娠中10例.平均分娩孕周(34.9±4.1)周,孕28周后分娩率为92.6%(25/27).(3)新生儿平均出生体重:单胎妊娠新生儿平均出生体重为(3014±640)g,双胎妊娠为(2557±573)g,三胎妊娠中除1例两个胎儿存活(出生体重分别为1400及1500 g)外,其余均死亡.(4)安全性:除2例单羊膜囊双胎在减灭1个胎儿后,另1个胎儿随即死亡外,其余多胎妊娠妇女的保留胎儿均未发生胎死宫内.(5)并发症:37例多胎妊娠妇女中仅3例发生子痫前期,减胎术后均无凝血功能障碍发生.(6)阴道流血:有13例孕妇减胎术前发生阴道流血,其中1例在妊娠13周强烈要求减胎,减胎术后于孕22周流产;另12例均在阴道流血停止1周以上后施行减胎.结论 (1)孕中期选择性多胎妊娠减胎术,可以有效减少多胎妊娠胎儿数目、避免异常胎儿出生,降低孕产妇并发症,提高新生儿出生体重.(2)胎儿保留数目以达双胎为好.(3)减胎术前有阴道流血者,避免在流血期间减胎,应选择在流血停止1周以上进行.(4)孕中期多胎妊娠减胎术不会造成孕妇的凝血功能障碍,也不会造成保留胎儿的宫内死亡,安全性好;减胎术后子痫前期的发病率明显下降.     

三种经阴道减胎术的比较研究

选择性减胎术作为多胎妊娠的补救措施[1,2],能有效地降低多胎妊娠给母儿带来的风险。目前常用的减胎方法有经腹或经阴道途径。经阴道减胎术多用于妊娠早期,国内常用胎心氯化钾注射和胎儿心脏负压吸引法[3]。本研究分析了胎心注射氯化钾、卵黄囊负压抽吸、胎芽负压抽吸3种减胎方     

多胎减胎术的应用进展

随着人类辅助生殖技术的发展,多胎妊娠减胎术(MFPR)在降低多胎妊娠率,改善妊娠结局中发挥了重要作用.近二十余年来,MFPR在手术途径、手术方式上都有了很大的进步,已成为目前解决多胎妊娠的主要手段之一.多胎妊娠包括双胎的患者,减少胎儿数量可明显降低流产率,改善围生儿结局.同时,减胎前有必要进行产前基因诊断,并且建议有经验的医师操作.     

辅助生殖技术(ART)助孕获得多胎妊娠行减胎术后妊娠结局观察

目的:探讨辅助生殖技术(ART)获得的多胎妊娠孕早期行经阴道减胎术的有效性和安全性。方法:以经ART助孕获得多胎妊娠行经阴道减胎术的患者123例为减胎组,根据减胎后保留的胎儿数分为双胎组(A组,n=90)和单胎组(B组,n=33)。另以同期经ART助孕获得单胎妊娠(C组,n=36)和双胎妊娠(D组,n=57)的患者为对照组。回顾性分析患者的妊娠结局及妊娠期并发症发生情况。结果:减胎组的减胎成功率为100.0%,妊娠成功率为91.9%。A组胎膜早破发生率、早产发生率、新生儿低出生体质量发生率、新生儿重症监护室(NICU)入住率均高于B组(P<0.05)。结论:多胎妊娠孕早期行经阴道减胎术安全、有效、可行。多胎妊娠实施减胎术中减为单胎更为安全。     

选择性减胎术在中期妊娠的应用

目的　探讨选择性减胎术在中期妊娠的应用及其注意事项。　方法　对 19例多胎妊娠孕妇在妊娠 12～ 2 5周行选择性减胎术。其中双胎 6例 ,三胎 11例 ,四胎、六胎各 1例。在超声引导下经腹向胎儿心内或胸腔内注入高浓度的氯化钾。　结果　 6例双胎除 1例单绒毛膜双胎外均获减胎成功 ;11例三胎 ,除 1例减胎后计划生育引产 ,1例单卵三胎外 ,9例中 7例减胎成功 ,2例减胎后流产 ;1例四胎减胎成功 ;1例六胎减胎后流产。　结论　选择性减胎术可成功应用于妊娠中期 ,母亲无严重的并发症 ,但有一定的流产率。如果减胎术前能排除单卵双胎或单卵三胎 ,或能选择近宫底的妊娠囊进行减胎 ,或能将被减胎儿的羊水抽尽 ,或推迟减胎的时间 ,可能会降低流产率。     

经阴道多胎妊娠胚胎减灭术55例临床分析

目的 分析在阴道B超引导下对早期高序多胎妊娠进行胚胎减灭术的可行性,安全性及对母儿的影响。方法 对55例经辅助生育技术受孕的早期（妊娠49－79d)多胎妊娠,在阴道B超引导下行胚胎减灭术,其中1例为7胎妊娠,7例为5胎妊娠,16例为4胎妊娠,31例为3胎妊娠。用减胎穿刺针的针尖直刺待减灭胎儿的胎心搏动（心搏）处,直至原始心搏消失,抽吸胚囊内容物,或在穿刺胚胎的同时向羊膜囊内注射生理盐水。结果 53例（96％）减胎成功,其中49例减为双胎,3例5胎减为3胎,1例7胎减为3胎,失败2例,均为4胎妊娠,其中1例为术中流产,1例为未减灭。术后流产8例（流产率15％）;早产21例,其中5名早产儿于出生后1－2d内死亡,未见畸形;足月分娩24例,共出生新生儿87名（包括42名早产儿）,82名新生儿存活,除1名为六指畸形,1名为房间隔缺损外,其余新生儿均健康,无畸形,无脏器损伤,血管损伤大出血及术后感染,发热等。结论 妊娠早期经阴道施行胚胎减灭术是一种定位准确,操作简单,易行,安全有效的手术。     

Selective reduction in twins and multiple pregnancies

The number of multiple pregnancies has increased, mainly due to the uncontrolled use of the assisted conception techniques. Multifetal pregnancy reduction (MFPR) has been used to reduce the risks associated with these high-risk pregnancies. It is performed in the first trimester of pregnancy by transabdominal injection of potassium chloride into the fetal heart. The risk of miscarriage seems to be associated with the final number of fetuses. A review of the literature suggests that MFPR results in better pregnancy outcome, regardless of the initial number of fetuses. The reduction to a lower number of fetuses reduces fetal losses, prematurity, infant mortality and morbidity.     

Second-trimester multifetal pregnancy reduction facilitates prenatal diagnosis before the procedure

OBJECTIVE: To evaluate the pregnancy outcome of selective second-trimester multifetal pregnancy reduction (MFPR) compared to first-trimester MFPR. DESIGN: Cohort analysis. SETTING: In Vitro Fertilization Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel. PATIENT(s): The study groups comprised 38 and 70 patients who underwent selective second-trimester MFPR (group 1) and first-trimester MFPR (group 2) at mean gestational ages of 19.7 +/- 3.3 weeks and 11.7 +/- 0.7 weeks, respectively. INTERVENTION(s): Ultrasonographically guided intracardiac injection of potassium chloride (KCl) solution. MAIN OUTCOME MEASURE(s): Pregnancy outcome and obstetric complications. RESULT(s): No statistically significant difference was found between group 1 and group 2 regarding mean gestational age at delivery (35.4 +/- 3.4 weeks and 35.9 +/- 3.1 weeks, respectively); mean birth weight (2,318.9 +/- 565.7 g and 2, 138.1 +/- 529.4 g); and the incidence of obstetric complications. These complications included pregnancy loss (5.2% and 15.7%), pregnancy-induced hypertension (0 and 10%), discordancy (12% and 18. 4%), intrauterine growth restriction (0 and 40%), and gestational diabetes (0% and 6%). However, the rate of all pregnancy complications was lower among second-trimester MFPR patients. CONCLUSION(s): Selective second-trimester MFPR is associated with favorable perinatal outcome and may facilitate detection of structural and chromosomal anomalies before the procedure and selective reduction of the affected fetus.     

Should multifetal pregnancy reduction be used for prevention of preterm deliveries in triplet or higher order multiple pregnancies?

This article reviews the arguments for the use of multifetal pregnancy reduction (MFPR) for the prevention of preterm deliveries in triplet and higher order multiple pregnancies and evaluates its effectiveness based on data from published studies. The arguments in favour of pregnancy reduction are based on the substantial mortality and morbidity associated with these pregnancies. Triplets and higher order multiples have increased rates of preterm delivery and intrauterine growth retardation, both of which are independent risk factors for death and handicap. Even controlling for gestational age, rates of mortality and handicap are higher for multiples than for singletons. Moreover, the family's risk of losing a child or having a handicapped child is greater because there are more infants at risk. MFPR effectively lowers these risk by reducing the frequency of preterm delivery. However, its effectiveness may be limited. In some studies, the proportion of preterm deliveries in reduced pregnancies remains above levels found in spontaneous twin or singleton pregnancies and MFPR does not appear to reduce the prevalence of low birth weight. Furthermore, the procedure itself has unwanted side effects: it increases the risk of miscarriage, premature rupture of the membranes and causes adverse psychological effects such as grief or depression for many patients. The authors note that a majority of the higher order multiple pregnancies result from a medical intervention in the first place, either through IVF techniques or the use of ovulation stimulation drugs. Although MFPR is an effective measure for reducing the substantial morbidity and mortality associated with higher order multiple pregnancies, preventive methods, such as limiting to 2 the number of embryos transferred for IVF and better control of the use of ovulation induction drugs, remain more effective and less intrusive.     

Multifetal pregnancy reduction in cases of threatened abortion of triplets.

OBJECTIVE: To investigate the course of pregnancy and fetal outcome after first-trimester multifetal pregnancy reduction (MFPR) in patients with triplet pregnancies and uterine bleeding. DESIGN: Case series of patients with threatened triplet pregnancies considered for MFPR. SETTING: Department of Obstetrics and Gynecology, Rabin Medical Center, Petah-Tiqva, Israel. PATIENT(S): Forty-two patients with triplet pregnancies and first-trimester uterine bleeding. INTERVENTION(S): At 10-15 weeks' gestation, MFPR with intracardiac injection of potassium chloride was performed. The procedures were performed 7-10 days after cessation of bleeding (9-13 weeks) or in the presence of minimal uterine bleeding (14-15 weeks). In patients with heavy uterine bleeding, MFPR was postponed. MAIN OUTCOME MEASURE(S): Early- and late-pregnancy complications related to the procedure, pregnancy outcome, and fetal survival. RESULT(S): Performance of MFPR at 14-15 weeks was associated with a higher abortion rate (38.5%), lower mean gestational age at delivery (30.6 weeks), and lower mean twin birth weight (1,376+/-218 g and 1,014+/-202 g) than was performance of MFPR at 10-13 weeks (18.8%, 33.2 weeks, and 1,720+/-245 g and 1,596+/-170 g, respectively). Abortion occurred in four of the five patients with moderate to heavy uterine bleeding who did not undergo MFPR; the fifth patient gave birth prematurely at 28 weeks, and two of the newborns died. CONCLUSION(S): Pregnancy outcome and fetal mortality and morbidity in triplet pregnancy after MFPR are directly correlated with duration and amount of first-trimester bleeding.     

Multifetal pregnancy reduction and selective termination: the Canadian experience

OBJECTIVE: To describe the experience of two Canadian referral centres with multifetal pregnancy reduction (MFPR) and selective termination (ST). METHODS: Retrospective chart review of all MFPR and ST procedures during the periods from January 1, 1990, to December 31, 1997 (Vancouver), and from September 1, 1995, to December 31, 1997 (Toronto). Outstanding outcome data were obtained by telephone. All women were managed according to standard protocols. Non-parametric analysis of continuous variables and Fisher's exact test for categorical variables were used. RESULTS: 61 women underwent transabdominal MFPR (n = 44) or ST (n = 17). Median maternal age: MFPR and ST 33.0 years; gestational age at reduction: MFPR 11.4, ST 20.2 weeks; procedure duration: MFPR 4, ST 10 min. 89% MFPR and 12% ST cases followed assisted reproduction. 7% MFPR and 18% ST pregnancies lost <24 weeks (n.s.). 97% MFPR and 83% ST non-reduced fetuses delivered alive. Median delivery gestational age: MFPR and ST 37 weeks. CONCLUSIONS: The results are similar to published series. This procedure has increased options for Canadian couples, offering the procedure 'close to home', reducing costs and, more importantly, the significant psychological morbidity following these procedures.     

Pregnancy outcome after multifetal pregnancy reduction.

OBJECTIVE: To study the effects of multifetal pregnancy reduction (MFPR) as a means to reduce the adverse outcome of multiple gestations. METHODS: This was a retrospective study evaluating the outcome of 334 multiple pregnancies after embryo reduction. RESULTS: In 313 multiple pregnancies in which MFPR was performed before 15 weeks, the rates of miscarriage, preterm delivery <33 weeks, preterm delivery <36 weeks and total fetal loss were 9.12%, 13.33%, 38.60% and 16.25%, respectively, and median gestational age at delivery was 35 weeks. There was a significant correlation between miscarriage and the finishing number of fetuses. In 185 triplets reduced to twins, miscarriage, preterm delivery <33 weeks, preterm delivery <36 weeks and total fetal loss occurred in 8.25%, 11.18%, 40.59% and 15.41% of cases, respectively, and median gestational age at delivery was 36 weeks. In the subgroup of 32 reduced triplet pregnancies that also had second-trimester amniocentesis, the risk of miscarriage (3.13%) was not significantly different from that in the rest of the group. Among 21 twin pregnancies that had selective termination at or after 15 weeks, the risk of preterm delivery <33 weeks was three times higher than in the group of 22 twin pregnancies with first-trimester procedures. CONCLUSION: MFPR resulted in at least one live neonate in 83.75% of cases and was effective in reducing the risks of pregnancy loss and severe prematurity in quadruplets and higher-order pregnancies. The risk of miscarriage increased with increasing finishing number of fetuses. In reduced triplets gestation was prolonged in comparison with average figures reported in the literature. In twin pregnancies selective termination in the first trimester carries a lower risk of severe preterm delivery and this emphasizes the need for first-trimester diagnosis.     

减胎术联合宫颈环扎术治疗多胎妊娠并宫颈机能不全2例临床分析

多胎妊娠、宫颈机能不全等均是流产或早产的高危因素,若多胎妊娠患者合并宫颈机能不全则流产或早产的风险更高。现报道2例多胎妊娠合并宫颈机能不全患者,分别在孕11+5周和20+5周行减胎术,随后分别在13+4周和21+6周行宫颈环扎术,定期产检阴道超声监测宫颈长度并及时预防早产治疗,分别在孕36周和孕33+4周成功顺产活婴,认为减胎术是多胎妊娠改善妊娠结局的补救措施,减胎术后行宫颈环扎术可修复宫颈的机能,而定期随访对防治早产、指导临床用药及适时拆除宫颈环扎线并改善母儿预后至关重要。当多胎妊娠合并宫颈机能不全时,采用减胎术联合宫颈环扎术进行治疗是一个可供临床借鉴的选择方案。     

Spontaneous abortions in couples declining multifetal pregnancy reduction

Multifetal pregnancy reduction (MFPR) has clearly improved the outcomes of multifetal gestations. Several recent reports have also suggested improved outcomes in nonreduced cases, but there have been methodologic concerns about the denominators, i.e. have all cases been included and is there a 'hidden mortality' of unknown lost cases. Here we assessed the outcome of patients telephoning to discuss MFPR, but who chose not to have the procedure. Over a 3-year period, 446 patients had MFPR by one operator. Nineteen patients chose not to have the procedure. There were 11 preterm births, 1 term delivery, and 5 spontaneous losses (7 of 17) prior to 24 weeks, a loss rate of 35%. Two patients delivering triplets had a loss of 1 fetus/neonate. These data suggest that the loss rates of nonreduced pregnancies may be higher than generally thought, making the improvements with MFPR even bigger than generally realized.     

Selective reduction

Multifetal pregnancy reduction continues to be controversial. Attitudes about MFPR have not, in our experience, followed a simple "pro-choice/pro-life" dichotomy. As far back as the mid to late 1980s, opinions about the subject were varied. Even then, when much less was known about the subject, opinions did not always parallel the usual pro-choice/theological boundaries. We believe that the real debate over the next 5 to 10 years will not be whether or not MFPR should be performed with triplets or more. The fact is that MFPR does improve those outcomes. A serious debate will emerge over whether or not it is appropriate to offer MFPR routinely for twins, even natural ones, for whom the outcome is commonly considered "good enough." Our data suggest that reduction of twins to a singleton improves the outcome of the remaining fetus. No consensus on appropriateness of routine 2-1 reductions is ever likely to emerge. The ethical issues surrounding MFPR will always be controversial. Over the years, much has been written on the subject. Opinions will always vary from outraged condemnation to complete acceptance. No short paragraph could do justice to the subject other than to state that most proponents do not believe this is a frivolous procedure but do believe in the principle of proportionality ie, therapy to achieve the most good for the least harm). Over the past 15 years, MFPR has become a well-established and integral part of infertility therapy and attempts to deal with the sequelae of aggressive infertility management. In the mid 1980s, the risks and benefits of the procedure could only be guessed. We now have clear and precise data on the risks and benefits of the procedure and an understanding that the risks increase substantially with the starting and finishing number of fetuses in multifetal pregnancies. The collaborative loss rate numbers (ie, 4.5% for triplets, 8% for quadruplets. 11% for quintuplets, and 15% for sextuplets or more) seem reasonable to present to patients for the procedure performed by an experienced operator. Our experiences and anecdotal experiences from other groups suggest that less experienced operators have worse outcomes. Pregnancy loss is not the only poor outcome. The other main issue with which to be concerned is very early premature delivery, where there is an increasing rate of poor outcomes correlated with the starting number. The finishing numbers are also critical, with twins having the best outcomes for cases starting with three or more. Triplets and singletons do not do as well. We hope that MFPR will become obsolete as better control of ovulation agents and assisted reproductive technologies make multifetal pregnancies uncommon.